Another antitrust shoe drops: FTC, DOJ publish Draft Merger Guidelines for comment–what are the effects?

The Department of Justice (DOJ) and the Federal Trade Commission (FTC) have published for public comment a draft of revised corporate merger guidelines. These update prior guidelines from 1968 which have been revised six times since. These are stated as incorporating comments from hearings and comments that started in January

The Draft Merger Guidelines on FTC.gov are open for comment for the next 60 days (18 September), cleverly during a time when most of Washington DC is repairing to cooler climes for summer holidays. They are centered on what DOJ Antitrust and FTC loftily call The 13 Guidelines. These will be used singly or in combination for these agencies to determine “whether a merger is unlawfully anticompetitive under the antitrust laws.” 

  1. Mergers should not significantly increase concentration in highly concentrated markets;
  2. Mergers should not eliminate substantial competition between firms;
  3. Mergers should not increase the risk of coordination;
  4. Mergers should not eliminate a potential entrant in a concentrated market;
  5. Mergers should not substantially lessen competition by creating a firm that controls products or services that its rivals may use to compete;
  6. Vertical mergers should not create market structures that foreclose competition;
  7. Mergers should not entrench or extend a dominant position;
  8. Mergers should not further a trend toward concentration;
  9. When a merger is part of a series of multiple acquisitions, the agencies may examine the whole series;
  10. When a merger involves a multi-sided platform, the agencies examine competition between platforms, on a platform, or to displace a platform;
  11. When a merger involves competing buyers, the agencies examine whether it may substantially lessen competition for workers or other sellers;
  12. When an acquisition involves partial ownership or minority interests, the agencies examine its impact on competition; and
  13. Mergers should not otherwise substantially lessen competition or tend to create a monopoly

Assistant Attorney General Jonathan Kanter of the Antitrust Division stated in the DOJ/FTC release, “Today, we are issuing draft guidelines that are faithful to the law, which prevents mergers that threaten competition or tend to create monopolies. As markets and commercial realities change, it is vital that we adapt our law enforcement tools to keep pace so that we can protect competition in a manner that reflects the intricacies of our modern economy. Simply put, competition today looks different than it did 50 — or even 15 — years ago.” Not to be outspoken, FTC Chair Lina M. Khan, got her dibs in: “With these draft Merger Guidelines, we are updating our enforcement manual to reflect the realities of how firms do business in the modern economy.” Here the DOJ Antitrust Division takes the communications lead but the draft is published by FTC. These guidelines require no ratification by Congress as they are administrative in nature.

To this Editor, it is hard to see that any merger or acquisition of like companies or even complimentary organizations could pass. Consider the following scenarios: a leading telehealth or remote patient monitoring company offers to buy a struggling early-stage AI/ML or data analytics company to expand its capabilities, a larger health system buys a failing community hospital, one hotel looks to buy another down the street, VCs or equity investors look to exit just about anything through a sale. Every one of these situations triggers one or more of these guidelines.

Coupled with the proposed changes to the Premerger Notification under the Hart-Scott-Rodino Act (HSR Act) [TTA 29 June] now published in the Federal Register (29 June), open for comment until 28 August, we may be looking at the last few years as the Last Good Time for M&A, even with current restrictions in place.

As your Editor said last month, “For those surprised that FTC is taking the lead on this, this once-sleepy agency woke up late last year in a heckuva bad humor and is now taking a far more activist role in corporate oversight in areas such as privacy.” This was powered by a 2021 executive order by the current president for any and all mergers to be scrutinized. Earlier, FTC and DOJ withdrew antitrust policy statements that they now feel are overly permissive. FierceHealthcare

Already industry machers such as the American Hospital Association, Federation of American Hospitals, Pharmaceutical Research and Manufacturers of America (PhRMA) have asked the FTC mildly and politely for a further 60-day extension of the comment period. This includes non-healthcare organizations such as the American Hotel & Lodging Association and the Consumer Technology Association which runs CES. (Don’t hold your breath) FierceHealthcare

crystal-ballIn the cloudy crystal ball, this Editor sees a rush to complete acquisitions 1) below the HSR threshold ($111 million) and 2) in general before the new antitrust guidelines are adopted–and they will be as they are administrative measures and not laws. To reiterate previous comments, overall it will further depress M&A and investor exits, especially in healthcare and with mid-size private and public companies, funding beyond Series A/B, and valuations.  If you start a business, inherit one, or are trying to turn around one that has lost its markets or unprofitable–but can’t sell it in the future, what you have is a ton of frozen value and uninterested lenders. Will a thousand flowers bloom, like they did in airline deregulation 1980-1995–drive businesses to friendlier countries like Ireland or Poland–then lead to stagnation? Perhaps a new era of conglomerates of unrelated businesses a lá LTV and Gulf+Western in the 1960s? Tell your Editor and fellow Readers below.

Legal roundup: Teladoc class-action suit dismissed; NextGen EHR $31M Federal settlement; significant AliveCor-Apple antitrust ‘spoiliation’ update; class action suits filed against HCA, Johns Hopkins

The latest legal activity in digital health and cybersecurity:

Teladoc’s pending class action lawsuit by shareholders was tossed. This was originally filed in June 2022 after the crash of Teladoc’s shares after The Big Livongo Writeoff in May 2022. Shareholder Jeremy Schneider, represented at the time by Jeremy Alan Lieberman of Pomerantz LLP, filed a lawsuit in the US Federal Court for the Southern District, located in downtown Manhattan, representing shareholders who purchased Teladoc shares between 28 October 2021 and 27 April 2022. The lawsuit cited materially false statements that Teladoc made on its business, operations, competition, and prospects that were overly positive and inflated share value. Judge Denise Cote agreed with Teladoc’s 20 January motion to dismiss based on specific disclosures that Teladoc made in multiple SEC filings in that period from the 2020 10-K on that countered claims made in the class action lawsuit.

Reading Judge Cote’s decision, Teladoc used specific limiting and warning language (what marketers call ‘downside’ language) on the risks around the merger. Their executives in public statements indicated that operations and competition were challenging.  The class action suit failed to prove conclusively that the statements it identified were ‘materially misleading’ and would mislead a reasonable investor. Other statements made by executives were “largely non-actionable statements of opinion and/or expressions of corporate optimism”, a/k/a “puffery”. Class action suits of this type that go to Federal courts (versus state courts) rarely succeed due to the high bar of proof and volumes of case law at the Federal level.

This Editor noted that this particular class action did not include Mr. Schneider nor Pomerantz LLP. Different plaintiffs were represented by Labaton Sucharow LLP and The Schall Law Firm. Teladoc reportedly had no comment.  Judge Cote’s opinion (Casetext), Mobihealthnews, Healthcare Dive

Easier to settle for $31 million than fight the Feds. Charged with violating the False Claims Act (FCA) and providing illegal incentives for referrals (the Anti-Kickback Statute that applies to Federally funded healthcare), NextGen Healthcare decided to settle with the Department of Justice (DOJ) for a whopping $31 million. The settlement does not admit wrongdoing by NextGen, which in its defense told Healthcare Dive that the claims made were over a decade old–and they were. At the time, their EHR used an auxiliary software that was designed only to perform the certification test scripts, thereby gaining 2014 Edition certification criteria published by HHS’s Office of the National Coordinator (ONC). In this Ur-time of EHRs, fixes like this weren’t (ahem) unusual. Compounding it was that the EHR then lacked certain additional required functionalities, including the ability to record vital sign data, translate data into required medical vocabularies, and create complete clinical summaries. Making NextGen’s decision the proverbial ‘no-brainer’ was that the controversial US Supreme Court ruling in June ruled that under the FCA, defendants are now liable for claims they suspect or knowingly believe are false, versus the previous objective standard. The Anti-Kickback Statute violation was blatant.  NextGen was giving credits often worth as much as $10,000 to current healthcare customers whose recommendation of NextGen’s EHR software led to a new sale, along with incentives such as tickets to sports and entertainment events. Anti-Kickback is one of those ‘biggies’ that the average healthcare employee is trained on within their first 60 days. DOJ release

The AliveCor-Apple Federal antitrust case had a small but important split decision regarding ‘spoiliation’ in the discovery process that could impact the case’s outcome–and future litigation. This June US District Court for the Northern District of California order went against AliveCor in part of what it sought–that Apple’s deleted emails to and from Apple’s then Director of Health Strategy should be considered adverse by a jury. But Apple was then found at fault for deleting them despite their relevance to the case with a ‘duty to preserve’ that started on 25 May 2021 with the antitrust litigation. In general, emails such as these to and from relevant people are subject to a litigation hold.

  • The director departed Apple only one week prior, 14 May 2021. His emails were auto-deleted at some point in accordance with company policy. In the discovery process, through other documents, AliveCor determined over a year later that the director was, indeed, relevant to the case.
  • The order states that Apple should have preserved his emails from the start as he was an individual with potentially relevant information. From the order, “[the director] worked on strategic health initiatives, and the record shows that he regularly corresponded about the Apple Watch and AliveCor with individuals Apple did identify as relevant.” “Apple did not take reasonable steps to preserve electronically stored information that should have been preserved in the anticipation or conduct of litigation…” While it may have been “irresponsible and careless”, it wasn’t purposeful which then would have been considered for sanctions, but there is considerable strong language in the order that Apple’s counsel didn’t disclose the loss of this information even while under oath in a deposition. 
  • In the ‘adverse’ consideration, AliveCor did not gain what it wanted, which was an assumption that the lost emails were prejudicial–that they contained relevant material to AliveCor and Apple’s strategy of eliminating competition. “To the extent they existed, additional emails relevant to these topics may have been useful to enhance AliveCor’s case, but AliveCor has not shown that the absence of these emails will prevent it from proving its antitrust claims.”

AliveCor provided this Editor with a statement on the order:

“The Northern District of California judge’s description of Apple’s actions as ‘irresponsible and careless, and perhaps even grossly negligent’ in their handling of emails belonging to its former Director of Health Strategy that supported our pending antitrust case speaks to Apple’s usual playbook of shamelessly using legal tactics to steamroll innovative companies like AliveCor. Even though the judge stopped short of granting our motion to instruct the jury that they should assume the deleted emails were negative for Apple’s case, we are confident in the outcomes of our antitrust case and grateful for the outpouring of support we have received as we continue to hold Apple accountable.”

Editor’s note: she thanks an AliveCor representative for sharing this information along with the redacted court order. Apple is free to contact this Editor with its own statement.

Recent AliveCor versus Apple coverage on patents: ITC presidential review, ITC vs. PTAB, PTAB decision

Last but certainly not least, a class action lawsuit against HCA. To no one’s surprise, it was filed last week (12 July) in the US District Court for the Middle District of Tennessee, as HCA is headquartered in Nashville. The plaintiffs are named Gary Silvers and Richard Marous, two HCA patients living in Florida, and was filed by two law firms, Shamis & Gentile and Kopelowitz Ostrow Ferguson Wieselberg Gilbert. The suit claims that HCA failed in their duty of confidentiality to protect sensitive information– personally identifiable information (PII) and protected health information (PHI)–that was contained in the hacked records. While HCA has released that the records did not include the most sensitive clinical information as it was used for email communications, the volume of 27 million rows of data that was apparently unencrypted potentially affects 11 million individuals [TTA 12 July]. The suit charges HCA with failure to safeguard ‘Private Information’ as a reasonable expectation using reasonable security procedures in light of current regulations (HIPAA, FTC), plus the susceptibility of healthcare organizations to cyberattacks which is well known. It seeks monetary damages plus injunctive and declaratory relief. This lawsuit is likely the first of many. Healthcare DiveHealthcare IT News, HIPAA Journal

These lawsuits based on hacking and cybersecurity responsibility are becoming routine. On 7 and 10 July, Johns Hopkins was sued twice. This was for a May ransomware data breach on a software vulnerability called MOVEit that was exploited by a Russian ransomware group called CLOP. This may have compromised, according to the first suit, tens to hundreds of thousands of records, including sensitive PHI. Both suits allege negligence, breach of fiduciary duty, breach of confidence, invasion of privacy, breach of implied contract, and unjust enrichment. They seek monetary damages and injunctive relief. Both were filed in US District Court for the District of Maryland.  Becker’s, Healthcare Dive, HIPAA Journal

News roundup: MHS Genesis EHR completes US rollout, telehealth selective savings by disease, CarePredict’s $29M funding, Amazon Alexa *Spying on You*

At least one part of Oracle Cerner’s work is done. The Military Health System (MHS), which covers 9.6 million active duty beneficiaries and 205,000 medical providers, announced yesterday that the rollout of the Genesis EHR is complete in the continental US. The final go-live was at Wright-Patterson Air Force Base, which covers 6,800 clinicians and providers in military hospitals and clinics across Ohio, Virginia, Maryland, Indiana, Texas, and Kentucky. It was also deployed at the National Oceanic and Atmospheric Administration, NOAA Corps, which is under the Department of Commerce. The final 14% of the MHS system is overseas. That rollout will start in September 2023, including Landstuhl Regional Medical Center in Germany and Royal Air Force Lakenheath in the UK. Bases in Guam, South Korea, and Japan will follow in October. DOD’s one joint facility with the VA, the James A. Lovell Federal Health Care Center in Chicago, will deploy in March 2024. All other VA healthcare centers are on hold indefinitely. With the wrapup of MHS Genesis and the pause on VA’s Millenium rollout, Oracle has reportedly laid off over 500 staff on these Federal projects [TTA 16 June]. DVIDS release

 Telehealth’s selective savings. A new study out of the University of Texas-Austin McCombs School of Business found, like other studies such as Epic Research’s, that telehealth visits reduced future outpatient visits, in their study within 30 days, by 14%. This saved $239 per patient in outpatient costs. But telehealth was more effective for some specialties than others. It had the most impact on cost reduction for behavioral health, metabolic disorders, dermatology, and musculoskeletal (MSK) disorders, with a significant reduction of 0.21 outpatient visits per quarter (an equivalent cost reduction of $179). This suggested to the researchers a substitution of telehealth versus traditional clinic visits. But telehealth’s impact was nearly nil when it came to circulatory, respiratory, and infectious diseases, not significantly reducing the number of future visits or costs. The study sampled hospital-based outpatient clinics in Maryland from 2012 (not a typo) to 2021. Becker’s, UT News, Informs Pubonline (abstract only)  

Senior living monitoring system CarePredict adds $29 million from four main investors. This is a Series A-3, which one assumes adds on to an existing Series A, which was $9.5 million in 2019. The round was co-led by SV Health Investors’ Medtech Convergence Fund and Aspire Healthtech Partners with existing institutional investors Secocha Ventures and Las Olas Venture Capital plus private family offices and individual investors. CarePredict pioneered a wearable bracelet, the Tempo, that wirelessly tracks residents’ activities of daily living (ADLs) in assisted living (AL), independent living (IL), and continuing care (CCRC) settings. Interpretation of ADLs in a platform can predict changes in health and wellbeing leading to better health and extended residence. CarePredict has expanded its platform reporting with other tracking such as context beacons, visitor and wander management, PinPoint digital contact tracing, and family communication apps. CarePredict release, Mobihealthnews

How much does Amazon have on you? If you are a user of Amazon’s Echo system, you already know that Alexa is always listening to you. What you may not know is that Amazon stores that information in a database, including parts of overheard conversations that have nothing to do with Alexa, since Alexa is always on. Even if you (like your Editor) don’t have an Echo but have a Kindle (unlike your Editor) or use the app residing on most smartphones, Amazon knows what you read, what you flip through, and your start and stop times. The Amazon Sidewalk mesh network, used with Alexa and Ring cameras, extends the reach of your router and shares your network with your neighbors. This is in addition to your shopping and even what you look at. In the context of the rollout of Amazon Clinic pending, delayed to 19 July [TTA 27 June], where Amazon is 1) only an intermediary to providers but 2) demand access to all your PHI and PII before allowing access to them, can we as professionals admit this is a glaring privacy violation and that the FTC is actually right?

Kim Komando, well known for her radio and online shows advising non-techies on tech, has an excellent article on how Amazon is piling up information on us all. This is based on a 2021 Reuters investigation and also contains a link to her interview with the two Reuters reporters. The article also describes how to find out what Amazon has on you. Warning–they don’t make it easy. She also addresses the Amazon clinic issue in a FoxNews article.

“Hope is not a business model”–advice from two VCs, with a bit more advice on basic banking

With yesterday’s article on how digital health funding is resuming its 2019 ‘long and winding road’ trajectory, with 2020-2022 now revealed as a complete aberration (though Rock Health is having trouble admitting it), your Editor returned to two saved articles in her ‘pinned tab file’ to glean some advice for the funding-lorn. 

Funding advice for health tech and digital health companies was the theme of this recent article in MedCityNews. Two Merck Global Health Innovation Fund executives spoke at a late June NYC conference, the fund’s president, Bill Taranto, and vice president Joe Volpe. They highlighted three key points but more between the lines. Editor’s comments follow:

Don’t be afraid of down rounds (or flat rounds) if you need to survive  This referred to the inflated valuations digital health companies received in 2021-22, whether they were profitable or not. The down-round stigma is why we are now seeing a wave of unlabeled and lower-amount rounds for companies that raised Series A and B rounds only 12-24 months prior. “Lack of cash causes bankruptcy.” Quite true, but what if the company never hits the ‘inflection point’ and putters along longer than funders expected at breakeven or mildly profitable? They admitted that unlabeled rounds are a survival tactic. As noted yesterday, they cannot go on forever or even for another 24 months. Prediction: valuations will be coming down in a second-order effect by next year, as well as more companies going private, selling lines of business or IP, or being acquired for unknown amounts.

Expect slower timelines   Startups used to plan six to eight months in advance of fundraising, now they are advised to start a year or more. This reverts back to the norm this Editor personally observed in the first hype curve of 2006-8 where early-stage companies would no sooner close a round or private financing than plan for the next. Note rounds–equity offered in return for notes convertible into shares–are popping up. Volpe described this as frustrating for larger investors like Merck because other investors are taking due diligence to the max and once committed, Merck is having to fund or bridge the company longer. This is a repeat of 2007-8. Investors have lost the fear of missing out (FOMO) that drove 2021-22 funding. They are often happier to walk away and keep their powder dry–if they have any. [TTA 5 Apr]

Get your narrative right  “The most important thing a company has to do before pitching to investors is ensure that it can clearly and honestly describe its narrative, Taranto explained.” More than that, a company has to be realistic about its future. Don’t tell a story that investors will have difficulty believing. Identify what’s the inflection point, when will it be, and is it a hockey stick or a garage lift? Here is where the old saw ‘underpromising and overperforming’ come in handy, as well as running lean. Do this enough and investors will like you a lot. You may also want to get some outside help in crafting and wordsmithing that narrative from a person not invested in the company’s future or your parents.

Now that you have the money, some basic banking and money management advice for founders and company management. We are already seeing amnesia around the events of March-April when four US (SVB, First Republic, Silvergate, and Signature) and one Swiss bank (Credit Suisse) went belly-up, putting a giant hole in the fisc of both startups and VCs. Founders and startup execs can be forgiven for concentrating on The Big Idea, though they seem to be in abundance lately and is no guarantee of success. Now, your Editor has no special financial expertise but as a marketer, has always been dependent on good relations with the financial folks for her budget. Companies come and go, whether small or large, healthcare to car rental to airlines, but there’s much in common when it comes to money.

Your little company may be better off with a big bank. Healthcare Dive looked at this while the collapses were happening. Their article’s point was that dealing with a major bank can be reassuring to investors. A big bank may be what is left in some markets. The downsides are that they move slowly and may not be agreeable to short-term cash loans or bridges. 

Nest your eggs in multiple baskets. Diversify your banking business and keep it below FDIC insurance levels. Spread accounts among a major bank and your regionals. Develop multiple relationships. It’s not being disloyal, it’s being smart. This may also affect where you locate your business. Ask your funders for contacts, but avoid what funders urged prior to March–to go to one bank like SVB or Signature and put all your business there as part of a quid pro quo. It didn’t turn out well for those who did.

Trust but verify. Expect that a bank will be an honest and skilled steward of your precious funds, payables and receivables. But your financial head/CFO should spend a fair amount of time regularly checking that they are and remain so. As to your bank, community responsibility can be positive, but it’s management time taken away from their main business which is stewarding your money. Be insistent on this. If you see their management has many unfilled spots, spends more time on ‘issues’ than on banking, plays in politics, grows too fast, has a lot of investments in crypto, is in play or taken over, execute Plan B and go elsewhere

Don’t skimp on your financial staff, policies, and procedures. You may be able to contract for sales, marketing, and R&D, but financial governance–probably not, unless you’re very small and willing to go fractional. Hire a good CFO and give him or her the right staff and power. Adopt rigorous budget and reporting procedures that are adhered to from top down. Don’t assume you or your partners can do it all alone, even if you have Harvard MBAs, or your accountant can do it. And watch your CFO like a hawk. One of the best combinations I’ve observed is a CFO and general counsel. 

Thoughts? Comment below. 

Mid-week roundup: telehealth success in opioid use disorder treatment, Epic sees fewer followup visits from telehealth vs in-office, telehealth usage slightly lower, HCA data theft may affect 11 million

Success reported in opioid use disorder (OUD) treatment using telehealth in conjunction with medication-assisted treatment (MAT). A recent study presented at the annual ASAM Conference indicates that in a study published by a telehealth MAT provider, Ophelia, that telehealth+MAT can achieve retention rates significantly higher than traditional in-person care. Published in The American Journal of Drug and Alcohol Abuse, their findings were that 56.4% of Ophelia’s OUD patients remained in treatment for six months, with 48.3% remaining for one year. Their MAT is based on the Massachusetts Collaborative Care Model adapted to telemedicine and providing a framework for licensed MAT providers. Ophelia is licensed to provide care in 36 states plus has national and regional insurance contracts covering 85 million lives, including bundled rates across Medicaid, Medicare and commercial populations. A second study presented at ASAM indicated that home-based buprenorphine inductions guided by telehealth are both feasible and well tolerated, with 90% of patients returning for one or more follow-up sessions and more than 80% met HEDIS engagement criteria. While OUD is statistically down among adults according to the National Survey on Drug Use and Health, overdose fatalities have increased due to the deliberate contamination of opioids with fentanyl.  HealthcareITNews

Telehealth users aren’t doing in-person follow up for most specialties–is this good or bad? Epic Research’s original study noted that most telehealth appointments didn’t require an in-person follow-up appointment in the next 90 days. Their new study compares in-office visits to telehealth and finds pretty much the same. Follow-up rates for telehealth and office visits in primary care were within two percentage points of each other. The largest difference was in mental health care, the majority of telehealth currently, with 10% of telehealth visits and 40% of in-person visits having in-person follow-up within 90 days. Epic Research, Healthcare Dive

Telehealth utilization is down slightly but remains above 5%. FAIR Health’s monthly national survey of claims from private insurance and Medicare Advantage has telehealth declining from 5.6% to 5.3% (-5.36%). Mental health is again in the far lead with 68.4% of all diagnoses. A new breakout is asynchronous telehealth (store and forward) where acute respiratory diseases and infections lead with 21.6% of diagnoses with 12.6% related to hypertension in second place. Another new breakout is audio-only telehealth comparing urban and rural usage, both near or over 5%. FAIR also breaks out data by four regions. Becker’s

Some post-July 4th fireworks came with the announcement of a data breach at HCA Healthcare, one of the largest provider networks in the US. The hacking took place through an external storage location exclusively used to automate the formatting of email messages. The information up for sale by the unidentified hacker on a ‘deep web forum’ had some personally identifiable information (PII) including patient name, address information, emails, telephone numbers, date of birth, and gender. Some of the data posted included medical appointment dates and locations. The unidentified hacker (unusual) notified HCA on 4 July with a list of unidentified demands to be responded to by 10 July. It was flagged on Twitter by Brett Callow, an analyst at New Zealand-based Emsisoft. What wasn’t included was typical personal health information (PHI)–sensitive clinical information, payment information, or other PII such as driver’s license and Social Security numbers that can be cross-referenced with other hacked data. The sheer scope of the breach–reportedly 11 million records for patients across 24 states and 171 healthcare facilities, perhaps one of the largest breaches ever–while limited in harm to patients, is still going to create a big headache for HCA. CNBC, Becker’s, HealthcareITNews, DataBreaches.net

Rock Health’s first half funding roundup adjusts the bath temperature to tepid, the bubbles to flat

The ‘new normal’ continues, as the bubbles vanish and the poor duck’s feathers are getting soggy and cold. Rock Health’s roundup of digital health funding (US only) continues the chilly flat-to-downward trend to funding. What money and fewer funders are out there which persist in their dedication to healthcare are betting cautiously, minimizing their risk on the table in lower unlabeled funding rounds and pre-vetted concepts. 

  • First half 2023 (H1) funding closed at $6.1 billion across 244 deals. Average deal size was $24.8 million, the lowest since 2019.
  • Breaking down by quarter, Q2 2023 funding hit a new low– $2.5 billion in funding across 113 deals, lower than Q4 2022’s ‘hole’ of $2.7 billion. By comparison, Q1 2023 funding totaled $3.5 billion over 131 deals, adjusted from the earlier report of 132 deals [TTA 5 Apr]. The collapse of three banks, most notably Silicon Valley Bank in March, clearly affected Q2.
  • Given the trend, Rock Health projects that 2023 funding will fall well below 2022, between 2019’s $8.1 billion and 2020’s $14.3 billion

Delving into the numbers:

  • Those ‘generalists’ who jumped into the digital health pool in 2021-22 jumped out. H1’s 555 investors had a 71% repeat rate, meaning that those who knew the water saw some opportunity or put on their wet suits. The overall total dropped from 775 in H1 2022 and 832 in H1 2021.
  • Unlabeled raises were suddenly the way to go. 101 of 244 deals–41%–had no series or round attached. This unprecedented move avoids the spectre of down rounds for companies needing to raise funds–down rounds affect valuation. Interestingly, 67% of these companies’ prior raises were in 2021 and 2022. 37 of them were Series B or lower. 
  • Mega deals inhabit a different territory. H1 had 12 mega deals, 37% of total funding dollars, and was at the 2021 norm of $185 million. Half were at Series D and growth/PE. They clustered in value-based care, non-clinical workflow, and that former mouse in the pumpkin coach, in-home and senior care. This level of funding also gravitated to the pre-vetted: incubated by VCs included Paradigm (clinical trials) and Monogram Health (kidney care).  Recently funded Author Health, long in stealth, will operate in a narrow slice of mental health funded by Medicare plans.
  • Zero IPOs, but acquisitions and shutdowns/selloffs continue. Acquisitions continued on a track of about a dozen per month, down from 2022’s average of 15. On the gloomier side, quite a few companies simply ran out of runway after raising a little or a lot of funding. These hit the lights at the end resulting in hull loss: Pear Therapeutics, SimpleHealth, The Pill Club, Hurdle, and Quil Health. If they were lucky, they had intellectual property worth something to someone–Pear to four buyers including a former founder, 98point6’s AI platform business to Transcarent–or subscriber bases worth acquiring, such as Pill Club to Nurx, SimpleHealth to TwentyEight Health. This does not count Amazon shuttering Halo and leaving subscribers in the lurch. (Nor Amazon’s dodgy approach to privacy getting Federal and private scrutiny, which this Editor explores here and here.)

To this Editor, 2023 will be a ‘grind it out and survive’ year for most health tech and digital health companies. Survivors will carefully tend their spend, their customers (who will be doing their own cutbacks), and watch their banks. The signature phrase this year was written in 1950, another uncertain time, by Joseph L. Mankiewicz and uttered with flair by Bette Davis in a classic film about the theatre, ‘All About Eve‘: “Fasten your seatbelts; it’s going to be a bumpy night.”   Rock Health Insights

Short takes: FDA seeks feedback on home care tech; Japan care homes piloting AI; Author Health’s $115M bet on senior mental health; Alertacall’s Batchelor on ‘right fit’ finance support; Headspace in the wrong (layoff) space again

Short takes for a short (US) week

FDA seeks public comment on home care tech–an opportunity for developers and home care. The US Food and Drug Administration’s (FDA’s) Center for Devices and Radiological Health (CDRH) has a request for public comment on technologies that could improve home care, both in the traditional sense and in hospital-to-home transitional care. Their two key questions of nine are: “How can the FDA support the development of medical technologies, including digital health technologies and diagnostics, for use in non-clinical care settings, such as at home?” and “What factors should be considered to effectively institute patient care that includes home-based care?” The FDA’s language around this is anodyne as couched in ‘health equity’ but it’s seriously around increasing access to all, supporting innovation, reducing barriers to care, and empowering people to make better decisions around their health. All public comments must be submitted to FDA’s docket (FDA-2023-N-1956), available at Regulations.gov. Important–the public comment period will end on 30 August 2023. Healthcare Dive

In Japan, a nursing home operator/insurer is adopting analytics to track residents and reduce caregiver workload. The operator/insurer is Sompo Holdings (LinkedIn) and the analytics company is Palantir. The jointly designed software platform, egaku, integrates artificial intelligence and analytics with proprietary data on sleep, diet, medical treatment, and exercise. Sompo Care uses minimally intrusive devices such as sensor-equipped beds to evaluate sleep conditions via tracking of body movements, respiration, and heart rate. They are claiming a 15% reduction of caregiver workload in a typical 60-person capacity care facility, saving as much as $60,000 annually. Unfortunately, the FT article is paywalled but a partial citation is available on ACM TechNews   On the Palantir website, there is a fragmentary article on how Sompo used the Palantir Foundry platform to streamline gathering information for care plans by linking local resident data t0 additional care data to create ‘a single source of truth’. Sompo press release

Speaking of seniors, Boston-based Author Health launched at the end of June with a unique mission–reaching out to older adults with serious mental illness and substance use disorders–and with a tidy startup kitty. The company provides specialized physicians, nurses, therapists, and community health workers to deliver a mix of virtual and in-person care. Their first partnership is with Humana Medicare Advantage (MA) plans in Fort Lauderdale and Miami, Florida metros in conjunction with CenterWell Senior Primary Care. Author Health helps to treat conditions such as depression and anxiety, schizophrenia and psychosis, bipolar disorder, Alzheimer’s Disease and other dementias, and substance use disorders. Author is led by CEO Dr. Katherine Hobbs, a psychiatrist and former health insurance executive. The $115 million in initial financing was led by General Atlantic and included participation from Flare Capital Partners. Author Health release, FierceHealthcare, MedCityNews

TTA has previously profiled James Batchelor, CEO and founder of Alertacall. He is an old friend of TTA from early days with Editor Steve and Alertacall is one of the pioneering companies in UK telecare. Most recently (May 2022) Alertacall achieved the Queen’s Award For Enterprise: Innovation. This short interview with him in New Business UK discusses the importance of finding the right fit in long-term funding. If your buyers are in a sector with lengthy, complex sales cycles, it’s vital to find a backer that understands the selling space, which for Alertacall is ‘property management’. Even more important now!

Apparently in the wrong space is Headspace Health. The Los Angeles-based telemental health company is laying off 181 additional employees, or 15% of its current workforce. This follows on their December layoff of 5% or 50 employees. In the palmy days of mid-2021, Headspace acquired Ginger for a $3 billion valuation at that time [TTA 27 Aug 2021] to enter the enterprise market and acquired Sayana and Shine in 2022. It’s been a struggle ever since though they did not go the SPAC route, stayed private, and now claim 70 million members (actually downloads of their app), both individual and enterprise. Headspace expanded to the UK in January. Too much lookalike/soundalike competition and now a very hard road to that cliché, ‘a path to profitability’. LA Times, Mobihealthnews

Why the ‘insurtechs’ didn’t revolutionize health insurance–and the damage they may have done

crystal-ballIce water on hopes that many placed in ‘insurtechs’. This is the umbrella term that healthcare dubbed the upstart tech-enabled, health tech-friendly US payers which were supposed to deliver health insurance plans more efficiently (buy online!), more conveniently using apps and telehealth, with strong networks and at a lower delivery cost to consumers, from those who needed individual plans to Medicare Advantage. Around 2019-2020, these insurers gained billions in funding before going public through IPO or SPAC: Bright Health’s $500 million Series E in 2020 was only a chunk of their total $2.4 billion; Oscar Health raised $1.6 billion, Clover Health $1.3 billion. All three have struggled to stay clear of the insolvency precipice, with Friday Health Plans going over [TTA 23 June]. Bright Health Group will be exiting the insurance business after this year with the stock sale of their plans to Molina Healthcare–provided they survive to Q1 2024 [TTA 6 July]. Oscar and Clover have exited states and cut back offerings. In April, in a real retrenching, Oscar hired on Mark Bertolini, late of Aetna, pushing back a founder to an operational role. 

This Editor, in a marketing assessment for a client two years ago, believed as many did that Insurtechs Were The Future. At the very least, their practices would be adopted by the legacy insurers: easy online enrollment, lower premiums, predictive analytics, machine learning, digital documentation, online health education via apps, outsourcing areas such as customer service 24/7 and even marketing. Even those like Cigna through their Ventures arm bet some millions on insurtechs redefining payer-member relationships and payer structure, gaining better margins at profitable lines of business like Medicare Advantage (MA) and special needs plans (SNPs). After all, these plans did have people with decades of experience at insurers in their management, didn’t they, and they’d know what NOT to do. (And that’s the problem with gazing into crystal balls…eyestrain.)

Marissa Plescia’s article in MedCityNews is an excellent review on why the insurtechs’ centre did not hold. Key points made from her dive among the experts:

  • They underpriced and took heavy losses to grow their member base
  • They didn’t understand that some ‘inefficiencies’ in the health insurance market exist for reasons–perhaps not good ones, like state mandates through their departments of banking and insurance, but they exist and cannot be ignored. [Ed.–health education for MA has to be provided or at least available in written form in most if not all states]. Compliance can’t be skirted or ignored. Were they paying attention to the compliance of their plans?
  • They didn’t pay provider claims efficiently or at all [the SSM lawsuit of Bright]–a nifty way to lose networks and be sued by states, very damaging if the network wasn’t all that competitive to begin with.
  • Contracted rates with providers weren’t competitive. Were they managing risk adjusting coding well? 
  • Did they leverage sales channels beyond online such as brokers and their provider network? What about customer service?
  • The plans were not sticky enough to create some loyalty to an infamously non-loyal product

The insurtechs perhaps expected the technology to do too much–and for legacy payers to not catch up to them if they weren’t already moving there. Another problem–they (largely) were.

Disruption–but not the Clayton Christensen definition. Their disruption so far has been financial and legal (insolvency, cracked SPACs, lawsuits, share prices below $1.00, and delistings pending), loss of coverage for members; unpaid providers. With this track record, investors will avoid this category beyond the legacies. States won’t approve new plans from new companies. (This Editor believes that there are some overlooked positives such as inclusion in marketing of specialized and underserved groups, as well as some forced streamlining of processes.) There will be survivors–Alignment Health, kind of a below-the-radar operation and an afterthought in funding at $375 million, is in a few states and is mentioned. It’s also hard to bet against Bertolini leading Oscar–except that this is maybe Act V for him and he’s had his share of bunts and misses (bunt–ActiveHealth Management, misses–Healthagen, CarePass, iTriage) before his contentious departure from CVS. But in this particular widening gyre, while more revelations will be at hand, innovative newcomers in health plans won’t be seen for a long time, if ever. If the saga of airline deregulation (1980-1995) is a model, payer disruption just took a fraction of that time.

FTC, DOJ float enhanced information requirements for HSR premerger notification filing process–what will be M&A effects?

FTC, DOJ are now coming after M&A–and you thought they were tough before? New information disclosure requirements proposed by the US Federal Trade Commission (FTC) and the Department of Justice (DOJ) Antitrust Division for mergers and acquisitions that fall under the Hart-Scott-Rodino Act (HSR) may put a damper on an already stagnant business area. On Tuesday 27 June, FTC, notably taking the lead with the concurrence of DOJ, released multiple proposed changes to the premerger notification filing process, the most extensive since they were first published in 1978 after HSR was passed in 1976. HSR premerger notification is required for transactions that exceed the threshold currently set at $111.4 million.

These changes will be formally submitted for the standard 60-day public review and comment later this week in the Federal Register. Changes are typically made after that time before final rules are published, a process that may take months.

From FTC’s release, the proposed changes fall under these areas.

  • Provision of details about transaction rationale and details surrounding investment vehicles or corporate relationships.
  • Provision of information related to products or services in both horizontal products and services, and non-horizontal business relationships such as supply agreements.
  • Provision of projected revenue streams, transactional analyses and internal documents describing market conditions, and structure of entities involved such as private equity investments.
  • Provision of details regarding previous acquisitions.
  • Disclosure of information that screens for labor market issues by classifying employees based on current Standard Occupational Classification system categories.
  • These proposed changes also address Congressional concerns that subsidies from foreign entities of concern [North Korea, China, Russia, and Iran–Ed.] can distort the competitive process or otherwise change the business strategies of a subsidized firm in ways that undermine competition following an acquisition.

The National Law Review goes into far more detail on exactly what additional information will be required. This includes disclosure of what foreign jurisdictions are reviewing the deal. The rationale for the changes is that transactions have become far more complex since the original requirements were set and that the additional information will “more effectively and efficiently screen transactions for potential competition issues within the initial waiting period, which is typically 30 days.” According to FierceHealthcare, the FTC said it expects the proposed changes will take merging entities 144 hours per filing, up from the current 37-hour average. It’s clear that the mountain of information already needed to file a pre-merger notification and the time needed to gather such information will be much higher, perhaps to months and reveal far more than perhaps some companies want to disclose.

For those surprised that FTC is taking the lead on this, this once-sleepy agency woke up late last year in a heckuva bad humor and is now (more…)

Mid-week roundup: Optum buying Amedisys home care for $3.3B; Clover Health settles 7 shareholder lawsuits around SPAC non-disclosures; Walgreens cuts 2023 outlook, stock plummets 11%

UnitedHealth Group expands home health again, aces out Option Care Health in all-cash deal. Amedisys had previously accepted Option Care’s all-stock deal in May valued at $97.38 per share. Optum’s offer is at $101 per share in cash, a dollar higher than its previous offer, creating a valuation for the company at $3.7 billion. Amedisys will add to UHG’s $5.4 billion acquisition of the LHC Group in February, including the hospital-at-home market from its acquisition of Contessa Health for $250 million in 2021. 

Option Care is a public (Nasdaq: OPCH) post-acute and home infusion care company for which Amedisys in-home care delivery would have been an exceptional fit. It was last heard from in August making a run at Signify Health for home health and ACO providers. At that time, the not-well-known company was discovered to have some impressive backing from Goldman Sachs. Walgreens Boots Alliance also backed the company but cut its stake in March and sold the rest for $330 million earlier this month. Option Care will receive a termination fee of $106 million. Healthcare Dive, FierceHealthcare

Insurtech Clover Health settles seven lawsuits around its 2021 SPAC. Clover, with Medicare Advantage plans in eight states, went public in January 2021 at the very peak of ‘blank check’-dom. Almost immediately, after an explosive report by Hindenburg Research that revealed that the Department of Justice (DOJ) had been investigating the company on investor relationships and business practices starting in fall 2020 [TTA 9 Feb 2021], there were multiple lawsuits filed by shareholders (derivative litigation) over not revealing this material fact. Shares took the expected dive from their intro of $15.90 to today’s $0.85. The seven derivative lawsuits were in Delaware, New York, and Tennessee courts and are being settled without payment. According to Clover’s release, “the defendants in the derivative lawsuits will receive customary releases and the Company will implement a suite of corporate governance enhancements. The settlement does not involve any monetary payment, other than payment of an award of fees and expenses to plaintiffs’ counsel, which has not yet been set. The defendants have denied all wrongdoing and have entered into this settlement to avoid the burden, expense, and distraction of ongoing litigation.” In April, Clover settled a securities class action in which the class will receive $22 million, $19.5 million paid by the company’s insurance. Mobihealthnews

Walgreens Boots Alliance missed Wall Street expectations and lowered its outlook for the year. In their Q3, net earnings fell 59% to $118 million, mostly due to lower operating income. Their topline was healthy–$35.4 billion, up 9% year over year–driven by the US health provider segment (VillageMD, Summit Health, and CityMD plus at-home care provider CareCentrix and specialty pharmacy Shields Health Solutions) which was up 22%. However, both retail consumer sales and CityMD underperformed due to the absence of COVID and a mild respiratory illness winter. Together with VillageMD’s clinic expansions, this led to an adjusted operating loss of $172 million for US Healthcare. WBA cut its earnings guidance for the year to $4.00 to $4.05 per share from its previous outlook of $4.45 to $4.65. Walgreens has been selling off businesses or investments that are peripheral to providing healthcare services, such as its investment in Option Care (above). FierceHealthcare, Healthcare Dive

Amazon Clinic delays 50-state telehealth rollout due to Federal data privacy, HIPAA concerns on user registration, PHI–is it a warning?

Amazon delaying Amazon Clinic national rollout from today (27 June) to 19 July. Amazon Clinic, which debuted last November as an asynchronous, message-based telehealth consult or prescription renewal referral platform [TTA 16 Nov 2022], has run once again into Federal scrutiny. This time, it’s two Senators from New England–the well-known Elizabeth Warren (D-MA) and the little-known Peter Welch (D-VT)–who are poking Amazon with the stick of whether sensitive health and personal data are flowing into Amazon’s other databases.

Their letter to CEO Andy Jassy was fair warning that, as this Editor predicted last February (see the list of open issues) after the One Medical buy closed to high-fives all around, the government is nowhere near finished with scrutinizing Amazon and how personal data, including health data, flows between their units and is monetized. 

In a two-page letter dated 16 June based on reporting in the Washington Post (100% owned by Amazon’s 12.6% shareholder and controller, Jeff Bezos–the irony runs deep here), the two senators believe that they have caught Amazon but good–and with some of the goods. 

  • Users of the Amazon Clinic service are asked, in the registration form, to authorize the “use and disclosure of protected health information.” They are told that agreement to this gives Amazon access to the “complete patient file” and that this information “may be re-disclosed,” after which it will “no longer be protected by HIPAA”. By agreeing to this, users waive any HIPAA personal health information protections.
  • If the user declines to agree, they are redirected and unable to complete Amazon Clinic registration and denied care. HIPAA regulations specifically prohibit conditioning care on agreement to disclose patient information. (This is known by anyone who has taken required training or certification on HIPAA when working for health plans or other regulated healthcare providers including RPM and telehealth vendors.)

The letter raises the sensible, usual questions on why personal data is being collected and what Amazon is doing with it. For instance, it requests responses on how patient data is used by Amazon, what data is shared with third-party entities, and what data is used in any analytics or algorithms. It cites as a non-compliance example the $1.5 million that GoodRx paid in an FTC penalty on their past Meta Pixel usage for ad tracking. (Interestingly avoiding the $7.5 million Teladoc paid for similar ad tracker misuse by BetterHelp.)

The $30/visit service has been available in 33 states since last year and currently through asynchronous messaging, provides care for minor conditions such as UTIs, herpes, and skin infections. The expansion will cover all 50 states and add synchronous video telehealth.

One would think that with billions on the line with One Medical, Amazon would be more cautious about poking the Antitrust Bear. They have already been put on notice by the Federal Trade Commission, the Department of Justice (DOJ), Congress, and multiple states. For Amazon Clinic, requiring individuals to waive their right to protect their PHI in registering for the service is downright brazen. How this got past their legal and compliance departments boggles the mind. Why Amazon is not ‘hiving off’ PHI collected through this small service is another question. Doing so would show to FTC and DOJ that Amazon can play by the rules. Instead, it confirms the widely held belief of those in healthcare that Amazon culturally cannot deal with the restrictions that come with the territory. Are they deliberately ‘playing chicken’ with the Feds? Pollo loco? This up-to-the-line behavior tends not to end well, as the telemental health providers that over-prescribed controlled substances found out.  POLITICO, The Hill, mHealth Intelligence

Babylon Health to go private with AlbaCore in planned ‘Take Private Proposal’, combine with MindMaze

Babylon Health moving forward with AlbaCore Capital LLP ‘Take Private Proposal’ with AlbaCore affiliate MindMaze Group SA. On Friday, Babylon Health as Babylon Holdings Limited filed their Form 8-K with the Securities and Exchange Commission confirming their acceptance of AlbaCore Capital’s ‘Take Private Proposal’. No surprises here as announced in May along with AlbaCore’s interim funding proposal of $34.5 million plus the June timing of Babylon (inevitably) selecting the AlbaCore proposal. [TTA 11 May, 11 May followup]. Babylon did not disclose that there were other proposals under consideration between 10 May and last Friday. 

The 23 June Form 8-K (filed on a summer Friday when corporate news goes to hide till the following week) is brief in content despite its eight pages, half of which is devoted to the press release. It delivers the following:

  • The core operating subsidiaries of Babylon will be transferred to MindMaze. MindMaze is a private Lausanne, Switzerland-headquartered healthcare company in neuroscience and digital neurotherapeutics in areas such as stroke, traumatic brain injury, Alzheimer’s disease, and Parkinson’s disease. This apparently covers the ‘Go-Forward Business” mentioned in May. 
  • “The Proposed Transaction provides for a new capital structure and a reduction of pro forma company debt, and is expected to include immediate material funding for current business operations as well as a commitment to fund the combined business of MindMaze and the Company.” This presumably will resolve Babylon’s debt to AlbaCore of $300 million from the SPAC.
  • BBLN shares will cease trading upon closing. Class A ordinary shareholders or other equity instrument holders will receive no payment, as disclosed in May. (Shares are trading at $0.65 today, amazingly, but whatever shares are out there are being bought and sold, for instance in restricted stock units being vested and sold for whatever value could be obtained.)

There is no further mention in either the 8-K or the press release of the appointment of UK administrators (similar to a US Chapter 11). Per the May 8-K, these would be appointed by the High Court in London to supervise the transfer of assets from Babylon Holdings Limited to Babylon Group Holdings Limited and then their sale to the ‘NewCo’ formed after the reorganization by AlbaCore Capital as the Go-Forward Business. It may be that the transfer to MindMaze avoids that. Babylon is headquartered in Jersey (Channel Islands) along with Austin, Texas.

The transaction is expected to close in July, subject to regulatory approvals in the US and UK, with Babylon continuing in its business plan and in the press release’s terms, “accelerating its core mission” at least for the short term. In going private, Babylon will no longer have to disclose its ongoing problem of growing losses after this quarter. In Q1, they had a net loss of $63.2 million, a (20.3)% net loss margin, which was 117% greater than last year’s loss of $29.1 million or (10.9%) margin. Noticeably in the release, Babylon CEO and founder Ali Parsa is not quoted.

How it’s positioned: Both companies will operate independently until such time as they can become a “leading value-based care platform with cutting edge technological, clinical and operational ability to both provide holistic primary care and effectively diagnose, manage and treat major episodic and chronic diseases.” Over the longer term, the combination will “align the strengths of their organizations to deliver a truly novel care paradigm and deliver exceptional outcomes for all stakeholders.” No transition of headquarters, leadership, and staff was announced in the release.

The reality–one or the other will change: This Editor considers this a ‘marriage of convenience’ for their chief investor, AlbaCore, to financially reconcile two of their healthcare businesses. Neither are alike or complementary.

  • We know how Babylon is performing (or not) as a public company for now. We do not with MindMaze, hidden behind the veil of private financing and ownership.
  • Their core businesses are very different–primary care patient access and population health for Babylon, more rarefied and clinical neurotherapeutics for MindMaze.
  • Babylon Health is in a crowded primary care and enterprise telehealth sector of healthcare. Morphing to connect populations ‘from reactive sick care to proactive care’ has a few elephants in it named Teladoc and Amwell, along with multiple niche and private label players.
  • MindMaze’s public profile is that they have built a long-term clinical footprint–examples such as Izar, a FDA-cleared hand motor therapeutic, a partnership with the Vibra health system in two states, and Mount Sinai in NYC–along with two racing sponsorships in 2022–Andretti Autosport for US Indycar and internationally with Alfa Romeo F1 Team ORLEN, for promoting their MindMaze Labs R&D. According to Crunchbase, the company has raised $340 million over 10 rounds since 2012 including rounds by film star Leonardo DiCaprio, Concord Health Partners in NJ, and London-based Hambro Perks along with AlbaCore. 

Taking bets on which company and management survives.

Mobihealthnews and FierceHealthcare recap the releases and recent news for both companies.

Week-end roundup: Walmart Health adds 3 FL centers; wearables nudge close to 50%; Dandelion cardiac AI performance pilot; Aledade’s $260M Series F; $10M for DUOS’ older adult assistance platform; Friday Health Plans to close

Walmart Health continues Florida expansion with three new centers opening this week–two in Orlando and one in Kissimmee. This adds to their present five in the central Florida area: Orlando, Kissimmee, Ocoee, Sanford, and Winter Garden. By fall, plans are to have 23 in Florida, tracking to the Q1 2024 plan for 75 total, including 28 new locations in the Dallas (10), Houston (8), Phoenix (6), and Kansas City MO (4) metros [TTA 3 Mar]. Becker’s

New study by AnalyticsIQ indicates nearly half the US population may be adopting wearables and using digital health. Usage doubled in the midst of the pandemic (2020-21) with 46% reporting using at least one type of consumer health technology over the past six months. 35% of the 8,000 respondents used smartwatches, with Fitbit (42%) edging out Apple Watch (38%) followed by Samsung Galaxy Watch and Garmin Vivoactive. By other wearable device type:

  • Blood pressure devices: 59% of survey respondents
  • Sleep monitors: 21%
  • ECG monitors are still a niche: 11%
  • Biosensors such as glucose monitors, hormone monitors, fall detectors, and respiratory monitors are still niche at 8%, but the business grew to $25 billion in 2021
  • Smart clothing: a surprising 6%.

Unsurprisingly, wearable health tech usage skewed heavily towards Generation X-ers and men. Among ethnic groups, black and Latino groups had the highest usage.  Healthcare Dive

Dandelion Health testing cardiac dataset for AI reliability and bias. Starting with their data on ECG waveform algorithms, this startup will be validating the performance and bias of artificial intelligence across key racial, ethnic and geographic subgroups. NYC-based Dandelion is a public-service focused precision analytics company that works with three healthcare systems–Sharp HealthCare (San Diego, California), Sanford Health (Sioux Falls, South Dakota) and Texas Health Resources (Arlington, Texas) to aggregate and de-identify clinical data for roughly 10 million US patients. The validation pilot will start on 15 July and last for an initial period of three months. It may be expanded to include additional clinical data modalities such as clinical notes and radiology imaging. According to their founder and CEO Elliott Green, the “pilot program answers the question, does your algorithm do what it’s supposed to do? And does it do it fairly, for everyone?”  Release, Healthcare IT News

Who said big, late raises are a thing of the past? Not if your company is Aledade, which has solidly succeeded in management services for independent primary care practices transitioning to value-based care models. They just gained a shiny new Series F of $260 million on top of last June’s $123 million Series E for a new valuation of $3.5 billion. The Series F round was led by Lightspeed Venture Partners along with Venrock, Avidity Partners, OMERS Growth Equity, and Fidelity Management. Aledade has grown to manage 1,500 practices and has acquired in recent months Curia (data analytics for advance care planning) and Iris Healthcare (care planning technology). The additional funds will be used to opportunistically add capabilities into its platforms. FierceHealthcare, Bloomberg (paywalled)

Somewhat more in the recent range is DUOS’ $10 million venture capital raise for a total of $33 million. Leading the round were Primetime Partners, SJF Ventures, and CEOc’s Aging Innovation Fund managed by Castellan Group. What’s unusual is that the platform addresses older adults’ needs as a personal assistant in areas such as care, support in social determinants of health (SDOH), housing, and transportation against Medicare Advantage plan benefits, local community resources, and government programs. The benefit for the older person is to close gaps in care and increase utilization of Medicare Annual Wellness Visits (AWVs). Originally targeted to older adults, the company is broadening its markets to health plans, providers and employers. Release, Mobihealthnews, Home Health Care News

Insolvent ‘insurtech’ Friday Health Plans loses last two health plans to state receivership, will close. Colorado and North Carolina were the last two states the company operated in. Both states’ insurance departments put Friday into receivership this week after the insurer notified them that they could not raise additional cash to continue operations. This affects 35,000 and 39,000 individual health policyholders respectively. Texas, Georgia, Oklahoma, and Nevada were previously placed in receivership. State insurance regulators have assured providers that they can expect to be paid for their services per their contracts. Members generally need to find new insurance companies quickly, however. 323 Friday employees in Alamosa, Colorado, their headquarters, will be laid off between 23 June (this Friday) and 6 July, without the previously promised 60 day notice nor any notice of severance or benefit continuation. Friday is the largest employer in this Denver/Colorado Springs suburb. In its brief lifespan, Friday raised over $300 million and lost over $700 million. FierceHealthcare 22 June, 21 June.  Alamosa Valley Courier  Additional commentary by industry analyst Ari Gottlieb on LinkedIn

Mid-week update: Cano Health CEO finally booted, interim named; further information on Oracle Cerner layoffs

Cano Health CEO Marlow Hernandez stepping down, but remains on Cano’s board of directors. It looks like Florida-based value-based primary care provider Cano Health is finally starting to clean up its act. The fallout from the long-delayed shareholder meeting taking place last Thursday (15 June) was that the Cano 3 (resigned directors Barry Sternlicht, Elliot Cooperstone, and Lewis Gold), finally got their way with ousting Hernandez. Mark Kent, who was named chief strategy officer in April, will be taking over as interim CEO while the board performs an external search. No time frame was specified.

Hernandez’s departure was not a surprise since Cano had a miserable Q1, with a $60.6 million net loss versus 2022’s barely-there $100,000. Their adjusted EBITDA was only $5 million, compared to $29.2 million in Q1 2022 [TTA 12 May]. Their new chairman of the board, Sol Trujillo, also has a background in turnarounds.

The Cano 3 own about 35% of the shares and one, Barry Sternlicht, invested at least $50 million in the cracked SPAC’s PIPE. They started to push for change back in April. Today (20 June), they issued a statement approving of Mark Kent’s interim appointment though they were not able to prevent the reelection of directors Alan Muney and Kim Rivera as they urged shareholders to do in a 15 June public statement

Despite the ouster, the Cano 3 still have plenty of disagreements with how the company is run, nailing these to the door in their 20 June statement responding to what they called an “Offensive Friday Afternoon “News Dump” Regarding its Leadership Transition”:

  • Per his employment agreement, Hernandez is required to step down as a board director now that he is no longer CEO.Dr. Hernandez’s employment agreement plainly states that ‘the Executive shall be deemed to have resigned from all officer and board member positions that the Executive holds with the Company or any of its respective subsidiaries and affiliates upon the termination of the Executive’s employment for any reason.” They also cite ahistory of insider dealings and fiduciary delinquency.”
  • They demand that directors Angel Morales, Dr. Alan Muney, Kim Rivera, and Solomon Trujillo resign immediately as “Dr. Hernandez’s enablers for far too long”. The board permitted the reelection of directors Muney and Rivera despite 82% of shareholders withholding their votes, citing Cano’s post-meeting statement
  • Shareholders now must entrust the selection of a new CEO to a board that is not reflective of the majority of shareholders who have lost over 90% of their share value, and not collaborating with the Cano 3 on reforming the board and a new direction of the company. “In fact, it rejected our Group’s two highly qualified director candidates and a proposal to collaborate on a credible refresh of the Board. We are left to question whether Dr. Hernandez and his boardroom allies are continuing to box us out because they are hiding something nefarious. If not, we urge the Board to immediately align with us on a path forward that includes the addition of our candidates – Guy Sansone and Joe Berardo, Jr. – and other essential changes to leadership and strategy.” Both Sansone and Berardo are very senior executives with long, successful records in leading healthcare services and startups.

(Cano Health shares closed at $1.42 today, a decent bump from their valley last week.) To be continued….  Healthcare Dive

Last Friday, TTA was one of the first to cover the Oracle Cerner layoffs (along with HIStalk) affecting the Cerner Federal teams. This week’s coverage elsewhere confirmed that the layoffs were a minimum of 500 to possibly 1,200, plus rescinded job offers and reduced open positions as this Editor saw from employees posting on the Reddit group. They–in particular, The Register (below), confirmed where this Editor would not go in cause-and-effect–that the layoffs were largely due to VA holding further implementations after multiple failures in the five VA systems where it was implemented between 2020 and 2022. The layoffs were also due to the Department of Defense (DoD) Military Health System (MHS) implementation as largely completed, although not glitch-free. It’s a clear cleanout of what Oracle perceives as a problem. 

Oracle did not respond to these publications’ requests for comments.

The new contract’s focus is to fix these five and implement a sixth (James Lovell in Chicago) which is joint with MHS by 2024. This has to be accomplished before implementation starts in the 160 remaining centers plus satellite medical clinics (CBOCs). VA has much leverage in the five one-year terms and the monetary penalty structure [TTA 18 May]. The pressure to perform for an awakened VA–and Congress–is going to be intense on those remaining, and whomever is shifted over from Oracle. This Editor also noted speculation that Oracle Cerner may start to wash its hands of the just-renewed VA EHR implementation by outsourcing most of it.  The Register, Becker’s, Healthcare Dive   TTA’s coverage of the Cerner/VA implementation here.

Rounding up the week-end: Oracle Cerner layoffs hit 500+ in VA, DoD groups (updated); AWS cash cow stumbles; Transcarent-ViewFi team on virtual MSK; Veradigm delays annual, quarterly reports again; Olive AI sells BI to BurstIQ

Oracle, which already laid off 3,000 since its Cerner acquisition and dumped its real estate, is proceeding with more layoffs in Cerner groups serving the Federal government, specifically DoD and VA. According to the Reddit group r/cernercorporation on this thread, the layoffs hit broadly within the Federal teams: VA and DoD professional services, Federal care delivery, Federal change management, support service owners, and consulting. The number is at least 500 but may be more. The severance package is four weeks plus an additional week for every year of service plus unused vacation with the layoff date 30 June. Offers made to start for new hires have been rescinded. This has fueled speculation that Oracle Cerner may start to wash its hands of the just-renewed VA EHR implementation by outsourcing most of it. There is precedent for this: Cerner partnered with Leidos for the DoD implementation from the start and Oracle Cerner brought in Accenture for training in February. Of course, the all-heart Mr. Market liked the layoff news coupled with Oracle’s Q4 ending 31 May results of net income of $3.32 billion, a rise of 7% versus last year. CNBC  Oracle is now at a $342 billion valuation, a new high. HIStalk 16 June    

Updated 16 June: details remain sketchy but confirmation that layoffs are in the ‘hundreds’ Reuters, Becker’s, KC Business Journal (paywalled); the last posits from CEO Katz’s statement that this is only the first of many to come.   Further details on the Reddit group is that consultants were onsite at clients working on projects and go-lives when they received their layoffs, that 80% of departments were affected, and that the layoff may go over 1,000. 

Amazon Web Services’ business continues to slow, with the AWS cash cow’s growth slowing to half versus last year’s, with further decline expected this quarter. This Editor noted that market analysts at Seeking Alpha called it back in February when we looked at Amazon’s ability to spend cash so freely in healthcare, for example on OneMedical. Google and Microsoft have been tough competitors and while their growth is off too, they are starting with smaller pie slices. Companies are using more than one cloud provider in a ‘belt and suspenders’ approach; Gartner predicts that by 2026, more than 90% of businesses will use multiple providers, from 76% in 2020. AWS’ plans continue to build outside of the US, with a $12 billion investment in cloud infrastructure in India by 2030 as well as five data centers in Oregon due to a controversial $1 billion tax break. Google and Microsoft have also led in generative AI, while AWS has not. AP

Enterprise health navigator Transcarent has made another bid in the virtual health area. It’s a partnership with ViewFi, which helps MSK providers to diagnose and treat MSK injuries in real time. ViewFi providers are affiliated with the NYC-based Hospital for Special Surgery. The idea for ViewFi came from retired tennis champion Andy Roddick who, with his orthopedist Josh Dines, MD turned their bad experiences during the pandemic using FaceTime for virtual consults into a new platform. ViewFi’s platform now takes patients through an intro screener that records physical and mental health, through diagnosis and a recovery care plan with personalized diagnostic tests and exercises with real-time support from their health guides. For Transcarent-contracted companies, a ViewFi initial appointment can be set in as little as two days as opposed to the usual average of 17 days. Transcarent bought the virtual care platform developed by 98point6 in March. FierceHealthcare

We noted back in March and last month that Veradigm (the former Allscripts) had serious problems with their Q4 and FY 2022 reporting due to a software flaw (!) that affected its revenue reporting going back to 2021. Nasdaq has extended for the second time–from 14 June to 18 September–their 2022 annual 10-K filing and their 10-Q for the quarter ending 31 March 2023. Not filing the reports will mean delisting. Seeking Alpha

Olive AI’s reorganization continues [TTA 23 Feb], with data solutions company BurstIQ buying its business intelligence platform.  LifeGraph Intelligence uses AI tools such as natural language processing and machine learning to extract insights from clinical notes and EMR fields. The platform presents cost and clinical data in a meaningful way through cohort comparisons. According to an example on their website, it contributed to $90 million in savings for one health system. Acquisition cost and management transitions were not disclosed. BurstIQ release  Hat tip to HIStalk 16 June

‘The Future of AI and Older Adults 2023’ now published

Laurie Orlov of Aging and Technology Watch in her latest paper tackles the latest iterations of AI and ML, tracing their roots back to 2014 to the original smart speakers and voice assistance, technologies that enabled older adults to access services with convenience and at reasonable cost. What will be the impact of AI using tools such as large language models (LLM) like ChatGPT to develop improved search, voice assistance, answers to health questions, and care plans written in understandable and empathetic language? For care facilities and senior housing, will they leverage AI with voice and sensor tech to improve safety monitoring for both residents and caregivers, plus the dream of predictive health for residents or those living at home with limited assistance? Will chatbots get a lot smarter versus obnoxious? Find out what both the short term and long term (5+ year) impact could be. 

Ms. Orlov’s somewhat gimlety view includes Gartner’s infamous Hype Cycle chart on page 5. As of today, most AI technologies reside in the balmy Peak of Inflated Expectations, the place where whatever investment funding is going. There’s lots of innovation and kitchen table hackathoning. Looming about two years out is the inevitable Trough of Disillusionment which has already been kicked off by Big Thinkers such as Steve Wozniak. As this Editor observed last month, it is a double-edged sword, with the bad side in its potential for data misuse, fraud, fakery, and malicious action. It’s already created controversy that this Editor predicts will crest in the next year with demands for regulation. We’re not there yet, however.

Download of the PDF is here and free.