• How To Have Yourself A Guilt-Free, Green Christmas

    The festive season is always the perfect excuse for excess. Between all the mince pies, Christmas drinks, gifts and tinsel, it’s not only the most wonderful time of the year but the most wasteful, too. UK households generate 30% more waste over the Christmas period, and last year Brits binned the equivalent of 108 million rolls of wrapping paper and 54 million plates of food. According to a survey by sustainable packaging initiative Beyond the Box, 60% admit they don’t know what can and can’t be recycled at Christmas time.

    As this is a busy and stressful period for many, hopping from one party to the next and running around for last minute gifts, it’s understandable that you might not have time to research the most sustainable options available. Fifty-three percent of Brits admit that it’s sometimes easier to throw things in the bin rather than work out whether they can be recycled. Luckily, we’ve done the work for you. If you’re dreaming of a white green Christmas, read on for our top five eco-friendly festive tips.

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    It’s the annual Christmas debate: should you buy a real tree or a fake one? While it’s true that using the same artificial tree every year doesn’t produce more waste, many are made of PVC, which isn’t widely recycled and will likely end up in landfill. Most fake trees are also produced in countries like China and Taiwan, where environmental regulations aren’t as strict, and shipping across the world contributes to a huge carbon footprint. If real trees aren’t your cup of tea, opt for less traditional ones made of sustainable materials like wood.Choosing a real tree will limit plastic waste and since they’re grown in special tree farms, cutting them down doesn’t contribute to deforestation. Many local councils will collect your tree after Christmas and drop it off at a recycling centre where it can be chipped for pathways or turned into soil or compost – check to see if yours offers this service.If you want to go the extra mile, you can rent a potted tree through schemes like Forever Green Christmas Trees and Love A Christmas Tree – simply arrange delivery and return the tree without any decorations when Christmas is over. If you’re lucky enough to have a garden, you could buy a potted tree and avoid having to go through this whole palaver each year.
    Research by price comparison site finder.com estimates that Brits waste £5 billion on unwanted Christmas gifts over the holiday season. Generosity is a wonderful trait but this year, try being a little more mindful with your gift-giving and ask yourself if you really need to buy a present for your second cousin’s new girlfriend.Another way to cut back on unnecessary gifts is to do Secret Santa, not just in the office but among friends and family as well. Adopting a quality-not-quantity approach to presents could significantly reduce waste (and your overdraft). When shopping, opt for conscious consumerism. Stick to cruelty-free beauty and sustainable fashion brands, go for upcycled vintage like Mary Benson x Gemma Cairney berets, or buy products that help cut back on waste, like THINX period pants.
    A lot of festive wrapping paper isn’t recyclable due to the use of plastic, dyes and glitter. If you’re unsure how to dispose of your wrapping, try the ‘scrunch test’: Simply scrunch a piece of the paper in your hand – if it remains scrunched, it is paper-based and can be recycled; if it springs back, it likely contains metallised plastic film and is non-recyclable. Wrapping made from recycled materials is easy to find (your local post office will probably stock recycled brown paper and it’s cheap as chips), and instead of using sticky tape go for twine or paper tape, both of which can be recycled.Better still, try going without wrapping paper altogether or, if you’re giving someone multiple gifts, wrap them in a bundle rather than individually. Another option is to tie presents up in natural materials like cotton, hemp or silk, in keeping with the Japanese tradition of furoshiki – wrapping an item in a reusable piece of fabric. High street fave Lush sells knot wraps for this exact purpose, and they’re so beautiful they have the added benefit of being an extra gift.If you’re trying to save money – and let’s be honest, who isn’t – then get thrifty and upcycle brown paper bags from your last takeaway by tying some ribbon around them and turning them into minimal gift bags. Just make sure there are no grease stains…
    Christmas is a gloriously indulgent time, but while food is one of the best parts of the holiday season, it’s also the cause of a huge amount of waste. According to Unilever, the UK threw out the equivalent of 4.2 million Christmas dinners last year, which amounts to £64 million worth of food.The easiest way to cut back on food waste is to avoid buying more than you need by planning your meals (especially if you’re hosting a dinner or party), and try to buy loose food that doesn’t come in plastic packaging. Shopping at your neighbourhood grocer or market is also a great way to support your local economy and reduce your carbon footprint, so keep an eye out for farmers’ markets near you. If you’re willing to part with tradition and ditch the turkey and pigs in blankets, try opting for more veggie and vegan dishes. Should that be too much of a sacrifice, stick to local, free-range and organic meat wherever possible.
    Fairy lights and baubles scream Christmas, but all those pretty decorations aren’t great for the planet. LED lights with timers are a great way to save energy, as is remembering to turn off fairy lights during the day and while you’re out of the house. Figures show that 189 million batteries are used over the festive period, so use rechargeable batteries where you can, and remember to recycle disposable ones.As for decorations? Instead of festooning your flat with plastic knick-knacks and tinsel, go for decorations made from glass, wood, burlap or organic cotton (if you’re creatively inclined, why not try some DIY?). Nature is the best source for decor inspo, and things like pine cones, holly and cinnamon sticks make for a very atmospheric and fragrant room.Speaking of fragrance, most candles contain paraffin wax made from petroleum, which are no good for the environment – or your health, for that matter. Candles made from soy or beeswax are smoke-free and biodegradable.

    Source: Refinery 29 UK

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  • Victoria’s Secret Model Accused of Fat-Shaming Customers Eating at In-N-Out

    Victoria’s Secret model Kelly Gale really wants us to know she doesn’t eat In-N-Out. 
    Gale has come under fire after posting a series of Instagram stories at the fast food joint, where she munched on a pear (instead of burgers and fries) and even completed her rigorous workout routine. 

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    The Instagram story obtained by E! shows the model inside the restaurant with a friend saying, “We’re at…In-N-Out? So I guess I’m having my pear.” In the next video, Gale asks her friend, “You don’t eat In-N-Out? Me neither.”

    Embedded video

    Victoria’s Secret model Kelly Gale received backlash for exercising outside of an In-N-Out. https://eonli.ne/2RSm5jW 

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    The story continues with Gale showing off her workout equipment right outside the fast food joint with the caption, “Who else works out at an In-N-Out?”

    Driving the point home again, the model posted another photo with the caption, “Not gonna pretend that I eat here guys cause I don’t.”

    At the end of the story, Gale receives a huge delivery of vegetables to reward herself after working out.

    The post sparked backlash across social media with many accusing the model of fat-shaming and mocking In-N-Out customers.

    Who the hell does @KellyGale_ think she is? How dare you #fatshame others? #kellygale @innoutburger is the best and you can eat whatever you want Ms. Gale but please don’t be so pathetic and unkind to others. #Entitlement is not cute #InNOut

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    Yo #KellyGale, THIS is how you shoot fitspo at #innout @KellyGale_, treat yourself to a double double. It’ll help you think straight.

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    So @KellyGale_ is fat shaming customers at a fast food restaurant for no good reason but to make herself feel better or to get her name out there.
    Who is #KellyGale anyway??

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    Cali sunset

    I’ve loved VS models and thought highly of them since I was ten. Man you’re the worst tho. I’m vegan and don’t eat in-and-out and you’re obnoxious there was not need to work out there. Can’t you afford a gym. You should be ashamed.

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    The only thing I got from @KellyGale_ video is that she likes to go to places and eat there without actually ordering their food and thinks body shaming others is cute. What a shame to use your influence this way. #bodyshaming #allbodiesarebeautiful

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    The fact that @KellyGale_ felt it was necessary to go out of her way to shame people eating a burger and fries is pitiful. You don’t eat burgers?? DON’T GO TO THE BEST BURGER JOINT EVER THEN! Your loss #InNOut

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    Others thought Gale was just telling the truth about fast food and promoting healthy eating.

    For everyone freaking out over Kelly Gale, let me point out that only insecure people freak out over things like being told the truth. If she offends you by saying that eating fast food isn’t healthy, you are the problem, not her.

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    People getting salty at Kelly Gale for working out outside of an In-N-Out is comical. She’s drawing attention to healthy living, sorry that you’re realizing that stuffing your face with fast (fake) food doesn’t align with that

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    She’s promoting a healthy lifestyle. There’s no reason for anyone to get upset over this. People need to chill out. #KellyGale #InNOut

    Victoria’s Secret model Kelly Gale received backlash for exercising outside of an In-N-Out. https://eonli.ne/2RSm5jW 

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  • Here’s Why People Kiss Under the Mistletoe at Christmastime

    From Harry Potter’s first kiss to Justin Bieber’s holiday tune, kissing under the mistletoe is everywhere in pop culture. But this Christmas tradition — that if you’re standing under the leafy plant, it’s time for a smooch — existed long before it ever appeared in movies and pop songs.

    While historians are uncertain about why kissing under the mistletoe started, there is a general consensus regarding when and where the custom began, and how it became popular during Christmastime.

    The origins of kissing under the mistletoe, a plant that often bears white berries, are often traced to a tale in Norse mythology about the god Baldur. In the story, Baldur’s mother Frigg casts a powerful magic to make sure that no plant grown on earth could be used as a weapon against her son. The one plant the spell does not reach is the mistletoe, as it does not grow out of the earth, but out of a tree’s branches. The scheming Loki, upon learning this, makes a spear out of mistletoe — the spear that would eventually kill Baldur.

    But the connection between that story and the tradition is unclear, and may not even exist at all.

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    In many tellings, Frigg declares the mistletoe to be a symbol of love after her son’s death and promises to kiss anyone who passed underneath it. If that’s an accurate version of the story, it would be clear how it directly connects to the romantic act of today. Historian Mark Forsyth says this is not actually the way the story ends, however. Forsyth is the author of A Christmas Cornucopia: The Hidden Stories Behind Our Yuletide Traditions, and examined four Norse accounts of the god’s murder and the events that followed. “Baldur’s death involves mistletoe, but it’s got nothing to do with kissing or Christmas,” he tells TIME.

    Although Forsyth does not know why kissing under the mistletoe started, the author says he does know that the tradition began between 1720 and 1784, in England.

    Kissing under the mistletoe wouldn’t have existed as a popular tradition before 1720 because the most extensive research about the plant was published that year, and it did not reference the practice, Forsyth explains. John Colbatch, an English apothecary and physician, wrote two books on the mistletoe in 1719 and 1720. “He had a whole section on superstitions and customs associated with mistletoe,” Forsyth says, “and doesn’t mention anything at all about kissing under mistletoe.”

    Instead, the earliest reference of kissing under the mistletoe that Forsyth found comes from a song published in a 1784. The verses read,

    “What all the men, Jem, John, and Joe,

    Cry, ‘What good-luck has sent ye?’

    And kiss beneath the mistletoe,

    The girl not turn’d of twenty.”

    Other historians have also cited these lines as the first reference of the tradition. But what happened between 1720 and 1784 that made kissing under the mistletoe a holiday phenomenon remains unknown. “I can take a pretty shrewd guess that it involved a particularly lusty and inventive boy, and a particularly gullible girl,” Forsyth writes in his book.

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    Literature and art from the 18th and 19th centuries expanded upon this idea. Charles Dickens in The Pickwick Papers, published in 1837, portrays the holiday frenzy associated with this particular type of kiss. He writes that younger ladies “screamed and struggled, and ran into corners, and threatened and remonstrated, and did everything but leave the room, until some of the less adventurous gentlemen were on the point of desisting, when they all at once found it useless to resist any longer, and submitted to be kissed with a good grace.” In an art print from 1794, servants in a kitchen are poised for a smooch under the mistletoe, with a caption describing “Saucy Joe” who “rudely” kissed “Bridget the Cook.”

    The women in both scenes were depicted as resisting the kisses but having to give in after being caught passing under the mistletoe. Historians have said that they would have believed they had to accept kisses from men or risk bad fortune. Exactly how serious the resistance was is hard to say based on documentary evidence, but Forsyth says there were several stories from the period that depicted women “using the mistletoe excuse to elude possessive husbands and parents” who might have otherwise prevented such kisses.

    “A brief inspection of the ceiling would be all that it took to avoid that, whereas being forced into a loveless marriage in a world without divorce or any semblance of women’s rights would have been rather harder to escape,” he tells TIME. Noting that it is extremely difficult to decode a phenomenon two centuries later, he adds, “I can say with some certainty, though, that accidentally finding yourself under the mistletoe would have been very, very far down the list of worries and disadvantages of a woman alive in the year 1800.”

    Stateside, the popularity of kissing under the mistletoe as a Christmas tradition can be more easily traced, back to Washington Irving’s The Sketch Book, which was published in 1820.

    The American writer had returned from England, and recorded the yuletide traditions he had observed abroad. In the chapter named “Christmas Eve,” a footnote reads, “The mistletoe is still hung up in farm-houses and kitchens at Christmas, and the young men have the privilege of kissing the girls under it, plucking each time a berry from the bush. When the berries are all plucked the privilege ceases.”

    Forsyth says that Irving’s text, a bestseller, played a huge role in accelerating the tradition’s popularity. “Christmas was only a very, very minor festival in the early 19th century,” he explains. “Irving made the template for the modern Christmas in a lot of senses.” Because kissing under the mistletoe was mentioned in The Sketch Book, a large American audience was introduced to the practice, and eventually adopted this act — and ushered it over the centuries as it went from a semi-scandalous oddity to a well-known mutual romantic gesture of holiday cheer.

    This article first appeared on TIME

  • In their own words: how solo travel transformed the mental health of these teenagers

    While some see travel as a means of escape, others see it as a way to heal wounds. Working on projects and meeting people overseas certainly proved to be cathartic for these teenagers.

    ‘It was liberating not to be defined by what had happened’

    After Bridie O’Hare, 19, from Cleethorpes, was caught up in the Manchester Arena bombing on May 22 2017, a job with Camp America in June was the beginning of the healing process.

    The Ariana Grande concert had just finished and I was still in my seat, getting my phone out to call my mum and find out where in the car park she was, when the bomb went off. Just before the sound, it was almost like the air went still and everyone froze; then it felt like a sonic boom echoing through the building. I knew instantly what it was, judging by everyone else’s reactions, and my immediate thought was: ‘It’s going to happen again, I need to get out now.’ Luckily, I wasn’t far from an exit, but it was mass panic; people were pushing and shoving, kids and adults were screaming – everyone was in fight or flight mode. 

    I don’t remember much else before getting to the car park; I know some people saw flames, and of course some saw horrific sights they’ll never forget. Although I made it out safely, it was with the overwhelming sense that if I’d been sitting somewhere else, I might never have made it. I didn’t see myself as lucky – more like guilty that I’d survived, when many others didn’t.

    Afterwards, I went from being a normal, happy, outgoing person to being very withdrawn, and wary. I was scared of going out – what if it happened again? Eventually I started seeing a counsellor, and tried to get back to normal. I even took up my place at Leeds University that September, but I just couldn’t deal with it. I found it hard being in an unfamiliar setting, surrounded by people I didn’t know, so I moved back home in January [2018]. There I felt safer, but [the attack] was still in the news; I felt I couldn’t get away from it. I was having nightmares and always thinking about what had happened. 

    Pescadero - Credit: Getty
    Natural landscapes abound in Pescadero Credit: Getty

    I’d always wanted to do Camp America, spending a summer working at a camp with young people. My mum agreed that a change of scene would be a good idea. I hoped that by getting some distance, I would be able to be myself again. 

    In June I headed to the Skylark Ranch, a girl scout camp in Pescadero, California, just north of Santa Cruz. I had no idea what would be expected of me, but my role was to help run activity programmes for the girls, who ranged from around seven to 17.

    My responsibilities varied from overseeing horse-riding to a really fun survival course based on the US TV show Gilligan’s Island. We had to show the kids how to make beds out of sticks and twine, and cook meals on a campfire. I’d never pictured myself doing anything like that, but it was great fun. At the end of that activity, we did a ‘mud hike’, where we all slid down a mudslide into a giant pit of, well, mud! It’s the sort of thing I would never normally do, but it helped me feel like a kid again and forget all my worries. Having some responsibility, and helping make a change in young people’s lives that hopefully they’ll remember forever, was a great feeling. 

    Bridie O'Hare - Credit: Alex Parkin
    Bridie at Camp America Credit: Alex Parkin

    I made really good friends at camp, and after it was over a few of us went on a road trip to New York. I rarely thought about what had happened, and it was liberating not to be defined by it. It did randomly come up in conversation once, but by then I really trusted the people around me so I felt comfortable talking about it. I was sad to come home, but now I really feel I can move on with life and hopefully go back to uni next year.”

    Further information: campamerica.co.uk

    ‘Out there, I could be myself’

    Alex Smith*, 19, from Coventry, found that a trip to Nepal when she was 16 helped put her problems at school into perspective.

    At the top of the steep steps leading to a viewpoint that overlooks a vast valley in the Annapurna Foothills of Nepal, I burst into tears. As part of my volunteering trip with Global Vision International, we were lucky enough to travel around the country – and this trek took us down the valley, then up these steps, the stairs to Ghandruk. As I looked across at the seemingly endless landscape we’d traversed, I felt an incredible sense of achievement, coupled with a feeling of being utterly tiny and insignificant. It gave me a real sense of perspective; suddenly all the problems I’d experienced back home faded into insignificance. 

    The girls at my school who made me feel bad about myself just didn’t matter – out here, I could be who I was, and everyone I’d met so far had responded to me on that level. It was a highly emotional experience, and it has stayed with me ever since. 

    Annapurna Foothills of Nepal - Credit: Getty
    The Annapurna foothills, Ghandruk Credit: Getty

    Things started to get difficult for me at the all-girls school I attended around Year 9. I wouldn’t call it outright bullying, but something harder to put your finger on. I’d describe myself as an individual, not like everyone else, but that can make you a target. Once, I came in wearing a pair of shoes I’d saved up for, but because some of the girls thought they looked unfashionable, they shared pictures of them on Instagram, saying how horrible they were. I was also teased for the fact that I can speak Mandarin – I’ve been learning it for years – and I became more and more shunned and isolated. No one wanted to sit with me at lunchtime, or pick me for gym teams; there was nothing outright nasty, but it was enough to make me miserable and vulnerable. I became withdrawn, and gave up on making friends, throwing myself into my studies. My parents didn’t notice how unhappy I was; they saw my good grades and thought I must be OK.

    By the time I was 15, things were bad enough for my parents to start thinking about me changing schools. I just wanted to get away from everything and began researching how I could. I found GVI, the only organisation that offered a volunteer programme for people my age, and applied. I chose Nepal because it sounded fascinating. I’d only ever been on family holidays to Spain, and, once, to Sri Lanka, but I’d never done anything truly adventurous. So the next summer I flew off to Kathmandu, more excited than nervous. 

    Kathmandu - Credit: Getty
    “So the next summer I flew off to Kathmandu, more excited than nervous” Credit: Getty

    It felt instantly overwhelming: the noise, the chaos, the dirt roads… but also absorbing. The volunteer work involved cleaning and renovating the dormitories of a school in a tiny village in the middle of rice fields. Seeing where these children lived, it felt so different to my own life – but it was amazing. It showed that I could make a difference to others; as a teenager, you don’t feel like you have much power or agency to make things happen, but this proved that, actually, you do. 

    I felt blissfully disconnected from everything during the two weeks I was there; there was very little Wi-Fi, so it felt like a release from the pressure of social media, which I do think can also be damaging to mental health. A lot of the girls at my first school had the attitude ‘If it’s not on Instagram, did it even happen?’ rather than just enjoying a moment for what it was. 

    I loved connecting with people who were different from me. We visited a shelter for women who had been sold into sex slavery and escaped, but had then been rejected by their families. I’d shaved my head for charity and all these women had shaved heads, too – their hair had been removed when they’d been sold. It was a powerful moment of connection, but for very different reasons. 

    When I got back, I started at a new school, which felt like a clean slate. I made new friends there, and had much more confidence to be myself. It felt as if I had matured so much in a very short space of time. 

    These days, I don’t get stressed about small things and I also feel incredibly lucky to have so much when so many people have so little. Next year I plan to go to college, but I would definitely do this again – and I recommend it to anyone.” 


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    * Name has been changed

    ‘Looking out at the view made me feel like I didn’t have a care in the world’

    Jonathan Berry, 19, from Liverpool, struggled with depression in the aftermath of his parents’ divorce, but working with elephants in Chiang Mai helped him feel happier.

    Just after I got back from volunteering in Thailand this summer, I met up with my friend Joanne and she said she’d never seen me look so happy. It’s certainly true that when I was out there I hadn’t felt that good about myself in a very long time. 

    Chiang Mai - Credit: Getty
    Jonathan spent time in Chiang Mai Credit: Getty

    When I was 14, my parents went through a bad divorce. My brother, sister and I were caught in the middle, and as a result I don’t have a relationship with my mum any more. I thought I was dealing with it all OK, but over the next few years I became more and more depressed. I had no idea what I wanted to do after my A-levels and felt really unfulfilled and directionless. I rotated between different jobs and apprenticeships, so I wasn’t left on my own to sit and think. I tried to explain how I felt to Joanne, but didn’t feel I could open up to others. 

    While I was at school, we’d gone on a group trip to Peru when I was 15, helping out on a project there. I’d really enjoyed it, and liked knowing that I was contributing to a good cause. Earlier this year, the school where I’m doing teacher-training offered to extend my contract full-time, so I took the opportunity to find another volunteering project before I started again this September. I chose one via GVI, in Chiang Mai, which offered the chance to work with elephants, an animal I love, on a conservation programme. 

    I’d never been away on my own before, so it was scary, but I soon felt like part of the group. I was there for four weeks, but you can stay just one week, so new people were coming and going all the time. My job was to help collect data on eight elephants near Huay Pakoot, where we were based. 

    Jonathan Berry
    Jonathan in the rainforest near Huay Pakoot

    Every day we’d hike out into the rainforest to find them, which could take hours, but there was a lot of camaraderie and bonding between the volunteers and the Thai staff. What really struck me, too, was that I never saw anyone local who didn’t have a smile on their face. The villagers would be working hard every day, farming, and yet they still found life good. It made me realise we don’t have a leg to stand on back home, as far as complaining goes – yet so many of us are miserable. These people were satisfied with very little. 

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    I got into a routine every morning of going to a little café run by one of the villagers. I’d get there just as the sun rose and have my coffee lying in a hammock on his deck, overlooking a valley. It was my bit of me-time every day, and I’d look at the view and feel like I didn’t have a care in the world. 

    Making friends helped. Several volunteers based in the UK have come to Liverpool to visit, and I’m off to Northern Ireland soon to meet up with another guy. The experience helped clear my head and made me realise I don’t have it that bad – so I’m going back to Thailand after Christmas. 

    I think mental health issues should be discussed more openly at school, so young people know where they can go for help. I’m currently liaising with government authorities to try to get people to come and talk to the kids at my school. I now feel 100 per cent happier, and a lot more stable. Going away has had a profound effect on who I am, and how I feel.”

    Further information: gvi.co.uk

    Article originally appeared on The Telegraph

  • Brainstorm Health: Health Care Predictions, Diabetes Tests, Gilead CEO

    Good afternoon, readers. We have a special treat for you today—Bob Kocher and Bryan Roberts, longtime health care venture gurus at Venrock, are back to offer even more of their unique wisdom on what we might expect in the health care world come 2019. I hope you take the time to read Bob’s and Bryan’s insightful analysis. I’ll be back with you tomorrow.

    Health Care Predictions for 2019

    It is soothsaying time again. Our annual plunge into the choppy waters of predicting the future, amid increasing economic and political uncertainty. Ever gluttons for punishment, we are ready to make 10 new predictions for 2019. But first, we should look back on how we did predicting what happened in 2018

    In 2018, five of our 10 predictions came true and two more seem on-track to become true in 2019. We correctly predicted another Theranos with the implosion of Outcome Health. We were correct that Amazon would not disrupt PBMs, rather they launched their Atul Gawande led collaboration with JPMorgan and Berkshire Hathaway.

    Our successful exits prediction was validated by Flatiron, Landmark, and Pillpak. Also, Medicare Advantage gained in popularity with Centers for Medicare and Medicaid Services (CMS) issuing favorable rules and nearly 50% of new Medicare beneficiaries choosing a Medicare Advantage plan. Finally, we were correct that payers would aggressively acquire higher margin, less regulated businesses with Aetna merging with CVSCigna merging with ESI, and perhaps, soon, Humana merging with Walgreens.

    We missed on our predictions that hospitals would slow hiring. In 2018, hospitals added about 250,000 jobs and were able to keep raising prices to offset rising labor costs. We were overly optimistic that AI would make a big impact. While AI has lots of potential and may eventually warrant “Intel Inside” status, we are yet to see meaningful commercial traction, outside of it being included in every innovative product description. We were also wrong about big pharma getting bigger (but next year…). We remain hopeful that our predictions about CRISPR commoditizing, as demonstrated by China’s gene editing of a baby in November, and the Affordable Care Act (ACA) being repaired, since we will soon have a Democratically controlled Congress that will no longer contemplate repeal, will both come true in 2019.

    Now, onward with our 10 predictions for 2019.

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    1. More payer consolidation

    There is stiff competition from not only stalwart United Healthcare, who boasts much lower administrative costs and higher margins, but also the rejuvenated higher margin PBM-enabled versions of Aetna and Cigna. As a result, many smaller payers will struggle to retain national accounts as well as compete against pure plays in the Medicare Advantage and Medicaid markets making them use their strong balance sheets to become acquirers. We also think the growth of Medicaid, with several states electing to expand, and Medicare Advantage will also trigger M&A in order to enter these growing and more profitable market segments.

    2. Physician-led Accountable Care Organizations will grow rapidly

    Medicare’s Accountable Care Organization (ACO) 2.0 regulations strongly favor doctor-led ACOs over hospital-led ACOs. Doctors will quickly realize that they can earn much higher wages independent from hospitals. Moreover, access to capital, managed care contracts, and low-cost analytical tools will make it easier to doctors to gain the benefits of scale while retaining independence. We anticipate the fracturing of some large health system’s employed groups, when the primary care doctors realize that they can do better if they break free. We also expect the performance gap between doctor-led ACOs versus hospital-led ACOs to become even more dramatic.

    3. Doctors get less dissatisfied

    We believe health systems have heard the cries from doctors about terrible user experience and administrative burden of electronic health records. Since health systems cannot afford to replace doctors who make credible threats of retiring or resigning, they will make investments to improve morale. We are bullish that electronic health records will move doctor user experience up the product roadmap priority list and that innovations like voice interfaces and machine learning will help a great deal. Teams at Google and many start-ups are making large strides in building voice technology to reduce typing, electronic medical record clicking, and searching burdens for doctors. Interestingly, it may be easier to use voice for healthcare than for consumer applications since the vocabulary is smaller and context is far more predictable. Amazon’s newly released tools to mine clinical data will help make these systems work better too.

    4. Interoperability becomes interoperable

    Five years after being declared successful, forces will finally come together to lead breakthroughs on cross health system and platform interoperability. Electronic health record firms are coalescing around standards for exchanging data (HL7 FHIR) and CMS is expressing willingness to use regulatory power to drive adoption with the “patients over paperwork” initiative. States are pushing for connectivity as one tactic to address the opioid epidemic and to improve resiliency from (seemingly more frequent) natural disasters, necessitating the need to access data. At the local level, the prisoner’s dilemma of health systems leveraging market power to impose three-week turnarounds and PDFs no longer makes sense when physicians on both sides of the transaction are increasingly trying to manage risk.

    5. Consolidation in digital health

    Growth equity will get tighter in 2019 for small companies that have not achieved product market fit. This will lead to a flurry of consolidation into platforms. Many new companies have been started over the last five years, and it is time to sort the true successes from the “just OKs”. Compounding this trend is large employers going from being the early adopters, to more willing to rely on their health plan partners who have responded to the proliferation of point solutions by incorporating many of them into their standard benefit designs. This will be a rough transition for many early stage companies since payers have even longer sales cycles and higher standards for proving effectiveness than large employers.

    6. InsureTech takes a lump or two

    We think that we are near peak hype cycle for insurance technology. 2019 is likely to be a year of toe stubbing for many. Upcoding is one area of risk since it has proven to be the fastest way to make money in Medicare Advantage. Coding has led to a cat-and-mouse game of payers mining charts for uncoded diseases and CMS auditing them and nearly always finding errors and levying fines. Upcoding is so pervasive that CMS actually cuts Medicare Advantage reimbursement annually using a “coding intensity adjustment.” Start-up payers that have enjoyed great fundraising success are likely to find the very complex operations and scaling required for their actual businesses much harder than investor PowerPoint pitch creation.

    7. Dialysis disrupted

    It is Norman Rockwell-esque that patients drive to brick-and-mortar dialysis centers three days a week and lay in a chair for three hours at a time. Just as Sears has been replaced by home delivery, dialysis centers will be supplanted too. It is far better for patients to have their blood cleansed daily and it is cheaper to have patients do it themselves daily at home. Sweden has embraced patient self-serve dialysis for years and it has proven to be both safer and more reliable than dialysis centers. As we move to risk-based payments, better and cheaper approaches to care will be embraced by doctors managing risk.

    8. Telemedicine takes off

    We think that 2019 will be the year that payers finally realize that it is far better to fully embrace and encourage telemedicine usage as opposed to burying it in their unengaging member portals and clunky mobile apps. Oscar compellingly reports that more than half of their members use telemedicine and rely on Oscar to route them to care, increasingly telemedicine. Kaiser will do more than half of all visits virtually. Health plans now have enough years of claims data to discover that telemedicine saves a bunch of money and makes members far happier than going to a doctor’s office. Even Medicare is adding codes to reimburse telemedicine. As a result, we expect telemedicine usage to more than double in 2019, while making substantive inroads beyond flu & cold into areas such as chronic disease management.

    9. PBM disruption talk becomes reality

    While Trump’s proclamations about lower drug prices have backfired, with drug companies raising prices even more aggressively, a byproduct of Executive branch rhetoric has been scrutiny over drugs getting marked up a bunch, after they leave the drug maker. Drugs are marked-up, on average, 40% by the distribution system. The current opacity about how money flows, leads to patients paying more for drugs and excessively large margins being captured by intermediaries. We expect next generation pharmacy supply ecosystem efforts to gain real traction in 2019.

    10. Real progress with new DNA sequencing platforms

    DNA sequencing is a very large, and growing, opportunity. New applications, such as single cell genomics, have driven growth over the last 24 months. We believe that new sequencing platforms (or at least the specter of them) will enter the fray in 2019, leading to decreasing per Gb pricing (while still providing healthy margins) which will both open up additional applications and volume as well as erode Illumina’s market dominance.

    We look forward to seeing what happens and reporting back to you next year.

    Bob Kocher and Bryan Roberts are both health care investors and partners at the venture capital firm Venrock.

    DIGITAL HEALTH

    There’s too much at-home diabetes testing. A new study analyzing data from some 370,000 people finds that many Americans with well controlled diabetes symptoms don’t regularly have to monitor their blood sugar at home. To be clear, this applies to patients who, say, don’t have to take medication—but among this group, nearly half who do so (and often have to submit insurance claims in order to do the finger pricks) don’t have to, according to the study authors. (Reuters)

    INDICATIONS

    Gilead is getting a new CEO. Gilead Sciences has picked up Roche executive Daniel O’Day to be its next CEO, ending a search that’s been ongoing since the summer. O’Day will take over for John Milligan and control a biotech giant that’s sitting on massive piles of cash; while at Roche, O’Day oversaw several successful drug launches and the pharmaceutical arm’s purchase of Flatiron Health, a digital health and cancer-focused data upstart. (Wall Street Journal)

    THE BIG PICTURE

    Kaiser Permanente mental health workers begin strike. About 4,000 mental health clinicians and workers at the renowned Kaiser Permanente medical centers have launched a five day strike, protesting as part of a dispute with the non-profit giant over staffing boosts and long therapy appointments, Modern Healthcare reports(Modern Healthcare)

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    Produced by Sy Mukherjee

     

    Article originally appeared on Fortune