If you read the business press, as I do every day, It is impossible to escape the “disruption” meme. Clayton Christiansen’s 1997 Innovator’s Dilemma explored how established businesses are blindsided by lower cost competitors that undermine their core products, and eventually destroy their businesses. Classic examples were the displacement of film-based cameras by digital cameras and then cell phones, the destruction of retail shopping by Amazon and of video rental by streaming video services.
A Civic Religion
Perhaps because Christiansen’s analysis arrived at the peak of the first Internet boom, it generated a high level of anxiety in the corporate world. It did not seem to matter that Christiansen’s analysis was riddled with flaws, meticulously detailed in Harvard colleague Jill Lepore’s takedown in the New Yorker in 2014.
By then, the disruption thesis had become a cornerstone of a kind of civic religion, an article of faith and an indispensable staple of fundraising pitches in the venture and private equity worlds. No one seemed to be asking how great a trade for the society was, say, tiny Craigslist taking down the newspaper business by drying up its classified ad revenues.
Disrupting a $4 Trillion Health System
I believe that, twenty five years on, the notion of disruptive innovation has reached its “sell-by” date. At least in healthcare, the field of commerce I follow most closely, it is now doing more harm than good. The healthcare version of the disruption thesis was found in Christiansen’s “Innovator’s Prescription”, written with health industry maverick Dr. Jerome Grossman in 2009. Christiansen and Grossman forecast that innovations such as point-of-care testing, retail clinics, and special purpose surgical hospitals threatened to take down healthcare incumbents.
A swarm of breathless (and reckless) healthcare disruption forecasts shortly followed.
These are grim days for innovative healthcare companies. The health tech and care innovation firms mature enough to make it to public markets have been eviscerated in the ongoing market correction. As of January 29, 2022, high fliers like One Medical (down 83% from peak), Oscar (down 83%), Bright Healthcare (down 85%), Teladoc (down 77% but still selling at 6X revenues!), and AmWell (down 90%) are the tip of a much larger melting iceberg. The dozens of digital health unicorns (e.g. pre-public companies valued at more than $1 billion) and their less mythical brethren, into which investors poured more than $45 billion during 2020-2021, are sheltering in the comparative safety of VC/Private Equity balance sheets. They are protected from investor wrath until those firms’ limited partners force a revaluation of their portfolios based on the market value of their publicly traded comparables.
Yet it is the next moves that these innovative firms and their equity holders make that will determine whether these firms realize their full transformative potential or fade into insignificance. The Gartner Group, which tracks the technology industry generally, popularized the notion of the Hype Cycle- a seemingly universal trajectory that tech innovations and the firms that produce them follow (see below).
The Gartner Hype Cycle
Everyone seems to focus on the colorful first phase of this cycle- the inflating and deflating part- where an innovation rises on a wave of the adulatory press (and breathless futurist punditry), then crashes ignominiously into the Slough of Despond. A classic example was the Apple iPhone’s ill-starred great uncle, the Apple Newton, which launched in 1993 and crashed shortly thereafter.
For founders and investors, as well as customers, however, it is the less visible succeeding phases that determine if the innovation survives and the firms that produce them become ubiquitous and indispensable parts of our lives. The rising initial phase of Gartner’s Hype Cycle is driven by the question “Is it cool”?, mediated by hyperactive media and Internet buzz. The inevitable crash, on the other hand, is almost always driven by the troublesome real-world question, “Does the product actually work as advertised?” Analysts, writers, and, most importantly, customers press uncomfortable questions about not only functionality, but also reliability, affordability, stickiness, and “value for money”.
How do firms survive the crash and climb Gartner’s “Slope of Enlightenment”? This is the unglamorous “pick and shovel” part. If the sticky “product integrity” issues (does the product actually work?) are resolved, then a host of important questions challenge the firm, its founders, and owners, which answers the crucial question: whether it is a real business:
1. relating to or denoting an imagined state or society where there is great suffering or injustice.
1. a person who imagines or foresees a state or society where there is great suffering or injustice.
There are certain words that keep popping up in 2021 whose meanings are uncertain and which deserve both recognition and definition. And so, the offering above – the word “dystopian.” Dystopian as in the sentence “The term was coined by writer Neal Stephenson in the 1992 dystopian novel Snow Crash.”
One word leads to another. For example, the above-mentioned noun, referred to as dystopian by science fiction writer Stephenson three decades ago, was “Metaverse”. He attached this invented word (the prefix “meta” meaning beyond and “universe”) to a vision of how “a virtual reality-based Internet might evolve in the near future.”
“Metaverse” is all the rage today, referenced by the leaders of Facebook, Microsoft, and Apple, but also by many other inhabitors of virtual worlds and augmented reality. The land of imaginary 3D spaces has grown at breakneck speed, and that was before the self-imposed isolation of a worldwide pandemic.
But most agree that the metaverse remains a future-facing concept that has not yet approached its full potential. As noted, it was born out of science fiction in 1992, then adopted by gamers and academics, simultaneously focusing on studying, applying, and profiting from the creation of alternate realities. But it is gaining ground fast, and igniting a cultural tug of war.
Those of us of a certain age remember the Timex slogan that bragged about its watches’ durability: “It takes a licking and keeps on ticking.” A recent article about our military, of all things, made me wish we had a healthcare system that prized that kind of durability.
I can never resist analogies between the U.S. healthcare system and the U.S. military system. They’re both huge, they’re both wildly expensive, they both rely on a combination of high tech and front-line people, and they both protect us from threats. In some ways, both are the best in the world, and, in other ways, both have weaknesses that are embarrassing. And, as I wrote last year, both are often still fighting the wrong wars.
Ms. Herz notes how Americans love innovation, but:
This mythos informs a narrative that what is valuable is The New—the upgrade to something bigger, badder, and sexier…What the United States needs to reinvigorate its defense base, compete with China, and win the global economy must be more innovation.
Except the United States does not suffer from a lack of innovation; it suffers from a lack of resilience.
Crises — like our
current COVID-19 pandemic — force people to come up with new solutions.
They slash red tape, they improvise, they innovate, they collaborate, they cut
corners. Some of these will prove inspired, others will only be temporary,
and a few will turn out to be misguided. We may not know which is which
except in hindsight.
If, as they say, necessity is the mother of invention, then you’d have to say that the COVID-19 pandemic is proving to be the mother of invention and innovation. And, like Isaac Hayes sang about Shaft, it is a “bad mother…(shut your mouth).”
Many believe that the Allies won WWII in large part because of how industry in the U.S. geared up to produce fantastic amounts of weapons and other war materials. It took some time for businesses to retool and get production lines flowing, during which the Axis powers made frightening advances, but once they did it was only a matter of time until the Allies would prevail.
Similarly, COVID-19 is
making scary inroads around the world, while businesses are still gearing up to
produce the number of ventilators, personal protective equipment (PPE), tests,
and other badly needed supplies. COVID-19 is currently outnumbering
these efforts, but eventually we’ll get the necessary equipment in the needed
Andy Slavitt, former Acting Administrator of the Centers for Medicare and Medicaid Services and founder and partner at Town Hall Ventures, talks about how venture capitalists and health tech startups can help make healthcare more affordable and accessible for the 130 million Americans beyond the “Peloton crowd.” We ask Andy if he thinks “social determinants of health” is more than just an industry buzzword, get his advice for startups motivated to make a difference, and hear his predictions for what will change healthcare in this new decade.
Filmed at J.P. Morgan Healthcare Conference in San Francisco, January 2020.
Financially backed by the EU, EIT Health is a pan-European network of health innovators and 150+ corporate and academic partners across the continent who pool their assets to support widespread health innovation across Europe. We caught up with Katharina Ladewing, Managing Director for EIT Health Germany, about the group’s priorities, how they enable early and late stage startups to find funding and business partners, and how digital health has been evolving (rapidly) in the EU over the past few years. Wondering what the differences are between the health tech startup ecosystems in Europe versus the US? Katharina shares some of the insights she’s gained after four years watching this space mature.
Filmed at Frontiers Health in Berlin, Germany, November 2019.
Is healthcare innovation more challenging in a public healthcare system? We sat down with the Chief Medical Officer & Director of Innovation for the Hospital Clinico San Carlos, Dr. Julio Mayol, to find out! A large, academic research hospital in Madrid, Hospital Clinico San Carlos is an 800-bed facility that has served Madrid since 1717. The hospital counts the entire population of the city (all 6.5M of them) as their patient base and, as such, takes a different approach to integrating new health technology and innovations. Dr. Mayol unpacks the way he leads population health initiatives in his institution, talking through his approach for engaging physicians, external partners, and patients alike to improve the quality of care. Is it different than the way it works in the U.S.? Tune in to find out!
Filmed at Barcelona Health Hub Summit in Barcelona, Spain, October 2019.
As we near the end of the year, rather than reflect on fond memories of 2019 (for which I’m grateful for my family, friends, readers, and Twitter followers), I’ve already started thinking about 2020. If you ever wanted to get inside my brain for 5-10 minutes (scary proposition I know) related to healthcare startups and innovation, here are some areas or trends that I will be following in the new decade.
1. Medicare-For-All Will Be Everywhere
As we move closer to the Democratic Presidential caucus, some of the top-polling candidates (Sen. Elizabeth Warren, Sen. Bernie Sanders, Andrew Yang) are endorsing a Medicare-For-All (M4A) platform. If one of those candidates receive the nomination for the 2020 Presidential election, private v. public health insurance will be front and center. It will dominate all major news. I’m watching how the weight of the entire healthcare industry will politically respond to a national Medicare-4-All Presidential debate (both publicly and privately).
2. Updating Physician Anti-Trust Rules To Support Value-Based Care
In October, the U.S. Department of Health and Human Services (HHS) released their long-anticipated proposed rules to update the anti-kickback and physician referral regulations, to help spur greater provider participation in value-based care arrangements. Any changes once finalized would affect the Civil Monetary Penalties Law, the Federal Anti-Kickback Statute, and the Physician Self-Referral Law (“Stark Law”). After comments are received, I’m watching how the healthcare machine helps craft these new regulations that some would say, stifles innovation in provider care delivery.