MD here, what questions do you have about the healthcare industry ?

[Princepeter1234]

Hey everyone,

Long time lurker. My new year's resolution is to be less of an introvert, especially digitally. I want to be a helpful resource if possible on a few things :

1) I'm an MD at a top 5 hospital. What questions do you have about healthcare ?

2) ask me anything about healthcare startups, especially bootstrapping which I am a big fan of.

For some background , I work clinically and also have a side hustle that I have been with for about 5 years now. I also judge teams at my state accelerator and work with teams at our local innovation Lab at digital marketing (just the basics). I'd probably be most helpful in the healthcare specific space

Let me know how I can be helpful! And happy holidays to everyone !

Thanks everyone!



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[Scot]

Hey Doc! Welcome to the forum. I work in pharma and have been toying with the idea of a startup down the road in healthcare.

Feel free to pop over to my AMA if you have any pharma industry specific questions https://www.thefastlaneforum.com/community/threads/lets-talk-pharmaceuticals.69112/

But my question. How aware are doctors of IMS and Symphony data reporting (that your prescribing habits are data mined)?

Also, what're the laws on running a pharmacy in house? A couple of my clinics run small dispensaries but none of them run a full pharmacy. Does it require a full time PharmD to run? (This sounds like a dumb question but my wife is a Vet and they are allowed to dispense without a pharmacist)

 

[Princepeter1234]

Hey Doc! Welcome to the forum. I work in pharma and have been toying with the idea of a startup down the road in healthcare.

Feel free to pop over to my AMA if you have any pharma industry specific questions https://www.thefastlaneforum.com/community/threads/lets-talk-pharmaceuticals.69112/

But my question. How aware are doctors of IMS and Symphony data reporting (that your prescribing habits are data mined)?

Also, what're the laws on running a pharmacy in house? A couple of my clinics run small dispensaries but none of them run a full pharmacy. Does it require a full time PharmD to run? (This sounds like a dumb question but my wife is a Vet and they are allowed to dispense without a pharmacist)

Hey pharmacist! Thank you for all you do. God forbid I have to figure out the dosage of kcentra next time a GI bleeder rolls through the door.

So ur questions are interesting because it's a bit of a hole in my knowledge, specifically because I work at a large academic hospital that doesn't allow direct drug rep sales. However, regarding the prescribing habits, I do know and most of my colleagues are aware of tracking as my friends in the private community practice often communicate about how individual prescribers give specific medications and certainly talk about pressures form pharma if they don't hit certain benchmarks. I imagine it's not hard to look up our NPI numbers and the links to prescribing habits .

Regarding the standalone pharmacy, this is also a bit outside of my expertise since , well this is what we have pharmacists for. Our hospital has an in house standalone pharmacy but we're also a 1000 bed shop . Interesting, great questions , I will ask around though.

 

[becks22]

Welcome-- Glad you're here

Within the next couple of years I am looking to create a franchise model that is complimentary to my current business. My plan is to approach an area hospital (we have tons!) and see if I can work with them. I want to do this with one specific hospital because they have a lot of 'Health Partners' like regular MDs, Allergy doctors, OBGYNs, etc scattered around a 200 mile spread around me. Eventually then I would like to franchise the model to other hospitals around the country. This seems a little more confusing than it actually since I am trying not to be too specific. Mind if I PM you and ask you a few questions?

 

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[Princepeter1234]

Welcome-- Glad you're here

Within the next couple of years I am looking to create a franchise model that is complimentary to my current business. My plan is to approach an area hospital (we have tons!) and see if I can work with them. I want to do this with one specific hospital because they have a lot of 'Health Partners' like regular MDs, Allergy doctors, OBGYNs, etc scattered around a 200 mile spread around me. Eventually then I would like to franchise the model to other hospitals around the country. This seems a little more confusing than it actually since I am trying not to be too specific. Mind if I PM you and ask you a few questions?

Of course!

Sent from my SAMSUNG-SM-G891A using Tapatalk

 

[Scot]

Hey pharmacist! Thank you for all you do. God forbid I have to figure out the dosage of kcentra next time a GI bleeder rolls through the door.

So ur questions are interesting because it's a bit of a hole in my knowledge, specifically because I work at a large academic hospital that doesn't allow direct drug rep sales. However, regarding the prescribing habits, I do know and most of my colleagues are aware of tracking as my friends in the private community practice often communicate about how individual prescribers give specific medications and certainly talk about pressures form pharma if they don't hit certain benchmarks. I imagine it's not hard to look up our NPI numbers and the links to prescribing habits .

Regarding the standalone pharmacy, this is also a bit outside of my expertise since , well this is what we have pharmacists for. Our hospital has an in house standalone pharmacy but we're also a 1000 bed shop . Interesting, great questions , I will ask around though.

So awkward clarification. By pharma I meant I'm a pharmaceutical rep.

Most hospitals have strict rules about pharmaceutical reps. The reason I asked about data is because it's a huge opportunity to improve because it's so stagnant.

You mentioned GI bleeders, are you Internist or GI?

 

[Princepeter1234]

So awkward clarification. By pharma I meant I'm a pharmaceutical rep.

Most hospitals have strict rules about pharmaceutical reps. The reason I asked about data is because it's a huge opportunity to improve because it's so stagnant.

You mentioned GI bleeders, are you Internist or GI?

Ah, all good brother. I love my free lunches. Too bad I don't ever get them.

GI bleeders, re : Emergency Room.That's where the shit really hits the fan.

Can you clarify your thoughts on the data? Really interested in your thoughts.

Best!

 

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[Scot]

Ah, all good brother. I love my free lunches. Too bad I don't ever get them.

GI bleeders, re : Emergency Room.That's where the shit really hits the fan.

Can you clarify your thoughts on the data? Really interested in your thoughts.

Best!

Gotcha. All my drugs are GI, so my guys are always getting called in for consults any time there's a GI bleed or abdominal pain.

So for the data, pharma companies pay BIG money for data on prescribing habits. It's pretty much how sales reps get their numbers for their quota. There's one big player IMS Health and a smaller player Symphony. They both suck. And they don't care, because the entry barrier to get into data is astronomical.

I'd love to find a way to make it easier for pharmacies to send their data and to better sort it. All the data is approximations and a lot of the time data gets lost. It happens daily where a Dr shows me 4 approvals from insurance and then my report says he hasn't Rx'ed in months.

 

[Princepeter1234]

Gotcha. All my drugs are GI, so my guys are always getting called in for consults any time there's a GI bleed or abdominal pain.

So for the data, pharma companies pay BIG money for data on prescribing habits. It's pretty much how sales reps get their numbers for their quota. There's one big player IMS Health and a smaller player Symphony. They both suck. And they don't care, because the entry barrier to get into data is astronomical.

I'd love to find a way to make it easier for pharmacies to send their data and to better sort it. All the data is approximations and a lot of the time data gets lost. It happens daily where a Dr shows me 4 approvals from insurance and then my report says he hasn't Rx'ed in months.

So heres the thing.
1) Pharmacies don't actually talk to each other. Not even the same chain. So, if I were to prescribe a drug to Walgreen's in the Corner of A streen and 5th, the Walgreens on B streen and 6th will be COMPLETELY blind to the activities of the former. I suspect this might change given the way opiates have gone out of control, with some states enacting legislation that requires medication prescription databases about individual patients for controlled substances. However this is the current state of pharmacies and I suspect it is likely to do with the way franchising works with these chains. It doesnt give a competitive advantage to the franchisee or the national brand to have a linked system.

2) There are gobs and gobs of open access data for individual NPI numbers, by drug type, by state, by zip, everything.
Here, take this: https://data.cms.gov/Public-Use-Files/Medicare-Provider-Utilization-and-Payment-Data-201/465c-49pb
boom, you see every medicare beneficiary and the linked prescriptions, down to the individual doc. Interesting right? But the questions is how is it useful or actionable. This data is A) from medicare so you only get medicare patients B) usually weighted to some degree, really just for research purposes C) usually lags by about 2-3 years. Whats really interesting for sales is when you have live data. But here are the salient issues:

- The majority of what i prescribe likely goes nowhere. There is no guarantee that anything ever gets picked up or filled and frankly I have absolutely no way to tell. I'd love for the pieces of prescription paper to let me know if they have been filled or not, but the issues is #1: literally no one has any idea if things are filled or not, so how the heck am I supposed to ever find out?

 

[MidwestLandlord]

1) Pharmacies don't actually talk to each other. Not even the same chain. So, if I were to prescribe a drug to Walgreen's in the Corner of A streen and 5th, the Walgreens on B streen and 6th will be COMPLETELY blind to the activities of the former.

Are you sure this is true with the larger chains? This year I had 2 different prescription drugs filled for my daughter, both at Walgreen's but in different locations, and the second Walgreen's refused to fill the prescription because they said there was a "relative contraindication" between the two drugs. We had to get the doc to rewrite for something different. Other than their computer, I don't think they could of found out about the first drug she was on.

You'd know better than me, but that's what we found.

 

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[Niptuck MD]

what do you foresee changing regardless when Trump steps in office? Do you believe healthcare costs as a whole will continue to skyrocket and the cost of new biotech will also create good competition?

 

[Princepeter1234]

Are you sure this is true with the larger chains? This year I had 2 different prescription drugs filled for my daughter, both at Walgreen's but in different locations, and the second Walgreen's refused to fill the prescription because they said there was a "relative contraindication" between the two drugs. We had to get the doc to rewrite for something different. Other than their computer, I don't think they could of found out about the first drug she was on.

You'd know better than me, but that's what we found.

There may be pilots (things are changing every day!) but by and large this is true even for the larger chains. Now, what I will say is that most chains may know about insurance and what has been approved and if your insurance notifies the pharmacy, then they will tell you because otherwise the pharmacy won't get paid. Thus your insurance tells store B that they won't pay for the medication because you received a medication at store A, and thus you need to be prescribed a cheaper medication (wink wink). Does that make sense?

This was confirmed to me by a pharma executive a while back when we noticed that people were getting massive amounts of opiates filled at the same chain but just different locations. It became a big hugaboo, as you might imagine.

 

[Scot]

So heres the thing.
1) Pharmacies don't actually talk to each other. Not even the same chain. So, if I were to prescribe a drug to Walgreen's in the Corner of A streen and 5th, the Walgreens on B streen and 6th will be COMPLETELY blind to the activities of the former. I suspect this might change given the way opiates have gone out of control, with some states enacting legislation that requires medication prescription databases about individual patients for controlled substances. However this is the current state of pharmacies and I suspect it is likely to do with the way franchising works with these chains. It doesnt give a competitive advantage to the franchisee or the national brand to have a linked system.

2) There are gobs and gobs of open access data for individual NPI numbers, by drug type, by state, by zip, everything.
Here, take this: https://data.cms.gov/Public-Use-Files/Medicare-Provider-Utilization-and-Payment-Data-201/465c-49pb
boom, you see every medicare beneficiary and the linked prescriptions, down to the individual doc. Interesting right? But the questions is how is it useful or actionable. This data is A) from medicare so you only get medicare patients B) usually weighted to some degree, really just for research purposes C) usually lags by about 2-3 years. Whats really interesting for sales is when you have live data. But here are the salient issues:

- The majority of what i prescribe likely goes nowhere. There is no guarantee that anything ever gets picked up or filled and frankly I have absolutely no way to tell. I'd love for the pieces of prescription paper to let me know if they have been filled or not, but the issues is #1: literally no one has any idea if things are filled or not, so how the heck am I supposed to ever find out?

Let's talk over PM. There are

So heres the thing.
1) Pharmacies don't actually talk to each other. Not even the same chain. So, if I were to prescribe a drug to Walgreen's in the Corner of A streen and 5th, the Walgreens on B streen and 6th will be COMPLETELY blind to the activities of the former. I suspect this might change given the way opiates have gone out of control, with some states enacting legislation that requires medication prescription databases about individual patients for controlled substances. However this is the current state of pharmacies and I suspect it is likely to do with the way franchising works with these chains. It doesnt give a competitive advantage to the franchisee or the national brand to have a linked system.

2) There are gobs and gobs of open access data for individual NPI numbers, by drug type, by state, by zip, everything.
Here, take this: https://data.cms.gov/Public-Use-Files/Medicare-Provider-Utilization-and-Payment-Data-201/465c-49pb
boom, you see every medicare beneficiary and the linked prescriptions, down to the individual doc. Interesting right? But the questions is how is it useful or actionable. This data is A) from medicare so you only get medicare patients B) usually weighted to some degree, really just for research purposes C) usually lags by about 2-3 years. Whats really interesting for sales is when you have live data. But here are the salient issues:

- The majority of what i prescribe likely goes nowhere. There is no guarantee that anything ever gets picked up or filled and frankly I have absolutely no way to tell. I'd love for the pieces of prescription paper to let me know if they have been filled or not, but the issues is #1: literally no one has any idea if things are filled or not, so how the heck am I supposed to ever find out?

Shoot me a PM, I'd definitely like to talk with you about some of this stuff.

 

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[Princepeter1234]

what do you foresee changing regardless when Trump steps in office? Do you believe healthcare costs as a whole will continue to skyrocket and the cost of new biotech will also create good competition?

Leaving out political induced changes (medicare phaseout?) and assuming everything stays as is, I'd say the big ones are this (and I'll focus on things that allow for entrepreneurs to get involved):

1) Increased competition in the microEMR space
the biggest players in electronic medical records have basically consolidated their space but will continually be challenged by better, faster, more actionable EMR's that are smarter and better. But since the biggest players have taken their space, a second generation will undoubtedly take foothold and keep challenging the big players. What happens then is unclear. However, startups like Oscar are a great thing. Epic is a terrible system.

2) Online delivery of healthcare, especially medications
- PantherX was an amazing innovation and I'd even classify healthcare (soft) services like Warby parker as an online delivery service of glasses. Small parts of healthcare will keep moving moreand more online. There's niches to be had everywhere. And when I mean niche I mean like hundreds of millions of dollars for small niches.

3) Telemedicine: more and more medicine will be delivered via telemedicine services. There's ample opportunity everywhere. Doximity now has a "telemedicine in a box" like service that lets independent docs to virtual consults and there's definitely opportunities here for auxillary services like advertising for independent docs, marketing firms for docs, etc.

4) Better data , less useless data: This is more on the startup side and less on the side hustle (I'm a big fan of the latter), but every month I get at least 1-2 pitches for stuff in healthcare that are just made because of poor understanding of testing and statistics. This is a must read for anyone looking to do anything related to healthcare testing: http://fivethirtyeight.com/features/theranos-is-wrong-we-dont-need-more-blood-tests/. The number of false alarms that go off in hospitals is unreal and the same goes for a lot of our tech in healthcare--its dumb and just pours data into the environment without any clear idea of how anyone is supposed to act on it. There's a lot of hand waving for "algorithms." and "more data is better" but in truth there will be more and more ideas for "less is better" and "we just get rid of bullshit." Lots of opportunities for decreasing clutter and bullshit.

5) Decreased cost as things shift to outcomes based healthcare models
- besides the fact that healthcare spending cost curve is already decreasing (it can't beat inflation by that much--people just go broke), the shift towards outcomes based models of healthcare is going to be a huge opportunity for lots of niches. Orthopedic surgeons operate on a knee. They see them in clinic a month later. They have no idea if this operation actually helped the patient in the long run in the quality of life. But what is quality of life? Its basically like trying to define happiness and lots of people will try . This is a great sector to be in becuase there's a lot less regulation compared to medical devices or medication delivery.

 

[Niptuck MD]

Leaving out political induced changes (medicare phaseout?) and assuming everything stays as is, I'd say the big ones are this (and I'll focus on things that allow for entrepreneurs to get involved):

1) Increased competition in the microEMR space
the biggest players in electronic medical records have basically consolidated their space but will continually be challenged by better, faster, more actionable EMR's that are smarter and better. But since the biggest players have taken their space, a second generation will undoubtedly take foothold and keep challenging the big players. What happens then is unclear. However, startups like Oscar are a great thing. Epic is a terrible system.

2) Online delivery of healthcare, especially medications
- PantherX was an amazing innovation and I'd even classify healthcare (soft) services like Warby parker as an online delivery service of glasses. Small parts of healthcare will keep moving moreand more online. There's niches to be had everywhere. And when I mean niche I mean like hundreds of millions of dollars for small niches.

3) Telemedicine: more and more medicine will be delivered via telemedicine services. There's ample opportunity everywhere. Doximity now has a "telemedicine in a box" like service that lets independent docs to virtual consults and there's definitely opportunities here for auxillary services like advertising for independent docs, marketing firms for docs, etc.

4) Better data , less useless data: This is more on the startup side and less on the side hustle (I'm a big fan of the latter), but every month I get at least 1-2 pitches for stuff in healthcare that are just made because of poor understanding of testing and statistics. This is a must read for anyone looking to do anything related to healthcare testing: http://fivethirtyeight.com/features/theranos-is-wrong-we-dont-need-more-blood-tests/. The number of false alarms that go off in hospitals is unreal and the same goes for a lot of our tech in healthcare--its dumb and just pours data into the environment without any clear idea of how anyone is supposed to act on it. There's a lot of hand waving for "algorithms." and "more data is better" but in truth there will be more and more ideas for "less is better" and "we just get rid of bullshit." Lots of opportunities for decreasing clutter and bullshit.

5) Decreased cost as things shift to outcomes based healthcare models
- besides the fact that healthcare spending cost curve is already decreasing (it can't beat inflation by that much--people just go broke), the shift towards outcomes based models of healthcare is going to be a huge opportunity for lots of niches. Orthopedic surgeons operate on a knee. They see them in clinic a month later. They have no idea if this operation actually helped the patient in the long run in the quality of life. But what is quality of life? Its basically like trying to define happiness and lots of people will try . This is a great sector to be in becuase there's a lot less regulation compared to medical devices or medication delivery.

thank you sir

 

[Jon L]

Leaving out political induced changes (medicare phaseout?) and assuming everything stays as is, I'd say the big ones are this (and I'll focus on things that allow for entrepreneurs to get involved):

1) Increased competition in the microEMR space
the biggest players in electronic medical records have basically consolidated their space but will continually be challenged by better, faster, more actionable EMR's that are smarter and better. But since the biggest players have taken their space, a second generation will undoubtedly take foothold and keep challenging the big players. What happens then is unclear. However, startups like Oscar are a great thing. Epic is a terrible system.

2) Online delivery of healthcare, especially medications
- PantherX was an amazing innovation and I'd even classify healthcare (soft) services like Warby parker as an online delivery service of glasses. Small parts of healthcare will keep moving moreand more online. There's niches to be had everywhere. And when I mean niche I mean like hundreds of millions of dollars for small niches.

3) Telemedicine: more and more medicine will be delivered via telemedicine services. There's ample opportunity everywhere. Doximity now has a "telemedicine in a box" like service that lets independent docs to virtual consults and there's definitely opportunities here for auxillary services like advertising for independent docs, marketing firms for docs, etc.

4) Better data , less useless data: This is more on the startup side and less on the side hustle (I'm a big fan of the latter), but every month I get at least 1-2 pitches for stuff in healthcare that are just made because of poor understanding of testing and statistics. This is a must read for anyone looking to do anything related to healthcare testing: http://fivethirtyeight.com/features/theranos-is-wrong-we-dont-need-more-blood-tests/. The number of false alarms that go off in hospitals is unreal and the same goes for a lot of our tech in healthcare--its dumb and just pours data into the environment without any clear idea of how anyone is supposed to act on it. There's a lot of hand waving for "algorithms." and "more data is better" but in truth there will be more and more ideas for "less is better" and "we just get rid of bullshit." Lots of opportunities for decreasing clutter and bullshit.

5) Decreased cost as things shift to outcomes based healthcare models
- besides the fact that healthcare spending cost curve is already decreasing (it can't beat inflation by that much--people just go broke), the shift towards outcomes based models of healthcare is going to be a huge opportunity for lots of niches. Orthopedic surgeons operate on a knee. They see them in clinic a month later. They have no idea if this operation actually helped the patient in the long run in the quality of life. But what is quality of life? Its basically like trying to define happiness and lots of people will try . This is a great sector to be in becuase there's a lot less regulation compared to medical devices or medication delivery.

Favorite quote in that FiveThirtyEight.com article where it was discussing why access to tests won't matter much in regards to actual outcomes:

"For example, almost 35 percent of American adults are obese, which is likely quite apparent to them, yet many have great difficulty losing weight."

...

That said, I still think we should have the right to order whatever tests we want, as long as we are willing to pay for them. If I want to be an idiot and diagnose myself without a doctor's help, I should have that right. Maybe that's just the libertarian in me.

 

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[Princepeter1234]

Favorite quote in that FiveThirtyEight.com article where it was discussing why access to tests won't matter much in regards to actual outcomes:

"For example, almost 35 percent of American adults are obese, which is likely quite apparent to them, yet many have great difficulty losing weight."

...

That said, I still think we should have the right to order whatever tests we want, as long as we are willing to pay for them. If I want to be an idiot and diagnose myself without a doctor's help, I should have that right. Maybe that's just the libertarian in me.

Keep in mind a positive test is not a diagnosis. You have the right to give yourself a positive test, not a diagnosis. They are not the same thing. A diagnosis is something that is legally protected, and frankly, something I'm legally liable to. You can give yourself a positive test and I'm dealt with the ramifications.

Let's illustrate the risk of malpractice here. Say you come in with shortness of breath and chest pain and you've given yourself an allergy to contrast and I can't send you to the CT scanner and you plop dead of a PE. Is that my fault? If you diagnose yourself with hyperKalemia am I obligated to treat you? What if I treat you and then do harm, am I liable?

In a sane world, you can do whatever the hell you want but I'm not obligated to do jack for you. Would you consent to that?

 

[Jon L]

Keep in mind a positive test is not a diagnosis. You have the right to give yourself a positive test, not a diagnosis. They are not the same thing. A diagnosis is something that is legally protected, and frankly, something I'm legally liable to. You can give yourself a positive test and I'm dealt with the ramifications.

Let's illustrate the risk of malpractice here. Say you come in with shortness of breath and chest pain and you've given yourself an allergy to contrast and I can't send you to the CT scanner and you plop dead of a PE. Is that my fault? If you diagnose yourself with hyperKalemia am I obligated to treat you? What if I treat you and then do harm, am I liable?

In a sane world, you can do whatever the hell you want but I'm not obligated to do jack for you. Would you consent to that?

yeah that makes perfect sense - I can order whatever test I want, take whatever drug I want.

You, as my doctor, are also free to tell me I'm full of crap, ignore all the tests that I ran and start from scratch. Or not. You certainly shouldn't be forced to rely on my 'diagnosis.' You should only rely on your own diagnosis, or the diagnosis of an actual doctor.

Its similar to my line of work. I develop custom business software. Often, I'm brought in after a project has failed, and my job is to rescue things. When I start in on a project like that, even if I wasn't the cause of the problem, my customer assumes that every problem from there on is my obligation to fix. That is why, much of the time, I start from scratch.

Clients will often tinker with stuff on their own, often making things worse. That's completely their call, though. They'll end up paying more for my services because of what they did beforehand.

However, there are some clients that actually know what they're doing - they know what they're able to do, and they do that stuff. They also know the boundary between what they can actually take on, and what should be left of to the experts.

(this is a bit of a soap-box for me, so sorry)

We have this weird hyper-regulated nanny-state thing going on with medicine - everything is monitored and controlled to such a degree that a friend of mine passed a kidney stone and was charged $10,000 for the privilege of peeing into a screen in an ER room (they did nothing else for her except ask her how she was doing every now and then. They may have prescribed pain meds too. not sure.). My dog broke its leg, and I was charged 1/20th the price that would have been charged for the same surgery had it been my child. That is nuts. I don't know what the difference in surgery outcomes are for humans vs animals, but I'm guessing it not worth the 20x price. Obviously, I want a better outcome for my kid than for my dog, but for 20x the price? That's not just market forces at work.

(edit: The other thing this does is it separates the patient and the doctor - patients are involved in very little of the work of their doctor, so they're not invested in the treatment prescribed. I don't know what the compliance rate among patients is, but I've heard its pretty low. Part of the reason for that is that patients are dictated to instead of worked with.)

ok I'll get off my soapbox and let you continue with the rest of your thread, which is really quite interesting, by the way. Thanks for doing this.

 

[Princepeter1234]

yeah that makes perfect sense - I can order whatever test I want, take whatever drug I want.

You, as my doctor, are also free to tell me I'm full of crap, ignore all the tests that I ran and start from scratch. Or not. You certainly shouldn't be forced to rely on my 'diagnosis.' You should only rely on your own diagnosis, or the diagnosis of an actual doctor.

Its similar to my line of work. I develop custom business software. Often, I'm brought in after a project has failed, and my job is to rescue things. When I start in on a project like that, even if I wasn't the cause of the problem, my customer assumes that every problem from there on is my obligation to fix. That is why, much of the time, I start from scratch.

Clients will often tinker with stuff on their own, often making things worse. That's completely their call, though. They'll end up paying more for my services because of what they did beforehand.

However, there are some clients that actually know what they're doing - they know what they're able to do, and they do that stuff. They also know the boundary between what they can actually take on, and what should be left of to the experts.

(this is a bit of a soap-box for me, so sorry)

We have this weird hyper-regulated nanny-state thing going on with medicine - everything is monitored and controlled to such a degree that a friend of mine passed a kidney stone and was charged $10,000 for the privilege of peeing into a screen in an ER room (they did nothing else for her except ask her how she was doing every now and then. They may have prescribed pain meds too. not sure.). My dog broke its leg, and I was charged 1/20th the price that would have been charged for the same surgery had it been my child. That is nuts. I don't know what the difference in surgery outcomes are for humans vs animals, but I'm guessing it not worth the 20x price. Obviously, I want a better outcome for my kid than for my dog, but for 20x the price? That's not just market forces at work.

(edit: The other thing this does is it separates the patient and the doctor - patients are involved in very little of the work of their doctor, so they're not invested in the treatment prescribed. I don't know what the compliance rate among patients is, but I've heard its pretty low. Part of the reason for that is that patients are dictated to instead of worked with.)

ok I'll get off my soapbox and let you continue with the rest of your thread, which is really quite interesting, by the way. Thanks for doing this.

Nono, let me be clear, I would always retest you, even if I had rock solid proof it was correct. Gotta document that it was correct. But then you'd be billed cash because your insurance deemed that visit /test without medical necessity. Would you pay cash for that recheck? Also, let's face it, your clients can tinker all they want with stuff, but in the end, would we as a society be ok with tinkering if it could kill you? The funny thing about people and families when they die is that its ALWAYS someone's fault. Its never Darwin. Let's say you agreed 100% that it was your responsibility. You know who doesn't agree when you die needlessly so young? Your mom. And your mom is gonna get her meat. Sorry bud.

Here's the thing re: hyperregulation. The issue is what people expect from medicine. Would you go visit the doctor, or find it acceptable if it were to work, just most of the time? Would you be okay if the normal saline maybe wasn't ultrasterile and you had a pn infection? Overall, we as a people decided, no that was not okay. In fact, there are a whole host of things deemed "Never events" that should literally never happen, from simple things like wrong sided surgeries to less obviously controllable things like central line complications. If you get a "never event" (which, by the way, happens all the time), the hospital gets literally ZERO reimbursement for that.

also, second common misunderstanding regarding the cost of medicine. The charges you are seeing are driven in large part by two things that have nothing to do with how much the care cost to deliver.

1) What you are charged is not the price you pay. This is something I just posted on another forum and I'll repost it here:

The Chargemaster rate, the rate of procedures from the "chargemaster" of a hospital, is the same no matter who you are, the different is what people pay from the chargemaster bill. Let's say you are given tylenol and the charge master is $50. The reason why this is so high is because medicare will then say that they pay , say, 20% the chargemaster rate, and thus elderly patients pay $10. This is why elderly patients are seen as great patients for revenue: They all actually can pay something, even if its only a fraction of the chargemaster. A gold plated insurance patient will pay Medicare+30%, and thus the gold plate insurance pays $20. The patient with no insurance then is also billed $50 because they don't have an agreement with the hospital. Thus, what likely happens is that they pay $0 and goes bankrupt, or more likely, these patients don't have any net worth at all. This creates a weird situation where the homeless, destute, and people with no net worth essentially get infinitely free healthcare. These patients tend to be very high volume healthcare users (homeless patients that take $5000 ambulance rides as taxis because they know they will never actually pay a penny, despite having millions of dollars of charges.). This is what the Affordable Care act tried to prevent: by making people pay something, you were actually decreasing costs for all because you remove free riders who present the majority of sunk costs in the healthcare system. Very few people if ever pay for the full cost of a procedure or chargemaster. The chargemaster is a negotiation tactic. Not a final bill.

riding on that latter point from above,
2) You are subsidizing for people who can't pay. The 1 million dollar hospitalization for the gangbanger who got into a gun fight? You know who pays that? You, because that dude didn't have insurance. Sucks doesn't it? Happens all the time, like, daily.
http://nypost.com/2009/07/12/hosp-itality-abue/

 

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[Princepeter1234]

Also, appreciate the kind words, I'm really trying to get out of my solopreneur box. I find myself working in medicine never talking about entrepreneurship and never talk to entrepreneurs because they never talk medicine. Having that mix of discussions is great for me and I really want to be sure that I'm enjoying this journey with other people. Its all about the connections you make and memories you form and I have definitely been taking that for granted for too long. I'm really enjoying this, and hopefully I can make a difference for ya'll!

 

[MidwestLandlord]

It's nice to see the other side of the debate with hospital charges and Obama care and all that. It's easy to be very politically opinionated about these things without seeing that side of it. (don't make this political guys)

You've helped this stubborn fool see things differently, thanks @Princepeter1234

I don't know what your goal is for becoming an entrepreneur with your medical skills, but I'll share something I saw where I live:

2 doctors from our public hospital got together and started an urgent care business. They put 3 of the other 4 urgent care places out of business in the first year, because their service is phenomenal. In three years they went from 1 location to 5.

I won't go anywhere else. I've even fired my kids' pediatrician and only use them, because they do a way better job. It's less "urgent care" and more of a regular doctor visit without the wait or appointment scheduling.

The doc I use drives a Bentley, so it seems she does alright haha. Happy to help her pay for it, because her service is great and the place seems to run like a well oiled machine.

Just a thought. Seems urgent care places are ripe for a movement into good service, good processes, and clean facilities.

 

[S. Brown]

Leaving out political induced changes (medicare phaseout?) and assuming everything stays as is, I'd say the big ones are this (and I'll focus on things that allow for entrepreneurs to get involved):

1) Increased competition in the microEMR space
the biggest players in electronic medical records have basically consolidated their space but will continually be challenged by better, faster, more actionable EMR's that are smarter and better. But since the biggest players have taken their space, a second generation will undoubtedly take foothold and keep challenging the big players. What happens then is unclear. However, startups like Oscar are a great thing. Epic is a terrible system.

2) Online delivery of healthcare, especially medications
- PantherX was an amazing innovation and I'd even classify healthcare (soft) services like Warby parker as an online delivery service of glasses. Small parts of healthcare will keep moving moreand more online. There's niches to be had everywhere. And when I mean niche I mean like hundreds of millions of dollars for small niches.

3) Telemedicine: more and more medicine will be delivered via telemedicine services. There's ample opportunity everywhere. Doximity now has a "telemedicine in a box" like service that lets independent docs to virtual consults and there's definitely opportunities here for auxillary services like advertising for independent docs, marketing firms for docs, etc.

4) Better data , less useless data: This is more on the startup side and less on the side hustle (I'm a big fan of the latter), but every month I get at least 1-2 pitches for stuff in healthcare that are just made because of poor understanding of testing and statistics. This is a must read for anyone looking to do anything related to healthcare testing: http://fivethirtyeight.com/features/theranos-is-wrong-we-dont-need-more-blood-tests/. The number of false alarms that go off in hospitals is unreal and the same goes for a lot of our tech in healthcare--its dumb and just pours data into the environment without any clear idea of how anyone is supposed to act on it. There's a lot of hand waving for "algorithms." and "more data is better" but in truth there will be more and more ideas for "less is better" and "we just get rid of bullshit." Lots of opportunities for decreasing clutter and bullshit.

5) Decreased cost as things shift to outcomes based healthcare models
- besides the fact that healthcare spending cost curve is already decreasing (it can't beat inflation by that much--people just go broke), the shift towards outcomes based models of healthcare is going to be a huge opportunity for lots of niches. Orthopedic surgeons operate on a knee. They see them in clinic a month later. They have no idea if this operation actually helped the patient in the long run in the quality of life. But what is quality of life? Its basically like trying to define happiness and lots of people will try . This is a great sector to be in becuase there's a lot less regulation compared to medical devices or medication delivery.

I appreciate the good value you are providing in this thread regarding a industry (medicine/pharmacy) many entrepreneurs don't step into because of the high barrier to entry.

What are your thoughts on the disconnect or issue of communication between the doctor, pharmacist/pharmacy, and patient dealing with prescriptions?



Sent from my SAMSUNG-SM-G920A using Tapatalk

 

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[throttleforward]

the shift towards outcomes based models of healthcare is going to be a huge opportunity for lots of niches. Orthopedic surgeons operate on a knee. They see them in clinic a month later. They have no idea if this operation actually helped the patient in the long run in the quality of life.

Thanks for mentioning this. As a former EMT, I was often frustrated with the lack of follow-up efficacy data, and noticed that it was pervasive throughout healthcare.

One example stands out - we decided to medevac a lady who had been thrown from a horse with pelvic instability and pain on palpation with no other apparent injury or obvious distress on suspicion that she may have a bleeding pelvic break and may not survive the 45 minute ride to the hospital. It was a significant decision - we were taking the area's only helicopter out of the system and causing our patient to incur a $30,000 charge, based only on our hunch. Our OMD later informed us that she did, in fact, have a massive pelvic bleed, that she rapidly decompensated in the helicopter, and had we decided to transport by ground she likely would have died. If our OMD didn't casually tell us that fact a few weeks after the call, we would have never known if we made the right call. And she was certainly under no obligation to tell us anything - it probably violated HIPAA to do so.

Another easy example - my son was diagnosed with pneumonia over Thanksgiving break. The pediatrician gave him the standard round of antibiotics. How does he know how my son faired? What if it was viral or he developed some other complication? He doesn't know...and even if we went back to the same office, there is a decent likelihood that we would be seen by another pediatrician.

I don't know exactly how a startup profits financially from closing this feedback loop (I have some thoughts, but they are based on my limited experience in healthcare), but it'd be nice to see some progress in this area.

 

[Princepeter1234]

I appreciate the good value you are providing in this thread regarding a industry (medicine/pharmacy) many entrepreneurs don't step into because of the high barrier to entry.

What are your thoughts on the disconnect or issue of communication between the doctor, pharmacist/pharmacy, and patient dealing with prescriptions?



Sent from my SAMSUNG-SM-G920A using Tapatalk

Kind words appreciated! I think there legitimately are a ton of niches in healthcare that are outside the regulatory realm. People almost reflexively go to vitamins and supplements and I just keep hoping someday people will fill more of the microniches and make themselves a nice little lifestyle. Just one example:
- there are a lot of private practice docs that see patients for cash for single problems like ADHD, work evaluations, etc. This economy is really a space where entrepreneurs can get involved. Offer private rooms on breather (I wish that app had a better name) for healthcare exchanges that docs can rent out. Place it in a great spot in SF and rent by the 1/2 hour. Put a little cart in there and a nice comfy reclining bed and boom you have a nice profitable niche.

anyways, I digress. Regarding the issue of communication, its a total cluster and again, great opportunities abound. A lot of issues with HIPPAA though and i see probably one or two large players taking over this space. However there isnt a dominant one at the moment. We still do followup calls. The issue once again is HIPAA. you'd rather not receive convenient texts or emails about your chlamydia results only to find out your wife received that text...right?

 

[Princepeter1234]

It's nice to see the other side of the debate with hospital charges and Obama care and all that. It's easy to be very politically opinionated about these things without seeing that side of it. (don't make this political guys)

You've helped this stubborn fool see things differently, thanks @Princepeter1234

I don't know what your goal is for becoming an entrepreneur with your medical skills, but I'll share something I saw where I live:

2 doctors from our public hospital got together and started an urgent care business. They put 3 of the other 4 urgent care places out of business in the first year, because their service is phenomenal. In three years they went from 1 location to 5.

I won't go anywhere else. I've even fired my kids' pediatrician and only use them, because they do a way better job. It's less "urgent care" and more of a regular doctor visit without the wait or appointment scheduling.

The doc I use drives a Bentley, so it seems she does alright haha. Happy to help her pay for it, because her service is great and the place seems to run like a well oiled machine.

Just a thought. Seems urgent care places are ripe for a movement into good service, good processes, and clean facilities.

I love being able to give something back. I started a company back in 2013 that does robotics and hardware in the healthcare industry and we've grown a ton. I don't do a great job with connecting with local entrepreneur networks on a regular basis other than occasional workshops here and there and digital applications, so I think having the ability to see what other people are doing is really exciting for me. Gets me motivated!

The urgent care business is growing every day. Great service in clean locations. Tons of opportunity there for docs. If you aren't you can still get involved with auxillary services like front side hospitality, communications, marketing, etc.

 

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[Princepeter1234]

Thanks for mentioning this. As a former EMT, I was often frustrated with the lack of follow-up efficacy data, and noticed that it was pervasive throughout healthcare.

One example stands out - we decided to medevac a lady who had been thrown from a horse with pelvic instability and pain on palpation with no other apparent injury or obvious distress on suspicion that she may have a bleeding pelvic break and may not survive the 45 minute ride to the hospital. It was a significant decision - we were taking the area's only helicopter out of the system and causing our patient to incur a $30,000 charge, based only on our hunch. Our OMD later informed us that she did, in fact, have a massive pelvic bleed, that she rapidly decompensated in the helicopter, and had we decided to transport by ground she likely would have died. If our OMD didn't casually tell us that fact a few weeks after the call, we would have never known if we made the right call. And she was certainly under no obligation to tell us anything - it probably violated HIPAA to do so.

Another easy example - my son was diagnosed with pneumonia over Thanksgiving break. The pediatrician gave him the standard round of antibiotics. How does he know how my son faired? What if it was viral or he developed some other complication? He doesn't know...and even if we went back to the same office, there is a decent likelihood that we would be seen by another pediatrician.

I don't know exactly how a startup profits financially from closing this feedback loop (I have some thoughts, but they are based on my limited experience in healthcare), but it'd be nice to see some progress in this area.

This is definitely a big issue. I would love for my EMR to track all the outcomes of my patients and give me a summary. We are totally blind, partially because of HIPAA and partially because EMR's are really focused on billing and less actually on providing patient care.
You probably did the right thing with that pelvic fx, that shit is unstable. Especially if she was young enough to be riding horses. I really wish there were field C-arms's that could just take a quick snap to see whats going on.

also, re: PNA, it makes no sense to me either. We've built the whole system around RCT's because we never actually get any feedback. These RCT's are great on the aggregate but realy dont tell us if our individual patients get better. I work on the ER and this problem is basically the biggest issue I have. I literally have no idea what happens to people I discharge unless I actively seek it. Maybe thats why I am so happy. I always think people did well.....

Also, thank you for your work as an EMT, that is not an easy job.
Let me ask you something--what were the regulations in your state for giving medications for ACLS? fun fact: In the state I operate in, the only two medications that EMT's are allowed to give are: Aspirin, Tylenol, and Fentanyl. Like, literally you get a tylenol, or Friggin Fentanyl. Toradol? Nope. Ibuprofen? Nope. morphine? Heck no. But fentanyl, sure!

 

[throttleforward]

This is definitely a big issue. I would love for my EMR to track all the outcomes of my patients and give me a summary. We are totally blind, partially because of HIPAA and partially because EMR's are really focused on billing and less actually on providing patient care.

My hunch is that if a startup could find a way to do secure, HIPAA-compliant automated follow up, that office-based docs, dentists, optometrists, therapists, etc. would see an increase in patient retention, and therefore a reduction in cost (i.e. less $ to acquire a new patient) and increase in profitability (thus justifying the cost for the service).

I know that I've personally switched providers because I felt I got an incorrect diagnosis due to lingering pain that I though had been fixed, only to find out from my new provider that the diagnosis was actually correct, but the persistent pain and discomfort for my illness was to be expected (this was never communicated originally). The problem is I don't think most private practice docs care about those things, because they are so busy to begin with and already have a stream of patients (that's my hunch). Maybe group practices would be more interested in that?

Also, thank you for your work as an EMT, that is not an easy job.
Let me ask you something--what were the regulations in your state for giving medications for ACLS?

Appreciate that - always nice to hear that ER docs understand our pain I spent my urban EMS time in a progressive 911 system (Richmond, VA), so medics had free reign over the entire drug box without need for online medical control (and were expected to follow the full ACLS protocol). We also did cool stuff like clinical trials (autopulse, polyheme, active cooling, etc.) and trained special forces medics before the got sent to Afghanistan and Iraq. It was an awesome place to work. I also volunteered in a rural EMS system with on-line med control, with fairly wide latitude and drug-pushing abilities.

 

[CommonCents]

Are there any/many patient centric medical info apps/services that would consolidate various silos of patient info into one spot for the patient? (medical, chiro, pharma, dental, etc....) Like Mint.com does for bankings/credit card/savings accounts etc....

 

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[Princepeter1234]

Are there any/many patient centric medical info apps/services that would consolidate various silos of patient info into one spot for the patient? (medical, chiro, pharma, dental, etc....) Like Mint.com does for bankings/credit card/savings accounts etc....

Not from the EMR side. Epic and alot of other systems have crappy API access because they engage in a lot of anticompetitive behavior (built a cool app? copy and it integrate it, screw you!)
Google tried to do something where you could wallet your medical records.But it went belly up when it turns out not enough people actually give a damn about their own health.
https://en.wikipedia.org/wiki/Google_Health

 

[ElevatedAssociat]

Hello MD,

I would love to share with you a technology I developed that now carries two US parents that is very applicable to the healthcare realm and get your unbiased opinion. Would you be willing to provide this service as part of your paying it forward campaign? Please let me know! My email is elevatedassociations@gmail.com
Thank you for your consideration!
Caitlin

Hey everyone,

Long time lurker. My new year's resolution is to be less of an introvert, especially digitally. I want to be a helpful resource if possible on a few things :

1) I'm an MD at a top 5 hospital. What questions do you have about healthcare ?

2) ask me anything about healthcare startups, especially bootstrapping which I am a big fan of.

For some background , I work clinically and also have a side hustle that I have been with for about 5 years now. I also judge teams at my state accelerator and work with teams at our local innovation Lab at digital marketing (just the basics). I'd probably be most helpful in the healthcare specific space

Let me know how I can be helpful! And happy holidays to everyone !

Thanks everyone!



Sent from my SAMSUNG-SM-G891A using Tapatalk

Hey everyone,

Long time lurker. My new year's resolution is to be less of an introvert, especially digitally. I want to be a helpful resource if possible on a few things :

1) I'm an MD at a top 5 hospital. What questions do you have about healthcare ?

2) ask me anything about healthcare startups, especially bootstrapping which I am a big fan of.

For some background , I work clinically and also have a side hustle that I have been with for about 5 years now. I also judge teams at my state accelerator and work with teams at our local innovation Lab at digital marketing (just the basics). I'd probably be most helpful in the healthcare specific space

Let me know how I can be helpful! And happy holidays to everyone !

Thanks everyone!



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