Healthcare saw a flurry of activity and interesting trends during Q1 as the U.S. welcomed the Biden Administration into the White House and public market activity continued to surge. Let’s dive into the biggest healthcare stories from Q1 2021.
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Talkspace goes Public.
Talkspace, the virtual behavioral health app, will go public via merger with Hudson Executive Investment at a $1.4 billion valuation. The firm becomes the latest in a long stretch of digital health firms to hit the public markets this year and last. The fact that Talkspace operates in the behavioral health sector is a tailwind for the firm, as the behavioral health market is expected to grow significantly in the coming years. (Link)
- Speaking of SPACs…Intel’s Chairman is planning to raise funds for a SPAC targeting up to $1 billion in the health tech space. Yet another indication of money pouring into healthcare…and the markets in general! (Link)
Hims & Hers debuts on the public markets.
Going public: in late January, Hims & Hers tied the knot with the public markets and started trading under the ticker ‘HIMS.’ (Link)
What to know about HIMS. The company – which offers a variety telehealth and medication delivery services – has exhibited a meteoric rise in scale since its inception in 2017. 3ish years to go from inside someone’s brain to a $1.6 billion company today? That’s impressive.
Drastically scalable: Since its inception in 2017, Hims & Hers expanded dramatically:
- Once only known as Hims, the firm started with selling just four products, the most popular of which was its ED medication business.
- Hims rebranded into ‘Hims & Hers’ when the company added a women’s health service line.
- More recently, Hims & Hers expanded into a wide array of virtual services, including behavioral and mental health, primary care, and now a partnership with Privia Health – an extension of its primary care offering.
Bottom line: pay attention to Hims & Hers and other firms like it as COVID accelerates telehealth and digital health adoption, while easy money and low interest rate policies allow digital health players the capital to make a realistic foray into our sluggishly innovative healthcare system.
- If you want to learn more about Hims & Hers, I highly recommend this Bloomberg article (note – soft paywall) which dives into how the firm grew so quickly and effectively, but also takes a critical look at its business practices and prescription services.
- One more thing: Interestingly, during its earnings call, UnitedHealthcare mentioned that telehealth and online pharmacy services are key focuses for the business in 2021 which is…basically what HIMS offers. (Link)
Biden’s Executive Action in Healthcare.
Biden got to work quickly in unraveling several Trump-admin policies as well as pushing his own agenda through a multitude of executive orders. Here’s what he did healthcare-wise during his first week in office:
OSHA: Biden issued an executive order calling for OSHA to look into ways to improve safety for healthcare workers in vulnerable positions working on the frontlines of Covid. (Link)
WHO: The U.S. immediately rejoined the World Health Organization after Trump’s scuffle with the org last summer. Fauci will head this committee. (Link)
Mask Mandates and Travel Bans: Biden instituted a nationwide mask mandate on federal property (Link)
Vaccination Goals: Biden achieved the goal of 100 million vaccine doses in 100 days in the U.S. (Link)
About that Stimulus: This one requires Congressional action – but Biden’s $1.9 proposed injection into the economy expanded ACA subsidies, instituted a $20 billion national vaccine program (rather than the state-led initiative currently in place), and increased testing, among plenty of other funding proposals. (Link)
The SPAC Takeover Continues: Ro, Sharecare, and 23andMe next up
Ro: Not to be outdone by its little brother Hims & Hers, the telehealth and online pharmacy firm Ro was in talks to go public via SPAC. The merger was expected to value Ro at around $4 billion; however, Ro opted to privately fundraise, raising $500 million in a round in mid-March, valuing the business privately at $5 billion. (Link)
- As of April, Hims is trading at about 28x revenue, so some significant growth seems to be priced in for Q4 earnings and/or 2021 outlook. Hims & Hers sits at an enterprise value of around $2.6 billion.
Sharecare: Will also go public via SPAC after also merging with doc.ai. Founded by WebMD’s founder, Sharecare is an online health & wellness platform that provides its customers with personalized programs and resources to help improve their health. The combined firm is expected to go public at about a $4 billion valuation. Seems like the lucky number these days. (Link)
23andMe: Also plans to go public via SPAC. You’re probably more familiar with this company – it provides personalized DNA testing to individuals and is also trying to leverage that genetic data with biotech firms, launching studies to see what insights can be gleaned from DNA data and drug development.
- 23andMe’s primary competitor, Ancestry, was valued at $4.7 billion as recently as December. Still, both of these businesses seem a bit risky to me given that the consumer DNA testing craze appears to be dying down while there’s no guarantee that any of these biotech data partnerships pan out. (Link)
All About Oscar Health.
The long-awaited tech-full-stack-healthcare-unicorn company firm startup Oscar Health filed its IPO paperwork late last year and published its S-1 form for the world to see during Q1. (Link)
Oscar, the Good: The health insurance firm provides insurance plans mainly focused on the individual market and differentiates its product from other insurance offerings through its tech platform. Their data shows that the platform enables a better customer experience, which provides the firm with data-driven insights into care delivery patterns. Oscar’s membership base is growing big-time.
- Compared to the big insurers, Oscar claims a much better patient experience (the firm’s Net Promoter Score is 30 compared to the average insurance NPS of around 0). Its platform also seems to be scalable, which could be a yet-untapped avenue for growth.
Oscar, the Bad: Despite a decade of operation, Oscar is still hemorrhaging losses. The jury may still be out as to whether or not the product is differentiated enough to create staying power against the incumbent insurance behemoths.
More Oscar Health analyses:
- The Caseload: Oscar’s S-1: Why it matters. (Link)
- Kevin O’Leary’s bull and bear thesis for Oscar. (Link)
23AndMe’s Sketchy SPAC.
After 23AndMe’s announcement to go public via SPAC, a few individuals took deep dives into the DNA testing firm’s investor presentation and well, folks…there’s some definite spin going on. I found this Twitter thread especially amusing and quite the bearish opinion. (Link to investor presentation)
Incredibly, 23andMe is going public at a time when its revenues are shrinking significantly as the DNA testing fad dies out. To counter the unfortunate shrinkage, the firm is trying to pivot into a value-add for biotech giants and research into promising new drugs while adding a subscription product to its offerings which no one appears to know what it actually is.
- Then there’s the question of data privacy, too. Maybe if things don’t work out, 23andMe will sell American DNA data to China. I suppose it’s more of a threat than we might think, considering 60 Minutes just released a feature on it. (Link)
Clover Health’s Rough Week.
Not to be left out of the fun, recently SPAC’d insurance product Clover Health took a beating in February resulting from famed short-selling shop Hindenburg Research’s scathing short selling report on the company, which touched on:
- An undisclosed DOJ investigation connected to Clover potentially paying illegal kickbacks;
- A sketchy related party subsidiary also ‘thinly disclosed’ by the firm, Seek Insurance;
- Turnover at the executive level in the company implying inner struggles;
And more. You can read Hindenburg’s Twitter thread here, which touches on the main points from the report. Of course, Clover replied quickly with a Medium post of its own from its CEO and President claiming that the firm believes it made all appropriate disclosures and that its subsidiary Seek Insurance is truly independent. (Link to Clover Response)
Large Health Systems form Truveta, a bet on Big Data in Healthcare.
Hospitals are sitting on a treasure trove of data just waiting to be analyzed. That’s the thesis behind Truveta, anyway, which is a partnership between 14 of the largest health systems. Formed in late 2020 as a for-profit entity but officially announced during Q1, Truveta plans to aggregate clinical-level, de-identified patient data to provide meaningful insights for researchers, physicians, biotech firms, and everyone in between. (Link to Truveta Blog Post)
- This partnership isn’t the first foray into the health data space. Remember Project Nightingale, the Google-led venture with Ascension that caused a whole lot of patient privacy controversy? While that partnership used identifiable patient data which was accessible by Google employees, this new venture with Truveta seems to indicate that the appetite for big data insights from health data is stronger than any potential backlash from a vast amount of data sharing – albeit, HIPAA-compliant data sharing.
- Other thoughts: I’m personally curious to see whether any actionable insights come from this venture. I also wonder how much competition Truveta will take away from firms like 23andMe and Ancestry, who are trying to leverage their DNA databases into actionable data for drug and other research.
- Finally, I’m also curious whether these health system coalitions continue in the future. We saw Civica Rx form in late 2018, a partnership for addressing generic drug shortages. Now Truveta, a data sharing platform…what could be next?
SPACs Surge On: More about Sharecare, Sema4, and Uphealth.
We’ve talked about the Sharecare and Uphealth SPAC announcements in past editions during Q1. We’re now starting to learn a bit more about these companies from publicly disclosed SEC filings along with a newly announced health-tech SPAC announcement from Sema4.
Sharecare: Is going public via SPAC merger at a $3.9 billion valuation and will receive an investment from Anthem as part of the transaction. Right before debuting publicly, the firm also combined with health AI startup Doc.AI. Sharecare seems to be a conglomerate of all sorts of perks and benefits that works with health plans – including drug discounts. If you know exactly what this thing does, feel free to give me a shout. The co. will soon trade under the ticker $SHCR. (Sharecare’s Background)
- Link to 8K and merger documents (Link)
- Link to merger press release (Link)
- Access the investor presentation here. (Link)
- An informative Twitter thread on Sharecare. (Link)
Uphealth: Is merging with GigCapital2 (who comes up with these SPAC names?) and Cloudbreak at a $1.35 billion valuation, so a few orders of magnitude smaller than Sharecare’s transaction. The firm, after its merger with Cloudbreak, appears to be positioned in several fast-growing healthcare sectors including telehealth, behavioral health, integrated care management, and digital pharmacy. The combined co. will trade under the ticker $UPH and will close sometime in the first quarter, so pretty soon.
- Link to press release (Link)
- Link to S-4, investor presentation (Link)
- Bigger picture: Through this merger, Uphealth & co. seems to be creating another digital health conglomerate – a tech enabled firm focused on a variety of service lines (e.g., Teladoc and Livongo).
Sema4: Chalk another one up on the board for digital health companies I don’t understand. CM Life Sciences is taking Sema4 public via SPAC in a transaction valuing the firm at about $2 billion. Sema4 seems to run an operation similar to what 23andMe is trying to break into – i.e., using data analytics to help enable drug discovery for biotech firms and researchers, creating genomic maps, etc.
I’m personally hoping that all of these SPAC managers taking these confusing companies public know what they’re doing and aren’t just trying to make a quick buck. If not, the market might be in for a whole host of trouble one of these days…
Walmart scales down Health clinic goals.
After an initial enthusiastic and promising pilot and lofty goals for its health clinics rollout, Walmart might be slowing down the healthcare venture amidst shifting strategy.
A published article in March from Business Insider shed light on the operational speed bump. (Paywall)
- The initial rollout of the pilot health clinics was met with huge success. More than double the number of expected people visited the new clinics. Some drove more than 90 minutes away for an appointment as the ease of transparent, cash-pay drew in rural crowds. It seemed like a win-win – according to the article, the clinics were at a path to profitability within two years while boosting overall sales at the store itself.
Delays: Although the clinics were met with early success, a new CEO – along with the pandemic – slowed down the operation. From the article, it seems as if the new CEO wanted to pursue a new strategy: playing the long game by forging relationships with insurers, and slowing the rollout of new clinics as the firm worked to refine its care management strategy.
According to the article, Walmart was losing track of its ability to schedule people with their preferred doctors and keep up with communication because of the visit volume influx.
- Thoughts: I can’t say I’m not disappointed with this news. I can understand the delay from a logistical perspective (e.g., scheduling, prescription communication, etc.), but the fact that so many people were willing to travel large distances to visit your clinics indicates that you’re uniquely positioned to provide care in a transparent, cash-pay fashion while also boosting store sales.
- This quote from the article wraps up Walmart’s short-term sales-boosting strategy quite well: “One former employee who attended budget meetings said money to build new clinics dried up in favor of things like cooking devices that more directly boosted in-store sales.”
Side note: If you’re not subscribed to Insider, they post pretty great healthcare articles.
ATI Physical Therapy going public via SPAC in a $2.5 billion deal.
Next SPAC up: In another big Q1 story, Fortress Value Acquisition Corp. II (don’t you LOVE these SPAC names?) is taking national physical therapy operator ATI Physical Therapy public in a deal valued at $2.5 billion. (Link)
It’s one of the first healthcare services-related SPAC I’ve seen. AKA, there’s no fancy tech involved and I’m actually fairly confident in what the biz does.
- Details: ATI PT operates 900 clinics across 25 states. Interestingly, its private equity backer Advent International is rolling over a significant portion of its equity stake into the public entity which I’m sure will phase out over the next few years. Oh, and the valuation? ATI is going public at an adjusted EBITDA multiple of 14.0x…based on its EBITDA estimate for 2022. Physical therapy is a red hot space for acquisitions and heavily played by the private equity industry.
Post-Acute M&A activity in early March.
Lots of M&A in healthcare to headline early March and some interesting transactions in notable sectors to follow.
First up is the UnitedHealthcare and Optum reported acquisition of Landmark Health for $3.5 billion.
- Landmark is an in-home care provider that focuses on the sickest and most frail population of people. The firm works in 17 states and is involved in one of CMS’ new direct-contracting models. Seems like the firm is pretty scalable and with Optum backing it, we’ll probably see Landmark expand nationwide. (Link)
Next up: Cigna’s subsidiary Evernorth acquired telehealth provider MDLive for a reported $1 billion.
- The announcement is interesting as MDLive considered going public in early 2021. I’m thinking the firm left money on the table by being acquired but maybe not since the taste for telehealth is dying down a bit, especially after seeing Teladoc’s soft guidance numbers in its latest earnings report (more on that below). (Link)
Finally, hospital operator HCA is acquiring an 80% stake in Brookdale Senior Living’s home health and hospice firm.
- While HCA has traditionally focused on elective surgeries and expanded outpatient capabilities, the investment signals that HCA has plans to expand into post-acute and integrate care even further. (Link)
- Side note – Hospice is a hot, hot space right now as multiples are rising. Just last week, the Pennant Group (another publicly traded home health and hospice firm) boosted its credit facility to make way for more hospice acquisitions. (Link)
- Read more – why the HCA deal is a win-win transaction for Brookdale. (Link)
Amazon Care expands Nationwide.
It’s happening: The online retail giant just filed paperwork in 17 (and counting) states in order to expand the medical operation that seems to indicate that Amazon is ready to expand the clinics beyond just an employee-only benefit. (Link)
- About Amazon Care: Amazon evidently runs these clinics under a partnership with Care Medical, which is an independent medical practice that provides staffing for the Amazon clinics. The firm seems to be closely intertwined with Amazon and I have to wonder how provider costs will ramp up as the operation scales nationally. Note that Amazon Care will initially be available to its employees and any other large employers that opt in to the service.
Lobbying: In other Amazon-related healthcare news, Amazon and several other prominent public home care providers announced a coalition called Moving Health Home, which is essentially a pretty powerful lobbying group aimed at educating lawmakers on the benefit of in-home care as opposed to nursing homes and other post-acute settings. (Link)
Specifically, Amazon and the others (Signify Health, Dispatch Health, Intermountain, etc.) will start “lobbying lawmakers to ease regulations on what kind of health services can be performed outside of a doctor’s office — potentially widening the services Amazon Care can provide.”
Big Picture: Amazon’s moves make sense given their recent investments and announcements. In November, the firm announced its Alexa Care Hub, a way to check on seniors living alone through Alexa. Just a WEEK later, Amazon launched Amazon Pharmacy. Not to mention its acquisition of PillPack in 2018 or its venture with Haven that ultimately failed but probably succeeded in knowledge gained in running medical services. Finally, don’t forget about Amazon’s new wearable Halo – announced in late August 2020.
- Get your popcorn ready? If you think about it, Amazon really is attacking healthcare from quite a few different angles. It’s fascinating to watch. Amazon has made some big moves in the past, but this flurry of activity signals major moves are happening.
The Amazon Effect on Telehealth.
Shares of publicly traded telehealth firms plummeted after Amazon announced the nationwide rollout of its telehealth platform Amazon Care. (Covered in the March 8th edition).
Amid a wider market selloff, here’s how telehealth related firms have performed over the past month of trading:
- Teladoc: -31%
- HIMS: -26%
- Amwell: -30%
- GoodRx: -33%
The question is…is this a fire sale, or a problem for telehealth firms? Other Amazon announcements have resulted in stock selloffs, so this is nothing new.
- Grocers plummeted after Amazon announced its Whole Foods acquisition.
- Then don’t forget about retail pharmacies dropping after Amazon’s move into the pharmacy space.
GoodRx in particular has been getting hammered given its seemingly-delicate positioning between Amazon Pharmacy and now Amazon Care.
- It’ll be interesting to see how telehealth firms deal with increasing competition and whether there will be multiple winners in the space as firms differentiate in order to create compelling, sustainable competitive advantages.
InnovAge IPOs and Alignment preps its IPO paperwork.
InnovAge: At-home care provider InnovAge successfully debuted on the public markets in March at a $3 billion-plus valuation. The firm offers one of the largest PACE programs in the country and aims to be a compelling alternative to seniors facing nursing homes. (More about PACE) (More about InnovAge)
Alignment: Similar to Clover but with better financials, Alignment announced its intention to IPO later this year. The managed care firm operates in the Medicare Advantage space. Kevin O’leary had a great write-up on the company in his newsletter if you’re interested in getting into the weeds. (Link) (Link to S-1)
Ambulnz going public via SPAC at a $1.1 billion valuation
In what sounds like a terrible hip-hop group name, non-urgent care transport firm Ambulnz is going public via SPAC merger at a $1.1 billion valuation. (Link)
- Not much is known about the company right now, but it seems to me to be an Uber that’ll cost you an arm and a leg and take you to the hospital slightly faster. Here’s an article detailing the operation. (Link)
- Probably the most interesting part of the firm is that health professionals can select a vehicle option that fits the patient’s needs from an acuity standpoint (e.g., a wheelchair patient receives a handicap-accessible vehicle). Nifty, but worth a billion?
A bad week for nursing homes.
The 5-star rating system is broken: The pandemic really seems to have exposed major flaws in U.S. nursing homes. In March, the New York Times published a pair of hard-to-read stories related to nursing home operators’ ability to game the Medicare star rating system. (Link)
- The first report alleges the following and more:
- Much of the data nursing homes report to CMS is incorrect
- Staffing numbers are often understated
- Nursing home data is rarely audited by CMS
- Nursing homes often know when their ‘surprise’ inspections will take place
- Inspectors may find serious infractions anyway but rarely does it cause a drop in the home’s star rating (why not just…turn it into a 10-star system?)
Brookdale sued: As a closely related story, Brookdale Senior Living, the largest nursing home operator in California, was sued by the state for similar veins of ‘Medicare manipulation,’ including inappropriately discharging patients to allegedly fill those beds with higher paying patients. Brookdale denies any wrongdoing. (Link)
Grand Rounds merges with Doctor on Demand in multi-billion dollar deal.
More digital health conglomerates: Grand Rounds and Doctor on Demand reached an agreement in March to merge into what most would expect to be a multi-billion dollar company. The synergies are interesting here, as Grand Rounds provides patient navigation services (AKA, a direct competitor to recently gone-public Accolade) while Doctor on Demand is a telehealth service.
(Here’s some good background on patient navigation)
Broader trend: Like I’ve touched on before, these digital health firms are coagulating in efforts to differentiate themselves from one another. Think Teladoc-Livongo. Boom – immediately synergistic to each other and a much more compelling offering to employers. Uphealth and Cloudbreak, Teladoc-Livongo, now Grand Rounds and Doctor on Demand.
- I’m expecting a few publicly traded health tech firm mergers in 2021+ as they try to stay ahead.
Rise of the Medicare Advantage Startup.
More Payors: Alignment Healthcare, which is a managed care player focused on Medicare Advantage, debuted on the public markets in Mid-March, finishing at $19/share on its first day after pricing its IPO between $17-$19 per share. The firm operates ‘technology enabled’ Medicare Advantage plans in California, North Carolina, and Nevada and seems to operate those plans well. I’ll be watching how Alignment tracks compared to its recently beaten-up peers (AKA, Oscar and Clover). (Link)
Bigger picture: MA firms who have recently gone public or plan to in 2021 include Clover (58k members), Agilon (131k members), and now Alignment (81k members). Kevin O’leary has had some great write-ups about each of these firms:
DOJ to review Unitedhealthcare’s $13 billion acquisition of Change Healthcare
Litigation: At the request of the American Hospital Association, the DOJ is investigating UNH’s previously announced $13 billion acquisition of Change Healthcare – a revenue cycle and data analytics platform.
About the challenge: As more of an infrastructure-esque purchase, the acquisition was more behind the scenes in nature. But the AHA claims that the acquisition may result in less competition for IT and revenue cycle management services among providers.
- The DOJ case is just delaying the inevitable: that everyone in healthcare will eventually work for United. (Link)
Bonus Section: Healthy Muse Top Reads from Q1 2021
Systemic: How kidney failure is the perfect storm of an unequal health care system. (ProPublica)
Politics: The crash landing of ‘Operation Warp Speed’ (Politico)
Atul Gawande: To fix our broken healthcare system, start with primary care. (Fast Company)
Caseload: Read this informative post from Steve Hardgrove’s Caseload, which breaks down Accolade’s business model and describes how the firm can create value by enabling employers to make informed decisions on health plans.
- The analysis also dives into Accolade’s decision to buy 2nd.Md and how Accolade is developing a platform for employers, including opportunities and potential pitfalls. (Link – 11 minute read)
Out-of-Pocket: Read Nikhil Krishnan’s latest on the value of patient communities and how they should evolve to better suit those they serve given the evolving social media world. (Link – 11 minute read)
Acute Condition: Olivia Webb dove into the world of specialty pharmacy – how the system works and why innovation is frozen. (Link – 7 minute read)
Fierce: How the NFL tackled COVID-19 spread among its players and staff. (Link)
Semantics: Maybe the biggest news of the week – the Wall Street Journal announced a change in its stylebook from “health care” to “healthcare.” It’s a massive rift in the industry. I’m in the one word camp – more efficient! (Link)
Noah Smith: The U.S.’ vaccine rollout is world-beating. That doesn’t mean it’s good enough. But let’s take a moment to appreciate it. (Link)
Shady: Not only did New York officials admit that they lied about nursing home deaths back in August, a state-run nursing home also gave dozens of veterans experimental treatments without their family knowing. (Link)
Heroic? Read this gut wrenching story about a doctor’s decision to find 10 people for vaccine doses set to expire in 6 hours – and getting fired for that decision. (Link)
Big Data: Read about the multitude (thousands) of health datasets across the nation, the challenges that this fragmentation provides, and the opportunities to address the scattered resources. (Link) – Medium soft paywall.
From the frontlines: Read about Clover Health’s CEO’s reaction to the recent short-selling controversy, something I covered a few weeks ago. It’s quite the entertaining read. Let me know if you can sense Mr. Garipalli’s frustration. (**Link)**
Corona Reads: A couple of powerful coronavirus related reads were published by ProPublic and NPR. The first article dives into physicians around the country who had to decide which patients could live or die due to limited resources and time. The second article documents a physician’s experience in the ER through words and photos. (Link)
Small-Town Hero: Read about Marilyn Bartlett, a CPA who has saved the state of Montana over $30 million by creating a reference pricing model for hospitals – and the problems with scaling such a program nationwide. (Link)
Value-Based: Read this great breakdown of value-based care models from the Prescription. Worth a (sub)scription. (Link)
Disruptor: The healthcare revolution at-home. (Link)
Behavioral Health: The money behind mental health: How the pandemic increased innovation, investment in behavioral health care. (Link)
Policy: Read about Biden’s healthcare policies in the ‘new Washington.’ Deep dives from Axios on what to expect and what’s going on. (Link)
Rock Health: Read the latest from Rock Health on digital health – what’s working and how things are trending. (Link)
Report: Read McDermott, Will & Emery’s 2021 Health Report, which provides a spin on the legal ramifications of 2020 in healthcare. (Link)
Transparency: Here’s a super interesting read on the wide variation in pricing by hospital for the same procedures. (Link)
Logistics: Read this informative summary from Acute Condition of the vaccine distribution and absolute pandemonium of the patient intake process. (Link)
Consolidation: This Health Affairs article offers a somewhat contrarian viewpoint of health system consolidation in healthcare by arguing that consolidation allowed these health systems the scale to efficiently allocate resources to fight COVID. Quick actions included rapidly expanding ICU capacity and managing cases over a wide region. The article goes on to argue that maybe consolidation isn’t so bad – when it doesn’t increase consumer prices. (Link)
Teens: My final pick for the week comes from ProPublica – highlighting the emotional toll the pandemic took on crucial developmental years for teens. (Link)
Delivery: What it’s like to have a baby during a pandemic. (Link)
Family Feud: America’s Covid swab supply depends on two cousins who hate each other (Link – Bloomberg Paywall)
Doctor Fentanyl: The untold story of the doctor who fueled a drug crisis. (Link)
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