DataDrivenMD

I'd be curious to know if (and to what extent) these observations change the mid- and long-term impact of global climate change. That is: does this mean that the SARS-CoV-2 outbreak effectively bought us additional runway before we hit the "point of no return"?

I can't express how concerning this letter is to me. Some of the steps they're taking to prevent further spread of the disease are so unorthodox that I'm not sure what to make of them. On the one hand, it suggests that the Chinese government was not prepared to handle a pandemic (of any kind). On the other hand, it could mean that despite their best efforts and preparation, CoViD-19 is overwhelming their response. Any way you look at it, this is not good, and it seems increasingly likely that we're on the verge of a global pandemic with serious economic consequences.

Your point is well-taken. I agree that such an upgrade is unlikely to be sold as a standalone product. What is more likely to happen is that it will be included for a nominal fee as an add-on to a new purchase or service agreement.

To understand how this would work, we need to 1) understand the lifecycle of big-ticket medical equipment (ME) and 2) recognize that ME products are at the core of multiple revenue streams. The first point has to do with the renewed/refurbished market for used/last-generation ME. The second point has to do with the service agreements/warranties/support contracts that are needed in order to keep the ME operational. These factors combine to yield a sales process with multiple negotiating dimensions.

How these negotiations actually play out depends on whether you're a deep-pocketed healthcare system or not (it sucks, but it's true). If you can afford it, you'll have lots of ways to sport the latest and greatest ME without breaking the bank on any single purchase. Some of your old stuff will end up in the renewed/refurbished ME market, thereby offsetting your total cost of ownership (either directly or indirectly). Once used ME hits secondary markets, the customer profile changes: these customers are not looking to keep up with the Cleveland Clinics and Stanford's of the world. They're looking for long-term value, so reliability and longevity is top priority - and this is where I see software "upgrades" coming into play. Some of these customers may already have one or two MRIs, while others may not. In either case, the software "upgrade" becomes a differentiator that speaks directly to the priorities of these customers.

TL;DR - Today, healthcare providers with limited financial resources (e.g. those in developing countries, rural areas) are incentivized to purchase capital equipment through "discounts" on service/support. In the future, we're likely to see software "upgrades" (such as those made possible by FB's work) bundled/leveraged as an incentive. The net effect is the same: extend the clinically useful lifespan of medical equipment (MRIs in this case) and greater access to medical technology around the world.

A physician's $0.02 - The clinical relevance of FB's work is clearly stated in the blog post: "While state-of-the-art facilities today use 3 Tesla MRI machines, scanners with lower-strength magnets (1.5 Tesla, for example) are still commonly used around the world." Considering that a 1.5T MRI machine costs about $1M less than a comparable 3T model (+/- the cost of warranty, support, and installation), FB's work in this area has the potential to make a BIG positive impact on the lives of millions of patients. Which is why I will be cheering them on.

If they reproduce their results in other clinical settings, the immediate impact on patient care includes: 1) accelerating diagnosis (and treatment) for patients with traumatic brain injuries (by effectively up-scaling lower resolution scans) 2) healthcare providers in developing countries will effectively get a low-cost "upgrade" to their existing equipment 3) cancer patients in rural America could be monitored for treatment response in a setting that is closer to home (because rural communities tend to be resource-poor in terms of medical technology).

If we consider that a logical extension of their work could be to develop a compression algorithm for MRI data, then it's easy to see an even broader impact that includes: 1) connecting rural patients with high-quality radiologist services (i.e. remote MRI interpretations), and 2) decrease the cost of long-term storage, access, and retrieval for MRI data.

On the topic of FB's issues with privacy: I agree that FB has a long way to earn my trust as a doctor and a patient. That being said, it's important to give credit where credit is due. It seems that FB gained access to the imaging data by working collaboratively with NYU on this specific project. By comparison, it's an open secret among those of us in the biomedical informatics community that over the course of many years Google Cloud has quietly gained access to the personal health information of millions of Americans. So, when it comes to privacy concerns, it's important to avoid being myopic - the concern is valid, but the primary threat may not be as obvious as it first seems.

While it's too early to tell if any patients were harmed by these contaminated gowns, the hospitals impacted reads like who's who that includes Stanford, Stanford Children's, Northwestern, NY Presbyterian, Kaiser, BJC HealthCare, Rush, Jefferson, and Adventist Health.

In addition to the potential for patient harm, this recall will prove costly to hospitals, and ultimately patients. I have it on good authority that some hospitals have been forced to limit the number of elective surgical procedures as they scramble to secure acceptable replacements. Given that it is common practice to include these gowns in "surgical packs" (kits of sterile supplies and equipment used during a procedure), many facilities impacted by this recall will also need to tear down existing packs, re-sterilize equipment, and rebuild packs. This is a non-trivial process that takes time and is prone to human errors that could lead to case delays and/or cancellations.

Big picture: these sort of recalls are more common and widespread than one would think. In the last year alone, medical devices ranging from baby warmers to IV infusion pumps were recalled due to serious patient safety issues. For proof check out https://www.fda.gov/safety/recalls-market-withdrawals-safety....

Take home point: while it may be trendy to fund biotech startups, it'd be great to see a VC-backed company disrupt the medical supply chain with the goal of delivering safer products at lower cost. If someone out there is up for the challenge, I welcome the opportunity to help.

'Robert Nelsen, of ARCH Venture Partners, said he invested because “I think it’s really cool and I like throwing rocks into the pond.”'

Definitely a bold approach that will require lots of cash up front, which explains the $200M round. It will be interesting to see how many VCs let their FOMO get the best of them and fund the first credible copy-cat pitch they hear. After all, there is only one Alexis Borisy out there.

It will also be interesting to see what kind of tech or novel operational methodology is developed to deliver on their promise to lower costs. I'll also be interested to see whether they demonstrate substantive progress by the time they raise their next round.

This is a thoughtful, well-researched article, and I look forward to reading the rest of the series. My one criticism stems from the notion that the Taiwanese single-payer system is tantamount to "Medicare-for-all". Not only is this a gross oversimplification of both models, it requires making comparisons that just don't make sense. A more compelling argument would highlight specific attributes of the Taiwanese health system, and map those to relevant U.S. counterparts.

For example, the VA health system would be a more apt comparison if we're talking about a single-payer system operating within a common regulatory framework (all VAs are on federal property). If we're considering funding vis-à-vis taxpayer vs. employer contributions, the Taiwanese model starts to look more like Hawaii (maybe also Oregon). If we're interested in a solution that is known to scale up to 25-30 million individuals, it would be best to focus on the regulatory landscape in the state of New York. Factoring in the flexibility of higher-income individuals to purchase supplemental insurance, the Taiwanese system looks most like traditional Medicare (i.e. fee-for-service) in combination with a supplemental insurance market. Of note (and to the best of my recollection) the "Medicare-for-all" plan championed by Bernie Sanders specifically outlaws private insurance in order to avoid a scenario where we end up with a two-tier system (i.e. one for the rich, and one for everyone else).

TL;DR: A single-payer system is not Medicare-for-All. Single-payer solutions in and of themselves do not inform how we, as a country, should resolve the substantive policy differences inherent to our patchwork regulatory landscape without undermining states' rights and/or ballooning our national debt.

Not too long ago I led a team that built data products using a massive dataset comprised of more than 6B medical claims. This included Medicare, Medicaid, and private insurance. Two thoughts:

1) Trump is either bluffing or he doesn't have anyone around him that actually knows how medical billing works. If he were serious, the executive order would mandate that HHS publish the information based on the data that's already included in every claim (i.e. invoice) submitted to CMS for payment.

From a policy standpoint there are already rules in the federal register that allow HHS to publicly disclose cost information at the hospital-level. I'm no lawyer but it seems to me that a well-crafted executive order could stand up in court. Even if it were struck down, putting forth such an executive order would be a shrewd political move because it would cast its opponents in a bad light. These would presumably be insurance companies, the medical billing industry, and for-profit healthcare providers.

From a technical standpoint: there are already data pipelines in place for this sort of thing. The CMS Open Data initiative already reports hospital-level aggregates. It's not that hard to comment out a few 'GROUP BY' statements in order to get a POC up and running quickly.

2) Even if the current executive order comes to pass, people will continue to receive surprise bills and experience sticker shock. That's because the total (billed) cost is a function of:

- professional services (procedures rendered by doctors/therapists, etc)

- facility fees (hospital bed, in-house labs, etc)

For any given hospital stay or office visit the quantity and types of items in each category can (and does) vary. The current executive order mostly addresses the latter.

Furthermore, two patients seeing the exact same doctor for the exact same thing but using different insurance companies will get vastly different bills. That's because different insurance companies require healthcare providers to bundle/group (and sometimes break out/itemize) services in their own way.

Because out-of-pocket costs are, in turn, a % of the total negotiated rate patients necessarily end up with the short stick in terms of cost transparency.

Given the current medical billing system, there's simply no way for patients to know exactly what they're going to pay ahead of time because the charges won't be finalized until the insurance company decides what they will/won't cover.

No executive order will change that. Transparency will require Congress to muster up the will to write laws that put the patient first, not last.

The most valuable asset a doctor has is the trust of their patients. Not going to risk that for a half-baked product with lukewarm support from its developer and a weak endorsement from NPR.

Even if this product could aggregate data from all the PBMs, that doesn't mean the drug will be in stock at a patient's local pharmacy.

Furthermore, there are many commonly prescribed drugs that are cheaper to buy outright using a discount program (not insurance). Also, there are manufacturer-to-patient rebates offered for some brand name drugs without a generic.

In short, there's a lot more information that doctors already factor into their decision-making process. This tool is not compelling enough to bring into the mix.

They lost me at "might."

You'd be hard-pressed to find many docs (myself included) who are champing at the bit to adopt an informational resource with knowledge gaps.