The Takeaways: Week 34 of 2021

A periodic review of articles, newsletters, and podcasts that I found interesting, inspiring, or otherwise worth remembering.

Closed Tab of the Week

I always have many tabs open. A good number of them hang around because of the mismatch between my interest in engaging with them and the time I have available for that engagement. Here I pick one to review, think about, and close out.

Jordan Rau, The Washington Post. A digital tool promised to help patients manage their diabetes. Then the hospital behind it pulled the plug. (August 17, 2021)

The story of a digital medical app for managing diabetes that had a small, not-for-profit healthcare system had as its primary funder. While initial results from a two year-pilot (described in this 2018 press release) looked good, only two years later the healthcare system ended the funding.

“They did us a tremendous favor in funding us, but the one thing we needed them to be was a customer, and they couldn’t figure out how to do it,” said Jeanne Teshler, an Austin, Texas-based entrepreneur who developed Wellsmith and was its CEO.

Lots of interesting themes here:

  • A hospital/healthcare system acting in ways like a venture capital fund but not enough like such a fund. The descriptions in the article seem to suggest that the funds came out of the organization's core P&L rather than being allocated as a bet with some probability of zero return.
  • The risk tolerance frameworks seem very different, too, especially each party's understanding of time to market, the need for failure and the likelihood of pivots.
  • As always in healthcare, the path to reimbursement had to be clear and reliable, but fee-for-service is (for this case at least) being replaced too slowly by value-based care.
  • There was a go-to-market strategy, but I wonder if there was a leave-the-market strategy? What was it like taking the tool out of the hands of the people who had used it successfully during and after the pilot? The article notes that the codebase was "destroyed" - open sourcing not an option.

From the perspectives in the article, we see a story of misalignment across many factors. One that to me isn't nearly well enough articulated is that having the funder also be the proposed customer seems likely to create these kind of outcomes. This doesn't seem to have been a "app for hire" scenario, but it seems to have worked along those lines at the end.

It also seems like the CEO's observation about the health system not being able to be a customer could also be applied to the funding approach:

Teshler said [Cone Health of North Carolina] did not want to pay Wellsmith a fee when it had already lent it millions, since it could not bill insurers for the service.

The funding was a loan? If this an accurate description, then what an odd way to do this. While Rau contextualizes Wellsmith's story against the background of a number of well-known healthcare system venture capital funds, it's not clear that this was the playbook Cone Health was using.



Melissa Perri (host), Product Thinking. Episode 30: Understanding Continuous Discovery With Teresa Torres (August 25, 2021)

Torres: "If you really want to be customer-centric, you have to create business value." That is how you "earn the right to serve the customer over time."

Melissa Perri (host), Product Thinking. Episode 29: Dear Melissa - Answering Questions About Complex Product Problems (August 18, 2021)

Perri's answer to the first question about the role of compliance in building products is a good one: it's a constraint, not a nemesis - and constraints are a call to creativity.


Ted Gioia, The Honest Broker. Unpacking My Library (August 24, 2021)

How many books do you have, sir?

They’re surprised when I can’t answer that modest query. But is that really so odd? I read them, yes. I own them, yes. But it would take days to count them. So I honestly have no idea how many books I own. For the purposes of placating real estate agents and movers, I tell them that I possess between five thousand and ten thousand volumes. But that’s just a guess.

Chas Roades and Lisa Bielamowicz, MD, The Weekly Gist. August 27, 2021

Private equity as an enabler of Boomer doctor retirements: While we’ve long believed that PE firms are not long-term owners of practices, instead playing a roll-up function that will ultimately end in broader aggregation by vertically-integrated insurance companies, a recent conversation with one system CEO reframed the phenomenon in a way we hadn’t thought of before. It’s all about a demographic shift, she argued. There’s a generation of Boomer-aged doctors who followed their entrepreneurial calling and started their own practices, and are now nearing retirement age without an obvious path to exit the business.... What the PE industry is doing now is basically helping those docs transition out of practice by monetizing their next ten years of income in the form of a lump-sum cash payout.


Daniel Bean, The Signal. Tristan Handy on the changing face of the data stack (August 10, 2021)

Tristan gives this example: “If you want to create a good retention rate cohort analysis, it takes you about 80 lines of cleanly formatted SQL, and there’s probably four or five common table expressions in there.”

He’s trained a lot of people to essentially write that query. “It’s one of the hardest things that I’ve had to train people on,” he says. “You write it, use it for a day, and then you don’t have to use it for three months. By that time, you totally forget how to write the query again.”

Michael Karpman and Stephen Zuckerman, the Urban Institute and the Robert Wood Johnson Foundation. The Uninsurance Rate Held Steady During the Pandemic as Public Coverage Increased (August 23, 2021)

Between March 2019 and April 2021, the share of nonelderly adults reporting employer-sponsored insurance declined from 65.0 percent to 62.3 percent, a decrease of approximately 5.5 million adults. Over the same period, the share reporting public coverage increased from 13.6 percent to 17.5 percent, an increase of approximately 7.9 million adults. The national uninsurance rate held steady at approximately 11 percent.

The share of adults reporting public coverage increased in all 50 states, however coverage gains were larger in states that expanded access to Medicaid. Such coverage increased from 14.9 percent to 19.2 percent in expansion states and from 10.7 percent to 14.3 percent in nonexpansion states.

More than 1 in 3 adults with low incomes in nonexpansion states (37.7%) were uninsured in 2021, compared with about 1 in 7 of such adults in expansion states (14.5%).

Rich Mironov, Product Bytes. Merchandizing Product Management (August 17, 2021)

I observe that product management work is much easier when the product team is well-respected. When stakeholders and internal partners start from the assumption that we’re smart and hard-working and good at product stuff (even if they’re not sure exactly what we do). So an under-appreciated skill of product leaders is merchandizing good product work and good outcomes from our teams. Subtly but relentlessly sharing wins and learnings and improved metrics and customer insights and clear priorities with internal audiences. Positioning product management as a strategic spark for the company.

Katie Palmer, STAT. To boost Covid-19 vaccine uptake, one health system hunts for patients who fell through the cracks (August 24, 2021)

Over the first three months of this year, four nurses at the hospital called more than 500 people to share information about vaccine safety and logistics and answer any questions. They reached nearly 400 patients directly or by voicemail — and by the beginning of April, more than 100 had received or were scheduled to get a vaccine

Rachana Pradhan, KHN. At Urgent Care, He Got 5 Stitches and a Big Surprise: A Plastic Surgeon’s Bill for $1,040 (August 2, 2021)

“It really irked me that, it’s this classic thing you hear in this country all the time,” Keller said. “When you do all the right things, ask all the right questions and you’re still hit with a large bill because of some weird technicality that there’s absolutely no way for you to understand when you’re in the moment.”

Under a law Congress passed last year, many surprise medical bills will be banned starting in January. Patients with private insurance will be protected against unexpected charges for emergency out-of-network care, for treatment by out-of-network providers at in-network facilities and for transport in an air ambulance. But one gray area: visits to urgent care clinics, which have proliferated in recent years as patients seek speed and convenience over waiting hours at an emergency room or weeks to get a regular doctor’s appointment.

Casey Ross, STAT. Elizabeth Holmes will be on trial. But the evidence will expose a bigger collision between tech culture and health care (Aug. 24, 2021)

But perhaps even more striking will be the collision it spotlights between the “move fast and break things” culture of Silicon Valley and the more cautious cadence of health care, where the first rule is to do no harm. Legal experts said the verdict will turn on a narrow set of facts, but its fallout will be more widely felt in the burgeoning biotech and digital health sectors where entrepreneurs are actively raising huge sums of money based on products that often have little evidence behind them.

Julie Rovner, KHN. "Why Doesn’t Medicare Cover Services So Many Seniors Need?" (August 11, 2021)

As the years wore on, Medicare has remained popular, but it has grown less generous than most private insurance policies. Many Medicare patients, however, have been able to find supplemental coverage to fill in what Medicare does not cover, through private “Medigap” policies, employer-provided retiree plans or Medicaid for those with low incomes. Increasingly popular in recent years have been those Medicare managed-care plans, now known as Medicare Advantage, that were first authorized in 1982 and often provide extra benefits for members.