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Enabling Connected &
Independent Living
Through New Care Models
DECEMBER 2017
NEW MODELS OF CARE WORKING GROUP
Connecting The Dots To
Promote Innovation
1
in partnership with
HealthXL brings
people, thinking &
technology
together
The HealthXL Platform brings together
key market stakeholders in digital health
and empowers them to collaborate and
learn from each other. HealthXL
engages leading companies (see
members on the right).
2
This report is created as part of HealthXL’s New Models of
Care Working Group.
The aims of the report include:
* Provide a high-level overview of care models and tech-enabled
senior care solutions that promote connected and independent
living.
* Highlight venture capital / investor perspectives on the senior
care market, with a focus on what makes startup solutions
stand out.
* Facilitate discussion in areas of interest to HealthXL
stakeholders in order to guide deeper reviews and analyses in
the senior care market.
Note: In this report, “care” is broadly defined and encompasses both medical and non-
medical care (e.g., support with daily living, etc.).
Background
3
Overview & Trends
Solution Landscape
Investment Perspective
Section 1:
Section 2:
Section 3:
Overview & Trends
4
HowShouldWeThinkAbout
ImprovingSeniorLiving?
There is increasing awareness that seniors represent a diverse group ranging in age, ability, and
needs. As a result, senior care solutions are not “one size fits all” – an important lesson as
innovators aim to scale solutions.
Solutions geared towards seniors must be easy-to-use and solve a specific problem. This helps
ensure technology actually improves quality of life and wellbeing, and does not become a nuisance.
Ideally, developing senior care solutions should involve various stakeholders including clinicians,
designers, and seniors themselves.
Mass market products aimed at improving convenience and livability (e.g., Blue Apron, Amazon’s
Alexa) have the opportunity to enable independent living. However, large companies need to better
market their products to seniors and their caregivers.
Venture capitalists are realizing that seniors represent a significant opportunity, but usually tend to
invest in solutions that have a broader impact across more than one single population or disease
state (with some exception).
5
Trends Driving Senior Care Innovation
TECHNOLOGICAL ADOPTION
A greater understanding in how
seniors and caregivers utilize
technology, and where need remains.
INDEPENENT LIVING
An overwhelming majority of individuals
want to maintain independence and age
gracefully in their home.
WHOLE LIFE SOLUTIONS
Increasing realization that broadly
available consumer tech, particularly
those adhering to “universal design”
principles, can be helpful to seniors.
Source: Aging in Place: A State Survey of Livability Policies and Practices,” (AARP 2011), Trends in Seniors’ Use of Digital Health Technology in the United States, 2011 2014
(JAMA, 2016), Tech Adoption Climbs Among Older Adults (Pew, 2017) 6
NEUROLOGY
UNIVERSITY OF
ROCHESTER
Ray Dorsey MD, MBA
“Medicare has done an amazing job of ensuring access to care for acute conditions (e.g.,
heart attacks) but has come up short in ensuring access for chronic conditions. Over 40%
of Medicare beneficiaries with Parkinson disease do not see a neurologist for their
condition. Telehealth solutions, including the ability for older adults to receive care directly
in their home, are available, but Medicare’s reimbursement policies currently incent
institution-based care and discourage patient-centered care. Political will from
organizations like AARP can help change that to the benefit of soon-to-be 70 million
Medicare beneficiaries and 40 million Americans who care for adults.”
7
Caring For Seniors Can Be A
Costly Endeavor
The U.S. Centers for Disease Control and Prevention
defines Aging in Place (AiP) as “the ability to live in
one’s own home and community safely, independently,
and comfortably, regardless of age, income, or ability
level.”
Enabling seniors to reside in their homes may help
offset increasing long term care costs. Independent
living further helps seniors maintain social ties and
avoid feelings of displacement.
Medicaid continues to be a big payor of services,
followed by individual out of pocket and Medicare.
$45,760 $46,332
$17,680
$45,539
$82,215
$92,378
Home Care:
Homemaker
Services
Home Care:
Home Health
Aide
Adult Day
Health Care
Assisted Living
Facility
Nursing Home:
Semi Private
Room
Nursing Home:
Private Room
Median Annual Cost (2016, USD)
LOWER COST
HIGHER COST
Source: Genworth Financial Website (2016), CDC
8
More Cost Effective Models That
Enable Aging In Place Will
Increase, Reflected In Market
Forecasts
The range of products and services that seniors may
derive value from is diverse.
Park & Associates has forecasted key market
segments, further highlighting a shift towards
enabling seniors to live independently at home.
This shift gives rise to technologies and approaches
that enable more convenient living and remote
monitoring for patients where medical oversight is
desired.
Source: Park & Associates (2016)
$932
$1,663
$2,765
$4,405
$6,311
$9,104
$1,329
$2,353
$3,311
$4,183
$5,087
$6,369
$125 $212 $293 $431 $571 $632
2015 2016 2017 2018 2019 2020
U.S. Active Aging Market Forecasts – Connected
Solutions
(USD, Millions)
Safety & Smart Living
Health & Remote Care
Wellness & Fitness
9
Innovators Focused On Senior
Care Must Be Thoughtful About
Their Revenue Model
Medicare & Medicaid face cost pressures and places limitations on
coverage of newer digital health solutions, an issue compounded by a lack
of strong cost saving evidence by digital health players.
Costly solutions, such as remote monitoring approaches, may be untenable
for a direct-to-consumer model due to high cost of monitoring technology
and associated services. As a result, innovators often experiment with at-
risk revenue models to promote adoption.
Startups building senior care solutions often have to be resourceful and
implement a mixed business model combining several payment models to
optimize operations.
Source: Company Websites
SELECT PAYMENT APPROACHES
Medicare & Medicaid
Private Insurance
Government Assistance
At-Risk Models
Self Pay / Caregivers or
Family Pays
10
MANAGING PARTNER
7WIRE VENTURES
Lee Shapiro
“Health tech start-ups do not fully appreciate the purchasing power of the senior market
and their disposable income. This market is more tech savvy than is commonly perceived.
Further, start-ups may not appreciate that while individuals 65+ years of age have
Medicare, they also buy supplemental coverage. We see the Medicare Advantage market
as very attractive – and a place where the interests of consumer, provider and plan can be
highly aligned.”
11
Payment Reform Impacts A Broad
Range Of Services
[SELECT EXAMPLES / MODELS BELOW]
PRIMARY CARE & RISK BEARING
Primary care clinics designed
for adults with Medicare.
Founded: 2012 / Raised:
Undisclosed
Primary care for Medicare and
Wellcare Medicare, team based,
and incorporates wellness
classes.
Founded: 2011 / Raised:
$123.25M
Focused on senior patients who
are chronically ill and frail in
partnership with other
healthcare stakeholders.
Founded: 2013 / Raised:
$240M
TELEMEDICINE NEXT GEN INSURANCE
Preferred Provider Organization with
a Medicare Contract.
Founded: 2013 / Raised: $425M
Disease prevention through digital
therapeutics (with data on Medicare
population).
Founded: 2011 / Raised: $126.52M
Respiratory management through
sensor platform (with data on
Medicare population).
Founded: 2007 / Raised: $49.86M
Telehealth platform serving broad US
population.
Founded: 2002 / IPO: 2015
In-home senior care to enable
independent living.
Founded: 2014 / Raised: $62M
Medical Group and Medicare health
plans (subsidiary of Anthem).
Founded: 1993
A non profit community-based health
system with a long history of Medicaid
care.
Founded: 1999
Source: HealthXL Database, Company
Websites, Crunchbase (November, 2017)
DIGITAL THERAPEUTICS
GOVERNMENTALON DEMAND / HOME CARE
MEDICAL GROUP & HEALTH SYSTEMS
12
The Range Of Transportation Needs For Seniors
Highlights The Importance Of Thinking Holistically
About Patient Needs
Emergency
Transport
Medicare may cover depending on
situation and location/type of facility
(e.g., Critical Access Hospital, Skilled
Nursing Facility, etc.)
VALUE
Critical care management and
potentially life saving.
Non-Emergency
Medical Transport
General & Leisure
Transport
VALUE
Optimal disease management and
improved outcomes.
VALUE
Social connectedness and
reduction of isolation.
Source: Company Websites
13
Solution Landscape
14
Connected & Independent Living By Seniors Is Increasingly
Achievable Given Diverse Solutions
Source: HealthXL Platform (Note: The companies listed above are meant to be
representative, not exhaustive. Visit HealthXL.co for more detailed company
information including partners, funding, and publications).
TELEHEALTH & REMOTE PATIENT MONITORING
MEDICATION MANAGEMENT
SHARED CARE PLANNING & COORDINATION
HEALTH ASSESSMENTS
SMART LIVING &
HOME CARE
15
(acquired)
Multiple Stakeholders Have A Role To Play In
Helping Seniors Thrive
Source: HealthXL Analysis
SeniorMarketFocus
INTEGRATED
INFRASTRUCTURE
BROAD PLATFORMS
OR HARDWARE
CAREGIVER TOOLS
REGIONAL PROVIDER
SYSTEMS & PAYORS
(e.g., “Liveable” cities)
MassMarketFocus
Improved Convenience Clinical & Financial Outcomes
TargetMarket
Value Proposition
1
Focused on convenience, safety
monitoring, and family coordination;
requires more of an “evidence” mindset.
Senior care programs may be created
within systems or adopted from national
level programs such as PACE; scaling is
challenging due to “high touch” nature of
programs.
Broadly available technologies with mass
market appeal; strategic marketing towards
senior population can increase mindshare.
Multi-stakeholder initiatives to enable better
catering to seniors in everyday
environments; requires significant
forethought and planning.
2
3
4
16
Not All Senior Care Solutions Require
Reimbursement To Be Valuable
NOVEL CARE MODELS &
SOLUTIONS
New models of care including smart
home appliances (e.g. Nest) that have
not yet proved their ROI in a traditional
sense, or solutions that do not neatly fit
into established care models (e.g.,
voice technologies, circadian rhythm
optimization).
COST SAVINGS
DEMONSTRATED
A wide range of solutions that have
through pilots or otherwise, shown
some sort of cost savings … whether it
be around medication adherence or
hospital readmissions.
REIMBURSED BY
INSURANCE
Innovators can either choose to digitize
services that are already covered (e.g.,
transport or PACE) or build up the
necessary evidence to achieve
reimbursement.
Increasing levels of evidence, integration into care, and specialization in specific populations.
17
GERIATRICIAN, INFORMATICIST,
& CHIEF CONVERGENCE OFFICER
CATALAIZE
“The market size for startups that serve 65+ could be further
expanded if they take a Universal Design approach -- i.e. design
products/services that are super easy to use for all people (not
just older adults, but also middle age people with disabilities,
busy working moms, stressed out students, etc.).”
Source: HealthXL Advisors
Wen Dombrowski, MD, MBA
EMERGENCY MEDICINE
BRIGHAM & WOMEN’S HOSPITAL
“Successful companies will need to provide solutions that are
simple to use and provide true clinical value…. We need to start
picking parameters in the technology startup group that make
sense, and involve physicians who care for seniors and seniors
themselves early in the design.”
Peter Chai, MD
However, Applying Universal Design
Principles Ensures Usability By All,
Including Seniors
MILLENNIALS
Convenience
On-Demand
Experience
Voice-Based
SENIORS
18
Telehealth & Remote
Patient Monitoring
Vivify Health and Alignment Healthcare utilized Samsung
Galaxy tablets to provide remote care to Alignment’s
population. Over 120 patients have enrolled in the
program.
Omada Health is a CDC recognized-Diabetes Prevention
Program, among others such as Noom and Canary
Health, who has shown positive outcomes in a Medicare
population and modeled cost-savings.
19
Chronic disease management platform that accounts for
nutritional elements of various populations including
seniors. Livongo applied a universal design approach to
its solution to ensure seniors would be able to easily use
it.
What excites you about the potential of Livongo,
specifically looking at engaging a senior
population?
“Livongo Health fits seamlessly into the senior’s
workflow – he/she tests blood sugar as they might
normally do, but the process is informed with real time
insights that are personalized to that senior member.
The meter was designed with the senior in mind –
backlit; large chicklet style icons on an interactive
screen; strips that are easy to handle and insert… last
but not least, Livongo is extending into assisting the
senior with common co-morbidities to diabetes as well
as helping them optimize their medications...”
MANAGING PARTNER
7WIRE VENTURES
Lee Shapiro
Medication Management
What are the key business model
implementations that makes etectRx ‘senior
friendly’?
Pillpack is a broad adherence solution with applicability in
senior care. Earlier in 2017, Aetna Medicare members can
fill covered prescriptions through PillPack’s full-service
mail order pharmacy at preferred pharmacy co-pay levels.
etectRx is an innovative medication adherence solution.
The ID-Cap is a standard hard gelatin or HPMC capsule
with an embedded ingestible wireless sensor. Each time
an ID-Cap is swallowed, the ID-Tag uses etectRx’s
proprietary technology to transmit a very low power digital
message from within the patient’s stomach.
Medisafe is a smartphone based medication adherence
application and platform. It has shown benefit in improving
adherence rates for drugs covered by CMS, and has also
demonstrated how their application improves the patient-
caregiver experience.
Source: Company Websites, Aetna Welcomes PillPack to Preferred
Medicare Pharmacy Network (February, 2017)
“In the case of the ID Cap from eTectRx, we have
worked with eTectRx to build an unobtrusive and
seamless product that tackles one issue (medication
adherence/ingestion pattern) with a simple device (a
digital pill), that doesn’t require additional work from
the perspective of the senior or the physician (you
swallow the pill, it automatically logs the ingestion
and you’re done)…It’s important to simplify the
technology we are presenting to seniors.”
EMERGENCY MEDICINE
BRIGHAM & WOMEN’S HOSPITAL
Peter Chai, MD
20
Shared Care Planning
& Coordination
Evidence suggests that coordinated care models
improve patient outcomes and reduce cost.
Successful solutions will also have a plan for how
to best engage patients over time and carefully
consider how financial savings are achieved.
Atlas of Caregiving is creating a body of research about the
everyday experiences of caregiving to better understand
unmet needs and lead to the development of better solutions.
A recent, RWJF funded, study mapped the relationships
between people and their physical space through the use of
various sensors.
CareAngel helps address gaps in care between physician
visits through an AI-powered virtual caregiver, leveraging
basic telephone infrastructure. With Elite Health, it
demonstrated positive financial savings across a 500
patient implementation, enabling Elite Health to meet the
needs of their value-based contracts.
CareMore utilizes a coordinated care model that includes
neighborhood care centers and care teams, case
management that improves care coordination, a
commitment to primary care, and a reliance on extensivists
around hospitalization episodes. It recently introduced Lyft
as a partner for non-emergency medical transport.
Source: HealthXL Company Database, Company Websites,
CareAngel: How Elite Health Achieved Engagement of 83%,
69% Readmission Reduction and $496,000 in cost savings
(2017) 21
HEALTH
ASSESSMENTS Fitbit is a direct-to-consumer company that makes a
variety of fitness-related wearable devices. While its
products are not specifically created for seniors, the
company directly targets seniors and caregivers in various
marketing campaigns and collateral.
Neurotrack is a mobile solution that enables individuals
assess and improve memory capability, a particular issue
with aging individuals. Research on Mild Cognitive
Impairment (MCI) have shown positive results in
assessing risk of cognitive decline.
22
A wide range of solutions exist to measure and
assess the health of seniors – ranging from fitness
devices to disease-specific solutions.
The level of clinical or financial evidence that
exists for this class of solutions vary given the
diversity of approaches.
Neurotrack has been studied more formally, while
Fitbit takes a strategic marketing approach that
directly targets seniors while enabling researchers
to study its devices across various settings and
populations.
Source: HealthXL Company Database, Company Websites
Smart Living & Home
Care
Various solutions are emerging that better enable
living at home.
Traditionally, this category has focused on “home
care” solutions, but is now including a number of
new players that may not be considered, such as:
Honor provides non-medical home care through their Care
Pros and focuses on helping the elderly with activities of
daily living. Disease organizations like the Alzheimer’s
Association have partnered with Honor and made their
caregiver protocols available to Honor. Approximately
30% of Honor’s client base needs memory care.
A roommate matching service specifically aimed at baby
boomers and “empty nesters”, further enabling seniors to
remain in their homes and communities. The service
markets itself as an alternative to “assisted living facilities”
and as a means to generate additional income.
Bringing AI to dementia care and specifically helping
manage and prevent falls by seniors. It uses off the shelf
cameras to record falls and for a subscription fee, the falls
can be analyzed by a human and appropriate action may
be taken.
Source: Company Websites, Honor Partners with Alzheimer’s
Association for Caregiver Training (January, 2017). Medium:
There’s No Magic in Venture-Backed Home Care (Feb, 2017)
http://bit.ly/2sdiWSh 23
Companies To Watch In The Future
FUNDING AMT: UNDISCLOSED
Founded 2013
Stack is the 2016 winner of Aging 2.0’s Global
Startup Search, and maker of a smart
lightbulbs that respond to natural light and
occupancy.
It utilizes the same standards as other home
technology such as Amazon Echo, Alexa-
enabled devices, and Nest.
Cricket Health is a platform to enable better
Chronic Kidney Disease (CKD) management
for patients and caregivers.
Their technology enables home dialysis, a
patient community, educational materials, and
personalized care experiences.
Care3 is a community care collaboration
platform that brings together patients,
caregivers, and providers/staff members.
It offers a free app for families and enterprise
versions. The platform is well-suited for those
offering a care program like Program for All
Inclusive Care for the Elderly (PACE).
Source: HealthXL Database, Company Websites, Crunchbase
FUNDING AMT: $3.67M
Founded 2014
FUNDING AMT: UNDISCLOSED
Founded 2015
24
Investment Perspective
25
InvestorsTendToMakeInvestments
WithApplicabilityBeyondJust“Aging”or
“SeniorCare” Big tech VCs often struggle to see the value in hyper-niche solutions, while healthcare VCs understand those
struggles and emphasize clarity on revenue model, distribution, and access. Investment firms tend to have a
broader focus beyond simply aging, but examples do exist of niche-focused vehicles, such as the joint venture
between Ziegler and Link-Age.
Progressive organizations such as AARP, Aging 2.0, and RWJF help catalyze innovation through funding and
strategic partnerships, particularly helpful for solutions that hit address market needs without a clearly defined
revenue path.
Strategic investment by traditional healthcare players (e.g., health systems, payors) are able to provide capital,
resources to setup pilots, and actuarial know-how for proving cost-effectiveness.
26
Many Top Tier Investment
Funds Continue To View
Senior Care As Attractive
Source: HealthXL Analysis, Rock Health (2016 Year End Funding
Report: A Reality Check For Digital Health)
The most active funds in digital health have portfolio
companies representing all major areas of health and
healthcare.
These funds are not explicitly looking for “senior care”
solutions, but some of their investments have direct
relevance to senior care.
INVESTMENT FUND SELECT 2016 INVESTMENTS
27
Select examples showed.
Strategic Investors Are Also Well Positioned To Capitalize
On Care Platforms & Help Startups Partner With Leading
Health Systems
“Our goal is to provide all Trinity Health At Home patients with
care that is compassionate, proactive and transforming while
keeping them in their own homes.”
John Capasso
Executive Vice President of Trinity Health Continuing Care
The partnership will combine Vivify Health’s remote care
platform with Trinity’s virtual care initiatives.
Vivify Health enables capture of blood pressure, weight,
self-report, and the ability to involve caregivers.
The aim is to increase self-sufficiency while also reducing
readmissions and ER visits. The partnership is launching in
Michigan before expansion to up to seven states.
INVESTORPARTNER
Source: Company Websites, PR Web: Trinity Health to Provide Home Care Patients with
Continual, Virtual Care (February, 2017)
28
STARTUP
MANAGING PARTNER
FORTRESS INVESTMENT
GROUP
Blair Heavey
“When you look at the senior care space, specifically at home monitoring, I don’t see
entrepreneurs being able to go from startup to thriving company. I see the larger
companies Phillips, Amazon, Google Home crushing them before they get anywhere close
to getting to that level. Amazon and Google Home have that level of distribution. But if a
company was to be successful… I see the keys being some type of monitoring that
converts into engagement, and then being able to show proof of well being based upon
that.”
29
GENERAL PARTNER
STARTUPBOOTCAMP MIAMI
Christian Seale
“Dual eligibles represent an underserved and green field opportunity when you look at the
senior care space. More broadly, as average life expectancy continues to increase I
believe the most successful businesses will be built at the intersection of health and other
industries which affect the +65 population’s day-to-day quality of life - transport, housing,
finance, travel and lifestyle/wellness. Select point solutions will undoubtedly find success
but the real winners will be those that improve, extend and promote an active, healthy and
fulfilled life.”
30
Source: HealthXL
Interview
HealthXL&NorwestVenturePartners
MICROQ&A
We had the pleasure of connecting with Casper to learn more about his perspective on
what it takes to win in digital health. See below for a brief excerpt:
Do people engage over time? Show me how many people sign up and how many are still
active at 6 months. Omada has an advantage in that their program is 16 weeks not months
but even then it is hard work to keep consumers engaged. I measure this as value/friction.
How much value (benefit) do I get for the work I put in. Either I do no work and I get value
for free (think iTunes or Spotify finding songs I like) or I put more effort in to get more value.
Standing on a scale in the morning is not a big deal, charging my Fitbit is harder and I need
more positive feedback.
GENERAL PARTNER
NORWEST VENTURE
PARTNERS
Casper de Clercq
NextHealth Technologies
Omada Health
Science Exchange
ACTIVE COMPANIES
Basis
Crossover Health
iRhythm
Misfit Wearables
Telcare
ALUMNI COMPANIES
31
(Page 1 of 2)
HealthXL Question: As an investor what are the elements you look for in a tech enabled
service? What gets you excited about Omada potential and what can other entrepreneurs learn
about their model ideally as applied to a senior population?
Answer: There are four issues, including:
How much work/cost is it to keep people engaged? For longer term benefits you need
to provide short term rewards. In the case of Omada the coach and peers are essential to
provide positive feedback for all the work the consumer is doing. So what is the cost of
providing that service and how much revenue can I get for the solution. For example,
sensors in someone’s home for $50/month is too costly for what that person gets. No one
has found a scalable model yet.
1
2
Source: HealthXL
Interview
HealthXL&NorwestVenturePartners
MICROQ&A
What is the long term gross margin divided by the cost of getting a user?
Needs to be better than 3:1 In other words I need to get $3 (maybe over 3 years) but it
should not cost me more than $1 to get that user. Its similar to S&M spend. I cant spend
100% of revenues on commercial efforts – maybe 30-40%. If it costs me $1 and I plan to
get $3 over 3 years and 90% of my users are gone in one year I better get it down to
$0.30.
Finally. Full automation with software only is BS. You need to walk before you run.
Like manufacturing you would never set up full automation without hand assembly first.
Software likewise needs to be tested in the wild in all kinds of settings. The idea of bots,
automated responses and human like (AI) interactions are extremely difficult and as in #1
people are very sensitized to whether a human is on the other side. No person who cares
(coach), no social validation = no persistence. So the service inherently needs to get to
gross margin positive within a year or two assuming it is staffed with people and then it
can be automated over time.
3
4
32
(Page 2 of 2)
Even In Home Care, Aligning To Revenue Models
Can Positively Impact Company Success
Source: MobiHealthNews
“The main difference between our model and their models is we’re a marketplace,
whereas they are traditional agencies with their own tech staff. They basically
employ all these caregivers, which is very costly and makes the unit economics
hard to operate” (Sheik, CEO of CareLinx)
“[At CareLinx,] we set up families as the direct employer of record and then, similar
to ADP, we manage all the payroll, taxes, W2 issuance, on behalf of the patient
and the caregiver. That allows us to have a nationwide network of 200,000
caregivers on our platform versus competitors who are struggling with about 1,000
caregivers on staff. Unless you are an employer on the scale of Cisco Systems it’s
hard to compete with CareLinx’s model.”
33
CASE STUDY
External Factors Can Impact Unit
Economics, Evidenced by HomeHero
Source: There’s No Magic in Venture-Backed Home Care (Feb, 2017)
In early 2017, Home Hero ceased operations after raising $20M+ from
investors including Social Capital and Cedars Sinai Medical Center. Kyle Hill,
co-Founder and CEO, revealed the logic with much candor, highlighting the
following:
Longstanding players in home care have deep relationships with various inpatient
and outpatient facilities, which are tough to compete with.
Policy and national level wage laws can impact startups – as was the case in 2015
when US Department of Labor required all home workers to become W2s instead
of 1099 contractors.
Pilots with enterprise, health systems, struggle to convert to actual contracts with a
recurring revenue model.
Home care startups and others focused on senior care market should deeply
understand the market dynamics of entrenched solutions.
“One thing we learned about enterprise was that our
growth would be somewhat limited due to the lack of
financial incentive for certain health systems across the
country to pay for non-medical home care, especially if
they are only at-risk for a few thousand patients.”
34
CASE STUDY
A Multi-Stakeholder Ecosystem
Often Needs To Come Together
When Generating Evidence
Source: JMIR (2016)
Title:
Benefits of Diabetes Self-Management for Health
Plan Members: A 6-Month Translation Study
NON PROFIT
LEADING EFFORT
PATIENT
RECRUITMENT
DESIGN & DATA
ANALYSIS
FUNDER
DATA ANALYSIS
COMMUNITY-BASED
PROGRAM
COMMUNITY-BASED
PROGRAM
TECH SOLUTION
35
CASE STUDY
A diverse set of
activites and
players are
typically needed
to implement
novel programs.
Partner with innovative and visionary providers.
Identify insurance and payment models within care
setting.
WHEN THINKING ABOUT PROVIDER PARTNERSHIPS
How Can Digitally Enabled
Solutions Position
Themselves For Success?
Startups building senior care solutions require a
strong value proposition that addresses a real
problem.
Demonstrating effectiveness and cost savings
may prove challenging, therefore strategic
partnerships may be required.
Maintain strong ties with the broader healthcare
ecosystem that shares similar ideology and
mission to improve senior care.
Focus on user experience requirements for seniors.
Start thinking about how the product roadmap aligns to
future needs to generate evidence.
WHEN DESIGNING & BUILDING SOLUTIONS
Learn from past studies and reimbursement approaches.
Advocate for national level policy changes that broadly
impact seniors (e.g., medical, finances, etc.).
WHEN SEEKING REIMBURSEMENT
36
The Future
37
SVP, MARKET INNOVATION
AARP
Jody Holtzman
“Aging in America must change from its focus on cost and financial burden to opportunity,
in recognition of the true value older Americans contribute to innovation and the economy,
to our families and communities, to society and America’s future.”
38
Source: NextAvenue: Top 50 Influencers in Aging for 2017
Our societal values need to shift in
order to reframe the role seniors play,
particularly important as people
continue to live longer.
Human connections must continue to be
prioritized as assistive technologies such
as robotic companions, VR/AR, and others
continue to take hold.
Our communities of the future will be
designed and architected in a way that
promotes health and wellbeing for all
community members.
Future Thought
REDESIGNING SOCIETY FOR HEALTHY LIVING
As new models of care emerge and prove out their value, there’s a
real opportunity to ensure we keep implementing and enabling better
senior care.
1 2 3
39
Stay Connected & Learn About HealthXL’s Working Groups
40
Novel solutions that empower patients to
manage their own diseases and next-
generation approaches leveraging data and
behavior change to drive novel disease
management programs. Solutions and tools
include medication adherence, patient
communities, information repositories and
chronic disease chatbots.
Value pricing consists of the highest
possible health gains/outcomes for
patients, measured against the total
cost of care. We will look into areas
where value-based pricing may have
the greatest impact and how risk-based
contracts (including life sciences) can
impact care delivery.
Healthcare Payments
Best practices for gaining insights from big
data, identifying application areas including
healthcare, payors, and life sciences, and
improving insight reproducibility. Includes
analytics on vast amounts of data such as
genetic, claims or EHR information to provide
insights.
Big Data Analytics & AI Consumer Empowerment
New Models of Care
Precision Medicine is a customization of
treatment to an individual patient,
typically by using genomics, precision
nutrition, and microbiome information.
Looking into patient data security,
regulations, policy as it applies to
information repositories as well as CDS
solutions, diagnostic tests, or therapy
QOL trackers.
Precision Medicine
Looking into how traditional care
models are evolving to
incorporate technology such as
community based care using
remote monitoring tools and
telehealth, advanced analytics for
patient stratification.
Authors
FOUNDER & MANAGING
DIRECTOR
VOLAR HEALTH, LLC
+ HEALTHXL ADVISOR
Carlos Rodarte
CHIEF OPERATING OFFICER
HEALTHXL
Julie Carty
Acknowledgements
Ray Dorsey MD, MBA
University of Rochester
Blair Heavey
Fortress Investment Group
Peter Chai MD
Brigham & Women’s Hospital
Wen Dombrowski MD, MBA
CATALAIZE
We would also like to thank the following advisors on
HealthXL for contributing their insights:
41
SVP, MARKET INNOVATION AARP
Jody Holtzman
Christian Seale
Startupbootcamp Miami
Casper de Clercq
Norwest Venture Partners
Lee Shapiro
7Wire Ventures
Enabling Connected &
Independent Living
Through New Care Models
DECEMBER 2017
NEW MODELS OF CARE WORKING GROUP
Connecting The Dots To
Promote Innovation
42
in partnership with

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[Digital Health Report] HealthXL & AARP: Enabling Connected & Independent Living Through New Care Models

  • 1. Enabling Connected & Independent Living Through New Care Models DECEMBER 2017 NEW MODELS OF CARE WORKING GROUP Connecting The Dots To Promote Innovation 1 in partnership with
  • 2. HealthXL brings people, thinking & technology together The HealthXL Platform brings together key market stakeholders in digital health and empowers them to collaborate and learn from each other. HealthXL engages leading companies (see members on the right). 2
  • 3. This report is created as part of HealthXL’s New Models of Care Working Group. The aims of the report include: * Provide a high-level overview of care models and tech-enabled senior care solutions that promote connected and independent living. * Highlight venture capital / investor perspectives on the senior care market, with a focus on what makes startup solutions stand out. * Facilitate discussion in areas of interest to HealthXL stakeholders in order to guide deeper reviews and analyses in the senior care market. Note: In this report, “care” is broadly defined and encompasses both medical and non- medical care (e.g., support with daily living, etc.). Background 3 Overview & Trends Solution Landscape Investment Perspective Section 1: Section 2: Section 3:
  • 5. HowShouldWeThinkAbout ImprovingSeniorLiving? There is increasing awareness that seniors represent a diverse group ranging in age, ability, and needs. As a result, senior care solutions are not “one size fits all” – an important lesson as innovators aim to scale solutions. Solutions geared towards seniors must be easy-to-use and solve a specific problem. This helps ensure technology actually improves quality of life and wellbeing, and does not become a nuisance. Ideally, developing senior care solutions should involve various stakeholders including clinicians, designers, and seniors themselves. Mass market products aimed at improving convenience and livability (e.g., Blue Apron, Amazon’s Alexa) have the opportunity to enable independent living. However, large companies need to better market their products to seniors and their caregivers. Venture capitalists are realizing that seniors represent a significant opportunity, but usually tend to invest in solutions that have a broader impact across more than one single population or disease state (with some exception). 5
  • 6. Trends Driving Senior Care Innovation TECHNOLOGICAL ADOPTION A greater understanding in how seniors and caregivers utilize technology, and where need remains. INDEPENENT LIVING An overwhelming majority of individuals want to maintain independence and age gracefully in their home. WHOLE LIFE SOLUTIONS Increasing realization that broadly available consumer tech, particularly those adhering to “universal design” principles, can be helpful to seniors. Source: Aging in Place: A State Survey of Livability Policies and Practices,” (AARP 2011), Trends in Seniors’ Use of Digital Health Technology in the United States, 2011 2014 (JAMA, 2016), Tech Adoption Climbs Among Older Adults (Pew, 2017) 6
  • 7. NEUROLOGY UNIVERSITY OF ROCHESTER Ray Dorsey MD, MBA “Medicare has done an amazing job of ensuring access to care for acute conditions (e.g., heart attacks) but has come up short in ensuring access for chronic conditions. Over 40% of Medicare beneficiaries with Parkinson disease do not see a neurologist for their condition. Telehealth solutions, including the ability for older adults to receive care directly in their home, are available, but Medicare’s reimbursement policies currently incent institution-based care and discourage patient-centered care. Political will from organizations like AARP can help change that to the benefit of soon-to-be 70 million Medicare beneficiaries and 40 million Americans who care for adults.” 7
  • 8. Caring For Seniors Can Be A Costly Endeavor The U.S. Centers for Disease Control and Prevention defines Aging in Place (AiP) as “the ability to live in one’s own home and community safely, independently, and comfortably, regardless of age, income, or ability level.” Enabling seniors to reside in their homes may help offset increasing long term care costs. Independent living further helps seniors maintain social ties and avoid feelings of displacement. Medicaid continues to be a big payor of services, followed by individual out of pocket and Medicare. $45,760 $46,332 $17,680 $45,539 $82,215 $92,378 Home Care: Homemaker Services Home Care: Home Health Aide Adult Day Health Care Assisted Living Facility Nursing Home: Semi Private Room Nursing Home: Private Room Median Annual Cost (2016, USD) LOWER COST HIGHER COST Source: Genworth Financial Website (2016), CDC 8
  • 9. More Cost Effective Models That Enable Aging In Place Will Increase, Reflected In Market Forecasts The range of products and services that seniors may derive value from is diverse. Park & Associates has forecasted key market segments, further highlighting a shift towards enabling seniors to live independently at home. This shift gives rise to technologies and approaches that enable more convenient living and remote monitoring for patients where medical oversight is desired. Source: Park & Associates (2016) $932 $1,663 $2,765 $4,405 $6,311 $9,104 $1,329 $2,353 $3,311 $4,183 $5,087 $6,369 $125 $212 $293 $431 $571 $632 2015 2016 2017 2018 2019 2020 U.S. Active Aging Market Forecasts – Connected Solutions (USD, Millions) Safety & Smart Living Health & Remote Care Wellness & Fitness 9
  • 10. Innovators Focused On Senior Care Must Be Thoughtful About Their Revenue Model Medicare & Medicaid face cost pressures and places limitations on coverage of newer digital health solutions, an issue compounded by a lack of strong cost saving evidence by digital health players. Costly solutions, such as remote monitoring approaches, may be untenable for a direct-to-consumer model due to high cost of monitoring technology and associated services. As a result, innovators often experiment with at- risk revenue models to promote adoption. Startups building senior care solutions often have to be resourceful and implement a mixed business model combining several payment models to optimize operations. Source: Company Websites SELECT PAYMENT APPROACHES Medicare & Medicaid Private Insurance Government Assistance At-Risk Models Self Pay / Caregivers or Family Pays 10
  • 11. MANAGING PARTNER 7WIRE VENTURES Lee Shapiro “Health tech start-ups do not fully appreciate the purchasing power of the senior market and their disposable income. This market is more tech savvy than is commonly perceived. Further, start-ups may not appreciate that while individuals 65+ years of age have Medicare, they also buy supplemental coverage. We see the Medicare Advantage market as very attractive – and a place where the interests of consumer, provider and plan can be highly aligned.” 11
  • 12. Payment Reform Impacts A Broad Range Of Services [SELECT EXAMPLES / MODELS BELOW] PRIMARY CARE & RISK BEARING Primary care clinics designed for adults with Medicare. Founded: 2012 / Raised: Undisclosed Primary care for Medicare and Wellcare Medicare, team based, and incorporates wellness classes. Founded: 2011 / Raised: $123.25M Focused on senior patients who are chronically ill and frail in partnership with other healthcare stakeholders. Founded: 2013 / Raised: $240M TELEMEDICINE NEXT GEN INSURANCE Preferred Provider Organization with a Medicare Contract. Founded: 2013 / Raised: $425M Disease prevention through digital therapeutics (with data on Medicare population). Founded: 2011 / Raised: $126.52M Respiratory management through sensor platform (with data on Medicare population). Founded: 2007 / Raised: $49.86M Telehealth platform serving broad US population. Founded: 2002 / IPO: 2015 In-home senior care to enable independent living. Founded: 2014 / Raised: $62M Medical Group and Medicare health plans (subsidiary of Anthem). Founded: 1993 A non profit community-based health system with a long history of Medicaid care. Founded: 1999 Source: HealthXL Database, Company Websites, Crunchbase (November, 2017) DIGITAL THERAPEUTICS GOVERNMENTALON DEMAND / HOME CARE MEDICAL GROUP & HEALTH SYSTEMS 12
  • 13. The Range Of Transportation Needs For Seniors Highlights The Importance Of Thinking Holistically About Patient Needs Emergency Transport Medicare may cover depending on situation and location/type of facility (e.g., Critical Access Hospital, Skilled Nursing Facility, etc.) VALUE Critical care management and potentially life saving. Non-Emergency Medical Transport General & Leisure Transport VALUE Optimal disease management and improved outcomes. VALUE Social connectedness and reduction of isolation. Source: Company Websites 13
  • 15. Connected & Independent Living By Seniors Is Increasingly Achievable Given Diverse Solutions Source: HealthXL Platform (Note: The companies listed above are meant to be representative, not exhaustive. Visit HealthXL.co for more detailed company information including partners, funding, and publications). TELEHEALTH & REMOTE PATIENT MONITORING MEDICATION MANAGEMENT SHARED CARE PLANNING & COORDINATION HEALTH ASSESSMENTS SMART LIVING & HOME CARE 15 (acquired)
  • 16. Multiple Stakeholders Have A Role To Play In Helping Seniors Thrive Source: HealthXL Analysis SeniorMarketFocus INTEGRATED INFRASTRUCTURE BROAD PLATFORMS OR HARDWARE CAREGIVER TOOLS REGIONAL PROVIDER SYSTEMS & PAYORS (e.g., “Liveable” cities) MassMarketFocus Improved Convenience Clinical & Financial Outcomes TargetMarket Value Proposition 1 Focused on convenience, safety monitoring, and family coordination; requires more of an “evidence” mindset. Senior care programs may be created within systems or adopted from national level programs such as PACE; scaling is challenging due to “high touch” nature of programs. Broadly available technologies with mass market appeal; strategic marketing towards senior population can increase mindshare. Multi-stakeholder initiatives to enable better catering to seniors in everyday environments; requires significant forethought and planning. 2 3 4 16
  • 17. Not All Senior Care Solutions Require Reimbursement To Be Valuable NOVEL CARE MODELS & SOLUTIONS New models of care including smart home appliances (e.g. Nest) that have not yet proved their ROI in a traditional sense, or solutions that do not neatly fit into established care models (e.g., voice technologies, circadian rhythm optimization). COST SAVINGS DEMONSTRATED A wide range of solutions that have through pilots or otherwise, shown some sort of cost savings … whether it be around medication adherence or hospital readmissions. REIMBURSED BY INSURANCE Innovators can either choose to digitize services that are already covered (e.g., transport or PACE) or build up the necessary evidence to achieve reimbursement. Increasing levels of evidence, integration into care, and specialization in specific populations. 17
  • 18. GERIATRICIAN, INFORMATICIST, & CHIEF CONVERGENCE OFFICER CATALAIZE “The market size for startups that serve 65+ could be further expanded if they take a Universal Design approach -- i.e. design products/services that are super easy to use for all people (not just older adults, but also middle age people with disabilities, busy working moms, stressed out students, etc.).” Source: HealthXL Advisors Wen Dombrowski, MD, MBA EMERGENCY MEDICINE BRIGHAM & WOMEN’S HOSPITAL “Successful companies will need to provide solutions that are simple to use and provide true clinical value…. We need to start picking parameters in the technology startup group that make sense, and involve physicians who care for seniors and seniors themselves early in the design.” Peter Chai, MD However, Applying Universal Design Principles Ensures Usability By All, Including Seniors MILLENNIALS Convenience On-Demand Experience Voice-Based SENIORS 18
  • 19. Telehealth & Remote Patient Monitoring Vivify Health and Alignment Healthcare utilized Samsung Galaxy tablets to provide remote care to Alignment’s population. Over 120 patients have enrolled in the program. Omada Health is a CDC recognized-Diabetes Prevention Program, among others such as Noom and Canary Health, who has shown positive outcomes in a Medicare population and modeled cost-savings. 19 Chronic disease management platform that accounts for nutritional elements of various populations including seniors. Livongo applied a universal design approach to its solution to ensure seniors would be able to easily use it. What excites you about the potential of Livongo, specifically looking at engaging a senior population? “Livongo Health fits seamlessly into the senior’s workflow – he/she tests blood sugar as they might normally do, but the process is informed with real time insights that are personalized to that senior member. The meter was designed with the senior in mind – backlit; large chicklet style icons on an interactive screen; strips that are easy to handle and insert… last but not least, Livongo is extending into assisting the senior with common co-morbidities to diabetes as well as helping them optimize their medications...” MANAGING PARTNER 7WIRE VENTURES Lee Shapiro
  • 20. Medication Management What are the key business model implementations that makes etectRx ‘senior friendly’? Pillpack is a broad adherence solution with applicability in senior care. Earlier in 2017, Aetna Medicare members can fill covered prescriptions through PillPack’s full-service mail order pharmacy at preferred pharmacy co-pay levels. etectRx is an innovative medication adherence solution. The ID-Cap is a standard hard gelatin or HPMC capsule with an embedded ingestible wireless sensor. Each time an ID-Cap is swallowed, the ID-Tag uses etectRx’s proprietary technology to transmit a very low power digital message from within the patient’s stomach. Medisafe is a smartphone based medication adherence application and platform. It has shown benefit in improving adherence rates for drugs covered by CMS, and has also demonstrated how their application improves the patient- caregiver experience. Source: Company Websites, Aetna Welcomes PillPack to Preferred Medicare Pharmacy Network (February, 2017) “In the case of the ID Cap from eTectRx, we have worked with eTectRx to build an unobtrusive and seamless product that tackles one issue (medication adherence/ingestion pattern) with a simple device (a digital pill), that doesn’t require additional work from the perspective of the senior or the physician (you swallow the pill, it automatically logs the ingestion and you’re done)…It’s important to simplify the technology we are presenting to seniors.” EMERGENCY MEDICINE BRIGHAM & WOMEN’S HOSPITAL Peter Chai, MD 20
  • 21. Shared Care Planning & Coordination Evidence suggests that coordinated care models improve patient outcomes and reduce cost. Successful solutions will also have a plan for how to best engage patients over time and carefully consider how financial savings are achieved. Atlas of Caregiving is creating a body of research about the everyday experiences of caregiving to better understand unmet needs and lead to the development of better solutions. A recent, RWJF funded, study mapped the relationships between people and their physical space through the use of various sensors. CareAngel helps address gaps in care between physician visits through an AI-powered virtual caregiver, leveraging basic telephone infrastructure. With Elite Health, it demonstrated positive financial savings across a 500 patient implementation, enabling Elite Health to meet the needs of their value-based contracts. CareMore utilizes a coordinated care model that includes neighborhood care centers and care teams, case management that improves care coordination, a commitment to primary care, and a reliance on extensivists around hospitalization episodes. It recently introduced Lyft as a partner for non-emergency medical transport. Source: HealthXL Company Database, Company Websites, CareAngel: How Elite Health Achieved Engagement of 83%, 69% Readmission Reduction and $496,000 in cost savings (2017) 21
  • 22. HEALTH ASSESSMENTS Fitbit is a direct-to-consumer company that makes a variety of fitness-related wearable devices. While its products are not specifically created for seniors, the company directly targets seniors and caregivers in various marketing campaigns and collateral. Neurotrack is a mobile solution that enables individuals assess and improve memory capability, a particular issue with aging individuals. Research on Mild Cognitive Impairment (MCI) have shown positive results in assessing risk of cognitive decline. 22 A wide range of solutions exist to measure and assess the health of seniors – ranging from fitness devices to disease-specific solutions. The level of clinical or financial evidence that exists for this class of solutions vary given the diversity of approaches. Neurotrack has been studied more formally, while Fitbit takes a strategic marketing approach that directly targets seniors while enabling researchers to study its devices across various settings and populations. Source: HealthXL Company Database, Company Websites
  • 23. Smart Living & Home Care Various solutions are emerging that better enable living at home. Traditionally, this category has focused on “home care” solutions, but is now including a number of new players that may not be considered, such as: Honor provides non-medical home care through their Care Pros and focuses on helping the elderly with activities of daily living. Disease organizations like the Alzheimer’s Association have partnered with Honor and made their caregiver protocols available to Honor. Approximately 30% of Honor’s client base needs memory care. A roommate matching service specifically aimed at baby boomers and “empty nesters”, further enabling seniors to remain in their homes and communities. The service markets itself as an alternative to “assisted living facilities” and as a means to generate additional income. Bringing AI to dementia care and specifically helping manage and prevent falls by seniors. It uses off the shelf cameras to record falls and for a subscription fee, the falls can be analyzed by a human and appropriate action may be taken. Source: Company Websites, Honor Partners with Alzheimer’s Association for Caregiver Training (January, 2017). Medium: There’s No Magic in Venture-Backed Home Care (Feb, 2017) http://bit.ly/2sdiWSh 23
  • 24. Companies To Watch In The Future FUNDING AMT: UNDISCLOSED Founded 2013 Stack is the 2016 winner of Aging 2.0’s Global Startup Search, and maker of a smart lightbulbs that respond to natural light and occupancy. It utilizes the same standards as other home technology such as Amazon Echo, Alexa- enabled devices, and Nest. Cricket Health is a platform to enable better Chronic Kidney Disease (CKD) management for patients and caregivers. Their technology enables home dialysis, a patient community, educational materials, and personalized care experiences. Care3 is a community care collaboration platform that brings together patients, caregivers, and providers/staff members. It offers a free app for families and enterprise versions. The platform is well-suited for those offering a care program like Program for All Inclusive Care for the Elderly (PACE). Source: HealthXL Database, Company Websites, Crunchbase FUNDING AMT: $3.67M Founded 2014 FUNDING AMT: UNDISCLOSED Founded 2015 24
  • 26. InvestorsTendToMakeInvestments WithApplicabilityBeyondJust“Aging”or “SeniorCare” Big tech VCs often struggle to see the value in hyper-niche solutions, while healthcare VCs understand those struggles and emphasize clarity on revenue model, distribution, and access. Investment firms tend to have a broader focus beyond simply aging, but examples do exist of niche-focused vehicles, such as the joint venture between Ziegler and Link-Age. Progressive organizations such as AARP, Aging 2.0, and RWJF help catalyze innovation through funding and strategic partnerships, particularly helpful for solutions that hit address market needs without a clearly defined revenue path. Strategic investment by traditional healthcare players (e.g., health systems, payors) are able to provide capital, resources to setup pilots, and actuarial know-how for proving cost-effectiveness. 26
  • 27. Many Top Tier Investment Funds Continue To View Senior Care As Attractive Source: HealthXL Analysis, Rock Health (2016 Year End Funding Report: A Reality Check For Digital Health) The most active funds in digital health have portfolio companies representing all major areas of health and healthcare. These funds are not explicitly looking for “senior care” solutions, but some of their investments have direct relevance to senior care. INVESTMENT FUND SELECT 2016 INVESTMENTS 27 Select examples showed.
  • 28. Strategic Investors Are Also Well Positioned To Capitalize On Care Platforms & Help Startups Partner With Leading Health Systems “Our goal is to provide all Trinity Health At Home patients with care that is compassionate, proactive and transforming while keeping them in their own homes.” John Capasso Executive Vice President of Trinity Health Continuing Care The partnership will combine Vivify Health’s remote care platform with Trinity’s virtual care initiatives. Vivify Health enables capture of blood pressure, weight, self-report, and the ability to involve caregivers. The aim is to increase self-sufficiency while also reducing readmissions and ER visits. The partnership is launching in Michigan before expansion to up to seven states. INVESTORPARTNER Source: Company Websites, PR Web: Trinity Health to Provide Home Care Patients with Continual, Virtual Care (February, 2017) 28 STARTUP
  • 29. MANAGING PARTNER FORTRESS INVESTMENT GROUP Blair Heavey “When you look at the senior care space, specifically at home monitoring, I don’t see entrepreneurs being able to go from startup to thriving company. I see the larger companies Phillips, Amazon, Google Home crushing them before they get anywhere close to getting to that level. Amazon and Google Home have that level of distribution. But if a company was to be successful… I see the keys being some type of monitoring that converts into engagement, and then being able to show proof of well being based upon that.” 29
  • 30. GENERAL PARTNER STARTUPBOOTCAMP MIAMI Christian Seale “Dual eligibles represent an underserved and green field opportunity when you look at the senior care space. More broadly, as average life expectancy continues to increase I believe the most successful businesses will be built at the intersection of health and other industries which affect the +65 population’s day-to-day quality of life - transport, housing, finance, travel and lifestyle/wellness. Select point solutions will undoubtedly find success but the real winners will be those that improve, extend and promote an active, healthy and fulfilled life.” 30
  • 31. Source: HealthXL Interview HealthXL&NorwestVenturePartners MICROQ&A We had the pleasure of connecting with Casper to learn more about his perspective on what it takes to win in digital health. See below for a brief excerpt: Do people engage over time? Show me how many people sign up and how many are still active at 6 months. Omada has an advantage in that their program is 16 weeks not months but even then it is hard work to keep consumers engaged. I measure this as value/friction. How much value (benefit) do I get for the work I put in. Either I do no work and I get value for free (think iTunes or Spotify finding songs I like) or I put more effort in to get more value. Standing on a scale in the morning is not a big deal, charging my Fitbit is harder and I need more positive feedback. GENERAL PARTNER NORWEST VENTURE PARTNERS Casper de Clercq NextHealth Technologies Omada Health Science Exchange ACTIVE COMPANIES Basis Crossover Health iRhythm Misfit Wearables Telcare ALUMNI COMPANIES 31 (Page 1 of 2) HealthXL Question: As an investor what are the elements you look for in a tech enabled service? What gets you excited about Omada potential and what can other entrepreneurs learn about their model ideally as applied to a senior population? Answer: There are four issues, including: How much work/cost is it to keep people engaged? For longer term benefits you need to provide short term rewards. In the case of Omada the coach and peers are essential to provide positive feedback for all the work the consumer is doing. So what is the cost of providing that service and how much revenue can I get for the solution. For example, sensors in someone’s home for $50/month is too costly for what that person gets. No one has found a scalable model yet. 1 2
  • 32. Source: HealthXL Interview HealthXL&NorwestVenturePartners MICROQ&A What is the long term gross margin divided by the cost of getting a user? Needs to be better than 3:1 In other words I need to get $3 (maybe over 3 years) but it should not cost me more than $1 to get that user. Its similar to S&M spend. I cant spend 100% of revenues on commercial efforts – maybe 30-40%. If it costs me $1 and I plan to get $3 over 3 years and 90% of my users are gone in one year I better get it down to $0.30. Finally. Full automation with software only is BS. You need to walk before you run. Like manufacturing you would never set up full automation without hand assembly first. Software likewise needs to be tested in the wild in all kinds of settings. The idea of bots, automated responses and human like (AI) interactions are extremely difficult and as in #1 people are very sensitized to whether a human is on the other side. No person who cares (coach), no social validation = no persistence. So the service inherently needs to get to gross margin positive within a year or two assuming it is staffed with people and then it can be automated over time. 3 4 32 (Page 2 of 2)
  • 33. Even In Home Care, Aligning To Revenue Models Can Positively Impact Company Success Source: MobiHealthNews “The main difference between our model and their models is we’re a marketplace, whereas they are traditional agencies with their own tech staff. They basically employ all these caregivers, which is very costly and makes the unit economics hard to operate” (Sheik, CEO of CareLinx) “[At CareLinx,] we set up families as the direct employer of record and then, similar to ADP, we manage all the payroll, taxes, W2 issuance, on behalf of the patient and the caregiver. That allows us to have a nationwide network of 200,000 caregivers on our platform versus competitors who are struggling with about 1,000 caregivers on staff. Unless you are an employer on the scale of Cisco Systems it’s hard to compete with CareLinx’s model.” 33 CASE STUDY
  • 34. External Factors Can Impact Unit Economics, Evidenced by HomeHero Source: There’s No Magic in Venture-Backed Home Care (Feb, 2017) In early 2017, Home Hero ceased operations after raising $20M+ from investors including Social Capital and Cedars Sinai Medical Center. Kyle Hill, co-Founder and CEO, revealed the logic with much candor, highlighting the following: Longstanding players in home care have deep relationships with various inpatient and outpatient facilities, which are tough to compete with. Policy and national level wage laws can impact startups – as was the case in 2015 when US Department of Labor required all home workers to become W2s instead of 1099 contractors. Pilots with enterprise, health systems, struggle to convert to actual contracts with a recurring revenue model. Home care startups and others focused on senior care market should deeply understand the market dynamics of entrenched solutions. “One thing we learned about enterprise was that our growth would be somewhat limited due to the lack of financial incentive for certain health systems across the country to pay for non-medical home care, especially if they are only at-risk for a few thousand patients.” 34 CASE STUDY
  • 35. A Multi-Stakeholder Ecosystem Often Needs To Come Together When Generating Evidence Source: JMIR (2016) Title: Benefits of Diabetes Self-Management for Health Plan Members: A 6-Month Translation Study NON PROFIT LEADING EFFORT PATIENT RECRUITMENT DESIGN & DATA ANALYSIS FUNDER DATA ANALYSIS COMMUNITY-BASED PROGRAM COMMUNITY-BASED PROGRAM TECH SOLUTION 35 CASE STUDY A diverse set of activites and players are typically needed to implement novel programs.
  • 36. Partner with innovative and visionary providers. Identify insurance and payment models within care setting. WHEN THINKING ABOUT PROVIDER PARTNERSHIPS How Can Digitally Enabled Solutions Position Themselves For Success? Startups building senior care solutions require a strong value proposition that addresses a real problem. Demonstrating effectiveness and cost savings may prove challenging, therefore strategic partnerships may be required. Maintain strong ties with the broader healthcare ecosystem that shares similar ideology and mission to improve senior care. Focus on user experience requirements for seniors. Start thinking about how the product roadmap aligns to future needs to generate evidence. WHEN DESIGNING & BUILDING SOLUTIONS Learn from past studies and reimbursement approaches. Advocate for national level policy changes that broadly impact seniors (e.g., medical, finances, etc.). WHEN SEEKING REIMBURSEMENT 36
  • 38. SVP, MARKET INNOVATION AARP Jody Holtzman “Aging in America must change from its focus on cost and financial burden to opportunity, in recognition of the true value older Americans contribute to innovation and the economy, to our families and communities, to society and America’s future.” 38 Source: NextAvenue: Top 50 Influencers in Aging for 2017
  • 39. Our societal values need to shift in order to reframe the role seniors play, particularly important as people continue to live longer. Human connections must continue to be prioritized as assistive technologies such as robotic companions, VR/AR, and others continue to take hold. Our communities of the future will be designed and architected in a way that promotes health and wellbeing for all community members. Future Thought REDESIGNING SOCIETY FOR HEALTHY LIVING As new models of care emerge and prove out their value, there’s a real opportunity to ensure we keep implementing and enabling better senior care. 1 2 3 39
  • 40. Stay Connected & Learn About HealthXL’s Working Groups 40 Novel solutions that empower patients to manage their own diseases and next- generation approaches leveraging data and behavior change to drive novel disease management programs. Solutions and tools include medication adherence, patient communities, information repositories and chronic disease chatbots. Value pricing consists of the highest possible health gains/outcomes for patients, measured against the total cost of care. We will look into areas where value-based pricing may have the greatest impact and how risk-based contracts (including life sciences) can impact care delivery. Healthcare Payments Best practices for gaining insights from big data, identifying application areas including healthcare, payors, and life sciences, and improving insight reproducibility. Includes analytics on vast amounts of data such as genetic, claims or EHR information to provide insights. Big Data Analytics & AI Consumer Empowerment New Models of Care Precision Medicine is a customization of treatment to an individual patient, typically by using genomics, precision nutrition, and microbiome information. Looking into patient data security, regulations, policy as it applies to information repositories as well as CDS solutions, diagnostic tests, or therapy QOL trackers. Precision Medicine Looking into how traditional care models are evolving to incorporate technology such as community based care using remote monitoring tools and telehealth, advanced analytics for patient stratification.
  • 41. Authors FOUNDER & MANAGING DIRECTOR VOLAR HEALTH, LLC + HEALTHXL ADVISOR Carlos Rodarte CHIEF OPERATING OFFICER HEALTHXL Julie Carty Acknowledgements Ray Dorsey MD, MBA University of Rochester Blair Heavey Fortress Investment Group Peter Chai MD Brigham & Women’s Hospital Wen Dombrowski MD, MBA CATALAIZE We would also like to thank the following advisors on HealthXL for contributing their insights: 41 SVP, MARKET INNOVATION AARP Jody Holtzman Christian Seale Startupbootcamp Miami Casper de Clercq Norwest Venture Partners Lee Shapiro 7Wire Ventures
  • 42. Enabling Connected & Independent Living Through New Care Models DECEMBER 2017 NEW MODELS OF CARE WORKING GROUP Connecting The Dots To Promote Innovation 42 in partnership with