idea-004 · desirability deck
Every slide states a condition that would have to be true, then reports where it stands using the candidate file's own claim and its own confidence tag. A deck never upgrades a tag, invents a number, or recommends anything, and there is no ask slide.
The chair: the user. Here that is three people at once: the parents who would operate a light wrap on a jaundiced newborn at home, the discharging clinician or general pediatrician who would have to prescribe it instead of admitting, and the newborn, who has no say.
How to read this: every slide is a condition, not a conclusion. A bracketed claim reference points into knowledge-base/candidates/idea-004.md — the number is the claim's position in its ## Claims list, and the tag is copied from that line and never adjusted here. A [no claim] marker means nothing in the file speaks to the condition at all. See docs/deck-spec.md.
What changed since the last build. The Verifier moved three reimbursement claims to verified on 2026-09-29: the code exists claim 3verified, its descriptor names a photometer claim 4verified, and Medicare publishes a monthly capped-rental allowable for it claim 5verified. None of the three is about whether anyone wants this, and none moves a condition on this deck from unbacked to backed. The business case rebuilt the same day put four payer-side assumptions on record; one of them bears on what a family pays (slide 4). This deck put one new condition on record (slide 2). Rebuilt from the file, not patched.
Would have to be true: A material share of US newborns of 35+ weeks who cross the phototherapy threshold in the eligible band would have to be treated today by inpatient admission or readmission whose only purpose is lying under a lamp — so that there is a hospital stay for a home device to replace.
Where it stands: The premise is on record and unconfirmed claim 17unconfirmed. The moment itself has a US size signal: in a Kaiser Permanente Northern California cohort of 148,162 infants of 35+ weeks who had no phototherapy in the birth stay, 1.8% crossed the threshold after discharge claim 37unconfirmed. But some of those infants are already treated at home: in a US review of 359 newborns across 9 pediatric clinics, 44% used a home biliblanket claim 38unconfirmed. The 2022 AAP guideline raised treatment thresholds, "narrowly" claim 11unconfirmed, which shrinks the moment rather than enlarging it.
What would settle it: A human read of the full KPNC paper for how the 1.8% were treated; a state Medicaid or all-payer claims extract counting newborn phototherapy readmissions against home-DME (durable medical equipment) rentals for the same diagnosis. No connector in this repo reaches either.
If it's false: If the eligible infants are already mostly treated at home on a blanket, there is no readmission to displace, only a fleet slot to take — and this becomes a competitive-intensity question (Factor 8), not a desirability one. Slides 2-5 lose their "instead of hospital" framing.
Would have to be true: The parents, in the first postpartum week, would have to keep a wrap positioned on their newborn for the prescribed hours, day and night, and get that newborn to the ordering clinician's outpatient serum bilirubin draws on schedule — without a nurse in the home.
Where it stands: Sustaining the irradiance-hours is on record and unconfirmed claim 18unconfirmed. The follow-up draws are the half this build newly put on record: the design keeps bilirubin monitoring with the ordering clinician's outpatient draw, and nothing in the file said families would manage it claim 72unverified. The only observation of a wearable in use comes from a 12-infant Dutch pilot: 10 of 12 completed within 48 hours, 2 were switched to conventional intensive phototherapy because bilirubin kept rising claim 41unconfirmed — a hospital setting, non-US, and a different device. What parents would prefer is recorded as unanswerable in its stated form claim 49unconfirmed.
What would settle it: Adherence logs and draw-completion records from the first home episodes — which is exactly the dose record this device proposes to produce. Before a device exists: a human read of the home-phototherapy literature for missed-draw and early-termination rates, and ten structured parent interviews.
If it's false: Under-dosing at home becomes a behavioural failure rather than an engineering one claim 14unconfirmed, and a missed draw is the missed-escalation path. The clinician on slide 3 would be right to refuse.
Would have to be true: A discharging birth-hospital clinician or general pediatrician would have to write a home phototherapy order for an in-band infant, with no home bilirubin measurement added — and a DME supplier would have to deliver the unit, and a payer authorise it, inside the same clinical window.
Where it stands: The clinician's yes is on record and unconfirmed claim 19unconfirmed; the file's Verifier notes call it the assumption the whole home-vs-readmission substitution rests on. Where home phototherapy has been measured, uptake is thin: 12% of 497 Canadian paediatricians worked at a centre offering it claim 43unconfirmed (a Canadian survey — the claim itself flags its US jurisdiction as wrong). An implementation study names reaching all the relevant clinicians for education as one of the two main barriers claim 42unconfirmed. The supplier's yes is unconfirmed claim 22unconfirmed, and so is the payer's in hours rather than days claim 67unconfirmed. The launch design deliberately excludes bilirubin measurement to stay on an existing predicate claim 1verified — so the clinician is asked to accept exactly the monitoring gap the regulatory strategy creates.
What would settle it: Twenty structured interviews with discharging clinicians and general pediatricians in two large-birth states, asking one question: would you discharge an in-band infant of 35+ weeks on home phototherapy, with serum draws at your usual outpatient interval and no home bilirubin reading? No connector answers this; adoption returns unverifiable by design.
If it's false: Nothing downstream arises. No prescription means no supplier order, no claim, no dose record with a reader. It is also the one slide where the candidate's own de-risking lever (treatment-only scope) reappears as the risk.
Would have to be true: The family's cost — money out of pocket, a week of broken sleep tending a wrap, and the risk of a readmission anyway — would have to be lower, in their own reckoning, than a hospital stay with the baby.
Where it stands: Out-of-pocket exposure low enough that families do not decline is unconfirmed claim 21unconfirmed. The business case added an assumption that sharpens it: a payer pricing E0202 (a HCPCS code for durable medical equipment) as a monthly rental may pay one full rental month for a 2-4 day episode claim 69unverified — and Medicare's only line for the code is a monthly capped rental claim 5verified, though newborns are not Medicare beneficiaries claim 6unconfirmed. If a family's cost-share is on a full month, the price of a few days at home is set by a month. The readmission risk points both ways: a 2024 meta-analysis found readmission higher after home than inpatient phototherapy, RR 4.61, very-low-quality evidence claim 39unconfirmed; a 2026 review of 31 studies found a pooled 3.5% (re)admission after home initiation claim 40unconfirmed; a US clinic review found 4% readmitted with a home biliblanket against 13% without claim 38unconfirmed.
What would settle it: A commercial plan's DME benefit terms for E0202 read by hand (deductible and coinsurance on a rental month); a state Medicaid cost-sharing rule for newborn DME; a human reading the two meta-analyses side by side.
If it's false: The family declines at discharge and the baby stays in — the substitution on slide 1 fails at the last person in the chain, after every other yes was obtained.
Would have to be true: The clinician would have to find home phototherapy sanctioned by the guideline they practise to, and would have to act on the device's per-episode delivered-dose record rather than file it.
Where it stands: Whether the 2022 AAP guideline addresses home phototherapy and states when it is acceptable is unconfirmed claim 20unconfirmed. Whether clinicians would use the dose record to make a decision they cannot make today is unconfirmed claim 33unconfirmed. The one behavioural signal in the file cuts against it: only 24% of US birthing hospitals surveyed reported the post-phototherapy transcutaneous check the same guideline recommends claim 45unconfirmed. The exclusion boundary the clinician would have to trust — under 35 weeks, hemolytic or complicated disease, and near-escalation infants treated elsewhere — is unconfirmed claim 66unconfirmed.
What would settle it: A human reading the 2022 AAP guideline full text for home phototherapy criteria (a document read, and the cheapest item on this deck); a chart review at one practice already prescribing home blankets, for whether any record the blanket produces is ever opened.
If it's false: The dose record — the one differentiator the file leaves unoccupied by the cleared wearable claim 2verified — has no user. The moat argument on the viability deck and the hardest-unknown slide on the feasibility deck both lose their reason to exist.
Would have to be true: In the first handful of prescribing practices, clinicians would have to write home orders for in-band infants, parents would have to complete the episode and the follow-up draws, and the infants would have to come back in no more often than comparable infants treated inpatient. Any practice where clinicians decline to order, or where draws are routinely missed, falsifies slides 2 and 3.
Where it stands: No observation of this kind exists in the file for this device. The nearest proxies are the US biliblanket clinic review claim 38unconfirmed and a completed US randomised trial of a competing wearable with no results posted claim 48unconfirmed. Each condition it would test is on record: prescribing claim 19unconfirmed, parent adherence claim 18unconfirmed, follow-up draws claim 72unverified.
What would settle it: The twenty clinician interviews on slide 3 first, because they are cheap, need no device and test the upstream condition. Then the guideline read on slide 5. A human-subjects observation of real episodes is downstream of both and is not an agent's decision.
If it's false: Every other deck for this candidate is describing a product nobody orders.
Every condition above with nothing verified behind it — which is all six. The verified claims cited on this deck (the launch classification, the cleared analog's indication, the code, its descriptor and the Medicare rental line) describe permission and price; none says anyone wants this. No condition here carries a [no claim] marker only because write-back has put each one on record — the honest count is that the deck rests on unconfirmed and unverified throughout.
The rubric scores no factor for whether a user wants the thing. A list this long, with nothing verified in it, is the expected result — and it is information about the pipeline as much as about this idea.
If only one thing from this chair could be checked: whether discharging clinicians and general pediatricians will substitute home phototherapy for inpatient treatment in the eligible band without an added home bilirubin measurement claim 19unconfirmed.
It is unchanged from the last build, and the week's verified claims are why it did not move: they settled that a code exists and what Medicare pays for it, which is a question about the money after someone has said yes. This condition is the yes. It is also the condition the candidate's own central design choice creates — excluding bilirubin measurement to stay on an existing predicate claim 1verified — so a deliberate regulatory de-risking move reappears as user-side risk. Parent capability, family cost and the dose record's reader are all downstream: none of them arises if nobody writes the order.
Naming it is not a recommendation, a gate, or a kill.
_shared/plain-language.md