Telehealth and the Future of Healthcare

As Washington continues to war over “Repeal and Replace” of the Affordable Care Act, one thing is certain: the need for affordable and accessible healthcare that is patient-centered and personalized. Millions of women, senior citizens, employees and independent business professionals will be affected by the expected changes to Obamacare, including, but not limited to, reduced health benefits and preventative services, discontinued subsidies, and rollback of Medicaid.

Waiting for sweeping government changes is not the solution, and development of innovative health solutions have already been underway. There’s no question that the future of healthcare is digital, where individuals are equipped to self diagnose, doctor communication is remote and timely, medication is on-demand, and data is empowering prevention, drug discovery and development. Concern and curiosity motivated me to explore our current healthcare progress and available solutions.

Remote care delivery will evolve to become the first point of contact for everything healthcare

 

There have been a number of telehealth startups that have entered the space in the last ten years, spanning doctor discovery and scheduling, remote care delivery, prescription management, patient monitoring and education, and more. However, remote care delivery proves to be a unique entry point with strong network effects that will enable it to quickly scale and evolve to offer services and products across the healthcare space.

Copyright© 2014 Motivation Science Inc.
Copyright© 2014 Motivation Science Inc.

While the barriers to entry are low, new entrants’ will face a difficult and costly uphill battle as they attempt to bring on high quality providers onto their platforms, and compete to secure employers and health plan contracts in advance of leaders like Teladoc, MDLive, American Well and Doctor on Demand, who are already expending significant costs to capture market share of these customers. A robust salesforce and brand awareness are key to penetration, but also not effective without offering ease of product implementation & interoperability, billing & claim filing, and regulatory compliance (HIPAA, NCQA). The strategy to secure employers and health plan contracts is an attempt to capture mass membership quickly and establish high switching costs as many self-insured employers (ASO) and insurers may only adopt one telehealth platform; according to a 2016 analysis released by the Congressional Budget Office, ~155 million Americans have employer-based health insurance coverage.

However, there is room for certain specialist-focused telehealth startups, such as Spruce, who is primarily focused on the dermatology market, which remains untapped by incumbents and accounts for >5% of annual visits, or 56 million visits. This type of specialist visit is recurring and typically costs higher (up to 3x – 4x the cost of a primary care visit).

The existing focus among players remains client growth, but the future indicator of market dominance will be member conversion and [recurring] utilization to drive PMPM, visit fees and secure client relationships. Achieving these future indicators will rely on management, business models, consumer-centered & mobile-optimized products, and seamless integration of concentric mergers.

Why now? – Political

This future of healthcare has been accelerated because of easing regulation on telemedicine definition, reimbursements and coverage. Already in 32 states and the District of Columbia there are parity laws that require private insurers to cover telemedicine visits the same way they cover in-person encounters, and in 49 states and District of Columbia reimbursements are now provided for video visits in Medicaid fee-for-service programs.

Additionally, more states have removed the requirement for a tele-presenter to be present during a virtual consultation. Finally, 18 states have enacted laws to join the Interstate Medical Licensure Compact, which will begin to grant crossborder licenses.

Why now? – Social

Easing regulation complements today’s consumer needs. Consumers no longer want to pay high costs for healthcare and are looking for more personalized care at a time when many of the other decisions they make on a daily basis have been empowered with technology and made more affordable, accessible and personalized (i.e. food, wealth management, online streaming, transportation, travel, shopping). Early direct-to-consumer fitness trackers and health apps invited consumers to increasingly value and invest in their health, and track their own progress and symptoms.

Telehealth will continue to gain traction especially at a time when Repeal and Replace Obamacare risks exacerbating lack of access and rising costs. Approximately 1/3 of all ambulatory care visits, or 417M, are treatable via telehealth, which would result in an annual saving of $6 billion in U.S. healthcare costs. Cost saving opportunities via telehealth are also true for other specialist services.

Big 4 Telehealth

The four largest telehealth players are Teladoc (NYSE: TDOC), MDLive, American Well, and Doctor on Demand. Despite Teadoc’s current leading market position with ~17M members, it still represents only a minority of the whole market.

Teladoc Investor Presentation

Of these four, Doctor on Demand (DoD) is unique as it does not charge a “Per Member, Per Month” (PMPM) subscription fee, which typically costs $1 PMPM. Unlike the other three, DoD only charges visit fees, which they keep ~25%:

Medical Doctor:
$49 for a 15 min consultation

Psychology:
$79 for a 25 min consultation
$119 for a 50 min consultation

Lactation Consultant:
$99 for a 25 min consultation
$229 for a 45 min consultation

As telehealth platforms compete for employers, DoD offers an affordable option without the PMPM fee. While DoD’s model lacks the initial recurring revenue from PMPM fees, it is able to more easily align with the cost savings and ROI incentives of employers, drawing evidence that utilization rates are below 5% with other major players; Compared to Teladoc’s 5%< utilization rate, DoD boasts a much higher utilization rate of 25%-30%.

In other words, the cost per visit with Teladoc is significantly higher than $49 when factoring in PMPM. This strategy has had promising evidence as DoD now has about 400 employers (200% increase YoY) including Comcast and Union Bank & Trust, covers more than 45 million Americans and has secured relationships with UnitedHealth, Highmark*, Humana, and a number of Blue Cross Blue Shields.

*Highmark ended $1.5M contract last year with Teladoc to switch over to DoD and American Well. Most Teladoc contracts are only 1-year old…

Adoption goes both ways.

Slack, Dropbox, LinkedIn and many others have demonstrated that adoption goes both ways. And similarly, monetizing the B2B becomes much easier to achieve if you’re able to demonstrate success with B2C. DoD has since introduced a Per Provider Subscription Fee…(I don’t have numbers around this).

This is a defining time for healthcare – the winners have yet to take all and new entrants will need to be thoughtful about their unique entry point and resourceful with acquisition.

The Future As We Saw It At SXSW

A few days at SXSW is enough to challenge your current perspective and expectations of the future of markets, industries, technologies and human behavior. This year at SXSW Interactive, social media, connectivity (IoT), 3D printing, healthtech and sustainability were all major topics of discussion.

Social Media

The newest member to the tech community, Meerkat, proved that video is the future as a form of communication between individuals, not just brands to individuals, and that communities quickly form around the sharing of short, real-time and visual content. Meerkat successfully leveraged an existing social network, Twitter, to create overnight communities and viral content.

The challenge now will be how Meerkat can continue to grow independently and maintain engagement on its own platform as Twitter has limited Meerkat’s access to its social graph going forward. Piggy-backing large social networks is nothing new and neither are the lessons learned – take for example Zynga and Facebook.

With so much content flooding the twitter streams during SXSW, from meerkat tweets to keynote quotes to party pictures, the hashtag proved its power and necessity to individuals. With the hashtag, you were able to find everything related to a campaign, event, brand, discussion all in real-time and instantly react to it. #FOMO would be even worse without the hashtag.

At a panel called “Breaking News in the Age of Snapchat”, a White House Senior Advisor, Dan Pfeiffer, and News and Guts CEO, Dan Rather, emphasized the distinction between news and content. Social media has completely redefined who is a reporter and the role of a reporter. With the barriers of information distribution removed, traditional systems will need to adapt quickly to these new channels to be able to manage their own content and distribution (but of course there will never again be complete ownership of information with the growing adoption of social media across the world). I share the same views that live-streaming video services will do to television news what blogs did to printed news.

Transportation

Lyft stepped up its game with Lyft Line, while the SXSW shuttle was a total fail and ultimately converted shuttle pass holders to lyft riders. With Lyft, there was a $10 fixed price per ride as long as you requested Lyft Line. Profitability aside, the campaign was successful with new lyft users and communicated loud and clear its mission – to reconnect people and communities through better transportation. Would love to see some of those numbers from Lyft after SXSW.

The limited transportation options in Austin was also a reminder that there is much innovation needed still in transportation, including public transit, real-time navigation and road closure/traffic/accident notifications, and parking. Most recently, Leap Buses launched in SF to provide a more convenient public transportation solution that enables riders to continue their mobile experience on the bus and access wifi, food and drinks all from their phones. It’s no doubt that connectivity is the next big thing in transportation.

Leap Buses also makes me wonder if individuals are willing to pay a premium to ride Leap Buses because of their need to access wifi while in transit or if they just want the more luxurious experience compared to the regular buses. Or maybe they want to be surrounded by the type of people who value the availability and use of such technologies – tech-savvy individuals are a new class in our society that now exist between the upper middle class and upper class. These type of people are the ones who have transformed Uber into a successful global luxury brand.

At the Interactive Innovation Awards, there was indeed a transportation category and the company that won was Guide Dots – an audio-based guide app for the visually impaired.

Diversity and Workforce

Diversity was a big topic this year at SXSW, while the Pao vs. Kleiner trial continues. I appreciated that more industry leaders, including many women, voiced their opinions about evaluating individuals not based on ethnicity, gender or sexuality but based on their unique background and what they bring to the table. I truly believe that until companies and individuals stop encouraging women and employing or promoting them in order to “achieve” diversity in their workforce, will we be able to reach equality. Equality is not in the numbers, its in the mindset.

Princess Reema’s keynote on the taboos and struggles women face in Saudi Arabia was definitely a highlight at SXSW.

We are at the heart of the “mobile workforce movement” as Kevin Gibbon, CEO of Shyp, calls it. On-demand services such as Uber, Lyft, 3D Hubs, TaskRabbit, Seamless, Wun Wun, and many others enabled individuals to create value with their idle talent, time and assets. I’m particularly excited to see so many individuals become merchants of their own skills and small business owners. As the mobile workforce grows, we will begin to re-define what it means to be a contractor or part-time employee, and tangent industries such as insurance will evolve to service this new workforce (Check out how my friend Tristan Zier’s startup Zen99 is supporting contractors).

HealthTech

I noticed a growing presence and emphasis on HealthTech at SXSW this year, including a health and medtech expo at the JW Marriott Hotel. We are seeing more technology applications in the healthcare space (Go SOLS!) and there is a lot of discussion about the future of remote [self] diagnosis, health monitoring from afar, preventative solutions and use of wearables. Many venture capital firms have recognized this opportunity and need for innovation and healthcare and have already begun investing heavily in this space.

We are seeing new tools for diagnosis, such as the aliveCor and Cell scope that have re-invented the stethoscope and otoscope, respectively. However, on the wearables side, there is struggle to establish trust and engagement with both the consumers and providers. We continue to see a high drop-off rate with consumer engagement with wearables; the length of use is not long enough for the consumer to benefit from the device’s collection of the individual’s data. As such, the consumer is unable to see or benefit from the long-term use of the wearable. There needs to be a series of measurements over time and visual data to help individuals understand their health and encourage preventative behavior (i.e. decreased smoking benefits are made aware to the consumer through the wearable)

While I agree that the fashion first approach is necessary at the point of purchase with the consumer, incentivizing individuals to buy the product, it does not prevent the product from becoming an idle asset (My Nike Fuelband looks great on my dresser…).

Ayesha Khalid beautifully summarized one of the most pressing questions in healthtech: “How can information from all these apps and devices feed to EMR providers to enable effective and consistent information sharing between the patient and provider for more accurate health monitoring and diagnosis?”

When at SXSW in 2016…

Convinced you’re going to be at SXSW in 2016? Great – here are just a few tips before you set out for next year then.

– Pick out your top hotels for the day and just jump in and out of talks at that location. Each hotel has a theme.
– Pick talks on topics that are foreign to you. This is an opportunity to learn not to reassure your knowledge on a topic or justify your opinions.
– The keynote speakers is a Must attend! Illuminating, educational and inspirational talks from industry leaders.
– Explore topics across industries – finance, health, fashion, enterprise, etc. This is your chance to gain a holistic view on the latest leading technologies in the world.
– Challenge yourself throughout the week to meet someone new. SXSW is one of the best and most natural ways to meet people.
– Party. But don’t party too hard – lesson learned.

Tiffany’s Birthday Fundraiser for BrightEyes

Please help me celebrate my 25th birthday by joining me in contributing to BrightEyes, a mentorship program dedicated to providing college students a unique opportunity to explore different career paths.

Four years ago, I started BrightEyes in hopes to make mentorship and career opportunities more accessible to students. With your help and generosity, we will be able to send a class of students to San Francisco, where they will be able to meet with their role models and future mentors as well as tour leading companies in startup, tech and venture capital.

I’ve also decided that I would be matching the total donations made on my campaign page, up to $1,000, so please consider giving!

To be successful, we all require someone willing to invest in our potential and vision. We’ve all had someone invest in us along the way. Join me in investing in these students’ vision and potential.

Contribute to BrightEyes: http://brighteyes-students.org/donations/

If you are not in a position to donate monetarily, please like BrightEyes on Facebook and share the program with friends & family, on Facebook, Twitter, and anywhere else you’d like!

Thank you for helping me celebrate my birthday this year.

My Notes on “Notes on Startups, or How to Build the Future”

I’ve decided to share my notes and thoughts on Peter Thiel’s Zero to One. Additionally, I’ve also embedded suggested reads in my notes that are relevant to the topic or chapter. For those who haven’t read the book (read it!), here’s a preview of it and some of the more powerful takeaways for me while reading it. For those who have read it, I hope this is a helpful reminder for you and a good reference as you continue to help build our future.

Note: Comments in parentheses are my own.

Zero to One
Peter Thiel with Blake Masters

(1) The Challenge of the Future

The act of creation is singular, as is the moment of creation, and the result is something fresh and strange.

By creating new technologies, we rewrite the plan of the world.
Debate: Is there a formula for entrepreneurship?

The single most powerful pattern I have noticed is that successful people find value in unexpected places, and they do this by thinking about business from first principles instead of formulas.

What important truth do very few people agree with you on?

Conventional beliefs only ever come to appear arbitrary and wrong in retrospect; whenever one collapses, we call the old belief a bubble.

What triggered dot com bust / bubble pop?

Dot Com Timeline

(2) Party Like It’s 1999

4 Lessons from Dot Com Crash:
1 – Make Incremental Advances

2 – Stay Lean and Flexible: lean = unplanned. You should not know what your business will do; planning is arrogant and inflexible. Instead you should try things out, “iterate” and treat entrepreneurship as agnostic experimentation.

3 – Improve on the Competition: don’t try to create a new market prematurely. The only way to know you have a real business is to start with an already existing customer, so you should build your company by improving on recognizable products already offered by successful competition

4 – Focus on Product, not Sales: technology is primarily about product development, not distribution

( Did companies like Product Hunt have a market-ready product first or did they build with the market and succeed with distribution as a result of social media?)

(3) All Happy Companies are Different

Monopolists, by contrast, disguise their monopoly by framing their market as the union of several large markets:

(Examples)
Search Engine X Mobile Phones X Wearable
Computers X Self-driving Cars

Monopoly is the condition of every successful business

(4) The Ideology of Competition
Carl von Clausewitz
Sun Tzu

(5) Last Mover Advantage

A great business is defined by its ability to generate cash flows in the future.
(Bubbles form when individuals inflate a company’s ability to generate CF in the future!)

Characteristics of a Monopoly:
1 – Proprietary technology: rule-of-thumb prop. tech must be at least 10X better than its closest substitute
2 – Network effects: network effect businesses must start with especially small markets
3 – Economies of scale
4 – Branding

People then products then traffic then revenue – Marissa Myer’s rebrand of Yahoo!

(It’s a balance of first-mover advantage and last-mover advantage)

(6) You are Not a Lottery Ticket

“Success is never accidental.” – Jack Dorsey on twitter

(Most people believe getting a job in finance is impossible without previous finance experience or technical skill set. The same is true for when people think about getting a job in tech. It’s possible to create the experience for yourself by accessing the same resources, engaging in the same conversations and building the same relationships with those already in those roles in the industry. So really, nothing is impossible because nothing can’t be learned.)

(Diversification of experiences and skill sets. In my opinion, specialization is overrated. I haven’t felt the need to specialize to be successful, only to be good at what I’m currently doing. And if you’re doing what you’re passionate about, you can’t fail.)

You’ve spent a decade curating a bewilderingly diverse resume to prepare for a completely unknowable future. Come what may, he’s ready – for nothing in particular.

Indefinite Optimism

Today, “good design” is an aesthetic imperative
It’s true that every great entrepreneur is first and foremost a designer
Visual + Experiential Perfection

(Design your business)

(7) Follow the Money

Two Rules for VC:
1. Only invest in companies that have the potential to return the value of the entire fund
2. Because rule number one is so restrictive, there can’t be any other rules

People who understand the power law will hesitate more than others when it comes to founding a new venture: they know how tremendously successful they could become by joining the very best company while it’s growing fast.

(8) Secrets

What secret is nature not telling you?
What secrets are people not telling you?

The actual truth is that there are many more secrets left to find, but they will yield only to relentless searchers.

A great company is a conspiracy to change the world.

Thiel’s Law: a startup messed up at it’s foundation cannot be fixed

(9) Foundations

To anticipate likely sources of misalignment in any company, it’s useful to distinguish between three concepts:
1. Ownership: who legally owns a company’s equity?
2. Possession: who actually runs the company on a day-to-day basis?
3. Control: who formally governs the company’s affairs?

Anyone who doesn’t own stock options or draw a regular salary from your company is fundamentally misaligned

Any kind of cash is more about the present than the future.

(10) The Mechanics of Mafia

‘Company culture’ doesn’t exist apart from the company itself: no company has a culture; every company is a culture

Never outsource recruiting

Why should the 20th employee join your company?

2 Great Points of Evaluation of a Candidate:
1. Good candidates can answer why your mission is compelling or why you’re doing something important that no one else is going to get done
2. Why is your company a good match for the individual personally

Everyone at your company should be different in the same way

The early team should share a common, unique obsession/idea that relates to the company’s mission
(Value propositions must be defined early on. Essentially, you’re forming a cult. Airbnb is one of the best examples of a great culture that’s continued despite its growth in size)

On the inside, every individual should be sharply distinguished by her work

Defining roles reduce conflicts
– Most fights inside a company happen when colleagues compete for the same responsibilities; startups face an especially high risk of this since job roles are fluid at the early stages
– Eliminating competition makes it easier for everyone to build the kinds of long-term relationships that transcend mere professionalism

Every company is also its own ecosystem

(11) If You Build It, Will They Come?

The engineer’s grail is a product great enough that “it sells itself.” But anyone who would actually say this about a real product must be lying…

If you’ve invented something new but you haven’t invented an effective way to sell it, you have a bad business – no matter how good the product.

Advertising works for startups when CAC and CLTV make every other distribution channel uneconomical (i.e. The advertisements justify the method of acquisition because of users and revenue achieved…all about ROI)

A product is viral if its core functionality encourages users to invite their friends to become users too. (Network effects in The Networked Age)

Just get on distribution channel to work, then have a great business

Important to have PR strategy; selling company to media is necessary part to selling to everyone else

(12) Man and Machine

People compete for jobs and for resources; computers compete for neither

But big data is usually dumb data. Computers can find patterns that elude humans, but they don’t know how to compare patterns from different sources or how to interpret complex behaviors. Actionable insights can only come from a human analyst

(Will this statement always be true? Maybe the human role will change but will not become obsolete with new technologies that require human guidance but predictive analytics will become so powerful that patters across sources can and will be effectively interpreted by computers)

(13) Seeing Green

Seven questions every business must answer:
1. The Engineering Questions: Can you create breakthrough technology instead of incremental improvements?
* Proprietary technology significantly differentiates?
2. The Timing Question: Is now the right time to start your particular business?
3. The Monopoly Question: Are you starting with a big share of a small market?
* Identify and Own a niche market
4. The People Question: Do you have the right team?
5. The Distribution Question: Do you have a way to not just create but deliver your products?
6. The Durability Question: Will your market position be defensible 10 and 20 years into the future?
* The Last Mover
7. The Secret Question: Have you identified a unique opportunity that others don’t see?

Myths of Social Entrepreneurship:
“…corporations have great power, but they’re shackled to the profit motive; nonprofits pursue the public interest, but they’re weak players in the wider economy. Social entrepreneurs aim to combine the best of both worlds and ‘do well by doing good.’ Usually they end up doing neither.”

Great companies have secrets: specific reasons for success that other people don’t see.

(14) The Founder’s Paradox

A unique founder can make authoritative decisions, inspire strong personal loyalty, and plan ahead for decades.

Paradoxically, impersonal bureaucracies staffed by trained professionals can last longer than any lifetime, but they usually act with short time horizons.

*We need founders…a great founder can bring out the best work from everybody at his or her company

(Conclusion) Stagnation or Singularity?

“Our task today is to find singular ways to create the new things that will make the future not just different, but better – to go from 0 to 1.”

Joining the SOLS Family

Ever since I learned about 3D printing, I’ve been fascinated with the technology and even more excited about it’s many applications across all industries.  What makes 3D printing special is the ability to customize at scale in a short amount of time.  Although 3D printing has been around for over 30 years, its place in the consumer space is only beginning to be realized.  We are now seeing experimentation with everything from game figurines to home decor to orthotics.

Today, I am excited to share that I am joining the SOLS family.  At SOLS, the team is focused on creating products custom to the human body and movement, empowering individuals to move in new ways and push their physical limits.  SOLS is improving our human abilities one step at a time.

SOLS