Tunstall’s 2013 fiscal report: debt service makes short term gloomier

July 10, 2014 | by
[grow_thumb image=”https://telecareaware.com/wp-content/uploads/2014/07/Big-T-thumb-480×294-55535.gif” thumb_width=”150″ /]Updated…Released on this ‘getaway day’ (in the US), and surprisingly only covered by the local Yorkshire Post, is the report of Tunstall Healthcare Group’s year-end closing (30 Sept 2013) results. The short term news is positive: 21 percent revenue growth to £221 million in its 2013 statutory accounts. However, this adds in the acquisition of Spanish monitoring provider Televida for £27.4m in January 2013 and the 2012 purchases of AMAC in the US and STT Condigi in Sweden. The official posture of the company, expressed by CEO Paul Stobart, is that “with continuing Government austerity measures and a fragile global economy, the business does face challenges in the short term.” And one of those challenges making for a gloomy picture is debt service. We’ll let the YP speak: “The group, which is owned by private equity house Charterhouse Capital Partners (CCP) paid £13.7m of interest in cash on its senior and mezzanine debt of £265m, as well as a total of £114.4m non-cash interest on long-dated shareholder loan notes and other loans. This results in a statutory reported loss for the group of £127.8m.” That change of nearly £350 million, which includes operating costs and other expenses, illustrates the critical consequences of debt service on the bottom line, indeed [TTA 22 May]. Many thanks to one of our reliable sources for picking up this report.

New: Founder Steve reminds us of his related (and oh, so prescient) analysis from 2010 about Tunstall’s earnings versus debt service balancing act in Telecare Soapbox: Equity capital. A cautionary tale. (Thank you Steve for adding)

It is worth a detailed read because the 2009 numbers were also ‘challenging’. Steve dug through 2009 publicly filed (in UK) numbers to reach his conclusions. In sum, “The important question is whether their underlying position is sound and reliable, or whether they are shaky. They also tell me that the robustness of a company’s cashflow is the most important survival factor.”  If I am reading the report on CompanyCheck correctly, the eye-watering negative net worth of the Group and the low cash positions of both the Group and UK are oddly reminiscent of airline financial statements when this Editor was still in that business. Do remember the object examples of Texas Air Corporation (once the world’s largest airline holding company), Pan Am and TWA!  You also have to have some sympathy for the management which was not part of getting into this ‘pickle’ now tasked with getting the company out of the barrel.

Soapbox Round 2: ‘disruptive innovation’ debate disrupts ‘the chattering classes’

June 30, 2014 | by
[grow_thumb image=”https://telecareaware.com/wp-content/uploads/2014/06/img_5.jpg” thumb_width=”180″ /]It’s a Blackboard Jungle out there. Clayton Christensen rebuts Jill Lepore on most–but not all–of her views on his theory of disruptive innovation [TTA 24 June] aired in a New Yorker cover story. The forum is a follow up interview (20 June) with BusinessWeek. (Hat tip to Tom Boyle commenting on the original Soapbox. Also see a just-released HBR video interview, link below.)

Your Editor agrees with his point that his theories have been developed and updated far beyond his first (1997) book, ‘The Innovator’s Dilemma’, the only one she refers to.  (Similarly, I am most familiar with ‘The Innovator’s Prescription’ of 2008, but we’ve commented on his more recent relevant work, readily searchable here.) This is, unfortunately, her argument’s major flaw. It is akin to ceasing your review of WWII history with A.J.P. Taylor and Cornelius Ryan; as fine foundationally as they are, the scholarship and strategic debates will extend far beyond our lifetimes.

Mr Christensen in his rebuttal is appealingly modest in bringing up where he got it wrong (the iPhone), where his model has gone off (in 2002, a mathematician from Tuck demonstrating the causal mechanism as incorrect to that point) and that he still sees problems with the theory. Moreover, her strongest point is one he agrees with: (more…)

Soapbox: Is ‘disruptive innovation’ a theory gone off the tracks?

June 24, 2014 | by | 2 Comments

[grow_thumb image=”https://telecareaware.com/wp-content/uploads/2014/04/Thomas.jpg” thumb_width=”200″ /]Having publicly stood as a huge fan of Clayton Christensen’s theories of disruptive innovation, particularly the ‘broken circle of innovation’ as an explanation of our current economic stagnation (if not ‘stagflation’ which was a hallmark of my early adulthood and yes, now) and disruption in healthcare (even if it hasn’t started yet because it’s been sidetracked), this Editor was prepared to savage, demolish and otherwise lay waste to a New Yorker article by Jill Lepore (a Harvard professor of American History, for Pete’s sake).

Having read and digested the article, I am surprised in largely agreeing with Prof. Lepore. She brings forth certain weaknesses and concerns I had about the entire Weltanschauung of disruptive innovation, first as an overarching theory equivalent to Darwin’s theory of evolution. There is a veritable industry around disruptive innovation which she outlines, reminding me that hype of this type around any theory I find profoundly irritating because theories are just that–to be reality checked early and often, just like voting in the 1930s in Jersey City, New Jersey. Prof. Lepore then points out where fellow Harvard Prof. Christensen didn’t paint the complete picture (e.g. Bucyrus, US Steel) and–to me quite importantly–discounts external events and even aggressive, defensive business strategy (as Ron Hammerle’s Soapbox on sidetracked innovation pointed out). Many of Prof. Christensen’s acolytes ignore history (and business strategy) altogether in a near-religious form of Determinism-by-Innovation.

There is also another circle–a circular logic prevalent in Mr Christensen’s theories summarized aptly by Ms Lepore: (more…)

Picture murky: 23andMe and the FDA

April 2, 2014 | by | 2 Comments

Genetic testing company 23andMe seems to be in no rush to resolve its differences with the FDA, and the digitalhealtherati a/k/a D3H (Digital Health Hypester Horde) are wondering why. In late November, 23andMe executives undoubtedly had a depressing Thanksgiving when the FDA ordered them to stop providing health reports (interpretation of genetic results) and marketing kits. Four months later, 23andMe continues to sell its kits for $99, providing only raw genetic data and ancestry reports–and according to its 31 March blog posting, will do so for the foreseeable future as they complete the regulatory review process. The blog quoted CEO and co-founder Anne Wojcicki, “My main priority is resolution with the FDA,” but actions speak louder than words–and the FDA isn’t talking. The FDA standard is still validation–the company has to analytically and clinically validate 23andMe for its intended uses, which is why the FDA took action against them in the first place.

  • Is the lack of urgency more about continuing to gather raw genetic and health data unimpeded? Ms Wojcicki had widely stated her real aim was to build a 25-million-strong database (Fast Company).
  • Is the real revenue stream of the company not the kits but in monetizing a massive database, selling it to researchers and others (Matthew Herper in Forbes)–the Google model which Ms Wojcicki is quite familiar with? Consider that there’s $126 million into the company, that is a lot of $99 kits.

Most companies in this situation would be imploding. This one is not. Interestingly. FierceMedicalDevices, The Verge

Previously in TTA: all you ever wanted to know about the 23andMe kerfuffle in FDA tells 23andMe genomic test to stop marketing (including this Editor’s analysis of their pre-FDA website with copy breathlessly expressing potentially life-saving or critical lifestyle changing claims, countered by legal ‘educational use’ boilerplate) and The inevitable: class action lawsuit against 23andMe (a check of the Ankcorn blog has no updates)

Disruptive innovation in healthcare hasn’t begun yet: Christensen

March 31, 2014 | by | 6 Comments

Clayton Christensen, as many of our readers know, pioneered a theory of disruption in business models and a three-step cycle of innovation (empowering, sustaining and efficiency, now quite broken indeed). With two other writers, he applied these theories to healthcare in the 2009 book ‘The Innovator’s Prescription’ which this Editor heard co-author Jason Hwang, MD present in 2009 at the Connected Health Symposium and at a private meeting in 2011. One would think that we’d be well into disruption, which is part of the empowering innovation cycle and which the authors championed in the book as underway.

The surprise at the end of this Mobihealthnews article on his recent presentation at “Better Health” in Boston, a McKesson-sponsored meeting series, was not what constitutes disruption, but that it has not really started yet, four years later. This will be much to the surprise of many successful and unsuccessful companies (Misfit Shine, ZocDoc, Zeo, 23andMe) and health plans which have stoutly touted their products and services as The True Disruptors. Sorry, you may be only a part of the Big Shift: decentralization. Decentralization will push out parts of healthcare off the hospital (more…)

The future of doctors

January 23, 2014 | by

The Economist this week has an important leader and report on the future of work that has key implications for technology adoption by clinicians.  It is well worth reading in full. For those who cannot, the very basic issue raised is that technology is again replacing labour with capital. In the past this has always resulted in higher value jobs being created. This time though, there are many suggesting that it might just be different: some people will run out of road.

The Economist article does not go into the detail of many individual professions, however the description of the types of work most suited to this next wave of automation does cover much of the field of medicine (as, coincidentally I argued recently in my predictions for 2014). A particularly relevant section in the article is:

The machines are not just cleverer, they also have access to far more data. The combination of big data and smart machines will take over some occupations wholesale;

…which supports my contention:

And just think too, what correlations a single system overseeing the treatment of tens of thousands of people, with access to regular vital signs and other information on progress for each one of them, might be able to spot to enable it to improve patient care, that elude the best of GPs treating far fewer. Doubtless increasing genomic analysis & knowledge will enhance this too. –

So how should doctors react? Clearly one view, which seems still to be the minority approach (and that Telehealth & Telecare Aware is really all about trying to encourage) is to use existing technology, like telehealth and mHealth, to improve healthcare and reduce its cost. Automation is expensive so investors will look for those professions where the expected returns are highest; with this approach, the greatest benefits from automation will lie in other professions, so the greatest impact of automation on the medical profession will be delayed.

The alternative, which still seems to be the majority view, is to argue for the continuation of current practice and ignore the benefits of technology (and ignore the evidence that demographic changes will mean that the ratio of careworkers to those requiring care will render the current system infeasible anyway). That way will keep the cost of care relatively high and promote a crisis in the delivery of healthcare relatively soon, making early profound medical automation particularly attractive.

Of the two, from a patient point of view, earlier rapid automation looks superficially attractive although the chaos of rapid change will likely create many challenges that make it less attractive – let’s hope that the leaders in the medical profession, and those who appoint them, read the Economist this week and recognise the benefits to them (as well as to patients) of early technology adoption.

2014: the year of reckoning for the ‘better mousetraps’

January 1, 2014 | by

Or, the Incredible Immutability of the Gartner Hype Cycle

From Editor Donna, her take on the ‘mega-trend’ of 2014

This Editor expected that her ‘trends for next year’ article would be filled with Sensors, Wearables, Glasses, Smartwatches, 3D Printing, Tablets and Other Whiz-Bang Gizmos, with splashes of color from Continuing Crises like Healthcare.gov in the US, the NHS’ 3million lives plus ‘whither UK telecare’, various Corporate ‘Oops-ses’, IP/Patent Trolls and Assaults on Privacy. While these will continue to spread like storm debris on the beach, providing continuing fodder for your Editors (and The Gimlet Eye) to pick through, speculate and opine on, what in my view rises above–or is under it all–for 2014?

We are whipping past the 2012-13 Peak of Inflated Expectations in health tech…

…diving into the Trough of Disillusionment in 2014. Crystallizing this certainty (more…)

Mainly mHealth: a few predictions for 2014, and some speculation

December 31, 2013 | by

Editor Charles on what to watch for in 2014

As we have covered previously (and here), there’s no shortage of forecasts that the mHealth market will continue to grow faster, or of penetrating comments like that that won Research2guidance a What in the Blue Blazes award that smartphone user penetration will be the main driver for the mobile health (mHealth) uptake. mHealth apps continue to proliferate – there’s even shortly to be a Pebble apps store. There are a few straws in the wind that not is all well though – for example, as we covered recently, Happtique ceased, at least temporarily, its apps approval process, citing security concerns.  Elsewhere Fierce Mobile described serious data privacy issues with the iPharmacy app, and the ICO recently produced security guidelines for app developers in the UK.  The EU is also strengthening data privacy, moving from individual country directives to a pan-EU regulation. This leads us to our first prediction (more…)

Happtique halts app certification on data security concerns

December 13, 2013 | by | 1 Comment

Health app industry self-policing and ‘trusted sourcing’ credibility at stake?

Updated below. Last week, after Happtique announced its ‘Inaugural Class’ of 19 certified apps [TTA 2 Dec]–certified on their standards of operability, privacy, security and content–a young HIT software developer, Harold Smith III, discovered some major security flaws in two of them: MyNetDiary’s Diabetes Tracker and TactioHealth5. User names and passwords were stored in plain text files–not encrypted–and Mr. Smith then subjected them to a ‘man in the middle attack’ (MITM) which he explains as “…where a nefarious source intercepts your communication from the App to the server. They decrypt the SSL connection, pull out your data, and send the data on to the server.” Both failed. Worse, the ePHI (ePersonal Health Information) of both were not sent in a secured way and not stored in secure, encrypted files. After advising both companies of the problems (including one of these companies in person at the mHealth Summit), as well as Happtique, and receiving no satisfactory response after days passed, Mr. Smith went public Tuesday and Wednesday on his blog mHealth and Mobile Development. Both articles deserve careful reading. Our readers with software development background will appreciate 1) his meticulousness and 2) his ire not only at Happtique but their validator, Intertek, at the poor technical quality of their vetting; the non-techies like your Editor will appreciate the clarity of his writing.

Small blog, big impact today. Happtique has suspended its certification program (website notice) and on its website now has revised certification standards. Regarding the credibility of Mr. Smith, (more…)

FDA tells 23andMe genomic test to stop marketing (US)

November 27, 2013 | by | 2 Comments

Quantified Selfers and the D3H (Digital Health Hypester Horde) are in a swivet. This past Friday, FDA slammed the door shut on the 23andMe Personal Genome Service (PGS) saliva test. This past summer, the company broadly marketed to US consumers, including a TV campaign [Charles Lowe, TTA 7 Aug]. The FDA cease-and-desist letter cites that 23andMe never provided requested data on their July and September 510(k) filings, which are now ‘considered withdrawn’, and cites that “after these many interactions with 23andMe, we still do not have any assurance that the firm has analytically or clinically validated the PGS for its intended uses, which have expanded from the uses that the firm identified in its submissions.” The danger is that people will make medical decisions based on the testing information and that the results produced may be faulty. It appears from FierceHealthcare that the kit has actually been marketed for five years. According to MedCityNews, it is backed by Google Ventures (the CEO/co-founder is the estranged wife of Google head Sergey Brin), New Enterprise Associates, MPM Capital and the Moscow billionaire Yuri Milner. A private citizen is petitioning the White House to overrule the FDA (as if that extra-legal move would be possible, but who knows with the influence of the Googlesphere?) and states that the agency ‘grossly overstates the risks’ (also MedCityNews). As of 2 Dec there are 3,306 signatures of the 100,000 needed; one suspects this administration has bigger slices of uncooked turkey on its plate such as Obamacare and a kind-of-achieved 30 Nov deadline on Healthcare.gov, which is now clearly seen as just one problem.

The 23andMe website is still fully up and still selling kits.

Editor Donna sorts through the noise for possible reasons why:  (more…)

The train, plane and car wreck that is Healthcare.gov and Obamacare

November 8, 2013 | by

If the ACA and Healthcare.gov were Boeing or Airbus aircraft–they would have been grounded on 3 October.

Wherever you reside in the over 150 countries TTA is read in, if you need more convincing that the US Government is unable to be successful (and Editor Donna is being restrained and charitable) at 99 percent of everything contained in this misbegotten Act, all one needs to do is read our previous coverage and this latest update in the Daily Mail along with their links to their own previous coverage. Are you sure it’s going to be fixed within weeks, Mr. President? This is Obamacare website riddled with garbled messages today

[grow_thumb image=”https://telecareaware.com/wp-content/uploads/2013/11/article-2491576-1943076800000578-829_634x378.jpg” thumb_width=”600″ /]

Except in the minds of White House and HHS planners, the obvious solution would be to STOP: halt the enrollment process, suspend the ACA implementation, restore the right to current coverage for the millions who have been blocked from renewing their current individual coverage and take the entire website down. Rethink all the elements including the coverage structure and the website, send it back to Congress for relegislating and implement a program that works sometime in 2015 IF a way can be found. But no, Americans get piecemeal fixes on a website and system that increase the vulnerability of personal information to hackers and identity theft–and coverage they cannot afford. (And this is only in the individual and small group market. Wait till it applies to large employers–other than unions which have been exempted.) (more…)

Due diligence: the importance of the internal IP audit

November 4, 2013 | by

This is the fourth article of an occasional series on law and intellectual property (IP) as it affects software and systems used in health technology. The topic is the importance on implementing your own audit of your company’s IP and why you should enlist an outside company to do it. More than a list of your copyrights and patents, an independently conducted internal audit will prepare your company for the external due diligence expected when a bank wants to vet a loan or an investor knocks on the door–and it includes things like your website and IT. While Mr. Grossman is writing in the context of US law, our UK and international readers will find his pointers applicable both locally and in dealing with the US. What’s refreshing is his plain writing and lack of ‘legalese’. 

Mark Grossman, JD, has nearly 30 years’ experience in business law and began focusing his practice on technology over 20 years ago. He is an attorney with Tannenbaum Helpern Syracuse & Hirschtritt in New York City and has for ten years been listed in Best Lawyers in America. Mr. Grossman has been Special Counsel for the X-Prize Foundation and SME (subject matter expert) for Florida’s Internet Task Force. More information on Mr. Grossman here and at his blog.

INTELLECTUAL PROPERTY DUE DILIGENCE

Intellectual property may be among the most valuable assets your company owns. The problem with intellectual property (IP) is that by its nature its intangible. You can’t touch it or see it. So how do you know what you have and own?

The starting point is to look to any registrations you may have with the government. For example, you may have registered a copyright or trademark and have paperwork to prove it. However, the registrations are just the starting point. It turns out that getting a handle on your company’s IP assets can be a complex process.  (more…)

A highlight from ATA 2013 Fall Meeting: Psychiatric appointments as a ‘data-file’

October 29, 2013 | by

In a conversation at a recent Health 2.0 NYC event, this Editor asked Doug Naegele what was the most surprising topic at the recent American Telemedicine Association conference in Toronto. Doug has graciously contributed this short article. He is the founder of Infield Health, a firm dedicated to increasing health outcomes and reducing total cost of care by putting discharge instructions on mobile phones. 

At the ATA Fall Meeting in Toronto last month, Dr. Peter Yellowlees gave a presentation on his work at University of California-Davis around telepsychiatry. I was struck by a few of his discussion points:

1. It may be helpful to see psychiatric consults as ‘data files’ and not events that require mandatory real-time evaluation.
2. If we accept that these consults can be described as data files, then they can be forwarded to remote psychiatrists for viewing, evaluation, and treatment recommendations much in the same way radiological scans are remotely evaluated. (more…)

Is this Tunstall’s ‘taxgate’? Maybe not.

October 25, 2013 | by | 2 Comments
[grow_thumb image=”https://telecareaware.com/wp-content/uploads/2013/10/taxman_logo.jpg” thumb_width=”170″ /]On Monday, The Independent, one of the UK’s major national papers, turned its attention in a ‘Tax Special Investigation’ to nine healthcare companies which are using a corporation tax reducing scheme, the ‘Quoted Eurobond Exemption’, where they pay loan interest at high rates to their parent companies through a mechanism via the Channel Islands Stock Exchange, rather than their owners further investing by taking additional equity. (How it works–infographic from The Independent)

One of the companies the article focused on was Tunstall and its owners Charterhouse and Bridgepoint. Tunstall’s profits–like the other healthcare companies profiled, Partnerships In Care, Independent Clinical Services, Priory Group, Acorn Care, Lifeways, Healthcare At Home, Spire Healthcare and Care UK–come largely from the public sector and, by using this means to pay less tax, less money is recycled back to the Treasury. The article estimates the amount for each company which would have been paid had this tax exemption not been in place. This Editor notes that a number of the companies profiled have had significant inspection problems and numerous complaints–Tunstall is not one of them, but it is the second largest ‘tax avoider’ (after Spire) listed.

There seem to be three ways to regard this:
1) it’s a commendably clever contrivance
2) it’s a suspiciously shady stratagem
3) it’s a non-story because it is something imposed on Tunstall by its owners

Whatever it may be, we are left wondering if Tunstall’s customers benefit in any way from this tax saving. We will be interested in our readers’ views.

Independent article: Tax Special Investigation: Firms running NHS care services avoiding millions in tax It is equally popular with well known high street (US=Main Street) retailers and restaurant chains: Eurobonds scandal: The high street giants avoiding millions in tax    (more…)

Telehealth round-up: the good, the bad, and the future

October 20, 2013 | by | 2 Comments

Getting the bad news out of the way first, the seemingly-eternal researchers have thrown their grappling iron into the ancient store of data from the now-only-historically-relevant Whole System Demonstrator data pool and dragged out yet another unexploded bomb that they have then endeavoured to detonate, in the form of a short research article.

Thankfully the explosive has deteriorated with age so (more…)

Humana, Healthrageous and some object lessons

October 16, 2013 | by

The acquisition of the assets of Partners HealthCare spinoff Healthrageous by insurance and health service giant Humana is reverberating in the field in the US, particularly those in the buzziest digital health sectors. Some may look away, but a hard look provides some object lessons at the sheer unpredictability of the field for those who are innovating and attempting to shape consumer behavior and health. (Not behavioral health)

  • Healthrageous had an impressive lineage and credibility. Developed over three years at Partners HealthCare, it was spun off in 2010, PHC members on the board, leadership from well-known/regarded figures such as Rick Lee and Mary Beth Chalk–and enjoyed abundant, rapid startup funding–$12.5 million in two rounds, the last exactly one year ago, from equally impressive investors, reportedly $15 million total. No raiding the credit cards here.
  • It occupied what everyone for the past few years thought of as a sweet spot–personal health management targeted to employers/benefit managers along with health plans to lower costs that combined sensor-based telehealth data with individualized coaching and feedback–and data from a broad base of 10,000 users. (more…)