Nikhil Krishnan

The healthcare 101 course IS BACK STREETS BACK ALRIGHT!!! in 2 weeks I'll teach you all the main things you need to know to understand US healthcare - how the payment flows work, all the different kinds of insurance, what's the deal with electronic healthcare records, how do PBMs make money, wait what's a PBM, oh god why are no prices transparent what's wrong with this place It'll be fun, cathartic, and you'll learn a lot. If you or any of your employees need to get up to speed quickly, you should send them more details in the next tweet

@kumar_singaram a paritcularly tricky dynamic is understanding that brokers/middlemen are not offering you every single option that might be a good fit for you. They're offering the options where they have relationships, but it requires you to know there might be better offers out there

@nikillinit Great insight. It’s confused me too. Sometimes brokers will negotiate on behalf of their client but a bulk of their business will sit with a single insurance carrier, which doesn’t incentivize them to help their clients make a well informed decision.

I'm refreshing some of the slides in my healthcare 101 ​course​, and one of the things that always surprises me is how many two-way negotiators there are in healthcare. > Pharmaceutical Benefits Managers (PBMs) negotiate on behalf of their health insurance clients, but get rebates from pharma companies that they're negotiating against. > Group Purchasing Organizations (GPOs) for medical devices/supplies negotiate prices on behalf of hospitals, but their adminfee is usually a % of the total order that's paid by...the ​vendors​? > Benefits brokers negotiate on behalf of the employers to get better health insurance rates from carriers, but...get paid commission by the carrier? This dynamic exists in other industries, but I think is particularly prevalent in healthcare because 1) Consolidation means that a handful of two-way negotiators basically negotiate for everyone. It's hard for a new "non conflicted" competitor to come in because they'll lack the negotiating power of the existing player. 2) Because no one knows the prices for anything, it's hard to create accountability for decision makers around specific cost-savings they need to achieve. So might as well just picked the tried-and-true vendor, switching is a ton of work on the decision maker. A bunch of expensive wine, dine, and redlines for internal champions probably helps. 3) The buyer very rarely directly feels the pain of this two way negotiation. Usually the cost ends up getting passed to someone else (e.g. patients or the government) or it's felt indirectly through things like worse benefit design, fewer drugs covered, etc.

@Patrick_Maksoud you end up doing anything with the project?

My senior design project was a prosthetic arm, apparently there wasn’t a cooling prosthetic available on the market so we had a miniature fan installed and got past the sweat wicking issue.

@hyruliangoat I think it’s more about the perception of hospitals vs pharma tbh

@nikillinit Service vs product, that distinction alone kind of seperates it even though there may be some overlap in principle

how come people are up in arms about pharma advertising on TV but not about hospitals advertising on TV/stadiums/sports teams? Genuine q - feels like the same underlying issue

full post is here: outofpocket.health/p/the-barriers…

Open source healthcare has a ton of promise, but also a lot of problems to be solved. I wanted to write them out so we can think of solutions together. In the post today (next tweet), I go through each of the following issues and some proposed solutions. Tell me what you think, let's bring more open source to healthcare by getting in front of the issues

@WillManidis just put the lesson in the essay bro

we live in age of great moral panics about things that don’t matter at all and zero moral outrage over some of the most egregious societal sins we’ve ever seen

@Hihihqi3 sign up for the watilist and we'll try to slot you in if someone drops outofpocket.health/hackathon-hard…

@nikillinit Still accepting docs who are interested?

Very excited to announce the first wave of sponsors for our upcoming Hardware Hackathon in SF…Samsung Healthcare , Open Wearables, and Medplum!! We're really excited to see what people build with these tools - we think there's a huge opportunity to connect the immense amount of data that wearables create and healthcare workflows. Grateful to our sponsors who see that same vision - wave 2 to be announced soon 👀

Sign up to get the post, it’s the final part in a series I’ve been working on for the last few months: outofpocket.health

Open source for healthcare sounds great, but there’s a lot of issues we need to solve for it Tomorrow we’re going to go through some of the big ones including security, governance, big companies being freeloaders, and more One thing I think needs to change is a new license for open source enables the projects to capture some of the commercial value they create - I give some examples

you can also prompt doctors incorrectly by giving them wrong information and their output will be wrong too

@anandshroff Yes, I talk about it here: outofpocket.health/p/open-source-… But it’s still generally very underutilized

@nikillinit Are there any examples of open source having success in healthcare or life sciences?

Healthcare relies heavily on measurement tools (eg. measuring diseases). But many of those tools that are currently in use today are very old, were validated in a different time, and frequently rely on the subjectivity of the person administering the test. Could open source make existing measurements better and less static? Some examples I think are interesting Brooklyn Health's* OpenWillis is an open source Python library for digital phenotyping. It has software packages that can quantify things like facial expressivity, voice characteristics, and motor functioning as objective markers of mental health. This feeds into their commercial eCOA platform for pharma companies running trials that want to add these digital measurements into their trials. Kintsugi built an AI that could detect depression and anxiety from 20 seconds of voice. They recently announced they were shutting down, and open sourced their models and methodology. Pfizer's Scikit Digital Health is an open source Python package for processing wearable sensor data. If you strap an accelerometer on a patient in a clinical trial, the raw data you get back is basically meaningless noise until you process it. Scikit Digital Health has algorithms that turn that raw data into actual clinical metrics. Things like gait speed, physical activity levels, sleep patterns, sit-to-stand transitions, etc. which might be digital endpoints you’d want to capture during a trial. The obvious question is what validation looks like for a new measure and who maintains that validation over time. A traditional scale gets validated once and sits in a PDF forever. An open source digital measurement tool needs ongoing maintenance. If nobody's maintaining the repo or things keep getting added, how do we know it’s still a good measure? Will people continue to use it if they aren’t sure it’s still good?

Niche but…

Come through: outofpocket.health/courses/health…

Final week to sign up - also the one time were doing a Claude workshop for healthcare use cases I’ll get you up to speed quickly

@anandcpatelmdms @jselanikio @JosephSakran @RahulGorijavolu @washingtonpost @doctronic If the docs moved to being independent they’d get the financial upside of higher patient volume which would have to offset the malpractice risk

@jselanikio @JosephSakran @RahulGorijavolu @washingtonpost @doctronic Who do we sue for malpractice if the AI screws up? The big AI shops won't. So it'll be some physician using the tool that takes the fall as usual while the insurers requiring them to use it and the PE firm that owns the hospital practice group insist on 5 minute visits. 🤦🏽‍♂️

Last week, Hopkins trauma surgeon @JosephSakran and medical student @RahulGorijavolu wrote in the @WashingtonPost (buff.ly/6GuU9na) that the @Doctronic AI prescribing pilot rests on thin evidence. No argument. But ... the human physician renewal process has no peer-reviewed trial either. No national error rate. No demographic bias testing. And one study found pharmacists reviewing refills caught twice the problems that doctors did. So are we applying a standard to AI that we've never applied to the human baseline? How does that make sense? #HealthcareAI #DrYou #HealthcareDisruption buff.ly/xZ037lo

kinda funny how many companies entire pitch is “your internal people are bad, our people are much better” but they cant outwardly say that say they mask it