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Saturday, August 18, 2018

FinCanna, Undervalued Business Making Royalty Investments In Cannabis Startups


FinCanna provides financing to startup businesses in the cannabis industry in the form of perpetual royalty payments and/or loans.
The FinCanna management team has built a creative structure in which they help fund a highly capital-constrained industry – with strong growth prospects – at favorable terms.
While the investment portfolio remains unproven and significantly concentrated in one portfolio company, if the portfolio performs as expected FinCanna should generate ROI’s of 25%+ and support a high-margin business.
I value the company at 15x 2020 expected EBITDA, which equates to a price target for CALI of CAD 0.92.

Editor’s note: Seeking Alpha is proud to welcome Key Investment Partners as a new contributor. It’s easy to become a Seeking Alpha contributor and earn money for your best investment ideas. Active contributors also get free access to the SA PRO archive. Click here to find out more »
(Editor’s Note: Investors should be mindful of the risks of transacting in securities with limited liquidity such as FNNZF. FinCanna Capital’s listing on the Canadian Securities Exchange under the ticker CALI offers somewhat stronger liquidity.)

Overview of Investment Thesis

FinCanna Capital Corp (“FinCanna” or “the Company”) has developed a creative business model to finance startups in the capital-constrained cannabis industry. The management team invests in perpetual royalty payments at rates well above what could be earned in other industries given the limited number of competitors providing capital. FinCanna has funded three companies to date, all of which have shown positive momentum in their early days. However, on top of the numerous risks faced by most companies in the cannabis industry, FinCanna is exposed to significant concentration from its flagship investment, Cultivation Technologies, Inc. (or “CTI”). I value the company at 15x 2020 expected EBITDA, which equates to a price target for CALI of CAD 0.92. Once FinCanna’s royalties start flowing through the company’s P&L in FY’19 (year-end April 30), I expect that investors will take notice of this high-margin, scalable business model and that the stock price should rise accordingly.

Company Overview

Background
FinCanna was formed in Vancouver in November 2016 out of necessity. The management team of CTI had a permit approved to build a cannabis production and testing facility in Coachella, California (the “Coachella Project”) but needed funding (i) to acquire the real estate and (ii) to construct & operate the facility.
CTI’s management team began discussions with Astar Minerals Ltd. (“Astar”) regarding financing the project in 2016. Astar had initially formed as a project finance company for the exploration and development of minerals in Canada. After its initial exploration program returned inconclusive, Astar’s management team began exploring other business opportunities, which eventually led to the CTI introduction. However, Astar was publicly listed on the TSXV, an exchange which prohibits its listed companies from conducting cannabis business in the US. Instead, Astar’s principals connected CTI with individuals they viewed as capable of running a cannabis-focused investment vehicle, which became FinCanna. In turn, Astar was acquired by FinCanna in a reverse takeover (“RTO”)1 and was listed on the Canadian Securities Exchange (“CSE”), an exchange which does not have the same restrictions as the TSXV, in conjunction with the RTO. FinCanna now trades on the CSE as CALI and the OTCQB as FNNZF.
Business Model
FinCanna operates as an investor to companies in the cannabis industry, specifically focused on businesses operating in California. FinCanna has developed an investment portfolio over the past two years by raising capital through private placements of shares, then using those funds to invest in cannabis startups. The Company typically makes royalty investments, in which the portfolio companies pay FinCanna a certain percentage of their revenue in perpetuity (like the strategy commonly employed by Kevin O’Leary of Shark Tank). This structure provides an alternative option for cannabis companies who do not have access to financing from traditional sources and who may prefer to avoid giving up common equity at an early stage.
Prior to the RTO, FinCanna raised approximately CAD 6.3m through private placements2. In conjunction with the RTO on December 27, 2017, FinCanna privately placed shares for an additional CAD 7.1m. Year-to-date through August 16, 2018, the Company has completed two additional private placements for a total of CAD 10.0m. This capital (a cumulative CAD 23.5m) is being used to fund FinCanna’s investments (discussed further in Investment Portfolio). FinCanna plans to fund future investments through the cash flows generated by its existing portfolio. However, should FinCanna chose to invest in more companies in the near-term, the Company will likely need to privately place shares of CALI, leading to shareholder dilution3.
Investment Portfolio
CTI Permanent Facility: CTI is a provider of infrastructure, technology, manufacturing, and branding to the medical cannabis industry in California. CTI’ Coachella Project is a 6-acre medical campus and will include dedicated space for cultivation, manufacturing, distribution, lab testing and transportation. The 111,500 square foot facility will be developed in phases. Once at full capacity, the facility is expected to process 30,000 – 50,000 pounds of biomass per month, producing 18-30m grams of raw cannabis oil per annum.
FinCanna has committed to investing USD 8.1m in the Coachella Project in exchange for a 14% royalty from the facility. Additionally, this investment grants FinCanna the right to finance CTI’s next two licensed cannabis facility projects on the same terms (CTI is currently pursuing a second site in Colusa, California and has already obtained development entitlements for the first phase of the project)4.
In addition to the royalty payment, FinCanna has agreed to provide a USD 6.0m loan to CTI that matures in January 2023. This loan earns interest at 20% per annum and is secured by CTI’s assets. While the loan is outstanding, 7% of CTI’s revenues will be applied to pay down the interest and principal on the loan until it is fully repaid. Further, FinCanna has the right to convert the loan into a percentage (up to 5%) of CTI revenues on projects FinCanna chooses not to fund5.
CTI Interim Facility: While CTI’s permanent Coachella campus is under construction, an interim facility began operations in January 2018. The interim facility has the capability to process approximately 6,000 pounds of monthly biomass, which can produce approximately 3.7m grams of raw oil per annum. Further, CTI can add extraction equipment resulting in additional capacity of 3,000 pounds of monthly biomass. As of June 7, 2018, CTI’s interim facility had earned more than USD 1m revenue. While the interim facility is operational, FinCanna is entitled to receive 50% of its profits.
Green Compliance Inc.: FinCanna’s second investment, Green Compliance Inc., provides enterprise compliance and point-of-sale software (“ezGreen”) to licensed medical cannabis dispensaries and cultivators. Green Compliance has commenced sales in the US and targets dispensaries in all states (including Washington, D.C.) where medical cannabis is legal. FinCanna has agreed to fund USD 3.0m in tranches by September 2018 in exchange for a perpetual royalty of 10% of gross revenue, subject to certain buy-back options6.
Refined Resin Technologies Inc.: FinCanna and Refined Resin executed a royalty agreement in early July. Refined Resin is a cannabinoid research and refinement company that has leased a facility in Oakland and is currently in the process of retrofitting the facility, with plans to begin operations at the end of 2018. Refined Resin plans to produce bulk quantities of THC distillate and various concentrates and to provide white labeling services to other manufacturers who do not have access to compliant production facilities. Under the agreement, FinCanna will invest USD 3.0m in tranches in exchange for a tiered corporate royalty between 5% and 14% of Refined Resin’s revenues, adjusted based on revenue levels. FinCanna will also acquire an additional royalty of 2% of revenues for USD 1.795m (USD 0.5m in cash and the remainder in FinCanna shares), subject to certain repurchase terms.
Pipeline Opportunities: As of June 1, 2018, FinCanna had three pipeline opportunities for future investments at the Term Sheet stage. Summary terms for those opportunities are as follows:
Management Team
Andriyko Herchak, CEO: prior to running FinCanna, Mr. Herchak spent 20 years on the executive team of various publicly traded companies. From 2015 to 2017, Mr. Herchak served as CFO of Jewel Holdings Ltd., the largest end to end spooling/piping welding company in Western Canada, and from 2013-2014 he served as CFO of Nexgen Energy Ltd, a publicly listed uranium exploration and development company. From 2007 to 2012, he was CFO of Harthor Explorations, also a publicly listed uranium exploration and development company that raised CAD 100m equity and was eventually sold to Rio Tinto for CAD 650m. Mr. Herchak currently serves on Sixty North Gold’s Board of Directors (CSE: “SXTY”).
Robert Scott, CFO: Mr. Scott has over 20 years of experience in corporate finance positions. Mr. Scott is also the Founder and President of Corex Management Inc., a private company providing accounting, administration and corporate compliance services.

Industry

Given the size of California’s market (it would be the 5th largest country in terms of GDP if it was a sovereign nation), FinCanna’s management team has decided to focus on funding California based-companies. Legal cannabis sales in the state are projected to total USD 4.3bn in 2018 and to grow to USD 6.5bn by 20207. Cannabis businesses have limited funding available to finance their startup costs for a variety of reasons, including (i) national banks refuse to fund the industry due to the plant’s federal illegality and (ii) traditional venture capital funds typically avoid the industry due to regulatory concerns and vice clause8 restrictions. This has left a gap in the market for companies like FinCanna to develop clever financing structures and receive favorable terms with ROI’s well above what could be earned investing in other industries.

Investment Merits

Above market financing terms. In today’s regulatory environment in which traditional lenders have generally avoided lending money to cannabis companies, FinnCanna fills a unique market hole by providing financing in exchange for royalty payments. Most other financiers in the cannabis industry typically take significant common equity from their portfolio companies, which many founders consider more expensive in the long run. FinnCanna has shown its ability to capitalize on these market dynamics by (i) lending expensive paper at 20% interest and (ii) making royalty investments, which I assume generate a three-year ROI of approximately 27% (discussed further in Financial Performance & Valuation).
Positive momentum at CTI. CTI remains FinCanna’s most important portfolio investment, representing approximately 64% of the Company’s investment dollars to date. While CTI is privately owned, thus making financial information highly limited, CTI’s Coachella Project has demonstrated positive momentum in recent weeks, including (i) reaching over USD 1m sales and (ii) winning the exclusive rights to manufacture Phoenix Tears THC products in California. Further, CTI’s interim facility was positively impacted by an unexpected regulatory change that allowed CTI to own 100% of the facility, in effect increasing their profit expectations from the interim facility 5x.
Inexpensive valuation for the cannabis industry. Given (i) the uniqueness and complexity of FinCanna’s business model as well as (ii) the illiquidity of its stock due to low trading volumes, I view the Company as materially undervalued, especially relative to well-known and less scalable operators in the industry. I value the Company at a 15x 2020 EV/EBITDA multiple (discussed further below in Financial Performance & Valuation), which places the price target for CALI at CAD 0.92, well above the August 16, 2018 closing price of CAD 0.25. Given the industry-wide and company-specific risks discussed below in Investment Risks, I believe this significant upside potential (approximately 4x) is necessary to justify any investment in the cannabis sector.
Targeting the right market: California. As federal prohibition in the cannabis industry restricts companies from engaging in interstate commerce, each state that has legalized adult-use cannabis effectively acts as an independent nation with different regulations. FinCanna’s management team understands these dynamics and has intelligently chosen to focus on California, which is the largest legal market in the world and is still a very nascent industry (adult-use sales in the state just began on January 1, 2018).
Success of portfolio investments are not dependent on exit events. For financing companies that invest in cannabis businesses in exchange for common equity, the most important driver of their investment returns is an exit event (e.g. selling public shares of their portfolio company following an IPO or selling the entire business to a larger, strategic acquirer). Given the uncertain regulatory environment in the cannabis industry today, many companies have limited exit options, as (i) they are generally unable to meet the requirements for filing on a major exchange, (ii) companies listed on the CSE are often materially mispriced, and (iii) natural strategic acquirors like big pharma, big agriculture and big tobacco have generally shown reluctance to enter the cannabis industry. However, because FinCanna receives ongoing royalty payments based on revenues from its portfolio, exit timing is less of a concern for their book of business as their investments will generate recurring cash flows.

Investment Risks

Industry-wide risks. FinCanna faces numerous, industry-wide risks exhibited by most publicly traded cannabis companies, including:
  • The legal cannabis industry is nascent and highly fragmented, consisting predominantly of early-stage and unprofitable businesses. Regulations are unpredictable and constantly changing, which can materially impact performance.
  • Stocks traded on OTC markets and the CSE are thinly traded, which makes the investments more volatile than stocks listed on major exchanges (e.g. NYSE, NASDAQ and TSX). OTC securities are not registered with the SEC and are often unaudited, leading to less regulatory oversight and making these securities more susceptible to market manipulation (e.g. “pump and dump”).
  • Stocks listed in USD on OTC markets derived from a CSE-listed Canadian security are even less liquid than the native Canadian security, which can lead to significant bid ask spreads. USD/CAD foreign exchange fluctuations uncorrelated to the underlying security’s performance are passed onto the investor, leading to more volatility in the security’s price.
Significant portfolio concentration in CTI’s Coachella Project. While FinnCanna’s management team continues working to diversify its portfolio of investments, 64% of its investments to-date have been made in the Coachella Project (27% in the form of a loan and 37% in a royalty investment). Key risks specific to CTI include (i) the inability to raise enough funding to complete the Coachella plant build-out, (ii) timing delays in construction which would restrict their ability to pay interest and principal on the loan and (iii) declines in California’s cannabis oil price. Given the early stage of FinCanna’s book of business, should the Coachella Project fail, FinCanna would also likely fail as they will have lost the confidence of public investors, whose money they need from subsequent equity funding rounds to make more investments.
The investment portfolio is unlikely to become self-funding until 2020 at the earliest. FinCanna’s ability to make new royalty investments, which will provide further earnings potential and diversify their risk from their existing portfolio of just three companies, is dependent on their current portfolio throwing off sufficient cash. CTI, ezGreen and Refined Resin are all very early-stage companies, so this model will likely not become self-funding until at least 2020. In the meantime, FinCanna’s management team will either need to pass on pipeline opportunities, or they will need to issue new shares of CALI, which will lead to dilution for the existing shareowners.
Information on the status of underlying portfolio companies is critical yet difficult to ascertain. Valuing FinCanna and projecting their future cash flows is very difficult, as their underlying investments are all privately owned and thus do not disclose their financial performance. This same restriction applies to FinCanna’s management team, who depends on their underlying investments providing accurate financials and paying the proper amount of royalties (although FinCanna does have audit rights over its investments)9. In a downside scenario where performance at CTI, ezGreen and/or Refined Resin declines, the management teams of those companies may be incentivized to falsely report their numbers to FinCanna and to underpay what they contractually owe.
More competitors (e.g. traditional lenders and venture capitalists) will enter the industry as fear of retribution abates. The regulatory momentum across the US has been overwhelmingly in favor of legalizing cannabis, and this momentum appears to be accelerating. While this shift is certainly positive for the industry from a macro perspective, it will cause FinCanna to lose its competitive advantage over time. Once banking legislation has been changed to protect financial services companies and more traditional lenders enter the industry, FinCanna’s ability to drive above-market terms on its investments will decrease.
CAD/USD FX volatility. Because the Company reports in CAD but funds investments/ generates revenue in USD, the Company is exposed to transactional and translational FX swings. American investors in FNNZF are partially hedged from these FX swings, as a stronger USD will increase FinCanna revenue in CAD but decrease the market price of FNNZF relative to CALI (and vice versa). Note that because the Company only invests in California in USD and plans to reinvest all cash flows back into the state instead of repatriating cash to Canada, FX swings do not impact the Company’s operations (only its financial statements).

Financial Performance & Valuation

As noted in the Investment Risks above, projecting FinCanna’s financials is very difficult given the underlying portfolio’s (i) limited information available and (ii) uncertain timing of cash flows. However, I assume that once portfolio companies are operating at full capacity, they will generate royalties of approximately 100% of FinCanna’s investment each year, which is supported by the annual revenue expectations FinCanna presented for their Pipeline Opportunities. For example, the Payment Processing opportunity has the potential to generate a USD 3.2m annual royalty, approximately equal to the USD 3.0m funding amount, and the Consumer Products opportunity has the potential to generate a USD 2.24m annual royalty, approximately equal to the midpoint of the USD 1-3m funding amount. I further assume the portfolio companies take three years to reach their run-rate, returning 25% of FinCanna’s investment in year one, 50% in year two and 100% in year three and thereafter. This equates to an expected 3-year ROI of approximately 27% for each, which is a 700bps premium to the 20% interest FinCanna charges on the CTI loan.
In FY’19 (the year ended April 30, 2019), I expect FinCanna’s portfolio to generate sufficient cash flow to fund their existing investment commitments, but not enough to fund any additional opportunities. In the subsequent years, I expect the Company to utilize 90% of free cash flow to make new royalty investments, which will follow the same 25%, 50% and 100% pay-out in years 1-3. Further, I expect the majority of FinCanna’s expenses to grow at approximately 25% p.a., driving the Company to a steady-state EBITDA margin of 65-70%. I further assume the Company should trade at 15.0x 2020 expected EBITDA of CAD 7.2m, equating to an Enterprise Value of CAD 108.1m or a price per share of CAD 0.92 once considering dilution from stock options, warrants, and the component of the Refined Resin investment issued in the form of FinCanna equity.
The August 16, 2018 CALI closing price of CAD 0.25 is materially lower than when FinCanna started trading in January 2018 at CAD 1.02 (75.5% decline). Much of this decline is likely attributable to the unfortunate timing of FinCanna’s RTO, which took place shortly after a bull-run in cannabis stocks and days before US attorney general Jeff Sessions repealed the Cole Memo10, which has been a major contributor to the broader cannabis industry’s price decline (the Global Cannabis Stock Index is down 36.1% YTD). There is not a clear indicator as to why FinCanna’s performance YTD has been so much worse than the broader cannabis index, but I would reiterate that given the stock’s illiquidity and dearth of institutional investors, the market price is not a useful indicator of the stock’s intrinsic value. Additionally, I believe other public investors are generally (i) unaware of the company due to its small market cap and lack of institutional, sell-side research coverage, (ii) do not understand the business model because of its uniqueness and complexity and (iii) have not taken the time to project financials, which show a clear pathway to strong profitability in a short timeframe.
Comparable Companies
Publicly traded comparables consist of specialty finance companies focused on investing in small-cap and middle-market companies, predominantly in the form of syndicated, secured debt. These companies trade at a median 19.7x EV/EBITDA multiple, to which I apply a discount of approximately 25% to arrive at the 15.0x multiple for FinCanna. This 25% discount is justified due to:
  • FinCanna’s 2-year forward-looking EBITDA vs. comparable companies’ LTM EBITDA
  • The higher risk of the underlying cannabis industry relative to the more mature, traditional industries financed by comparable companies
  • The concentration of FinCanna’s investment portfolio
  • The fact that comparable companies typically invest in loans fully secured by their portfolio companies’ assets, while FinCanna has not disclosed the underlying securitization of their royalty investments
These factors are partially offset by the stronger growth profile of the cannabis industry.

Conclusion

FinCanna utilizes its creative and scalable business model to fund cannabis companies that have limited other options for accessing capital. While the portfolio today is concentrated and early-stage, the Company is at an inflection point and should start receiving material cash flows over the next 12-18 months. The stock, which has been flying under the radar since the reverse takeover, has the opportunity for the material price appreciation necessary to justify the investment’s extremely high risk profile.
Financial Model

[1] Public Filing: FinCanna Capital Corp – Annual Information Form for the year ended April 30, 2017
[2] Public Filing: FinCanna Capital Corp – Consolidated Interim Financial Statements for the six months ended October 31, 2017
[3] Dilution refers to the reduction in the ownership percentage of a company due to the issuance of new equity shares by the company. When FinCanna privately places new shares, they have historically offered the new shares at favorable terms relative to the outstanding shares to attract larger investors. For example, during the last private placement, CALI shares were trading around CAD 0.30. Investors in the private placement were able to buy common shares at CAD 0.30 and also received a warrant to purchase an additional common share at an exercise price of CAD 0.45 for the next 24 months. As such, when valuing the company and setting a price target, I assume full dilution from outstanding warrants and options. As of June 1, 2018, the Company had 75.5m shares issued, 25.8m warrants and 6.0m options outstanding.
[4] Public Filing: FinCanna Capital Corp – Annual Information Form for the year ended April 30, 2017
[5] Public Filing: FinCanna Capital Corp – Annual Information Form for the year ended April 30, 2017
[6] Public Filing: FinCanna Capital Corp – Annual Information Form for the year ended April 30, 2017
[7] Arcview Market Research
[8] Restrictions imposed by the underlying investors in a VC fund that prevent the funds from investing in certain sectors such as alcohol, tobacco, or drugs.
[9] Public Filing: FinCanna Capital Corp – Annual Information Form for the year ended April 30, 2017
[10] Memorandum issued by Obama’s Attorney General James Cole in August 2013 which stated that the Justice Department would not enforce federal marijuana prohibition in states that “legalized marijuana in some form and … implemented strong and effective regulatory and enforcement systems to control the cultivation, distribution, sale, and possession of marijuana”.

Weed killer in your cereal? Maybe, but don’t panic


Startling headlines about a weed killer in children’s cereal and snack bars are swamping social media and scaring parents this week.
An advocacy organization, the Environmental Working Group, said on Wednesday that it had found traces of the pesticide glyphosate, the main ingredient in Roundup, in certain popular breakfast cereals.
The group is not neutral on the issue. It actively campaigns against glyphosate, and this particular piece of research was not published in a peer-reviewed journal, which would have allowed other experts in the field to ask questions before the research was made public.
The amounts found are far below the allowable limits, and anyway, most experts in the field say there’s very little evidence that glyphosate causes cancer or any other health problems.
The Environmental Protection Agency has said for years that there’s not much evidence that the pesticide can cause cancer in people.
“The draft human health risk assessment concludes that glyphosate is not likely to be carcinogenic to humans. The agency’s assessment found no other meaningful risks to human health when the product is used according to the pesticide label,” the EPA says.
“Glyphosate is no more than slightly toxic to birds and is practically nontoxic to fish, aquatic invertebrates and honeybees.”
But what about the recent court case in which a California jury ordered Roundup maker Monsanto to pay $290 million in damages to a groundskeeper with non-Hodgkin’s lymphoma?
American juries do not necessarily rule based on scientific evidence, and they are not required to.
“From a purely scientific point of view I do not think that the judgment makes sense,” Paul Pharoah, a professor of cancer epidemiology at Britain’s University of Cambridge, said after the ruling.
He noted that evidence that glyphosate increases the risk of cancers such as lymphoma is “very weak.”
The European Food Safety Authority also said glyphosate probably doesn’t cause cancer in people.
Experts have criticized various court decisions punishing companies for making consumer products that people claim have caused cancer, including talcum powder.
The International Agency for Research on Cancer, part of the World Health Organization, has said glyphosate is a “probable” human carcinogen. The designation leaves room for doubt, and other panels dispute it.
And just because a compound is found in food does not necessarily mean that it is causing harm. Scientists love to remind people that the dose makes the poison.
“With all things, it is the level of exposure that matters,” said Fred Gould, head of the Genetic Engineering and Society Center at North Carolina State University.
“The poison is in the concentration.”
Gould points out that there are several steps to determining if a compound is dangerous to humans. Tests, usually done on animals, must show that it could cause harm. Then tests must be done to show how much of the compound it takes to do harm. Studies have to show that humans are in fact getting harmful doses of the compound, and more tests must show that people who are exposed to a compound have health problems more commonly than those not exposed, or those who are exposed to less.
The international research agency study, Gould said, only looked at animal exposures at very high doses — much higher doses than people have ever received.
“The WHO was asking, ‘Would this compound potentially cause cancer?’ ” he said.
Other groups have asked the remaining questions and found no evidence that the pesticide hurts people.
study published in May by a team at the National Cancer Institute found no evidence linking glyphosate with cancer. The team studied nearly 45,000 people who had applied glyphosate as part of their jobs.
“In this large, prospective cohort study, no association was apparent between glyphosate and any solid tumors or lymphoid malignancies overall,” they wrote.
There was some evidence suggesting that people who used glyphosate in their jobs might have a higher rate of acute myeloid leukemia, but the numbers were too low to say for sure and the team said more study of that particular question would be needed.
The EPA and the Food and Drug Administration say they are studying the current guidance for safe levels of glyphosate in food.
The Environmental Working Group said the levels of glyphosate it found in cereals were many times lower than the safe levels set by the EPA years ago, and even below the much more stringent levels set by California’s Office of Environmental Health Hazard Assessment.
California’s cancer risk assessments are based on a lifetime risk of cancer of one in 100,000 for an adult, but raises this to one in a million for water contaminants.
The environmental group said it decided to add a tenfold “margin of safety.”
“With this additional children’s health safety factor, EWG calculated that a one-in-a-million cancer risk would be posed by ingestion of 0.01 milligrams of glyphosate per day,” the group said.
Its criteria do not match anything set by international, state or local health organizations or regulators.
But they convince Alex Lu, who studies children’s exposure to pesticides at the Harvard School of Public Health. Lu said he personally would not risk ingesting any pesticide if he could avoid it.
“There is no safe level of carcinogen,” he said.
Gould is not so worried.
“We are always taking risks. Comparatively, from everything that I see, this is a small risk,” said Gould, who led a committee studying the safety of genetically engineered crops for the National Academy of Medicine.
“I would eat Cheerios before and after that announcement,” Gould said.

Time to get in the game?


Team sports aren’t just for kids. They offer adults a wealth of benefits, including a greater feeling of well-being, reduced stress and a strong sense of community.
You have many options for finding an adult club or team-based sport in your area. Your local park and rec department or “Y” might sponsor such activities. The World Adult Kickball Association has expanded to provide adult leagues in a variety of sports from softball to soccer — learn more at kickball.com.
If your child is on a team that’s coached by an outside professional, that coach may know of adult sports teams looking for new members.
But just as you wouldn’t send a child out onto a playing field without some prep steps, you don’t want to join a pickup game of basketball or sign up for a soccer league without taking some precautions.
Stay sports safe:
  • Get a “pre-season” physical.
  • Stay strong and flexible with regular strength training and stretching.
  • Warm up and cool down properly.
  • Always wear protective gear and make sure needed equipment is in good condition.
  • Make sure the field/court is in good condition.
  • Avoid playing outdoors in bad weather to minimize injury risk.
  • Hydrate as needed during play when you feel thirsty.
  • Don’t play through pain — see your health-care provider or an orthopedist if you get injured.
Most sports injuries stem from a lack of education and awareness about safety, wearing the wrong equipment, and being out of condition. So bone up on the ins and outs of your sport and get a checkup — a sports physical — if you’re out of shape.
On game days, make sure that everyone follows safety rules. Know that some medications, like allergy or cold remedies, can dehydrate you, and adjust your water intake as needed. Also, take breaks to prevent overuse injuries.
Now, what are you waiting for? Get off the couch and into the game!
More information
Play it safe with these tips on sports safety from the University of Rochester Medical Center.

‘The devil’s aspirin’: why do so many celebrities blame Ambien?


Elon Musk’s erratic public declarations are reportedly worrying Tesla board members, and a main concern for executives is a sedative Musk says he has been using: Ambien.
“It is often a choice of no sleep or Ambien,” Musk told the New York Times in an interview published on Thursday, which came after the Tesla founder claimed on Twitter that he was considering taking the company private.
The tweet sparked a furore among both markets and media, while lawyers warned he could have broken a law prohibiting publicly traded companies from announcing plans to buy or sell securities.
If Ambien is to blame, Musk would not be the only celebrity to act strangely under the influence of the sedative, or to claim that acting strangely was the fault of the sedative.
In May Roseanne Barr memorably blamed Ambien for a series of racist tweets which led to her ABC sitcom being cancelled.
“It was 2 in the morning and I was ambien tweeting,” was Barr’s defense for a message comparing former Barack Obama aide Valerie Jarrett to an ape. She also accused George Soros of being “a nazi”.
The drug manufacturer Sanofi, which makes Ambien, issued a statement after Barr’s outburst saying “racism is not a known side effect of any Sanofi medication”.
Ambien, commonly prescribed for insomnia, was found in Tiger Woods’ system when he was arrested for a DUI in 2017. Police found Woods’ car parked on the side of the road with the engine running, the brake lights on and a right turn signal blinking. Woods said prescription medication was to blame.
Charlie Sheen said Ambien was responsible for him allegedly trashing his New York Cityhotel room in 2010. The New York Post reported that “tables and chairs had been thrown around the room and a chandelier was also damaged”. In 2011 Sheen explained his behavior to the news show 20/20:
“Ambien, the devil’s aspirin! I think that led to that thing in New York. That was the one thing in the mix that was not part of my normal blend.”
Appearing on the Late Show in 2017, Sean Penn pre-emptively blamed Ambien for any potentially disruptive behavior.
“I’m doing well,” Penn told Stephen Colbert at the start of the interview. “You’ve inherited a little of the Ambien I had to take to get to sleep after a red eye last night.”
A disheveled-looking Penn then started smoking a cigarette.
Back in 2016 Paul Schrader, the screenwriter behind Taxi Driver and Raging Bull, pointed a finger at Ambien for a Facebook message in which he said Donald Trump’s presidency was “a call to violence” and “we should be willing to take arms”. The post earned Schrader a visit from the NYPD’s counter-terrorism unit.
“A couple of cabernets and half an Ambien, and God knows what you’ll post,” he later told the Hollywood Reporter. “That is something that you have to be careful about because Facebook is not private correspondence.”
Ambien’s pervasive influence in the world of celebrity is such that it even gets a mention in the Jay-Z and Alicia Keys song Empire State of Mind, in which the pair sing about New York City.
“MDMA got you feelin’ like a champion,” Jay-Z says in the song.
“The city never sleeps, better slip you an Ambien.”

Retail Mental Health Could Be Medicine’s Next Frontier


Throughout his residency and his last three years as a physician in psychiatry training at Mather Hospital in New York, Dr. Tamir Aldad saw upfront how thousands of mental health patients each year were sent home from the emergency room knowing they might not get follow-up treatment for several weeks.
Despite the urgency of care needed amid the nation’s opioid epidemic and related mental health crisis, millions of Americans like the patients Aldad sees are treated first in an ER, but often aren’t able to see a psychiatrist even after being screened for anything from substance abuse or phobias to PTSD or potential risk of self-harm. Aldad says they aren’t sick enough to be admitted so they “boomerang back to the ER in a couple weeks with the same or worse problem than they came in for in the first place.”
“There are 70% of patients with mental illness who are sent home because their symptoms aren’t severe enough to be admitted, but they don’t meet criteria for admission,” says Aldad citing New York City hospital statistics.
In New York alone, Aldad says the wait to see a psychiatrist in an outpatient clinic or doctor’s office is four to eight weeks. And it may be worse in other parts of the U.S. given there is a nationwide shortage of doctors and psychiatrists in particular.
“You could go through the phone book and beg psychiatrists to see them or they could get an appointment to see a psychiatrist on Park Avenue today, but you would need $500 to $600 to see them,” Aldad says.
To fill these potentially life-threatening gaps in U.S. healthcare, the 33-year-old physician and University of Chicago Booth Executive MBA student has developed an award-winning startup called Mindful Urgent Care staffed by a team of mental health professionals including psychiatrists to increase mental health access and speed quality and affordable treatment to a population of patients with unmet needs.
For his efforts, Aldad won $140,000 in the University of Chicago Booth School of Business’ New Venture Challenge and Global New Venture Challenge competitions that have launched startups like online food delivery service Grubhub and payment processor BrainTree. He says he’s also landed another $500,000 in funding from additional backers to help him open his first 3,000 square-foot retail clinic in September in New Hempstead, NY. A second 2,000 square foot clinic will open in midtown Manhattan in 2019.
He’s also hearing from additional potential investors he’s not ready to publicly disclose, which could be key to a business plan he has to open 35 centers in the greater tri-state area surrounding New York City in New York, Connecticut and New Jersey in the next five years.
It’s a unique approach to a market not tapped yet by big retailers. Though pharmacy chains like CVS Health and Walgreens Boots Alliance are big into retail health clinics, both confirm they don’t for now have plans to build out or add mental health services.
Such facilities cannot open fast enough. For years now, the U.S. health system has lacked enough primary care providers like family physicians and internists as more Americans with a pent up demand for treatment gained the ability to pay under the Affordable Care Act. And mental health needs in communities across the country are becoming as critical, with no way of filling the void in sight. Behavioral health facilities, hospitals and addiction centers cannot find the psychiatrists they need.
“We face a broad range of mental health issues, including the acute problems of opioid addiction and increasing rates of depression and suicide,” Dr. Darrell Kirch, a psychiatrist and chief executive of the Association of American Medical Colleges said in a report earlier this year on the psychiatrist shortage. There are 28,000 psychiatrists in the U.S., but three in five are 55 years of age or older, AAMC data shows.
But Aldad’s strategy is to meet patient need through a mix of psychiatrists and “physician extenders” like nurse practitioners and physicians assistants with mental health and psychiatric specialties to better triage patients in order to replicate the consumer-friendly Mindful Urgent Care model that will be open 15 hours a day and seven days a week.
Though big chains haven’t yet jumped on the retail mental health clinic concept, there have been other public and private urgent care centers open up in the space.
Psychiatric urgent care pioneers include Broadlawns Psychiatric Urgent Care in Des Moines and a new state-funded effort in North Carolina launched by Alliance Behavioral Healthcare, a managed care organization that asked a group of therapists in Durham to create a clinic, according to a report earlier this year in North Carolina Health News.
“Because we use physician extenders and not strictly psychiatrists, we are able to scale our model,” Aldad says. “By no means are we trying to compete for business and take away from psychiatrists in their practices, but we want to get these patients treatment. We want to give medication and provide simple symptom stabilization so you as a patient has relief.”
For now, Mindful Urgent Care has contracts with more than 30 health insurance companies through the New York psychiatrists that will be staffing and supervising the staff at the retail clinics.
But Aldad is hopeful the model will be attractive to health insurers on a broader scale given the move away from fee-for-service medicine that emphasizes volume of medical care delivered. Instead, insurers emphasize value-based care that encourages patients to get better treatment upfront in a doctor’s office. Such value-based models measure and reward providers based on how well they care for patients, treating them more holistically.
Value-based models reach out into the community to make sure patients get the right care, in the right place and at the right time so it’s quality and low cost. Health insurers like UnitedHealth Group, Anthem and Aetna and many others are now paying out more than half of their reimbursements to doctors based on such value-based formulas so Aldad’s idea should have merit with health plans.
Prices Mindful Urgent Care plans to charge are expected to cost $175 for an initial visit and $80 for follow-up care based on the average of what Medicare and private insurance pays, Aldad says. Most patients have coverage so they would likely pay significantly less based on their co-payments, deductibles and related out-of-picket costs.
“In value-based care, patient outcomes really matter and what we are instead seeing now is that patients in mental health are costing more and more,” Aldad said. “It’s even more costly if that hospitalization for mental illness is preventable because they couldn’t get in for a medication refill or they couldn’t get into their doctor’s office for an appointment. We have an opioid crisis and we have to proactively trend and work on how to prevent illness.”

Internet of medical things market seen hitting $158B by 2022


  • The internet of connected medical things (IoMT) market is expected to reach $158 billion by 2022, up from $41 billion last year, according to a new Deloitte report. The challenge for manufacturers is how to demonstrate to payers and providers that connected medical devices can benefit value-based care.
  • Deloitte surveyed 237 medtech leaders to learn how the IoMT is disrupting medtech’s role in healthcare. More than half (51%) of respondents said they are implementing new business models to drive innovation and sales.
  • Nearly one-third (31%) are deploying new funding models for data-as-a-service and 29% are adopting value-based pricing. In addition, 43% reported using real-world evidence to drive business decisions.

Connected medical devices and the IoMT has the potential to transform healthcare and improve patient outcomes through better disease management and remote monitoring of chronic diseases, improved drug management, and enhanced patient experience — while, at the same time, helping to reduce costs.
Major market segments by application include telemedicine, worth $12.9 billion in 2017, clinical operations ($8.8 billion), medication management ($6.6 billion), connected imaging ($5.7 billion) and inpatient monitoring ($5 billion).
But while the market is booming, there are still numerous challenges facing IoMT developers.
According to Deloitte, 71% of respondents feel hospitals and clinicians are not ready to use the data generated by connected devices and 67% believe it will take another five years for FDA’s regulatory framework for digital devices and medical software to catch up to what is possible today.
“Different types of innovation will require different business models, and progress will depend on both the innovators themselves working in new ways to take on risks and rewards, and the evolution of existing payment systems by both public and private payers,” the report says.
Other major challenges include interoperability and cybersecurity. “Interoperability is arguably the biggest challenge for medtech, including complying with various national and international standards and protocols around the exchange and use of data,” according to the report. “There are also technical challenges such as creating an integrated governance framework and obtaining consent for access to health care data.”
A number of EHR vendors have started to shift to open platforms, and Monday, Microsoft, Google, Amazon, Oracle, IBM and Salesforce announced an agreement to jointly commit to “removing barriers for the adoption of technologies for healthcare interoperability, particularly those that are enabled through the cloud and AI.”
Meanwhile, as more devices communicate in the ethersphere, companies overestimate their readiness to deal with cyberattacks. While four-fifths of respondents believe they are reasonably well prepared with the cybersecurity of their products, numerous studies suggest otherwise, the report says. In fact, a recent simulation by security firm McAfee showed just how easy it is for someone with ill intent to tamper with patient vital signsmonitored on a hospital’s network.
Other challenges include gaining an in-depth understanding of end users and determining what’s needed to scale up in the clinical space while ensuring providers and the public that patient data is protected and used responsibly. There is also concern that a growing skills gap could slow development of IoMT devices and slow market growth, the report says.

Apple may be eying health sensor data chips


  • Apple reportedly is assembling a team with skills in developing custom processors to interpret health-related data collected by sensors in wearables and other devices.
  • The news suggests Apple may be planning to build specialized chips to work with its health sensors, CNBC reports. Doing so would give Apple end-to-end control over product development without having to use components supplied by outside companies, and help protect valuable trade secrets as it ups its ante in the healthcare space.
  • Recent job postings by Apple’s Health Sensing hardware group said they are looking for analog and digital sensor ASIC architects and engineers and suggested an interest in people with experience in optical sensors.

There seems to be no end to Apple’s interest in healthcare. Last year, Apple CEO Tim Cook told Fortune the company is “extremely interested” in healthcare” and teased, “There’s a lot of stuff I can’t tell you about that we’re working on.”
The company already makes sensors that measure heart rate, and it makes chips for Apple Watch, iPhones and iPads and AirPods. The job listings suggest it may be looking to develop chips specifically designed to read user-generated health information collected on its devices.
Moving beyond wearables to more specific patient monitoring devices could lead to an array of potential clinical uses. According to an Ernst & Young report published this spring, Apple has filed applications for 54 healthcare patents, including ways to turn iPhones into medical devices that capture biometric data such as body fat levels and blood pressure.
Apple already has several health monitoring sensors on its products. AliveCor’s KardiaBand app lets Apple Watch users capture a 30-second EKG to detect normal heart rhythms and atrial defibrillation. In a Cleveland Clinic study, the app accurately detected AF versus normal sinus rhythm with 93% sensitivity and 84% specificity. Sensitivity increased to 99% when doctors reviewed the app’s recordings.
Other research by Mayo Clinic showed the app can identify high potassium levels in the blood. The app has FDA clearance, giving Apple Watch a plug as a medical device.
Apple also owns sleep-tracking startup Beddit, which detects heartbeats and breathing rhythms and relays the information via Bluetooth to a companion app on iPhone or other compatible device.
And the company is also reportedly working on noninvasive blood sugar tracking sensors and is partnering with a number of health systems that provide medical records to the company’s updated Health Records section for the iPhone. The records section, still in beta mode, allows users to view their medical records with the Health app. CNBC previously reported that the tech giant also is planning on opening a group of primary care clinics for its employees — a possible outlet for its monitoring technologies.