Why Physicians Are Turning to Startups

flying cadeuciiTo appreciate the potential impact of the startup movement on health and medicine, you really need look no further than Drs. Rushika Fernandopulle and Farzad Mostashari (disclosure: I was colleagues with both at college and later at MGH).

Both are passionate about transforming healthcare – Fernandopulle has an M.D. and a public policy degree from Harvard, and was the first executive director of the Harvard Interfaculty Program for Health Systems Improvement; Mostashari served as Assistant Commissioner for NYC’s Department of Health, and more recently as the National Coordinator for Health Information Technology in the U.S. Department of Health and Human Services in the Obama administration.  Both are committed to improving the delivery of patient care.  And both have deliberately chosen to pursue their vision by creating a company as the vehicle to deliver the change they each believe in.

“The world of start-ups may not be the usual path for those leaving a senior federal post,” wroteMostashari about his new direction, “but it’s the right decision.”

Last month, Mostashari founded Aledade, which seeks to enable independent, primary care physicians to establish accountable care organizations.

A few years earlier, in 2010, Fernandopulle co-founded Iora Health, aninnovative model of direct primary care, and continues to serve as CEO.

Explains Fernandopulle,

“As a practicing physician it soon became obvious our current model of care delivery does not work; instead of simply complaining about it I felt I needed to try to fix it, but got frustrated trying to do it within existing health systems, and found studying the problem (in academics), working through the government, and consulting was not effective. I decided that the best way to make change happen quickly was to simply strike out myself and just do it- being an entrepreneur allows you to break what others think are the rules (they aren’t) and take change into your own hands.”

Fernandopulle and Mostashari aren’t alone – across the country (and the world), physicians from every specialty are creating, joining, or hoping to joinstartups.  While many of these doctors are fairly junior, and have little (if any) substantive clinical experience, some are more seasoned – HealthLoop’s Jordan Shlain comes to mind, for example.

While the motivation is probably slightly different for each physician-entrepreneur, I suspect that the common theme is a deep-seated passion forexplosivetangible real-world impact – and the optimism and conviction to believe you can achieve this.

Passion: Participation in the startup is an expression of a heartfelt conviction – it’s not a job, a way of getting paid, but rather a form of self-actualization.  This is the John MacKayRichard Branson, Howard Kurtz, and Mark Zuckerberg view of the world – not that of Valeant’s Michael Pearson and the “Outsider,” spock-like CEO’s William Thorndike lionizes, nor the middle manager phenotype that Monster.com famously mocked.  (Then again, Scott Adams, of Dilbert fame, has argued it’s misguided to follow your passion, suggesting you tend love what you’re successful at, not successful at what you love.)

Explosive: “Startup” is used here explicitly in the Paul Graham, Startup=Growth sense – generally VC backed, formed with expectation and intention of hitting a phase of exponentially accelerating growth.  Most new companies (think local dry cleaners and restaurants) aren’t startups, in this sense (though occasionally they hit it big; the EMR giant Epic, for instance, grew gradually and famously never took a penny of VC funding).  In contrast, companies started by doctors like Fernandopulle and Mostashari are supported by A-list VCs (Polaris, Fidelity Biosciences [disclosure: I spent some time with this firm about eight years ago], Venrock) precisely because of the aspiration for explosive growth.

Tangible, real-world: The goal of Aledade and Iora Health isn’t to come up with a brilliant idea validated by publication in a top-tier scientific journal or think tank white-paper, but rather to tether a promising idea to successful implementation, as demonstrated by adoption in the market.  Startups – as Iargued in 2005 – represent, in a sense, the purest distillation of the translational research ideal.

Impact: Perhaps no aspect of startup culture has been more lampooned than the idea that you’re trying to dent the universe, disrupt, revolutionize, and make the world a better place.  Turns out: it’s true – most entrepreneurs truly are striving for outsized impact.  Similarly, many physicians were drawn to medicine because they saw in it an opportunity to make a difference; startups, it would seem, represent a natural vehicle for this ambition.

Optimism and conviction: These qualities – which I might summarize as “startup=applied hope” — represent my favorite aspect of silicon valley, and arguably capture its most distinctive, compelling, and essential features.  There’s a pervasive sense of possibility out here, a belief that a smart, motivated group of people can, must and will change the world.   While such fervent, almost religious optimism can be both excessive and dangerous (see here and here), in moderation it can also be enormously attractive – and for many physicians, ego-syntonic.

With so much going for startups – not to mention the ever-increasing number of digital health accelerators, incubators, and translational centers that now dot the landscape (I’ve been very impressed by the experiences I’ve had with Rock Health, the UCSF Center for Digital Health Innovation, and theMakerMD community, and I’ve been privileged to be a co-founder of the MGH/MIT Center for Assessment Technology and Continuous Health [CATCH]) – the real question may be why more physicians aren’t leaving for startups.

Four factors may stand in the way:

  • Professional pressure to stay in the system.  Many early career physicians contemplating entrepreneurship are counseled by colleagues not to “throw away” their training, and to remain in clinical medicine.  While the idea of academic physicians urging young doctors to become…academic physicians is hardly new, entrepreneurship may be seen to represent a double disappointment – leaving the fold, and joining the private sector.
  • Institutional pressure to surrender all (promising) IP to the university or hospital.  The flip side of the first challenge: many institutions, perennially on the hunt for new sources of revenue (especially in the context of a tight NIH budget) pounce on any physician advancing a promising idea – see this 2012 Boston Globe story involving a doctor from MGH.  I’ve been amazed by the amount of feedback I’ve received from fellow physicians about this specific concern.  I suspect many academic leaders may  inadequately appreciate the extent to which their own institutional policies may be damping the exact entrepreneurial spirit they’re trying so intensively to cultive.
  • Concern from potential collaborators and (especially) investors that physicians are more likely part of the problem than part of the solution.  I’ve heard some well-known technology-focused VCs here in the Valley suggest doctors are too enmeshed in the system to develop radically disruptive solutions — though many of these same investors have also gone on to fund companies with physician founders or co-founders.  As I’ve long argued (here, too), physicians can bring unique insight to the problems of their profession, and are often more motivated than anyone to drive change.  I believe deeply in the value of what Eric von Hippel’s, “field discovery,” in Aenor Sawyer’s “front line innovators,” in Judah Folkman’s “inquisitive physicians.
  • Inertia:  The challenge of change may be the most difficult problem to solve.  Especially as their careers start to accelerate, physicians tend to be both extremely busy and reasonably well-paid (certainly compared to the salary they’d likely pull at a newly-funded startup).   It’s hard to leave something you know well, and that you’re good at, at that you’ve invested so much time in, and leap into the unknown – to say nothing about the open architecture (most startups have not gotten Maria Konnikova’s brilliantNew Yorker memo) and brogramer culture.  Not surprisingly, many physicians who ultimately leave medicine to become full-time entrepreneurs do so gradually, or else make the decision before they even enter clinical practice.

Despite these concerns, and others, the draw of entrepreneurship in medicine may prove too overpowering to restrain.  As Fernandopulle summarizes,

“When I decided to strike out on my own it was seen as crazy, and there were very few physicians doing it. Now I see more and more (mainly younger) doctors deciding to leave full time practice and spend some or all of their time in startup companies. They sense the huge opportunity to remake the health care system, and people with both a clinical perspective and credibility and system/business skills will be key to building new tools and models.”

I share Fernandopulle’s enthusiasm — I’m tremendously optimistic about the potential for synergy and the opportunity for impact that physicians have at startups.  So much so that (disclosure) I’ve recently changed jobs, and this very week, joined a silicon valley startup, DNAnexus, as Chief Medical Officer, where I’ll get to focus on a topic that’s animated me since I read Eighth Day of Creation in high school: delivering upon the collaborativepatient-inspired vision of genome-enabled (really, data-enabled) medicine.

My former biotech colleagues have no doubt concluded that the world is already a better place.

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35 replies »

  1. Subsequently, after spending many hours on the internet at last We’ve uncovered an individual that definitely does know what they are discussing many thanks a great deal wonderful post ?Nice Post. It?s really a very good article. I noticed all your important points.

  2. Peter1, I actually don’t like the tax deduction and would end it for healthcare, but since some get the deduction for the increased premium that covers near first dollar care it is only fair that the same deduction be given to those with high deductibles.

  3. Don, you didn’t explain the process so that one could understand what is being done.

    Why not provide an example including how a premium is determined and how it might change, the deductible and how that might change as well.

  4. “As you know I like high deductible insurance and HSA’s because they make people think before spending.”

    And the tax savings of course.

  5. In a nutshell, we serve as the primary insurer from the first dollar of claims for self-funded employers.
    Heretofore, the employer assumed all the risk, up to the stop-loss point, other than deductibles, co-pays, and co-insurance.
    Employers can set up deductibles, if they wish, and utilize our unique deductible refund feature.
    The bottom line for employers is that their risk lessens significantly, over time, as our risk increases over time.
    With less risk, the employer needs lower reserves.
    Premiums are lowered significantly, for our benefits accrue on a paid-for basis (other than a recurring $60 per month administrative fee).
    So, once an employee accrues $60,000 of paid-for benefits, his premiums are reduced 80%. (the same would be true for any insurer whose coverage starts after $60,000 of expenses)
    Many brokers are on board , those advising employers who self-fund with 250 employees or more.
    Earlier this week, we met with union leaders who are renegotiating their contract. Initially they were interested in HSAs.
    When they saw our contributions earning a 35% return – guaranteed – they quickly decided HSAs, with their piddly interest, are not for them.
    We now have a small portion of the union on board for 2015.
    If we perform as illustrated, we should get most of the remaining union for 2016.
    Madison Higginbotham, the largest third party administrator in Texas, is on board.
    Their president has called us several times in the last month, asking if we are approved yet by the Texas Department of Insurance.
    Unless new information is needed we are not aware of, we are looking for approval in the next 7 days.
    I understand people’s reluctance and skepticism, while hearing only of the highlights.
    Once they see the meat and potatoes of the plan, most people can’t wait for dinner to start!
    Brokers working with self-funded groups of 250 or more employees are welcome to contact me at donaldlevit@aol.com.
    Don Levit

  6. Send an email to the blog administrator. I am sure they will post any reasonable op ed that is relevant, but be prepared for a lot of criticism.

    If they won’t there is nothing stopping you from explaining it in your responses.

  7. “It’s managing risk, just like a high deductible plan”

    Then it has some of the benefits of a high deductible plan and that might include a reduction in moral hazard.

    There are many ways to shift numbers so you probably are correct in your attitude. As you know I like high deductible insurance and HSA’s because they make people think before spending. I thought he might have something new that affected behavior, but you seem to be better informed on his plan than I.

  8. It’s managing risk, just like a high deductible plan, no better, no worse. As Don agreed, the risk is the risk, all you can do is manage it. We also don’t know what his risk mix is to compare it. He admitted, if you don’t have claims you pay cheaper price – well duh, all insurance does that.

    Does his plan determine if people put off necessary care, I don’t know, but it probably doesn’t work any better or worse than a HDHP with HSA. It’s just a buy my bananas or buy my oranges marketing gimmick, if you luck out on claims you pay less, if your luck is bad you pay more.

    Does his plan work any better than not having insurance and always paying out of pocket in managing behavior – I don’t know.

    What his plan does not do is cut medical provider prices – now that would be innovative.

    As I said, the patent office is overworked and full of idiots. You can now have a vague concept and get it patented.

  9. Allan:
    If the blog administrator would like me
    to explain the general design and the
    Methodology and actuarials performed by Milliman for the last three years I would be willing to write up a separate posting
    Don Levit

  10. OK Peter1 then you can answer my question. Is Don’s development supposed to be managing risk better or is it managing behavior and cutting down on moral hazard?

    If risk (not saying what he is doing will work or not) is he reducing the selection process?

    Perhaps you can tell me the details of Don’s plan that is protected by patent.

  11. “Unless you discussed this elsewhere no one knows enough about what you are doing. ”

    Well allan, it looks like I know enough about insurance that Don answered my questions in the affirmative about his “plan”.

    There’s nothing new in risk management.

  12. Don, I don’t know how the others can even discuss this situation with you. Unless you discussed this elsewhere no one knows enough about what you are doing. Have you considered writing this up and then posting it as a new blog on this site?

  13. “Lowering our risk by reducing one’s HMI account balance offsets the claim”

    So it’s not as if the insured is not loosing anything. You cover the claim by a reduction of HMI. If the claim is big enough there is no HMI.

    The rouse that the insured is not having a premium increase is offset by the higher risk assumed by the insured.

    Unfortunately insurance companies have the ability to fool all of the people all of the time.

  14. I think we are talking over each other because we are looking at different definitions of risk.

    How sick is your cohort compared to enrollees of other insurers?

  15. Not exactly.
    Traditionally, health insurance is defined benefit plans.
    When the benefit is used, the risk stays the same, but the premiums rise.
    Lowering our risk by reducing one’s HMI account balance offsets the claim, without having to raise premiums.
    It is vital to making our plan work, actuarially.
    Don Levit

  16. Initially we are looking at self-funded employers of 200 or more employees.
    Currently, the employer/employee has the first dollar risk, up until stop-loss insurance takes over for catastrophic claims.
    We are now the insurer of first dollar, from a zero deductible,reducing the employer’s risk and needed reserves, over time.
    Next year, we will consider smaller employers
    and be on the exchanges in 2016.
    Don Levit

  17. How does the health status, co-morbidities of your pool compare to other large insurances? Medicaid?

    Without adjusting for co-morbidities it’s simply not possible to make any judgment on the efficacy of the design.

    It’s quite possible that your system deals with healthy people better than others.

  18. “How would you define “accurate risk adjustment?”
    In the parameters of our product, we are reducing the employee’s/ spouse/dependents accounts , dollar for dollar, based on claims.”

    That’s no different from any other insurance – claims=cost

    Don, your just putting the pea under a different shell, it’s the same game.

  19. How would you define “accurate risk adjustment?”
    In the parameters of our product, we are reducing the employee’s/ spouse/dependents accounts , dollar for dollar, based on claims.
    For example, if the employee has $10,000 of Health Matching Insurance benefits, and he has a $3,000 claim, his total is now $7,000.
    He reverts back to the month corresponding with $7,000 of benefits, and his account starts to rebuild.
    By lowering his HMI account balance, we feel we are “risk adjusting” his benefits. We have used reserves to pay his claim, and we have offset that reduction in reserves by reducing his benefits balance.
    Note that the spouse and children’s accounts are not affected by the adjustment to the employee’s balance. In effect, we are pooling each person’s account balance.
    Don Levit

  20. Without accurate risk adjustment incremental efficacy of an innovative insurance design can never be known.

  21. Thanks. I was reading the responses and from some of the comments it seemed as if Don might have posted more information in a prior blog that I was unaware of.

    I have been listening for about 1 year to Don’s proposal, but I know earlier he was reluctant to discuss details pending some type of patent to protect his IP.

  22. Saurabh, do you know the details behind the plan? I can easily see a plan saving money if it involves incentives similar to those seen with HSA’s. Insurer’s don’t always have to adjust for every disease or even co morbidity since they can also rely upon total costs within a group (that depend upon personal actions rather than disease) that covers these diseases whether or not they are accounted for. I neither know nor understand anything about Don’s plan. If you know more can you explain to me what he is attempting to do.

  23. Agreed, I think physicians are not alone here. Many senior employees in their specific field come up with their new venture because they feel it will help them to serve much better and give them satisfaction.

    Health sector is very crucial as every life is dependent on health sector and if it shows quality improvement then it can certainly enhance the everybody’s health.

  24. Mostashavitz of the ONC was successful with the venture dollars?

  25. Correct.
    The risk is still there.
    It is the pooling of the risk that makes the difference.
    We intend to make a big splash.
    Putting theory into practice:
    Every dollar not taken as a claim is part of our reserves.
    Every dollar taken as a claim reduces our risk and our reserves.
    The benefits grow much faster than the typical claimant.
    The excess paid-for benefits is created by sharing our reserves, while claims are lower.
    Don Levit

  26. Don, you did not make the risk go away, you, as all insurance people do, re-packaged the same risk as a marketing tool to hoodwink premium payers into thinking they’re getting a better price. The premium payers are still paying for the risk.

    The risk is the risk, Milliman had just not seen it packaged your way before.

    The patent office is full of idiots.

  27. Good point
    When we first met with Milliman it took three hours for these conservative statisticians to even understand which is really a very simple design
    They simply had not seen anything innovative in 20 years and it took some time for their somewhat narrow minds to grasp
    The concept
    Regarding the patent I was surprised it went through
    How can such a simple but yet revolutionary concept not have been previously submitted
    No doubt many others conceived of it
    Don Levit

  28. You are right to inquire about risk composition. I don’t think that current methods of risk adjustment adequately adjust for co-morbidities.

  29. Saurabh, my cynicism has been vindicated by Mr. Levit’s response. The laughable part is he claims it’s patented.

    Whenever I hear “actuary” and “innovative” in the same paragraph my cynic meter goes off the chart.

  30. Correct
    Our risk builds with each $300
    Month contribution
    At over 30 percent return which is guaranteed benefits build rapidly on a paid for basis other than a reasonable administrative fee
    With no claims benefits build to $25,000 at 36 months and $50,000 at 60
    Months – guaranteed
    Claims lower the defined contribution balance and benefits start growing again from that point
    With a $25,000 deductible pre funded premiums reduce 55
    At $50,000 premiums reduce 75 percent whether one is b
    Blue Cross or National Prosperity Life and Health
    The difference is that with NPLH we negate medical trend and once the person reaches his maximum level the only cost that remains is a $60 per
    Month administrative fee
    Don Levit

  31. “Thru our patented Health Matching Insurance”

    Your risk is low so also is your rate?

  32. This is exciting and hopeful news
    I had an innovative idea for a health insurance plan about 20 years ago but had no practical way to implement it until I met two owners of an insurance agency 4 years ago
    After three years of further product design with Milliman a well respected actuarial firm we applied for our license as a life and health insurer two months ago
    We expect approval in the next ten days
    Thru our patented Health Matching Insurance we are able to offer lower costs today and significantly lower costs over time for self funded employers with 250 employees or more
    In 2016 we will expand to smaller employers and in 2017 to the public exchanges
    We will make our product known to private exchanges the day after we are approved by the Texas Dept of Insurance
    Don Levit, CLU,ChFC
    Treasurer and Head of Product Development of National Prosperity Life and Health