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.

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

Twitter & My 5-Year Anniversary

I joined Twitter July 2009.  5 years later…I’m more active on my account than I’ve ever been.  I began as a follower, became a curator and now also a content creator through my blog posts.

Twitter has granted me ease of access to information across a range of topics, allowed me to create real offline connections that I would not have otherwise been able to make, given me a voice and power of influence with the CEO’s, politicians and educators of this world, and created a new habit for me.

#onlinefirst

With only 140 characters, we are able to stay current with the news, learn something new, engage with our immediate and the global community and express ourselves. Twitter has removed the need for search and given us constant access to knowledge; search now happens after. And having this channel of real-time information has provided us with transparency about industries, corporations and governments. We are more informed and educated than we’ve ever been because of twitter, and this has inspired individuals to challenge long-established systems and advocate change to remove constraints to our freedom, such as we’ve seen recently with Turkey and during the Arab Spring, and also with Student Voice – twitter chats that enable students to be heard and influence decisions around education.

#transparency

Twitter has also allowed me to connect with individuals in a new way and so much of my network today has originated from twitter. There once was a time when online connections were considered ingenuine, such as when people distinguished between “Facebook friends” and real friends. But on Twitter, conversations initiate relationships; followers are less predetermined by existing relationships and driven by content, not by professional statuses or pictures that typically create exclusivity or immediate filtering.

#relationships

Twitter has touched upon every area of my life, from social to education to professional, and has changed how I explore and connect within these areas. I have yet to see another web and mobile service that is able to provide such speed and penetration of information and enable its users to create impact at a global level.

twitter-icon

Follow Me on Twitter @tiffanydstone

Show Me the Money

Created by Tiffany Stone
Created by Tiffany Stone

Alternative lending involves various types of loans available to consumers and business owners outside of a traditional bank loan.  Alternative lending includes crowdfunding (rewards and equity-based), peer-to-peer lending (interest-based, asset-based, consumer, small business) and other non-bank financial firms.

I’ve shared below my comparison of a few major online alternative lenders, including Lending Club, Prosper, Earnest, LendUp, Sofi, Upstart, OnDeck, Kabbage, Borro and Wonga.

Alternative Lending Comparison Slide 1 - Tiffany Stone Alternative Lending Comparison Slide 2 - Tiffany Stone Alternative Lending Comparison Slide 3 - Tiffany Stone Alternative Lending Comparison Slide 4 - Tiffany Stone Alternative Lending Comparison Slide 5 - Tiffany Stone Alternative Lending Comparison Slide 6 - Tiffany Stone