Venture capitalists are increasingly interested in emerging markets, and in working with local funds based in those markets (despite the fact that reverse innovation in venture capital seems counterintuitive). The reason for the interest in in part because the industry has suffered from poor returns on investment over the last decade; indeed, some sectors, including biotechnology, report negative aggregate returns. China and India, in particular, offer attractive liquidity and investment opportunities VCs haven’t seen for a while.
The interesting part of this shift is that VCs are taking a more holistic or “systems” approach to investing than they typically do in developed markets. Traditionally, VCs evaluate each investment as a discrete entity; the firms in their portfolio rarely interact with one another. In contrast, emerging-market VCs such as Nadathur Holdings (established in 2000 by N.S. Raghavan, one of Infosys’ co-founders) create intentional links between firms. Nadathur’s portfolio includes firms operating in drug discovery research, companion diagnostics, pharmaceutical analytics, reimbursement claims processing, patient relationship management, and specialty healthcare delivery for running clinical trials — and they all work together. In effect, the VCs at Nadathur Holdings serve as the executive team for a miniature healthcare innovation ecosystem.
Why do VCs in emerging markets take a systems approach? Because of three significant challenges innovators face in emerging markets:
- Innovation ecosystems are not well-developed. The supporting industries that an early-stage tech start-up needs simply don’t exist locally. VCs encourage upstream and downstream, often service-based, investments. These can be exited at lower multiples, with the trade-off of higher success rates for the R&D-intensive high-multiple investments.
- Technology-intensive firms are expected to generate revenues before they make an exit; local investors are reluctant to put money into start-ups centered on intellectual property. Portfolio firms upstream or downstream can help establish commercial proof, generate retained earnings and make it easier to get additional customers.
- Few local financial intermediaries (including VCs) exist. A portfolio that contains an entire ecosystem helps to decrease risk by allowing inferior business models to be refined or killed faster.Continue reading…
Unless you spend a lot of time around health policy wonks, you’ve probably never heard of the term “value-based health insurance benefits.” In fact, you may not even know that it’s the hottest new fad in the field.
Here is my layman’s summary: If you are like most people, you are not a very good consumer of health care. Odds are, you will fall for the latest fad advertised on TV or follow the advice you get at the bridge club instead of buying the care that has been scientifically shown to be better for you.
So as a corrective, a lot of employers are finding ways to “nudge” you into better decisions through financial incentives. Say you have a chronic condition and need to take certain medications. Your employer might drop your deductible down to zero (or may even pay your to take them) to encourage your compliance. But for services where there appears to be wasteful overuse (such as MRI scans), the employer might impose a hefty $500 deductible.
This idea intrigued me, so I turned to a rather lengthy article in the Washington Post, which informed that value-based insurance benefits are incorporated into the new health reform law, “including the requirement that new insurance provide free recommended preventive services such as mammograms and colon cancer screenings.”
In the world of big business, this idea is all the rage. One in every five employers employing at least 500 people is already doing it. Four in five employers who employ at least 10,000 workers say they are interested.
So if big business is for it; the government is mandating it; and health policy wonks like it; how could anyone possibly obj-……..Continue reading…
A couple of years ago my primary care physician suggested that I have a colonoscopy at the age of 47. My father died from Hodgkin’s disease at 34 and my mom survived breast cancer in her 40’s. I suffer from irritable bowel syndrome so she suggested that I have my colon checked out just in case. She recommended a very experienced gastroenterologist at a major Boston hospital.
My insurance would not cover the procedure because I am younger than 50, so I called the hospital to investigate how much it would cost me to have the procedure. Their first answer was that they did not know because no one had ever called in with that question before. This is a hospital which probably does more than one thousand of these every year.
I was transferred to someone else who was more helpful. She said it would depend quite a bit on what they discovered while I was undergoing the colonoscopy, but gave me a range of $2,000 to $4,500. I asked if there would be other charges and she said that the physician screening could cost $770 or more.Continue reading…
Game Show Watson wants to be a doctor. Well, almost.
Fresh off a commanding victory on Jeopardy, IBM will try to demonstrate that the combination of advanced natural language processing and sophisticated algorithmic decision-making capabilities involved in its extraordinary Watson computer can help humankind, not merely humiliate human competitors.
As I wrote on a previous blog, IBM began eying the medical marketplace more than 45 years ago. IBM CEO Thomas J. Watson, Jr. – son of the IBM CEO for whom this computer was named – put it this way in 1965: “The widespread use [of computers]…in hospitals and physicians’ offices will instantaneously give a doctor or a nurse a patient’s entire medical history, eliminating both guesswork and bad recollection, and sometimes making a difference between life and death.”
Now, IBM is ready to turn that vision into reality. At heart, Watson is the world’s most sophisticated question-answering machine. The company is collaborating with Columbia University and the University of Maryland to create a physician’s assistant service that will allow doctors to query a cybernetic assistant. IBM will also work with Nuance Communications, Inc. to add voice recognition to the physician’s assistant, “possibly making the service available in as little as 18 months.” For Nuance, it could be a major business line, and promises to carry over in the not too distant future to the mobile phone market, such as Apple’s iPhone, where Nuance is a major presence.Continue reading…
“England and America are two great nations separated by a common language.”
-attributed to both Winston Churchill and George Bernard Shaw
In 1965 I spent the summer of my third year in medical school at the General Practice Teaching Unit of the Royal Infirmary in Edinburgh, Scotland because I wanted to learn more about the National Health Service (NHS). My impression then was that both the U.K. and U.S. medical care systems were evolving toward the same end result from very different directions. (1) That viewpoint has been reaffirmed by recent events. Both countries have embarked this past year on significant health care reform. Both countries are seeking to reduce costs, improve quality, become more patient-centered, and invest in health information technology (HIT). In both countries the majority of patients are highly satisfied with the NHS or Medicare and are vigilant about not giving up any of its benefits.
Both health care reform acts are being criticized for being too timid, or too bold, or too incremental, or too radical. The U.K. plan is being attacked by some as a disastrous turn toward privatization while the U.S. plan is “another step toward socialism”, i.e. very little change in the tenor since 1965. Vocal U.K. critics on the left decry the proposed move away from regulation (NHS) toward competition and market-place economics while the vocal U.S. critics on the right warn against more regulation and movement away from reliance on competition and market-place forces.
Increased Primary Care Support
The basic foundation of the NHS has always been General Practice physicians (GPs) who have no hospital privileges and refer all patients needing hospitalization to full-time hospital specialists (Consultants). (2) In 1965, and in 1996, such a separation of outpatient and inpatient medical practice was threatening to community physicians in the U.S. (3) Today it is difficult to recruit primary care physicians (and some specialists) to a community unless the hospital has hospitalists to care for inpatients. The community-based internist in U.S. is now more like the GP in U.K. then ever before, and that is not a bad thing.
The most common question first year medical students ask me is how do they become efficient at taking a patient history. Can they skip certain parts of taking the patient history and avoid asking about a social history, whether a patient drinks, smokes, uses drugs, or is sexually active?
When can they stop asking about the review of systems, a list of questions asked about each organ system? A comprehensive history is used in the emergency room, hospital, or during an annual physical, not in urgent care or an outpatient appointment, right?
Patients lie and don’t even know it. It’s not that they mean to. In fact, they are trying to be helpful when giving a history of their symptoms. Medical students concerns about taking a fast history reflects two things. First is the reality of the limited amount of face time with patients, which unfortunately seems to be even less than the past. Second, more importantly, is their fascination and desire to get started on real medicine — what are the diagnoses, treatments, and tests that must be learned to be a good doctor.
In fact, what they realize after working with me is that the most important part of being a doctor is talking to patients and listening. Taking a good history is the essential part of being a good doctor.
Here are two examples of patients who I saw during the winter. The practice is busy this time of year. I’m often running late. Like many encounters, I’ve never met these patients before. In many ways, it can feel like an urgent care practice. Which patient is lying? Can you tell?
Twenty years ago, IMS Health got the idea to purchase prescription records from pharmacies, license physician information from the AMA’s Physician Masterfile, and link the two databases so as to create something new and different: prescriber-level data (PLD).
It was a brilliant idea. Almost immediately, pharmaceutical and device companies, government analysts and public health officials began lining up to buy raw PLD and/or the reports that IMS created from it.
And with good reason. By applying statistical tools to analyze PLD (a technique known in the vernacular as “Data Mining”) IMS and the purchasers of its data could obtain fresh insight into many topics of interest. These include prescribing pattern variations across regions, where and when influenza outbreaks occur, how physicians respond to these outbreaks and hundreds of others. Drug makers found PLD information to be particularly helpful. With it, they could refine marketing pitches and improve sales force efficiency, among other things.
Since those early days, the scope of the data compiled by IMS and other PLD providers has expanded to a point where it is truly breathtaking. The AMA Masterfile includes current and historical data on 880,000 physicians. IMS and similar companies collect information on more than 70% of all prescriptions filled in the US. SDI Health, another PLD provider, has billing information from 100% of inpatient and outpatient activity at 500 hospitals dating back to 2002. Their databases are large enough to detect national trends and withstand the most exquisite stratification analyses. Furthermore, PLD providers have perfected ways to exclude information from their databases that could be used to identify patients, so the data comply with HIPAA and other privacy-protecting laws.
I have been a strong proponent of the creation of a National Health Record (NHR), but will it increase the quality of care for each citizen? Without 100 percent compliance by all healthcare providers the establishment of the NHR will bear little fruit for its expense. Proponents of a NHR site the achievements of the VHA. VHA patients include highly mobile active and inactive soldiers. Ubiquitous methods for viewing clinical data are critical, however Joe Outpatient doesn’t move around in this manner nor does he stray far from the facilities where he receives care.