Things I’m Thinking About In Healthcare Part 3

Nikhil Krishnan
Jan 23 · 17 min read

I’m doing an experiment with “continuous content” and more stream of consciousness analysis. Part 1 and Part 2 are here. Check out the central page for more details.

Table of Contents

  1. The Wisdom Of The Crowds Opportunity
  2. Equipping The Modern “Barefoot Doctor”
  3. Serving The Independent Practice
  4. Who’s The Right Doctor?
  5. Health Startup Studios

1) The Wisdom Of The Crowds Opportunity

Crowdsourcing is underutilized in healthcare. I see a couple of opportunities here.

Crowdsourced triaging and symptom management — Patients turn to the internet for help understanding a condition, ask small everyday questions, find second opinions on a diagnosis, and receive support post-diagnosis.

At the moment, this is almost entirely outside of existing care delivery options, even though building communities is one of the most common defensibility strategies modern companies use.

Patients are looking to the crowds to help them navigate the treacherous waters of healthcare or answer a random question or two that doesn’t require an entire visit. Instead of dismissing internet advice, we should find ways to meet patients where they’re already going…which is reddit apparently?

I took a short break from r/historymemes to check out the healthcare subreddits

The issue is that it’s very difficult to know whether the source of advice has any actual authority (is u/narutofan4ever really a doctor?) and whether the aggregate advice given is similar to what doctors would suggest in clinic.

Patients also go to other patients living with their disease to find practical pieces of advice. This can be anything from how to deal with taking meds, caring for a loved one with a disease, managing side effects, etc. This is the empathetic and practical part of care that doctors simply can’t give without living with the disease. Narratives often work better than checklists.

The Crohn’s subreddit is very active and has a great sense of humor

And in many cases, these subreddits arm patients with information to ask at their next doctor’s visit, or when they should be seeking a new doctor.

Right now, this is happening on the internet with little oversight or integration into regular care. The functionality of existing social media wasn’t built for this. What if there was a platform that could:

  1. Provide some authenticity around whether an anonymous account has medical expertise (so the author doesn’t have to reveal themselves, but the user knows they’re semi-legit)
  2. Give weights to the answers based on the author’s level of expertise + history of giving correct advice
  3. Produce a crowdsourced answer to a patient (maybe guide them to a telemedicine follow-up)
  4. Integrate the patient’s record via patient portal to confirm or refute the weighted crowdsourced diagnosis
  5. Connect them to other patient communities where they can get answers to day-to-day questions

I don’t expect this to replace in-person care, but I think it’s a great way to provide some structure and oversight to a behavior that’s already happening. Besides, maybe patients shouldn’t rely on the opinion of one doctor in case that doctor isn’t good. It’s difficult for most patients to assess when to go to the doctor and the quality of advice their doctor gives them. Maybe forums can help provide them with guidance.

So yes, I can’t believe I’m saying this but… maybe we should listen to the comments section of the internet.

Crowdsourced data-tagging — Luis Von Ahn coined the phrase “massive-scale online collaboration”, the idea that aggregating lots of small tasks from the internet + some data science could solve a gigantic task using the crowd’s wisdom (I’m poorly paraphrasing). This was actually the origin of CAPTCHA, which was not only used to stop bots, but the aggregate answers were used to digitize the archives of the New York Times.

One of the difficulties in training healthcare AI models today is getting diverse datasets and also annotating/tagging/structuring them properly. What if there were some equivalent crowd-sourced tagging mechanisms?

There’s an interesting experiment which created a game that had players tag malaria infected red-blood cells. The gamers (regular people, not MDs) were trained on what to look for in the tutorial, and then set out to tag the right cells.

The gamers tagged the cells with 99% accuracy, even better than a trained machine vision algorithm.

Human:1, Machine:0

Now this is just one example, but we should think about how we can attempt more ways to enable this massive-scale online collaboration and create better and more varied AI training data sets.

What if regular people were taught to look at for abnormalities and tagged those images?

What if there was a physician-specific CAPTCHA, where you tag/annotate images and get access to journals? Or took an unstructured text paragraph and structured it/highlighted the key parts of the text?

Companies like Figure1 and Centaur are examples of companies tackling this. To get a more heterogenous dataset, maybe patients to submit their records to get a crowdsourced diagnosis.

2) Equipping The Modern “Barefoot Doctor”

In the 1950s/1960s, communist China had a big problem. The revolution was dependent on a healthy rural farming population, but they had extremely poor health and very little access to care. The government then instituted 3–6 month healthcare crash courses for semi-educated farmers/people who lived in rural villages so they could treat many of the largely preventable and infectious diseases in those villages at the time.

The outliers in rural areas are particularly bad

Fast forward to today, and we see the collapse of health services and hospitals in rural America, massive patient:physician ratios + lack of access to any services in many developing economies, and the burden of disease has shifted from infectious to chronic conditions and diseases of despair (addiction, mental health, etc.).

But alongside a new set of challenges, we have a new set of tools. Specifically, we have new diagnostic + screening tools, artificial intelligence, and telemedicine.

What if we could equip nurse practitioners, physician assistants, or even non-MDs in rural areas to better support people in these health deserts? What if there were crash courses to train them in the basics to support their communities?

Today we have more and more tools to bring non-invasive diagnostic and screening tools closer to these patients. Maybe the modern barefoot doctor is equipped with:

Utility belt not required but would be sick

Data is captured from this toolset and interpretation can either happen via AI if it’s validated or via telemedicine. Escalation can then begin, or support/follow-up testing can happen on the ground from the non-MDs on the ground. TytoCare has an interesting process for this with guided exams.

I think the reality is that healthcare in rural areas is going to be restructured thoroughly — high overhead operations are no longer sustainable and leaner operations are likely more cost effective. Care will likely need to be split into more semi-trained non-MDs and frontline staff to provide as much care and screening as they can, with specialists providing largely remote support and instructions. Escalation would occur as necessary to more densely populated cities where higher overhead hospitals would be situated. Maybe Federally Qualified Health Centers (aka. government supported care centers where there’s a physician shortage) are set up to support local emergencies to stabilize patients or a specific purpose like pregnancies. The tools front-line staff uses will alert them that SOMETHING is wrong, and then go to the right specialist to tell you exactly WHAT is wrong.

My perpetual skipping of leg day makes my legs closer to 10% each

There’s a secondary effect to better tools — structuring and standardizing more measurements in clinics. One thing that’s surprised me is how subjective and archaic a lot of scales and measurements are. Take Body Surface Area (BSA) for example — in many cases physicians will estimate using a “rule of nines” to split the body into 9 parts that should add up to 100%. This doesn’t take into account body differences and is usually eye-balled. Measuring this way not only takes time but also can vary from physician to physician. This gets even more subjective when you enter areas like neurodegenerative disorders, mental health scales, etc.

More digital tooling on the front-lines would hopefully increase standardization of first assessments and make measurements faster to take. It would also potentially make it easier for caregivers to take more of these measurements in day-to-day life too, for situational data points (after a meal) and a larger sample size.

In fact, caregiver enablement seems like the biggest opportunity here. The benefit of the barefoot doctor was the fact that people embedded in the community were trained and could make a side income — what if caregivers went through a care management bootcamp of sorts to help manage the care of a population in a rural area + were equipped with the modern tools so they could take care of their loved ones and neighbors (maybe even make additional income)? New doctors/healthcare workers don’t want to move to rural areas where the need is high, so we need to empower the people that are already there. Combining new tools/devices with training for everyday community members a la CareAcademy would cover a huge gap here.

2019 Survey of Final Year Residents

The reality is most people in rural areas suffering from more chronic diseases need more frequent support from less specialized/cheaper frontline staff or their caregivers. We’re seeing this kind of labor triaging in areas like diabetes management, where coaches work together with MDs and NPs to provide the right level of care based on the situation. With the tools at our disposal today, we can equip non-MDs to better service this population and reduce healthcare deserts.

3) Serving the Independent Practice

Some things I believe:

  • A significant contribution to the physician burnout epidemic is the requirements large hospitals put on the staff. This makes patient relationships more transactional and physicians don’t capture the upside of attracting and retaining patients. More physicians are employees than owners for the first time.
  • Even as physicians are being squeezed to maximize RVUs (relative value units), document more, and generally work to the benefit of the hospital all of the money goes to the facilities instead of the physicians. Physicians capture very little upside of having a strong patient relationship vs. the work imposed on them.
  • A major way to bring down the cost of healthcare is by making healthcare services more competitive — to do this we need more independent physicians/physician groups. In many states a handful of dominant providers essentially control all referrals, and subsequently have all of the pricing power. However, it’s been demonstrated that consolidation actually has worse outcomes for patients and hospitals end up charging more.
Hospitals are gaining pricing power via consolidation and hospital services are the biggest coster center in healthcare (Source 1, Source 2)
  • Hospital consolidation has reached a tipping point — I think we’re finally going to start seeing physicians wanting to break away from large systems. This is likely going to start in primary care first, especially because payers largely support this. We’re seeing signs of this in North Carolina, where a large group of physicians left Atrium Health and Sutter Health settled its antitrust suit. This is a canary in the coal mine — hopefully more physicians push to go independent and antitrust scrutiny increases/hospital appetite for acquisition decreases.
  • One of the barriers to digital health on the B2B side is the lack of small/medium businesses to act as early adopters. In most other industries, SMBs are more willing to adopt new solutions + have much shorter sales cycles. But in healthcare, the lack of smaller providers and the pressure they face to simply stay operational has been a major impediment to solutions that would ultimately help physicians. Plus, the underlying infrastructure for these practices (e.g. EHRs) is so bad that it makes building any tools on top a massive hassle.

TL:DR — Helping doctors become independent would improve healthcare and increase innovation, and the timing is right.

The problem is that it’s extremely hard to start a practice today. Your negotiating rate with insurers is worse, your ability to acquire patients is much more difficult if the hospital owns the referral pathways in your geography, malpractice insurance is expensive, and it’s incredibly expensive to spin up a practice if you don’t have initial capital. But once established, practices are quite stable cashflow businesses. This is especially true in certain procedure-heavy specialties like dermatology, which not coincidentally have extremely high private equity interest as well.

It’s imperative to find a way to make it easier for doctors to be independent. I’m excited about what companies like DocSpace that are trying to make practice formation easier (disclaimer: I’m an advisor) — by starting with a virtual practice first, physicians can take advantage of the toolset that exists to power small tech companies and plug right into them. The tools right now available to physical private practices are hot garbage — if you’ve never seen what an EMR looks like for the long-tail of private practices you’re lucky. But an online-first practice can take advantage of APIs like Stripe, JustWorks, etc. to handle everything from payments to scheduling, encrypted chat, payroll, marketing, record collection and more.

If we want to see more physician-owned practices, one way to frame this is “what is a resource that a hospital currently provides that an independent physician could not have themselves?” At TrialSpark, one example is the clinical research coordinator. If you don’t run enough trials in your practice, then hiring a full-time research coordinator is too expensive relative to the infrequent trial dollars that come in (vs. a hospital, which runs many trials). But without a research coordinator, the logistics of running a trial become very time consuming. At TrialSpark, we have our own clinical research coordinators that support several practices each when they have a trial to run. What are other resources that could be split across practices that hospitals have?

You can also just dip into Alphabet Soup and see what 3 letter acronym independent practices need

Centralizing and splitting a resource exclusive to hospitals seems like an ancillary service layer to be built. Managed Service Organizations (MSOs), Independent Physician Associations (IPAs), and Group Purchasing Organizations (GPOs) are just some of these support services practices will need, but there’s likely an opportunity to build a new wave of these that have less invested hospital interest and more tactical ways to deploy tech-enabled services like patient engagement/management, claims processing, dealing with anything insurance/pharmacy related, etc. The most capital intensive part of a practice is the physical space. In the same way we’ve seen co-working spaces split the physical overhead across many companies, we’ll likely see more of a gradient in the future as physicians move from online practices, to partial renting of space, to franchising/full office ownership.

Contracting with payers/getting into risk-based contracts is going to be a big part here since independent clinics will have a hard time doing that alone. What Aledade and Iora are doing are important case studies and building blocks to enable smaller practices to participate in value-based care.

It’s time to start betting on the independent physician and building the tools and ecosystem to support that.

4) Who’s The Right Doctor?

In order for doctors to strike out on their own, we need people to know who the good doctors are. I want rockstar physicians to be able to shine and make a name for themselves. There should be a place where good physicians can be praised and highlighted by both patients and physicians alike, and that would give them more leverage in doing things like opening their own practices, etc. On the flip side, we can also avoid terrible physicians from shuffling through the system with no recourse because large providers are scared their reputation would be damaged. Everything still feels very gatekeeper-driven.

This is a question I (and I’m guessing many other patients) struggle with all the time: How do I find the best doctor for my issue and financial situation? This is key to better physician discovery, and therefore physician independence.

The reality is that the answer is going to be different depending on the issue and what you personally care about, but there’s no real way for a patient to examine and weigh the different factors. I have friends that have gotten surgeries at brand name hospitals simply because they equate brand name with “the best”, when the reality is that a better/more cost-effective choice is the doctor that’s done that surgery a million times.

It’s hard to know where to go for the information about how good a doctor is. Online reviews from patients focus on one aspect of care, getting a referral from one doctor is trusting a single opinion and they may just refer you to one of their med school homies, and no one knows your insurance plan coverage or personal financial status. Each is biased in a different way.

My mom is much nicer than this, sorry Mom

I personally have relied heavily on friends and family that are physicians to give me semi-objective, non-malpractice-fearing, fee-for-service-governs-my-life advice on next steps or best physicians to see. But that’s a privilege for people with access to physicians in their personal lives and it shouldn’t be.

Also physicians are optimizing generally for the “best” care, but honestly sometimes I just need “good enough” care, especially relative to the amount I want to spend. For routine things, I might ask my co-workers who have probably gotten X check-up or need Y specialist and likely have my same insurance coverage. This takes cost and convenience into account.

Here are some of the things I would want to evaluate:

From patients

  • Clinic, amenities, and operations — Was everything on time? Is the clinic a good experience? Are the staff helpful?
  • Doctor personality — Did they listen? Are they comforting? Are they trying to rush you out? Does it feel like they’re constantly upselling you?
  • Would other patients similar to me (demographically and with the same issue) recommend this doctor?

From data

  • How many people similar to me have come to this doctor? How many times have they done this procedure/assessment?
  • For the procedure/disease I have, what are the outcomes for this doctor? What are the most common negative outcomes?
  • For my issue, which treatment path does this doctor tend to prefer? Are they more surgery or physical therapy oriented? One medication type vs another?
  • Has this doctor done research in my area? Over what period of time?
  • What are the financial interests of this doctor? How much are they paid by third parties and which ones?
  • Hooking into my financial situation and dashboards — what is the smartest choice financially based on my insurance plan, amount of deductible I’ve hit, and other personal financial considerations? Because talking about personal finances is so taboo, this rarely gets included, but from the patient’s point of view this is a huge governing factor.
  • How booked is this doctor? Is their schedule constantly filled?

From other doctors

  • How would other doctors rate this doctor? Which dimensions do they think this doctor excels?
  • How many other doctors are repeat referrals to this doctor? How many have stopped referring to this doctor?

Most of the data required for this exists in separate places, but it exists. And individually each of these datasets would be biased— patients would care too much about one thing, doctors would be oblivious to others, and the data is biased based on its source and original use case. I wish there was an easy way to get this into one place, weight them, and tell me the answer of which doctor is the best for what I need.

At the very least we should moving away from these nonsensical and shady “Top Doctor” awards.

5) Health Startup Studios

I’m interested to see how the venture studio model plays out.

In this model, an investment fund is raised, but instead of investing it into external startups it uses in-house teams to incubate the company and then eventually spin it out into its own entity. Some examples of venture studios include Atomic, PreHype, and Human Ventures. We’re also starting to see some large companies come out of studios like Hims, Dollar Shave Club, and Managed By Q among others.

Apparently more than 200 studios now!

There’s a lot of debate on whether studio models work well — some people say an adverse quality selection is created because it attracts founders that want a de-risked way to startup companies. Plus equity becomes so divided that no one has enough skin in the game to drive the company to success.

But one of the reasons I think this has more legs in healthcare is because some of the most expensive early hires for a healthcare startup come from the traditional healthcare world, are generally more risk-averse, and can likely effectively be split across several companies at the very earliest stages as business models and efficacy are still getting proven out. This includes medical/clinical teams, legal, quality/compliance, etc.

Even more important is not relying on a single, specific hire for expertise. It’s easy to over index on one person’s advice when they’re the only person with experience in that area. But for one startup, having too many clinical people, etc. early on is too expensive/unnecessary.

The reality is that the time between starting a company and finding product-market-fit in healthcare takes much longer than traditional tech companies. Being able to use the same teams and experiment across a bunch of different concepts might actually be a more efficient use of capital by better utilizing a traditionally expensive labor force and being able to run more experiments.

Biotech actually does the studio model quite well — there are lots of relatively successful biotech studios like Flagship pioneering, Versant Ventures, and the 5AM Ventures 4:59 Initiative. IMO a few things make this work well in biotech:

  1. Very well-defined stages of company building that require different and specific skillsets (bench science, trials, commercialization).
  2. Relatively clear-cut ways to get signal on whether an idea is worth pursuing.
  3. Large upfront costs that benefit from being amortized across many companies (e.g. lab space and equipment).

Are there equivalents in health tech that we might be able to use as proxy?

  1. Very well-defined stages — product building, pilot, scaling out/commercializing/getting reimbursement
  2. Signal — results from the pilot or initial set of customers
  3. Amortized costs — a group of typically high cost hires (e.g. chief medical officer + legal team with deep health expertise), manufacturer relationships, an independent physician association as beta testers, discount group pricing licensing software or service providers (EMR integration specialists, data providers), real-estate + call centers for care delivery startups, etc.

A few healthcare studios seems to be popping up (Oxeon, Redesign, etc.) and it’s an area I’m watching closely. I think healthcare might be uniquely suited to do well in a studio model because the capital stretches further in experimentation and it might better attract strong healthcare talent into the startup world.

If anything I wrote in my stream of consciousness resonates with you, please reach out to me on twitter @nikillinit or, and I’d love to hear your thoughts.

Nikhil Krishnan

Written by

I try to be funny about tech but usually fail. Tech Industry Analyst @cbinsights, @columbia alum

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