One company’s managers think repeal would raise its health-care costs by hundreds of millions.
America’s CEOs might not admit it in public, but the Affordable Care Act—aka ObamaCare—has been good for business. Company benefits managers have watched as the double-digit premium increases under President George W. Bush slowed to a crawl. Venture funding has flooded into health care, boosting startups and stimulating innovation. This is the progress President Obama is trying to preserve as he meets Wednesday with Democrats on Capitol Hill in a strategy session about how to protect the health law.
To take a single benchmark, look at families who receive insurance coverage through an employer. Between 2001 and 2008, their average premium jumped nearly 80%, according to annual survey data from the Kaiser Family Foundation and the Health Research and Educational Trust. Under President Obama, the increase was only 36%. This represents real money: If the Bush-era rate of inflation had continued through 2016, each of these families would be spending about $5,000 more on annual premiums. For employers, the savings open the door to hiring more workers or raising wages.
At the same time, investment in medicine has boomed. Between 2011 and 2015, venture funding for health care—including biotechnology and medical devices—totaled approximately $62 billion, according to figures from PitchBook. In the four years before the Affordable Care Act, the total was $47 billion. New companies are working to improve everything from primary care, to home palliative care, to the management of mental health. These innovations are now beginning to realize cost savings.
The Republican plan to repeal and replace the Affordable Care Act threatens to reignite health-care inflation. First, this approach produces significant uncertainty in the market. The GOP has promised immediate repeal, but the talk of what would replace the health law—and when—is vague. “I don’t want to set a time limit that this has to get done by this certain date,” Rep. Kevin McCarthy, the majority leader, said in late November.
It is easy to repeal ObamaCare’s subsidies and the mandate to buy insurance, since that can be done with only 51 Senate votes using the “reconciliation” procedure. But enacting a replacement is harder, maybe impossible, since it would require 60 Senate votes to overcome a filibuster. Insurance companies hate uncertainty and respond by raising rates to hedge their risk.
A second problem is “cost shifting.” If Republicans repeal and replace the Affordable Care Act, millions of Americans will probably lose their insurance. The replacement proposal offered by House Speaker Paul Ryan would lead to four million fewer insured people by 2026, according to a review by the Center for Health and Economy. Nine million could lose coverage under the replacement plan offered by Sen. Richard Burr, Sen. Orrin Hatch and Rep. Fred Upton, according to scholars from Rand Corp.
The bulk of these newly uninsured would be low-income Americans who can’t afford private coverage despite the tax credits built into Republican plans. But such people will still be treated when they get sick. Though they cannot pay for it, they will still receive care at hospitals, urgent-care outlets and doctors’ offices. These costs will be rolled into the line item “uncompensated care”—which is ultimately paid for by higher prices on everyone else.
The Affordable Care Act has helped minimize this cost shifting. Specifically, the law’s expansion of Medicaid cut hospitals’ uncompensated care by roughly a third from 2013 to 2014, according to a study in Health Affairs. At the University of Pennsylvania Health System, bad debt—the accounting term for bills that are written off when patients can’t pay them—decreased from 6.1% of revenue in 2014 to 3.9% last year. Taken nationally, a drop that size is worth nearly $25 billion a year.
The GOP’s plans will reverse these incentives. Republicans want to send Medicaid back to the states using block grants. More important, they want Washington’s contribution to Medicaid to grow more slowly than the actual costs. A 2014 analysis by the Bipartisan Policy Center estimated that Rep. Ryan’s plans to block-grant Medicaid would reduce federal funding for the program by $160 billion in 2022.
State legislators are likely to respond in two ways. They can tighten Medicaid eligibility to reduce the number of recipients, which will increase the ranks of the uninsured. Or they can cut the rates that Medicaid pays to hospitals and physicians, who would make up the difference by increasing prices on everyone else.
Critics of the Affordable Care Act argue that when previously uninsured people gain coverage through Medicaid, they tend to use expensive emergency-room services. But people who have just gotten coverage can’t be expected to become sophisticated health-care consumers overnight. The use of the ER suggests they have unmet medical needs. Over time they can be educated to develop standard relationships with physicians. Even factoring in this greater use of ERs, however, the per person costs of Medicaid have decreased since 2010 after adjusting for inflation.
Businesses know all this. In response to the GOP’s call to “repeal and replace” ObamaCare, one Fortune 100 company with hundreds of thousands of employees is developing two HR budgets. The first reflects the status quo. The second factors in the higher prices Americans will face if more people become uninsured. Although these estimates aren’t final, the company thinks its health-care costs could rise by tens of millions of dollars in a single year if the Affordable Care Act is repealed and replaced.
President Obama’s health law really has been good for business. Republicans’ plan to dismantle it will take the country back to an era of high health-care inflation. If only CEOs would say as much before it is too late.
Ms. Lamont is a managing partner of Oak HC/FT, a venture fund investing in health care and financial services. Dr. Emanuel is vice provost for global initiatives, as well as chairman of the Department of Medical Ethics and Health Policy, at the University of Pennsylvania.
VillageMD is a primary care management services company that enables primary care providers (PCPs) to realize the benefit of value-based care delivery. At VillageMD, we strive to be the best partner to PCPs so that they’re able to deliver the best care for their patients and in a way that dramatically improves clinical outcomes and experiences, as well as significantly reduces total cost of care.
As a result of the changing economics of healthcare, we help PCPs think about what they can do differently and provide them with a combination of resources, data, technology and intellectual property to solve patient problems.
What are the biggest issues in your space and what are the biggest challenges you are addressing?
The U.S. healthcare system costs 2.5 times other industrialized nations yet still delivers inferior clinical outcomes. This has resulted in many PCPs being forced to do more with less. What VillageMD brings is a different way of thinking about healthcare so PCPs can feel they have the resources available to them, the knowledge about their patients, and a diverse set of processes to heal and see results from a better clinical and financial model.
How does technology play a role in your company?
At the core of our business is a human relationship between a physician and a patient. We believe it is our job to continue to foster that human interaction and service, and technology plays a core role in this.
For example, we identified in one of our markets that we had 1,800 commercial patients under the age of 65 suffering from posttraumatic stress disorder. The risk profile of these patients is nearly two times that of the “average” commercial population. Their access to healthcare, in terms of emergency room visits and hospitalizations, is through the roof. Yet, they still struggle with being able to have access to a defined clinical model that allows for PCPs and behavioral health specialists to partner with them to solve their health problems.
How we first identify these patients, and how we build the digital clinical maps detailing their care delivery, is driven by technology, claim and clinical data, and care delivery know-how. This includes how we schedule patients, talk to patients, see patients and document what’s going on with them – as well how we see all the different issues they face along their healthcare journey. Technology gives us that insight and points us in the right direction to introduce solutions that enhance this human-to-human interaction.
What attracted you to Chicago? How is Chicago advantageous for startups?
In 1993, I read a journal article from Personnel Psychology titled “The People Make the Place,” which addressed organizations and the importance of people in shaping organizational culture. When you think about Chicago it’s hard not to think about the people as what makes the city an amazing place to live and an exciting environment for startups.
Chicago has an intelligent workforce that is community-driven, knows how to grind and has a level of grit. Chicago is the “City of the Big Shoulders”, after all. In a startup environment you have to have that combination of commitment to a cause greater than yourself; a desire to work hard and a level of intellect that allows you to identify problems before they manifest into something larger. The people of Chicago are truly what make it a great place for startups.
I think the financial community is starting to appreciate that. The capital deployed in Chicago has generally flowed into companies at a more mature stage with higher predictability of revenue and earnings. For startups, this has not always been ideal, but the mayor, city institutions and VCs like Oak HC/FT allow Chicago to have more entrepreneurs step out onto that ledge and know they have the right level of capital and support. Together with a friendly business community, we can make these startups successful.
What attracted me to Chicago was all of that and more. I am originally from a small town in northeast Wisconsin. I had lived in Chicago after graduate school and then went out to the west coast and, later, Texas. The idea of coming closer to home was important and Chicago was my destination. It’s a city I would encourage all people to live in and experience the best blend of what it offers: thriving culture, arts and sports scene (Go Cubs!); a beautiful location; supportive business community; and small-city feel.
What were the defining moments that led you to where you are today?
I have four. Firstly, I am blessed with an amazing family. I grew-up with parents that always encouraged me to dream big and see beyond what is in front of me. I am also ridiculously lucky to have a wife who is supportive and patient and always encouraged me to pursue things I am passionate about.
Next is my first startup, which by many definitions failed. I started a company in my mid-20s and poured every cent into it. We experienced some wonderful ups and some incredibly low lows. We were living in a worst-possible situation any startup could be in: doing well enough to keep going but not well enough to keep going. By many circumstances it was the first time in my life I looked myself in the mirror and said, ‘I failed’. But it was an invaluable learning experience – to pour 20 hours into each workday and not come out with a positive outcome. It’s humbling and only helps you sharpen what you’re doing for the next three or four go-arounds.
As it relates to healthcare and VillageMD, there are two significant defining moments. First is when I started working at Blue Shield of California and helped create a return on investment model for a business case addressing congestive heart failure. The first meeting I was ever in I fell in love with healthcare.
In that meeting, we talked about different solutions that the best and brightest minds in healthcare all over the country had developed for managing congestive heart failure. Not one solution contemplated the role that the PCP played in a successful outcome. I was surprised to see we were developing solutions that didn’t involve the PCP, and only fragmented our healthcare system. That set me on a mission to identify a model bringing the best and brightest solutions to support physicians.
The last defining moment was working with Dr. Clive Fields, VillageMD Co-Founder and Chief Medical Officer, to establish a model for engaging PCPs around the country and working with large physicians groups or solo practitioners to realize that PCPs everywhere are struggling to deliver the kind of care they know is possible for their patients. If they have people working with and for them side by side we can realize better outcomes together.
Where do you hope to be, as an executive, in 5 years?
As an organization, in five years I hope to be working with several thousand PCPs across the country, which means VillageMD will be five years into a decades-long growth model. As an executive over the next five years, there will be a big push for us to build out a leadership team that embodies the same principles and focus on driving results for PCPs. That will allow me to spend more time in the field with PCPs, working with and talking to patients and providers, as well as working with our product development teams to think differently about what VillageMD can do for both providers and patients.
If I weren’t a CEO I would be…
Home with my kids. They are truly phenomenal and a lot of fun to be around. The legacy that we leave through those little people is everything to me.
My favorite movie is…
“It’s a Wonderful Life”
My favorite musician is…
My favorite hobby is…
Playing goalie in hockey
My favorite food is…
Chipotle Sofritas Salad
Do you have any pets?
Beyond my kids, I have a mischievous goldendoodle named Ollie.
This article original appeared in MedCity News by Stephanie Baum on November 11, 2016.
If you were to ask a healthcare investor what their investment strategy is, it is likely the product of some brilliant foresight, a little luck, and some lessons learned from bad experiences or near misses.
In a series of phone and email interviews, we picked the brains of health IT investors at four firms. We asked them what they learned from early investments and how those lessons and insights informed their strategy going forward. One theme that threads its way through the investment narrative of these companies is that technology is all well and good, but you need a service to support it as well.
Cotiviti (originally iHealth) and athenahealth were two of the firm’s first investments made in the space, Lamont said in an email.
“They were very much about fixing broken processes through software, services, and data. That’s been our approach – addressing a broken system and improving it through the powerful combination of software, data, and services. That’s particularly the case when behavior change is an important part of what needs to happen to improve healthcare and materially bend the cost/quality curve. Appropriately, Aspire Health, Quartet Health, VillageMD and Axial Healthcare all have service as a component.”
Were there any subsectors of health tech that you have invested in that you would not do again? Why?
The provider world. Consider two perspectives: It’s difficult to sell into providers, and it’s also hard to be a provider in an environment where reimbursements are going to come under pressure. Other than inpatient psych, which has massive scarcity and unending demand, we worry about reimbursement pressure in the near future.
In a value-based reimbursement environment, we think very differently about primary care physicians. Two decades ago there was a rush to build physician practice management (PPMs) roll ups. Mostly they were specialty plays, and the idea was leverage, but also IT and infrastructure enabled you to run businesses more efficiently and profitably. The reality was, we didn’t have the systems to manage them so the model broke down.
Fast-forward 20 years and, while IT systems are still imperfect, it makes tremendous sense to aggregate primary care physicians, empower them with information and systems, and support and leverage that all to improve quality and reduce downstream costs. Older PPM models focused on leveraging up pricing power. Now, primary care is about reducing overall cost. Two very different times, places and opportunities.
Kurtzman said the firm’s early experiences reinforced the importance of a strong management team, which goes for all industries.
“A great product with a weak management team nearly always fails, while a great management team with an average product can become a huge success.”
Looking back on your health IT investments, were there any that prompted you to rethink or tweak your investment strategy?
Safeguard’s capital deployment strategy has always been focused on growing markets and exciting products. While these remain important factors, several companies have shown how critical it is for an IT product to fit into a user’s workflow and for the product to connect seamlessly to existing systems. Both of these elements, particularly workflow, now play central roles in the way healthcare technology teams assess potential opportunities.
Were there any subsectors of health tech that you have invested in that you would not do again? Why?
In recent years, Safeguard has distanced itself from revenue models dependent on advertising dollars from pharmaceutical brands, because brand advertising can be fickle, leaving an uncertain financial forecast.
“Health Dialog was my most important investment and it dates back to 1999. We were doing population health before it became sexy,” Donohue said in a phone interview.
Health Dialog based its approach on research from Dartmouth, Donohue said. Based on geography, the company could predict the likelihood that patients would have a specific procedure.
For example, populations in Santa Barbara with a herniated disc would have surgery more frequently than a similar group of patients in New York. The company combined population health and data analytics with a healthcare engagement and literacy component. Their technology-enabled services helped identify people in the population making major medical decisions, helped them make more informed decisions, (which often led to less invasive procedures), reduced costs significantly and produced better outcomes.
British private insurer BUPA, an early investor in the business acquired Health Dialog in 2007 for $775 million and then Rite Aid acquired Health Dialog two years ago.
A positive lesson Donohue said he learned is the need to not lose focus on the patient.
“Most companies focus on the arms race between payers and providers but the patient is a powerful source and engaging them in healthcare is a critical lesson. Generally speaking, companies with a genuine mission and culture of supporting the patient end up creating better results…financial and clinical.”
The same focus on patients — in fact, the needs of specific patient populations — becomes paramount for companies engaged in remotely monitoring them through technology.
“It’s shocking to me how many deals that get funded with technology or services that are not likely to capture the sick, chronically ill, noncompliant patient population, but resonate more with the world of quantified self. When it comes to remote monitoring, technology needs to be passive to best capture the most costly patient population.”
Accolade was an early healthcare investment for Comcast, which the firm made in 2010. The move was a turning point because Accolade focused on employer wellness, an area that had not previously been of interest to the firm, Yang said.
“It was my first or second investment,” he recalled in a phone interview. “It was groundbreaking, novel and risky. We did it for a couple of different reasons and it has informed our strategy.”
First, Comcast was in the process of becoming a customer as it had embarked on a pilot with Accolade. Yang said early pilot data affirmed this model of employee engagement could work in affecting healthcare utilization and Comcast employees loved it. Second, investing in Accolade offered him a different perspective than other investors in health tech.
“A self-funded employer is an interesting channel with which to deploy innovative health tech and health services. Everyone in the health tech and digital health space was focused on direct to consumer or selling into insurers or providers. Very few entrepreneurs were thinking about employers as a channel back in 2009-2010 in start-up land. Accolade was positioned to be the general contractor of healthcare programs for employee populations and I was going to be exposed to a whole host of downstream products and services as deal flow.”
“What we learned from the wearables space was competition accelerates…and some of these markets are winner-take-all. That has helped inform our investment strategy.”
He added, “When you are making a bet into a hardware vertical, you better pick the right one. One tends to dominate the category and the spoils don’t go as much to the number three or number four player.”
Anil Aggarwal: We believed the payments industry desperately needed a platform like Money 20/20. From the beginning, our vision has been to go beyond typical payments events by redefining the industry dialogue and looking at the future, including emerging trends like connected consumers, omnichannel commerce and open platforms.
That might all sound familiar today, but it was groundbreaking and ambitious back in 2011. When we launched, discussions on FinTech and payments were still about incremental innovation—migrating specific paper-based payment systems to more efficient electronic ones. Mobile payments and digital wallets were still nascent.
So, our objective was to rethink the entirety of payments as a hardwired industry that would eventually be disrupted by digital transformations. We believed that digital would win in every possible way over the long-term. That original thesis continues to prove right and seems like a forgone conclusion today.
Jonathan Weiner: Money20/20 was also a risky proposition because there were a ton of existing payment events already well established and attended. When we began telling people about our idea, the initial reaction was, “Do we really need another payments event?” The space was crowded, but we still felt the market lacked a single, meaningful platform serving the entire payments ecosystem. That was where we saw our opportunity to address disruptions across the broader payments value chain.
Plus, we were already attending and exhibiting at other events but never felt they delivered a return on investment. We wanted to create a new platform for industry operators by industry operators. Somewhere we wanted to participate ourselves and could extract value; where important decision-makers across the payments value chain convened and felt they had to be; and where the industry would conduct business, announce new initiatives and debate important topics. That was our vision for Money20/20.
Why the focus on FinTech?
AA: By 2011, when we founded Money20/20, Jon and I had already spent more than a decade as payments and FinTech entrepreneurs.
Our first company, which we founded in 1999 during the dot com era, was called Clarity Payment Solutions (acquired by TSYS) and was among the first companies to utilize existing payment networks outside of their traditional use cases. We later launched TxVia, which Google acquired in 2012. Jon and I then headed up business development for Google Wallet. Several of our earlier initiatives also served the industry, including the Network Branded Prepaid Card Association (NBPCA), which we launched, as well as Prepaid Expo and Paybefore, both of which we created and later sold.
JW: That’s right—our backgrounds in FinTech and as payments entrepreneurs really enabled us to understand the industry landscape and then shape a dialogue and agenda around its evolution.
At what point did you realize Money20/20 was going to be a success?
AA: From the start, actually. As industry operators, we already recognized the value Money20/20 could bring to the entire ecosystem. However, we didn’t fully realize the extent of the role Money20/20 would play in shaping FinTech until we came out of the second event, in 2013, and were planning our third event, in 2014. That’s when the industry hit its tipping point.
First, financial institutions, both large and small, began to change in the post-financial crisis world. Next, you had the rise of bitcoin and blockchain as examples of entirely new payment systems emerging and achieving widespread consumer awareness. And last, you had the broadening of entrepreneurial interest in payments, as well as the payments investment thesis for the venture capital community. These factors and more like them enabled new entrants to disrupt decades, if not centuries, of established payments practices. The rapid proliferation of mobile devices played a critical role, too.
JW: From the beginning it was essential to focus our event on senior-level attendees from leading companies across the payments value chain. People felt they had to attend because all their peers were there; it was an opportunity for organizations and individuals to meet each other. That not only enabled networking to become a critically important aspect of the event, but also spurred business development initiatives and the announcement of several significant deals on-site. That all helped drive and sustain robust media interest and attendance.
What are some notable changes you’ve seen at Money20/20 over the last four years?
JW: The biggest changes to Money20/20 were over the first three years, when we were constantly adjusting the event to meet the needs of the industry. Remember, the industry was experiencing significant transformation during that period and we wanted Money20/20 to reflect those changes. For example, we introduced new topics into the agenda and also made it easier for startups to attend and exhibit. We introduced a hackathon event that is the world’s largest for FinTech and have since expanded into adjacent formats, like StartupPitch180 and Launchpad360.
Money20/20 will continue to evolve as the payments industry evolves, but I think we expect to remain a core part of the ecosystem regardless.
AA: For any business to be successful you have to focus on your customer and their experience. Throughout our careers as entrepreneurs, we always had a customer-centric approach and invested a great deal in creating a meaningful experience—with great speakers, attendees, food and exhibitors. The complete package is important and we’re always looking at ways to improve upon that so the experience is fresh, for returning attendees as well as for new attendees alike.
What led to the decision to launch a Europe edition of Money20/20?
AA: The same fundamental and structural shifts redefining payments in the U.S. are present in Europe. There are clearly many important differences, as well. Very different regulatory environments, for example. But just as Money20/20 was needed in the U.S. to help coalesce an otherwise fragmented dialogue and disparate ecosystem, the same was true for Europe.
So, we decided to launch Money20/20 Europe, which quickly became the largest FinTech event in Europe in its inaugural year with more than 3,500 attendees. Much of the support came from international sponsors of our Money20/20 U.S. event. These individuals and organizations, with businesses spanning multiple countries and global financial centers, were incredibly supportive of our European expansion.
JW: It was also important to create a unique European experience and not clone what we do in the U.S. We have a dedicated team based in Europe and hired people from within the European payments industry to drive our expansion into that region.
And from the start, we looked at the European region holistically. Many of our competitors were focusing more narrowly on the U.K., which is a major FinTech market but not singularly representative of the entire regional ecosystem. That was one of the major reasons we chose Copenhagen as our destination.
Looking into the future, how do you see Money20/20 evolving with time?
JW: Money20/20 will continue to play an important role in the evolution of payments. It’s the only event that has the critical mass and focus to sustain that. The key will be to not lose that focus. Deciding what not to do is just as important as what you do.
AA: It served as an early catalyst for growth and development of the payments ecosystem and we see Money20/20 continuing to do so into the future. As Jon says, getting that right without getting distracted is the key.
Anil Aggarwal, Jonathan Weiner, Patricia Kemp
Anil Aggarwal and Jonathan Weiner are Founders of Money20/20 and both serve as Oak HC/FT FinTech Venture Partners.
Oak HC/FT leads funding to enhance well-being of patients in chronic pain and drive value for client partners
Nashville, Tennessee (October 12, 2016) – Axial Healthcare, Inc., the nation’s leading pain care solutions company, announced today it has closed a $16.5 million Series B round of financing. Oak HC/FT, a venture growth-equity fund investing in healthcare services, led the funding round, which will be used to further drive expansion of axial’s suite of pain management capabilities, including a cloud-based, provider decision-support platform for pain treatment. Previous investors, .406 Ventures, BlueCross BlueShield Venture Partners, and Sandbox Advantage Fund, also participated in this latest round of financing.
“Over the last four years, axial has curated the country’s most comprehensive database of evidence-based best practices for pain treatment,” said Nancy Brown, Venture Partner at Oak HC/FT. “The rate of opioid misuse, abuse or overdose underscores the need for a smarter, information-driven approach to pain treatment that payers, providers and patients can use. axialHealthcare has pioneered evidence-based pain management solutions and is leading the way in addressing barriers to safe and effective pain treatment. I am excited to join their Board of Directors to continue to solve these issues.”
John Donahue, chairman and CEO of axialHealthcare, said, “We are excited to welcome Oak HC/FT into the axial family and look forward to leveraging their extensive healthcare expertise. Oak HC/FT’s funding comes as we build out our operational and clinical teams, continue to innovate and enhance our capabilities, and move to operationalize on our substantial pipeline of clients. We look forward to continuing our mission to mitigate opioid misuse and improve the care and well-being for patients in chronic pain.”
Pain treatment is a $330 billion annual spend category for payers and has escalated into an epidemic as opioid use has increased 400 percent in the last 10 years. In response to this situation, axialHealthcare was founded in 2012 to identify and address the drivers of poor clinical outcomes and escalating costs of pain management. The company has since assembled the nation’s largest data repository of patient pain claims and outcomes, as well as created the only evidence-based criteria for pain clinics.
axialHealthcare’s suite of pain management capabilities includes: predictive analytics; a decision-support platform that delivers pain population analytics, provider dashboard and content, network performance monitoring, and PharmD consultation for providers; and the nation’s only mobile patient app for patients experiencing chronic pain. axialHealthcare’s team of physicians, pharmacists, scientists, technologists and healthcare operators are uniquely positioned to ensure that patients in pain are provided with personalized, evidence-based care from informed practitioners. The company began deploying its pain care offerings with industry-leading client partners last year.
axialHealthcare is the leading pain medication and pain care management company and partners with health insurers nationwide. axial’s pain management solutions engage physicians, pain clinics and patients with coordinated care by applying advanced analytical insight, unmatched proven clinical evidence and highly effective consumer support. axialHealthcare’s solutions optimize pain care outcomes, reduce opioid misuse and materially improve financial performance for those who insure care. For more information, please visit www.axialhealthcare.com.
About Oak HC/FT
Oak HC/FT (http://oakhcft.com/) is the premier venture growth-equity fund investing in Healthcare Information & Services (“HC”) and Financial Services Technology (“FT”). Oak HC/FT is focused on driving transformation in these industries by providing entrepreneurs and companies with strategic counsel, board-level participation, business plan execution and access to an extensive network of industry leaders.