some interesting stuff in this report about the No Surprises Act and all the disputes around out of network billing

There’s a massive spike in number of disputes filed, and so far only 4% of them have reached a payment determination Unsurprisingly there seems to be admin issues - the biggest one being figuring out whether an issue goes through the federal process or the state-based one

It costs like $4M per quarter to deal with these disputes

our conversation with @bobkocher the GOAT has so many good opinions per second of conversation I actually had to go back and re-read the transcript a couple of times

some parts I particularly liked:

https://twitter.com/jacobeffron/status/1592940277563416576

some of the interesting things he found in the initial mckinsey study mapping out costs

-supply induced demand
-having multiple payers created less net admin spend than believed
-cross-subsidization lead to costs going down one place yielding costs going up somewhere else

someone asked me the other day what I thought the main issues in healthcare were

there's obviously an infinite list, but I tried to come up with a list that I thought were thematic across the industry

(add your own major ones in the replies) Principal-Agent Problem: The buyers and the users in healthcare are usually not the same people, and the two entities usually have different priorities (e.g. price vs. experience).

an excellent read on FQHCs (Federally Qualified Health Centers) in alternative payment programs

FQHCs are the backbone of care in a lot of lower-income communities, and the article goes through some specific examples of programs states run/FQHCs are in

commonwealthfund.org/publications/2… it’s clear that data report is a massive problem here.

States or MCOs need to give these FQHCs the data they need to accurately forecast costs + members, and the FQHCs need to be able to ingest and interpret that

this is probably the best and most honest writeup I’ve seen about how health systems think about building new solutions vs. becoming customers of external ones. It gives a 9 item assessment and two examples as demonstrations.

nature.com/articles/s4174… also contains all the reasons why selling to hospitals sucks

-Reliance on EMR vendors to build tools whene
ver possible, and if not then ask internal devs.
-need for proof points from other systems before bringing it internally

when I started doing some early stage healthcare investing I thought I had to have industry related theses to guide me

having founder theses is much more important at the early stage esp since the business is going to change so much anyway (this is prob obvious to others) one thing I've been trying to hone-in on are founder archetypes I particular enjoy working with. Three in particular I love

1) Extremely fast learners - people that are new to some problem but can get at the "existential questions" that the field struggles with

healthcare has a very large geographic spread of talent compared to other industries - there are a lot of people that are highly talented and severely undervalued at the companies they work for in these hubs that can now way more easily plug into remote-first companies there's currently a mismatch problem of companies that want to hire this under the radar talent but not knowing how to find them + people in these smaller healthcare hubs knowing they're undervalued and learning about all the new companies that are popping up

loose post idea I'm thinking through around breathing and air quality Breath work is becoming bigger in healthcare. Sleep apnea tracking is getting a ton of focus, nose breathing and the book Breathe is making breathwork a more explored area, etc.

We should move our mental model away from "insurance gets us good discounts via group negotiation" since it's simply not true

https://twitter.com/sarahkliff/status/1429497397214728202

my understanding also is that payers negotiate a basket of service lines and insurance types, and will trade prices/volume with providers. Providers make more margin on some service lines, payers make more on others, and those are traded around. That's important!

I was curious how these 15-20 minute grocery delivery services worked, so I tried Fridge No More. Here's a random set of observations - grocery is not really my area of expertise There aren't many quickly perishable foods (bananas, avocados, etc.). There's also 1 SKU per item, and there are many items that aren't there that I would normally buy (e.g. they don't have chicken breast, just thighs/wings). For many things they only have an organic version.

1/ Hello! Big announcement - I’m excited to announce the Out-Of-Pocket job board

Healthcare companies can get their jobs in front of big brain OOP readership, and people looking for jobs in healthcare can get alerted for jobs that match their preferences

pallet.xyz/list/out-of-po… 2/ Finding jobs today sucks. Most of job hunting now is some amalgamation of recruiters reaching out, sifting through stanza'd LinkedIn broetry, your friends telling you about jobs for companies they may or not be advising, crying until a job shows up, etc.

1/ Venrock's survey is always good to keep a pulse on how people feel about the state of healthcare. Nothing too crazy but a few things that caught my eye

hcprognosis2021.venrock.com 2/ More than half of people have new policies around not coming into the office with symptoms

82% of companies surveyed are moving to a hybrid model

I've been seeing this paper go around - it suggests that urgent care is actually more expensive than emergency departments because utilization increases

still chewing on it, but it feels like it might be incomplete

healthaffairs.org/doi/abs/10.137… The key limitation is that they didn't look at how primary care or retail clinic volumes changed for the same geography that they compared urgent care vs. emergency department

I'd guess increase urgent care usage is more of a shift from primary care to UC than anything else

Loose thought - a new publisher where you pay a subscription and they only publish quality books which they vet thoroughly (maybe with separate brands for separate topic areas).

The kicker is that the books are 100 pages or less only, but guaranteed extremely high quality I think most people know that most non-fiction books are 25% good 75% fluff, but people don’t buy short books. There’s not really a business model to support short books, but maybe a subscription could if it gives the same social signaling/proof that reading a long book gives

Anecdotally have a few friends that are great operators who want to write small checks ($2.5K-$10K) and are immensely valuable companies both because they know the ins-and-outs of building companies but also because they aren't prolific investors so spend more time with each co From the company side it's hard to see the value these folks bring since the check is tiny and most don't seem to care as much about how many investments a given angel has done + are attracted to brand name angels. But post investment they find the small checks hugely valuable.

lets talk about this paper (h/t @dvasishtha) which looked whether rollercoasters can dislodge kidney stones

jaoa.org/article.aspx?a… Who is this person??? Who passed a kidney stone on a rollercoaster and was like "fuck it, run it back"

the common refrain I hear re: writing is to be consistent - that might be true to get into the habit but IMO we've taken it too far

There are enough mediocre but consistent content out now, and if the quality is all over the place there's a good chance I'll miss your best stuff IMO now to stand out you should put out consistent high quality, even if the schedule itself is not consistent - there are some people making stuff where I know every single thing they put out is gonna be a banger and I would never miss it

We're watching the first stretch of the race between telemedicine-first companies trying to build in-person touch points vs. existing hospitals and practices trying to build telemedicine offerings I'm going to bet on group 1 for a few core reasons

1) these telemedicine-first companies have cultures that are way more oriented to build new offerings quickly

2) Large hospitals/in-person care is going to try to bring people into clinic for more fee-for-service revenue

COVID has made it abundantly clear how much of a shitshow appointment scheduling in healthcare still is and consumer-focused companies can shine just by having a functional appointment system in place I wish non-healthcare people could see behind the scenes of what happens when you need to create an appointment system module for a practice - the fact that this needs to pass through the EMR makes it so unwieldy and require so many random hacks to make this happen

I'll be writing about patient communities later this week (and announcing an investment in the space 👀) - a few things I'm thinking through and would love others thoughts

Sign up here to get it once it's cooked: outofpocket.health Patient communities as an afterthought for the claim of "defensibility" almost always fail. If the core product does not seamlessly lend itself to actually integrated as a part of the community itself, then you have a customer service channel not a community

Leaving a job to go solo is very intimidating - here are some tips that helped me. What works for you + your experience might be different Actually write out what your expenses look like so you have a really granular understanding of your personal burn rate. Are there areas you can reduce? What does "bare bones", "comfortable", and "saving money look like $ wise?