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On November 30, 2017, TOM4 commented on Starbucks: How to Save Our Coffee from Climate Change :

Thank you for your analysis of this important effect on my chemical romance.

I tried to import Arabica coffee beans from Central America when coffee planters were struggling with whether to plant their tropical evergreens in local forests among other local flora and fauna or continue to clear local forests to plant coffee bean trees. Interesting that Starbucks has the ability to address climate change on multiple fronts, including direct support of farmers from whom they source. While wheat leaf rust may be due to the effects of global warming and climate change in part, these effects have been compounded by land use strategies that have been in place for many centuries. Perhaps Starbucks can use this opportunity to not only restore damages done to farmers but to promote better farming practices for others and sourcing practices themselves. Experimentation with their own 240 hectare farm will be essential for proof of concept. While sourcing from new areas coffee-producing areas less affected by climate change may help Starbucks’ business, its commitment to best practices of sustainability and climate change mitigation will do more to prevent further damage by acting as an industry leader.

Excellent analysis of a city’s struggle with the effects of climate change.

From a cynic’s perspective, it’s clear that Dallas (and all southern US inland cities for that matter) has a lot to lose from the effects of climate change, but that it faces a tragedy of the commons problem when other cities, states and nations across the world don’t follow its lead. Cities and municipalities, particularly those without the resources to combat the effects of climate change (such as the hurricanes to which you refer), are perfect exemplars of what mitigation of climate change can entail. Perhaps it will be easier to achieve political consensus around issues of climate change when the changes seen are so close to home, and when local politicians can point to direct economic stimulus in the form of strategic partnerships with energy companies like Austin Energy. Thank you for sharing this movement in the right direction.

On November 28, 2017, TOM4 commented on Monsanto Predicting Weather: Crazy or Crazily Smart? :

Wonderful commentary and questions.

In particular, the ethical considerations surrounding Monsanto’s use of big data parallels concerns in other industries, such as healthcare. At times, big data is hailed as the omnipotent solution to varied problems that the end-consumer (or patient) faces, but too often we see that this data drives further information asymmetry.

For farmers, the value of ClimateCorp and SmartForecast come at a price that may be less than leaving farming altogether and shunting more food production to larger and larger agricultural firms whose growth is driven by land merging through acquisition. This only heightens the issue that monoculture crop production poses to US and international food scarcity. At this point, there may be no alternative other than relying on genetically-modified Monsanto crops to feed us out of human-driven climate change. While Climate Corp may help inventory optimization and supply chain management, it’s unclear whether it will truly benefit farmers’ crop yields.

On November 28, 2017, TOM4 commented on Monsanto’s Battle for the Future of Farming :

Laura, thank you for covering this broad topic, and for being discerning in your follow up questions!

I personally experienced Monsanto’s reputation damage, working alongside volunteer fellows in Latin America who had been dedicated to promoting permaculture, as opposed to the monoculture-based farming that Monsanto’s innovations primarily support. The reason for this support stemmed from a general distrust of corporate seed suppliers, but also spoke to the great risk a farmer faces when sowing a field full of one crop that is invariably exposed to stressors, be they climated-induced, pest-induced, or a combination. DroughtGuard, as you have presented it, reminds me of so many “me too” drugs in the pharmaceutical industry – drugs that offer little incremental benefit to diseases with significant patient volume and still command top dollar for their cumulative effect. Is addressing climate change on a corporate level best achieved by investing more in this sort of incremental benefit, by acquiring promising new technologies like Blue River, or by offering products directly to farmers based on idiosyncratic need for data that may help their harvest but not benefit their eco-efficiency?

Your analysis was excellent, because it raises even more questions than answers.

On November 28, 2017, TOM4 commented on Mercy: Delivering better quality healthcare at a lower cost :

Wonderful piece; thank you for discussing both supply chain digitization within hospitals and supply/demand mismatch with patient/providers as it relates to telehealth.

With regard to the first, the UAP program’s promise is clearly cost-reducing. However the peer effect it exerts on individual physicians who will increasingly be judged transparently against their peers (see example of Surgeon Scorecard by ProPublica – is an excellent impetus for providers to start thinking about their own performance. While individual physician’s cost reduction efforts may lag behind the times, leveraging this peer effect is the fastest way to achieve cost savings among driven, type A providers who have been educated in a system of peer comparisons.

Another system that is launching similar telehealth efforts is my own medical school’s health system – Jefferson Health System – see They used a well known telehealth platform to pilot with the lowest hanging fruit first, their own provider and workforce. By offering their own employees and constituents the ability to trial telehealth before exhausting excessive social and human capital selling the story for a patient-facing platform, leadership gained keys insights on what worked and what wouldn’t, avoiding some of the concerns you mention regarding spreading the provider systems’ resources too thinly.

To answer your final question, yes, so much stands to be gained from cooperation between payers and providers with regard to digitization and data-sharing. Unfortunately, data asymmetry is part of what makes each group effective. Providers known one thing about patients and are able to attract patients through branding and expanding, while payers know so much more about population quality metrics and what drives cost on a regional level. This situation is changing to some degree, but not fast enough. In fact, I fear that much of recent provider efforts to achieve inter-operability through their electronic medical records will only recreate a database that insurers already have. To truly unlock the value of data sharing that has stemmed from digitization, at least in the realm of health care, we need much greater cooperation.

Excellent insights, thank you for covering such a critically important topic.

Healthcare lags behind other industries in terms of most technologies that do not directly address procedural care. While Telehealth promises to match supply/demand mismatch between patients and providers, the upfront capital expenditures required to install working systems, alongside the already onerous CAPEX hospitals have recently (for the most part) spent on upgrading EMRs, may prove too costly. This is complicated by the fact that matching supply and demand may, at least in the short term, unleash so much unmet demand that costs will skyrocket further past 18% GDP if provider systems cannot figure out how to capture value from these systems by decreasing costs (as opposed to serving more patients alone) – see this recent Health Affairs article from Ashwood et al. for good exegesis: So far, it seems most value can be captured from these platforms in radiology (as above noted), dermatology (company profile: 3derm – and mental health with promising new local startups like Valera (

While large telehealth firms like Boston-based AmericanWell and provider groups have lobbied for improved interstate licensure and reimbursement of telehealth, its ultimate value add may be as a means of increasing touchpoints with patient in chronic disease management through capitated primary care systems that need more contact with a certain cadre of patients but less expensive visits.