News roundup: Waystar’s $8B IPO plan takes delay, Perficient to buy SMEDIX, PicnicHealth buys AllStripes, MDLIVE buys Bright.md, Sage garners $15M, Cureatr shuts suddenly, Calibrate reorganizes, BetterUp lays off 16% (updated)

October 26, 2023 | by
  • It’s a Tale of Two Cities…the best and worst of times, depending on what company you’re with.

Waystar files for the first IPO of 2023 in healthcare. Revenue cycle management (RCM) and payments software company Waystar filed a registration statement with the Securities and Exchange Commission (SEC) last week, after filing a draft with the SEC in August. Waystar, formed from RCMs ZirMed and Navicure, isn’t profitable (2023 first half net losses of $21 million on $387 million revenue) but it is big–30,000 provider organization customers in a subscription model generating $4 billion in healthcare payment transactions last year. The offering on Nasdaq under WAY potentially values the company at $8 billion.

The IPO offering is being led by JPMorgan Securities LLC, Goldman Sachs, and Barclays Capital. Swedish global investment firm EQT Partners and the Canadian Pension Plan Investment Board became majority investors in 2019 with Bain Capital retaining a share. Waystar also acquired that year Connance, Ovation Revenue Cycle Services’ transaction services tech, PARO and Digitize.AI.

A comparative factor is that its main competitor, R1 RCM, is public.

It’s been over a year since the last digital health company went public, but any speculation that this is a dambreaker for health tech IPOs would be premature, even in the ever-optimistic view of Rock Health. FierceHealthcare, Waystar release

Update: The WSJ reports that the Waystar roadshow to pitch the IPO to investors, scheduled for this week, has been delayed to December at earliest, pushing the IPO into 2024. Sometime. IPOs for other companies have gone south. Reuters

What is more typical are these three acquisitions and consolidations, mainly in the healthcare software and data collection areas, as time goes on and fresh funding rounds grow scarce.

Perficient, a ‘digital consultancy’, is in agreement to buy SMEDIX, a $12 million in revenue healthcare software engineering firm headquartered in San Diego, California, with offshore operations located in Cluj-Napoca, Romania. Acquisition cost was not disclosed. Closing is anticipated in January 2024. SMEDIX President and CEO Fayez Sweiss will join Perficient in a key leadership role and the release mentions the addition of 175 skilled global professionals.

Patient community, clinical data, and patient-reported evidence collector PicnicHealth is acquiring AllStripes, a platform for rare disease data and patient access. PicnicHealth’s partnerships are primarily with pharmaceutical companies and nonprofit research organizations for patient data. AllStripes generates research-ready evidence to accelerate rare disease research and drug development, as well as a patient/family-facing app connecting them to treatment research. AllStripes had a $50 million Series B funding round in 2021 and PicnicHealth had a $60 million Series C round in 2022 backed by new investor B Capital Group plus existing investors Felicis Ventures and Amplify Partners. But as is usual of late, the acquisition cost is not disclosed. Release

In TelehealthLand, MDLIVE is buying Bright.md. Announced at HLTH, MDLIVE, part of Cigna unit Evernorth, will add Bright.md’s asynchronous telehealth capabilities to its existing platform. The expansion will target their virtual urgent care area, adding chronic disease management and wellness visits in 2024. Asynchronous telehealth adds an information gathering and triage option to standard virtual consults in gathering initial information, optimally directing the patient to the right care at the right time. Acquisition costs (again) were not disclosed. MDLIVE also announced a care coaching option within its virtual primary care program. MDLIVE works with employers and health plans which gives them in total a 43 million member base. Healthcare Dive, FierceHealthcare

Sage scored a $15 million Series A. Funding for their senior housing care platform was led by Maveron with participation from Distributed Ventures, ANIMO Ventures, and Goldcrest Capital. The platform consolidates and coordinates nurse call and care information for residents. This follows on their August 2022 $9 million in seed funding.  Mobihealthnews

Also typical of late are closings, reorganizations, and layoffs.

NYC-based Cureatr shut down suddenly Tuesday 17 October. According to the sketchy reports on places like Reddit, it was with three days notice to staff nor severance and done on a Zoom call. Systems were shut down on Friday but not the website which is still up. Cureatr was a comprehensive medication management company with staff pharmacists working with topline providers like New York Presbyterian, Northwell, Penn Medicine, and DaVita. Surprisingly, they bought a competitor, SinfoniaRx, only last March. Posters on Reddit describe new hires starting in the last two months and people yet to start who had already left their jobs. From Glassdoor, posters state that the company went bankrupt after not getting more financing. Things went south fast. What is going on now is a bad rerun of the 2007-8 period when funding dried up and companies ran out of runway fast, a period that this Editor experienced firsthand at Living Independently Group. Shotgun takeovers and sudden closings. Thanks to HISTalk 23 Oct for the heads up.

Another NYC former high-flyer, ‘metabolic health’ weight loss digital health coach Calibrate, was sold in a ‘reorganization’ to private equity firm Madryn Asset Management along with other investors. Prior to the sale, Calibrate raised about $160 million in funding. With scarcity of their GLP-1  drug therapies Ozempic and Wegovy and insurers refusing coverage of their over $1,700 direct-to-consumer regimen (not including medication cost), plus new competitors like Teladoc, Calibrate lost patients, received rafts of angry social media postings, refunded millions to them, and laid off 150 staff in July 2022 with 100 departing last April. Weight loss/obesity management remains hot, but in more payer and employer-centered models, to which Calibrate announced it was pivoting to this summer. MedCityNews

Calibrate was one of the companies out of Redesign Health, which has developed about 50 health tech companies, the latest being Harmonic Health for care management of dementia patients and family support. 

Telemental health is also going wobbly, with BetterUp recently laying off 16% of its workforce or 100 employees. BetterUp provides virtual behavioral change coaching for corporate performance, including mental health. Their base is primarily enterprise clients with a B2C offering. The brief report in the Daily Beast states that the company has missed financial targets starting with last year and “grappled with internal tumult for many months, including a rebellion by its army of coaches last spring.” Back in the palmy days of 2021, BetterUp raised $300 million through a Series E in a total of seven funding rounds and achieved a $4.7 billion valuation, which is not likely to be the same now.

Yes, this is the company that employs Prince Harry, Duke of Sussex as its chief impact officer. No one quite knows what he does, how much time he spends on company business, nor what he is paid–which are issues with the employees, especially those facing or contemplating The Ax. The prince has made some corporate appearances at conferences. The CEO characterizes his duties as expanding “global community reach”. Perhaps this Editor is cynical, but Prince Harry a/k/a ‘This One’ is beginning to resemble one of his ancestors, Edward, the Duke of Windsor, without the splendid sartorial style.  The Mercury News manages to spin a whole article about this and Netflix. Certainly, a lesson to be learned about celebrity employees.

The end of the bubble? SOC Telemed, SPAC’d at $10 per share, acquired for $3 and $300M by Patient Square Capital

February 8, 2022 | by

SOC Telemed (NASDAQ: TLMD), one of the earliest health tech SPACs [TTA 4 Aug 2020], is going private in a deal with the Sand Hill Road healthcare investment firm Patient Square Capital. Patient Square is paying $3 per share in cash.

Based on the 100,840,000 shares outstanding (MarketWatch), this Editor’s best estimate of the transaction is about $303 million. Holders of 39% of the outstanding shares have already voted in favor of the transaction. The deal includes a 30-day “go shop” period in which SOC Telemed’s board of directors can solicit additional bids. Unless there is a superior bid, the deal with Patient Square is expected to close in the second quarter of 2022. 

According to the release, Dr. Chris Gallagher, CEO since September of 2021 will remain. He was previously co-founder/CEO of Access Physicians, a multi-specialty acute care telemedicine business acquired by SOC Telemed in March of 2021. SOC Telemed claims to be the largest telemedicine provider in the US acute care market, supplying virtual consults in specialty areas such as neurology, psychiatry, and ICU. 

Here is where it gets interesting–and worrisome for telehealth. SOC Telemed’s SPAC in August 2020 started at $10.00 per share and a valuation of $720 million. On 2 February, two days before the announcement, SOC Telemed was trading at $0.64 per share. That is a plunge of 94% from the SPAC, with a 72.6% drop in the prior three months that was only arrested by the buyout. The reality is that the Patient Square offer represents a 368% premium over SOC Telemed’s closing share price on 2 February. It is currently trading in about the $2.75 range. 

The worrisome trend is that since August, the publicly traded and established industry giants, Teladoc and Amwell, have also taken it in the shins on their share prices. Teladoc has tumbled by half and Amwell (American Well) by 60%. Even the private companies like MDLive and Included Health (Grand Rounds + Doctor on Demand) must take note that telehealth consults have plunged to about 4% of claims. SPACs, which had opened up an alternate, less complicated channel of public financing for health tech and had its own role in inflating company valuations, have faded due to a combination of circumstances. Will more cautious investments and fewer IPOs be the trend in telehealth for 2022?

Telehealth saves $100+ per visit or lab tests, reduces unnecessary ER/ED + urgent care visits 19%: Cigna/MDLIVE study (updated for RPM offering))

January 27, 2022 | by

Studies which quantify telehealth cost savings and visit reduction are always welcome. Cigna, through its telehealth company MDLIVE (purchased in April 2021), crunched the numbers and found some quantifiable savings and positive results:

  • Depending on whether the visit is for non-urgent primary care, visiting a specialist, or urgent care, telehealth savings are in the $100 range per visit: $93, $120, and $141 respectively. 
  • For urgent care, reducing unnecessary visits to both urgent care clinics and ER/ED settings is a major cost savings and a key measure of health plan performance. Virtual visits were found to reduce unnecessary emergency room or urgent care visits by 19%.
  • Lab visits were also reduced in cost. Patients who saw MDLIVE providers during urgent care visits were able to avoid unnecessary tests, saving an average of $118 for each episode of care.

Unfortunately, some of the results offered up by Cigna are countered by other sources–and surprisingly they didn’t cross-check:

  • Evernorth, their health services business, estimates that telehealth visits are currently 25% of all visits. That is far above the claims information that FAIR Health tracks, where telehealth is below 4%. Back in April 2020, it was 13%. Even Epic’s tracking indicated that the peak of 69% of visits in April 2020 tailed off one month later to 21% [TTA 8 Jan].
  • Citing 2020 only data around virtual wellness screenings and health conditions as a new normal is problematic. Cigna claims that more than 75% of Cigna customers who had an MDLIVE virtual wellness screening in 2020 not only lacked a primary care physician but also that two-thirds of these PCP-less patients learned they had a health condition via the virtual screening. Practices and people were locked down for most of 2020 and these numbers are likely skewed. 

But as quantifiable directional findings, the top three are welcome news. Cigna/MDLIVE release, Becker’s Payer Issues

Updated  MDLIVE announced today a remote patient monitoring program for members with chronic conditions Members can upload monitoring information such as blood glucose or blood pressure to their patient portal so that their MDLIVE doctor can review during the next telehealth visit. This feature will be available to health plans that utilize MDLIVE primary care services. Later this year, they will offer a device interface to the patient portal so that no manual entry will be needed. Mobihealthnews

What’s next for telehealth? Is it time for a correction?

October 14, 2021 | by

crystal-ballThe boom may be over, between shrinking visit volume and a pileup of providers. Is a correction in the cards? The flood of funding that started in 2020 and has not abated was kicked off by the pandemic and a massive shift to telehealth visits in March/April 2020 from a barely-above-plant-life number in January/February.

Post-pandemic, the shift corrected.

  • The peak of 69% of visits tracked by Epic in April had tailed off to 21% as early as May 2020 [TTA 2 Sept 20].
  • National commercial claims data via FAIR Health was lower. They tracked its peak also in April 2020 at 13%, falling continuously monthly: May to 8.69%, 6.85% in June, 6% in August, and 5.61% in October [TTA 9 Jan].
  • By mid-year 2021, the claims numbers continued to lose altitude: June 4.5%, July 4.2% (FAIR Health monthly report).

Despite the numbers, telehealth companies raised $4.2 billion of a total $15 billion in digital health funding in the first half of 2021, according to Mercom Capital Group, a global communications and research firm. So…what’s the problem with les bon temps rouler?

CB Insights notes the increased specialization of new entrants and, as this Editor has noted previously, the blending and crossing of business lines.

  • Companies like Heal, Dispatch Health, and Amazon Care will send a clinician to your house for a checkup–no running to your urgent care.
  • Kidney disease? Monogram Health. Musculoskeletal pain? Hinge Health. Child with an earache or fever? Tyto Care. Check symptoms first? Babylon Health.
  • Telemental health has gone from cocktail party repellent to the belle of the ball, concentrating on cognitive remote therapies. For the past year, it moved to more than half of all telehealth claims, with currently over 60% of procedure codes–and it’s consolidating. AbleTo was bought by Optum, Ginger bought by Headspace, SilverCloud by Amwell.

So for the Major League–Teladoc, Amwell, Doctor on Demand, Grand Rounds, and MDLive–what does this mean? If this interview with Teladoc’s CIO is an example, they plan to segue to a ‘hybrid’ model of virtual quick response plus integrating providers into a continuing care model with patients, creating a relationship with history and familiarity. A model that’s very much dependent on IT, analytics, and connecting with willing providers. But in this free-floating sea of verbiage, it didn’t come into misty focus till the very end, when he mentions Primary360 [TTA 7 Oct] and a virtual primary care team. (And let’s not forget Babylon360 along similar lines.) He finally sketches a view of all the connections to conditions coming together on a very far horizon. 

One can say it’s a cloudy crystal ball, indeed. FierceHealthcare, HealthcareITNews (Teladoc CIO interview)

News and deal roundup: Microsoft’s $20B deal for Nuance; Cigna Evernorth finalizes MDLive; GoodRx buys HealthiNation; Papa’s $60M Series C

April 21, 2021 | by

Our Big Deal is Microsoft’s acquisition of Nuance Communications, a cloud and AI-based speech recognition company which has been a leader in healthcare for a few decades. Most recognizable are their Dragon and PowerScribe trade names. Microsoft is paying $56.00 per share, a 23 percent premium to the closing price of Nuance on 9 April, an all-cash transaction valued at $19.7 bn. Closing is projected to be end of 2021 as subject to regulatory and final shareholder approvals.

Nuance and Microsoft have closely worked together for some time with Microsoft Cloud using Nuance speech recognition and Nuance clinical speech recognition offerings built on Microsoft Azure. Nuance claims that in the US, 55 percent of physicians, 75 percent of radiologists, and 77 percent of hospitals use their products. It’s a big but expected bet for Microsoft in healthcare against Apple that is expected to double Microsoft’s total addressable market (TAM) in the healthcare provider space to nearly $500 billion. It also adds enterprise AI expertise and customer engagement solutions in Interactive Voice Response (IVR), virtual assistants, and digital and biometric solutions for companies outside of healthcare. Microsoft release, Becker’s Health IT

Cigna closed its purchase of telehealth provider MDLive on 19 April. Purchase price and management transitions were not disclosed. MDLive will be part of Evernorth, Cigna’s health services portfolio. That portfolio includes Accredo, Express Scripts, Direct Health, fertility health, and more. Earlier coverage 27 February. Evernorth release, FierceHealthcare. 

GoodRx closed its purchase of health education video producer HealthiNation. Sale price was not disclosed. HealthiNation’s video library will reinforce GoodRx’s consumer information on prescription prices for better consumer decisions. Release, Mobihealthnews  

Senior services and socialization ecosystem Papa now has a brand new Series C of $60 million, via Tiger Global Management. Papa connects seniors with Papa Pals, a ‘family on demand’ that appear to be heavily college students. Papa Pals visit with them and provide in-person and virtual companionship, assist with house tasks, technology training, and transportation to doctors’ appointments. Scheduling is done via a smartphone app. The company added Papa Health last year, connecting in ‘Papa Docs’ (an unnerving term for those who recall ‘Papa Doc’ Duvalier of Haiti) for primary care, chronic care management, and urgent care. Papa works extensively with Medicare Advantage plans such as Humana, Reliance, Florida Blue, and Aetna. Founded in Miami in 2017 with now total funding of over $91 million and available in 50 states, earlier round funders include Comcast Ventures and Canaan Partners. Release, Crunchbase, FierceHealthcare

Weekend reading: the strange reasons why Amwell doesn’t consider Amazon a competitor; ground rules for the uneasy marriage of healthcare and technology

April 2, 2021 | by

Yahoo Finance interviewed co-CEO/founder of Amwell Ido Schoenburg, MD on the company’s 2020 results and forecast for 2021. It makes for interesting but convoluted reading on their growth last year in what is a consolidating field where Amwell was once one of the undisputed two leaders. They now compete against payers acquiring telehealth companies (MDLive going to Optum) and mergers like Doctor on Demand-Grand Rounds that are taking increasing market shares. Then there are specialty providers like SOC Telemed and white-labels like Bluestream Health. However, there are a couple of whoppers in the happy talk of growth for all. Dr. S pegs the current run rate of telehealth visits at 15-20 percent. The best research from Commonwealth Fund (October) and FAIR Health (August) tracked telehealth at 6 percent of in-office visits. Epic Health Research Network measured 21 percent at end of August. [TTA summary here] 

Then there’s the tap dance around Amazon Care. His view is that telehealth companies all need a connective platform but that each competitor brings ‘modular components’ of what they do best. What Amazon excels at is the consumer experience; in his view, that is their contribution to this ‘coalition’ because healthcare doesn’t do that well. There’s a statement at the end which this Editor will leave Readers to puzzle through:  

“And Amazon and others could bring a lot of value to those coalitions, they should not be seen as necessarily competing unless you’re trying to do exactly what they do. And there are some companies, including some telehealth companies, that that’s what they do. They focus on services. They try to sell you a very affordable visit with a short wait time and a good experience. They should be incredibly concerned when someone so sophisticated as Amazon is trying to compete in that turf.”

The last time this Editor looked, none of these companies were non-profit, though nearly all are not profitable.

Gimlet EyeLooking through her Gimlet Eye, Amazon Care is a win-win, even if the whole enterprise loses money. In this view, Amazon accumulates and owns national healthcare data far more valuable than the consumer service, then can do what they want with it, such as cross-analysis against PillPack and OTC medical shopping habits, even books, toys, home supplies, and clothing. Ka-ching!

A ‘bucket of cold water’ article, published in Becker’s Health IT last month, takes a Gimlety view of the shotgun marriage of healthcare and technology. Those of us laboring in those vineyards for the better part of two decades might disagree with the author in part, but we all remember how every new company was going to ‘revolutionize healthcare’. (The over-the-top blatherings of ZocDoc‘s former leadership provide a perfect example.) The post-Theranos/Outcome Health/uBiome world has demonstrated that the Silicon Valley modus operandi of ‘fake it till you make it’ and ‘failing fast and breaking things’, barely ethical in consumer businesses, are totally unethical in healthcare which deals in people’s lives. Then again, healthcare focused on ‘people as patients’ cannot stand either. Stephen K. Klasko, MD, President and CEO, Thomas Jefferson University and Jefferson Health in Pennsylvania, advocates for a change–far more concisely than Dr. Schoenburg. You may want to pass this along.

Two major moves and what they mean: Doctor on Demand, Grand Rounds to merge; Amazon Care will go national by summer (updated)

March 18, 2021 | by

This week’s Digital Health Big Deal (as of Wednesday!) is the merger agreement between telehealth/virtual visit provider Doctor on Demand and employer health navigator Grand Rounds. Terms were not disclosed. It’s important because it extends Grand Rounds’ care coordination capabilities beyond provider network navigation and employee clinical/financial tools for six million employees into an extensive telehealth network with 98 million patients in commercial, Federal, and state health plans.

Both companies had big recent raises–$175 million for Grand Rounds in a September 2020 Series E (Crunchbase) and Doctor on Demand with a $75 million Series D last July (Crunchbase). The transaction is a stock swap with no cash involved (FierceHealthcare, CNBC), and the announcement states that the two companies will operate under their own brands for the time being. Owen Tripp, co-founder and CEO of Grand Rounds, will run the combined company, while Doctor on Demand CEO Hill Ferguson runs DOD and joins the board. The combined company is well into Double Unicorn status with over $2 bn in valuation. Also Mobihealthnews.

What it means. Smaller (than Teladoc and Amwell) telehealth companies have been running towards M&A, with the most recent MDLive joining Optum’s Evernorth [TTA 27 Feb] creating interstate juggernauts with major leverage. Doctor on Demand was looking at their options for expansion or acquisition and decided 1) the time and the $ were right and 2) with Grand Rounds, they could keep a modicum of independence as a separate line while enjoying integration with a larger company. The trend is profound enough to raise alarms in the august pages of Kaiser Health News, which decries interstate telehealth providers competing with small and often specialized in-state providers, and in general the loosening of telehealth requirements, including some providers still only taking virtual visits. Contra this, but not in the KHN article, this Editor has previously noted that white-labeled telehealth providers such as Zipnosis and Bluestream Health have found a niche in supplying large health systems and provider groups with customized telehealth and triage systems.

UPDATED. In the Shoe Dropping department, Amazon Care goes national with virtual primary care (VPC). To no one’s surprise after Haven’s demise, Amazon’s pilot among their employees providing telehealth plus in-person for those in the Seattle area [TTA 17 Dec 20] is rolling out nationally in stages. First, the website is now live and positions the company as a total care management service for both urgent and primary care. Starting Wednesday, Amazon opened the full service (Video and Mobile Care) to other Washington state companies. The in-person service will expand to Washington, DC, Baltimore, and other cities in the next few months. Video Care will be available nationally to companies and all Amazon employees by the summer.

Notably, and buried way down in the glowing articles, Amazon is not engaging with payers on filing reimbursements for patient care. Video Care and Care Medical services will be billed directly to the individual who must then send for reimbursement to their insurance provider. The convenience is compromised by additional work on the patient’s part, something that those of us on the rare PPO plans were accustomed to doing back in the Paper Age but not common now. It also tends to shut out over 65’s on Medicare and those on low-income plans through Medicaid. It is doubtful that Amazon really wants this group anyway. Not exactly inclusive healthcare.

TechCrunch, FierceHealthcare. Jailendra Singh’s Credit Suisse team has a POV here which opines that Amazon continues to have a weak case for disruption in VPC, along with their other healthcare efforts, and an uphill battle against the current telehealth players who have already allied themselves with employers and integrating with payers.

Deal and news roundup: Cigna acquires MDLive, Oscar Health $1bn IPO preview, Teladoc’s smash revenue–and losses, Medisafe’s $30M Series C

February 27, 2021 | by

The big news this week in Telehealth World is Cigna’s agreement to acquire MDLive. MDLive will be part of Evernorth, Cigna’s health services portfolio. From the release and news reports,  Cigna has been a long-time partner of and investor (through Cigna Ventures) in MDLive, which has grown to 60 million members. No purchase price nor management changes have been disclosed. Headquartered in Florida, since 2009 MDLive raised close to $200 million in investment in five rounds, the last $50 million in private equity in September, and was rumored to be prepping an IPO. 

Evernorth was rebranded within Cigna last September for management services which can be sold outside of Cigna, a move that follows both CVS Aetna and UnitedHealthGroup. It contains pharmacy benefit management company Express Scripts, specialty pharmacy Accredo, and medical benefit manager eviCore along with several other smaller related businesses. Last year, it brought in $116.1 billion in revenues for Cigna last year, a 20 percent jump from 2019, according to Cigna’s annual report. MDLive release, Healthcare Dive, FierceHealthcare

‘Neoinsurer’ Oscar Health’s IPO raise, scheduled for next week, is now estimated to be in the eye-blinking $1 bn to $1.2 bn range, with over 30 million shares valued at $32-34 per share. At the beginning of the month, it was estimated to be a modest $100 million [TTA 9 Feb]. Daffodils in February? More in TechCrunch, Reuters

Meanwhile, the Big Kahuna of Telehealth, Teladoc, ended 2020 with a smashing $1.1 bn in revenue and equally smashing losses. Their Q4 revenue was $383 million, up 145 percent from $156 million in Q4 2019. Visits skyrocketed due to the pandemic of course–10.6 million, up 156% from 2019. Paid membership hit 51.8 million, up 41 percent from 2019’s 36.7 million. Both membership and visits are expected to increase in 2021. Livongo, acquired in October, added substantially to 2020’s losses of $485 million, up 389 percent from 2019’s $99 million. Q4 losses were $394 million in the fourth quarter, up from $19 million in 2019. FierceHealthcare, Teladoc release

And happily, but more modestly, Medisafe’s smartphone-based medication management app has raised a $30 million Series C, led by Sanofi Ventures and ALIVE Israel HealthTech Fund. From a basic app when this Editor first profiled the company and met Omri ‘Bob’ Shor over a coffee in 2013, the app now is more a digital drug companion and a platform for patient adherence programs. Kudos! Release

An admittedly skeptical take on the $18.5 billion Teladoc acquisition of Livongo (updated for additional analysis)

August 6, 2020 | by

Gimlet EyeIs it time to call back The Gimlet Eye from her peaceful Remote Pacific Island? Shock acquisitions like Wednesday’s news that Teladoc is buying ‘applied health signals’ platform developer Livongo may compel this Editor to Send a Message by Carrier Seagull. 

Most of the articles (listed at the bottom) list the facts as Teladoc listed them in their announcement. We’ll recap ‘just the facts’ here, like Joe Friday of ‘Dragnet’ fame:  

  • The merged company will be called Teladoc and be headquartered in Purchase, NY. There is no mention of what will happen to operations and staff currently at Livongo’s Mountain View California HQ. 
  • The value of the acquisition is estimated at $18.5 bn, based on the value of Teladoc’s shares on 4 August. As both are public companies (Livongo IPO’d 25 July 2019, barely a year ago), each share of Livongo will be exchanged for 0.5920x shares of Teladoc plus cash consideration of $11.33 for each Livongo share. When completed, existing Teladoc shareholders will own 58 percent of the company and Livongo shareholders 42 percent. 
  • Closing is stated as expected to be in 4th Quarter 2020
  • Expected 2020 pro forma revenue is expected to be approximately $1.3 billion, representing year over year pro forma growth of 85 percent.

The combination of the two is, this Editor admits, a powerhouse and quite advantageous for both. It is also another sign that digital health is both contracting and recombining. Teladoc has over 70 million users in the US alone for telemedicine services and operates in 175 countries. Livongo is much smaller, with 410,000 diabetes users (up over 113 percent) and over 1,300 clients. They reported 2nd Q results on Tuesday with a revenue lift of 119 percent to $91.9 million but with a net loss of $1.6 million. 

What makes Livongo worth $18.5 bn for Teladoc? Livongo has made a major name (to be discarded, apparently) in first, diabetes management, but has broadened it into a category it calls ‘Applied Health Signals’. Most of us would call it chronic condition management using a combination of vital signs monitoring, patient data sets, and information from its health coaches to make recommendations and effect behavior change. Perhaps we should call it their ‘secret sauce’. For Teladoc, Livongo extends their virtual care services and provider network with a data-driven health management company not dependent on virtual visits, and integrates the virtual visit with Livongo’s coaching. It also puts Teladoc miles ahead of competition: soon-to-IPO Amwell, Doctor on Demand ($75 million Series D, partnerships with Walmart and Humana), MDLive, and ‘blank check’ SOC Telehealth. For Livongo’s main competitor in the diabetes area, Omada Health, it puts Omada certainly in a less competitive spot, or makes it attractive as an acquisition target.

It is also a huge bet that given the huge boost given by the COVID pandemic, the trend towards remote, consumer healthcare and management is unstoppable. Their projection is (from the release): expected 2020 pro forma revenue of approximately $1.3 billion, representing year over year pro forma growth of 85 percent; in year 2, revenue synergies of $100 million, reaching $500 million on a run rate basis by 2025. 

Taking a look at this acquisition between the press release and press coverage lines:

  • The market same day responded poorly to this acquisition. Teladoc was off nearly 19 percent, Livongo off 11 percent. (Shares typically recover next day in this pattern.) Livongo had, as mentioned, recently IPO’d and was experiencing excellent growth compared to Teladoc which was boosted by the pandemic lockdown. This Editor also recalls Teladoc’s financial difficulties in late 2018 with the resignation of its COO/CFO on insider trading and #MeToo charges.
  • The projected closing is fast for a merger of this size–five months.
    • Teladoc does business in the Medicare (Federal) and Medicaid (state) segments. It would surprise this Editor if the acquisition does not require review on the Federal (CMS, DOJ) and state health insurance levels, in addition to the SEC.
    • Merging the two organizations operationally and experiencing all those synergies is not done quickly, and cannot officially happen until after the closing. A lot is done formally behind the scenes as permitted, which has the effect of hitting the rest of the company like a hammer.
  • Unusually, the release does not advise on what Livongo senior executives, including Livongo founder Glen Tullman and CEO Zane Burke, will be coming over to Teladoc. The only sharing announced will be on the Board of Directors. It’s quite an exit for the senior Livongo staff.
  • Both have grown through acquisition. These typically present small to large organizational problems in merging the operations of these companies yet another time into yet another structure. There’s also always some level of client discomfiture in these mergers as they are also the last ones to know.
    • Livongo bought myStrength in 2019, RetroFit in 2018, and Diabeto in 2017. 
    • Teladoc just closed on 1 August its acquisition of far smaller, specialized hospital/health system telehealth provider InTouch Health. Originally a bargain (in retrospect) at $600 million in $150M cash and 4.6 million shares of TDOC stock, after 1 July’s closing, due to the rise in Teladoc’s stock, the cost ballooned to well over $1bn.
  • Neither company has ever been profitable. 

Your Editor can speak personally and recently to the wrench in the works that acquisitions/mergers of this size present to both organizations. Livongo is a relatively young and entrepreneurial organization in California with about 700 employees, compared to Teladoc’s approximately 2,000 or more internationally. Their communications and persona stress strong mission-driven qualities. On both sides, but especially on the acquired company side, people have to do their short and long term work amid the uncertainty of what this will mean to them. Senior management is distracted in endless meetings on what the merged organization will look like–departments, where will they be, who stays, who is packaged out, and when. Especially when the press releases make a point of compatible cultures, on the contrary, you may be assured that the cultures are very different. The bottom line: companies do not achieve $60 million in cost synergies without interrupting the careers of more than a few of their employees.

Another delicate area is Livongo’s client base, both individual and enterprise. How they are being communicated with is not necessarily skillful and reassuring. Often this part is delayed because the people who do this in the field aren’t prepared.

One has to admire Teladoc, almost without needing a breath, coming up with $18.5 billion quite that quickly from their financing partners after the InTouch acquisition. The growth claimed for the combined organization is extremely aggressive, on top of already aggressive projections for them separately. It’s 18x 2021 enterprise value to sales (EV/S) targets. The premium paid on the Livongo shares is also stunning: $159 per share including $550 million in convertible debt.  If patients start to return to offices and urgent care, Teladoc may have trouble meeting its aggressive goals factored into both share prices, as Seeking Alpha will explain.

Editor’s final comment: In the early stage of her marketing career, this Editor had a seat on the sidelines to much the same happening in the post-deregulation airline business–debt, buyouts, LBOs, and huge financings. Then there is the morning after when it’s all sorted out.

Wednesday’s coverage: TechCrunch, Investors Business Daily, STATNews, mHealth Intelligence, FierceHealthcare, MotleyFool.com

Joint announcement website    Investor Presentation    Hat tip to an industry observer Reader for assistance with the financial analysis.

For a follow-up analysis (with apologies to Carson McCullers): Reflections in a Gimlet Eye: further skeptical thoughts on the Teladoc acquisition of Livongo

The REAL acute care: hurricanes, health tech, and what happens when electricity goes out

September 19, 2017 | by

This afternoon, as this New York-based Editor is observing the light touch of the far bands of Hurricane José’s pass through the area (wind, spotty rain, some coastal flooding and erosion), yet another Category 5 hurricane (Maria) is on track to attack the already-wrecked-from-Irma Puerto Rico and northern Caribbean, thoughts turn to where healthcare technology can help those who need it most–and where the response could be a lot better. (Add one more–the 7.1 magnitude earthquake south of Mexico City)

Laurie Orlov, a Florida resident, has a typically acerbic take on Florida’s evacuation for Irma and those left behind to deal with no electricity, no assistance. Florida has the highest percentage of over-65 residents. Those who could relocated, but this Editor from a poll of her friends there found that they didn’t quite know where to go safely if not out of state, for this storm was predicted first to devastate the east coast, then it changed course late and barreled up the west (Gulf) coast. Its storm surges unexpected produced record flooding in northeastern Florida, well outside the main track. Older people who stayed in shelters or stayed put in homes, senior apartments, 55+ communities, or long-term care were blacked out for days, in sweltering heat. If their facilities didn’t have backup generators and electrical systems that worked, they were unable to charge their phones, use the elevator, recharge electric wheelchairs, or power up oxygen units. Families couldn’t reach them either. Solutions: restore inexpensive phone landlines (which hardwired, mostly work), backup phone batteries, external power sources like old laptops, and backup generators in senior communities (which would not have prevented prevent bad fuses/wiring from frying the AC, as in the nursing home in Hollywood where eight died).  Aging In Place Tech 

It’s another reason why senior communities and housing are supposed to have disaster preparedness/evacuation plans in place. (If you are a family member, it should be included in your community selection checklist and local records should be checked. This Editor recently wrote an article on this subject (PDF) that mentions disaster and incident planning twice. (Disclaimer: the sponsoring company is a marketing client of this Editor.) In nursing homes, they are mandatory–and often not executable or enforced, as this article from Kaiser Health News points out. 

Another solution good for all: purchase 200-400 watt battery packs that recharge with solar panels, AC, and car batteries (AARP anyone?). Campers and tailgaters use these and they range below $500 with the panels. Concerned with high-power lithium-ion batteries and their tendency to go boom? You’ll have to wait, but the US Army Research Laboratory and University of Maryland have developed a flexible, aqueous lithium-ion battery that reaches the 4.0 volt mark desired for household electronics without the explosive risks associated with standard lithium-ion power–a future and safer alternative. Armed With Science

Telemedicine and telehealth are not being fully utilized to their potential in disaster response and recovery, but the efforts are starting. Medical teams are starting to use telehealth and telemedicine as adjunct care. It has already been deployed successfully in Texas during Harvey. Many evacuees were sent to drier Dallas and the Hutchinson arena, where Dallas-based Children’s Health used telemedicine for emergency off-hour coverage. Doctor on Demand and MDLive gave free direct support to those affected in Texas and Louisiana through 8 September, as well as Teladoc, American Well, and HealthTap for a longer period to members and non-members. Where there are large numbers of evacuees concentrated in an area, telemedicine is now deployed on a limited basis. Doctor on Demand release, STAT News, MedCityNews 

But what about using affordable mobile health for the thousands who long term will be in rented homes, far away from their local practitioners–and the doctors themselves who’ve been displaced? What will Doctor on Demand and their sister telemedicine companies have available for these displaced people? What about Puerto Rico, USVI, and the Caribbean islands, where first you have to rebuild the cellular network so medical units can be more effective, then for the longer term? (Can Microsoft’s ‘white space’ be part of the solution?)  

One telehealth company, DictumHealth, has a special interest and track record in both pediatric telehealth and global remote deployments where the weather is hot, the situation is acute, and medical help is limited. Dictum sent their ruggedized IDM100 tablet units and peripherals to Aster Volunteers who aid the permanently displaced in three Jordanian refugee camps in collaboration with the UNHCR and also for pediatric care at the San Josecito School in Costa Rica. In speaking with both Amber Bogard and Elizabeth Keate of Dictum, they are actively engaging with medical relief agencies in both the US and the Caribbean. More to come on this.

Debate on Care Quality Commission’s position on online prescription services on Radio 4’s TODAY (UK)

March 4, 2017 | by

Friday’s BBC Radio 4 TODAY breakfast show has two segments discussing the Care Quality Commission‘s public warning on online prescription services and potential danger to patients. The first is a short interview of Jane Mordue, Chair of Healthwatch England and independent member of the CQC (at 00:36:33-00:39:00). The second, longer segment at 02:37:00 going to 02:46:30 features our own Editor Charles Lowe, in his position as Managing Director of the Digital Health and Care Alliance (DHACA), debating with Sandra Gidley, Chair of the Royal Pharmaceutical Society (RPS) English Board. The position of the RPS is that a face-to-face appointment is far preferable to an online service, whereas Mr Lowe maintains that delays in seeing one’s GP creates a need for services where a patient can see a doctor online and receive a prescription if necessary. The quick response allays anxiety in the patient and provides care quickly. Both agreed that a tightening of guidelines is needed, especially in the incorrect prescribing of antibiotics, and that there is no communication between patient records. Mr Lowe notes that GPs have always been comfortable with a telephonic consultation but are far less so with telemedicine consults via Skype. Here’s the BBC Radio 4 link available till end of March.

In the US with 24/7/365 telemedicine services such as Teladoc, MDLive and American Well, there is a similar problem with patient records in many cases except for history that the patient gives, but this is an across the board problem as the US does not have a centralized system. The prescribing problem is less about antibiotics, though MRSA/MSSA resistant superbugs are a great concern. According to Jeff Nadler, CTO of Teladoc during his #RISE2017 presentation here in NY attended by this Editor, Teladoc has a 91 to 94 percent resolution rate on patient medical issues. Of that 9 percent unresolved, 4 percent are referred, 2 percent are ‘out of scope’, 1 percent go to ER/ED–and 2 percent of patients are ‘seeking meds only’, generally for painkillers. Teladoc’s model is B2B2C, which is that patients access the service through their health plan, health system, or employer.

The growth of telehealth, and the confusion of terminology (US)

December 24, 2016 | by

Becker’s Health IT and CIO Review has written up a US-centric review of recent advances in telehealth and telemedicine but kicks it off with the confusion level between the two terms. Internationally, and in these pages, they are separate terms; telehealth referring primarily to vital signs remote monitoring, and telemedicine the ‘virtual visit’ between doctor and patient, between two clinical sites, or ‘store and forward’ asynchronous exchange (e.g. teleradiology). Somehow, in US usage, they have been conflated or made interchangeable, with the American Telemedicine Association (ATA) admitting to same, and American Well simply ‘just doing it’ in relabeling what they provide. On top of it, the two are incorporating elements of each into the other. Examples: TytoCare vital signs measurement/recording into American Well’s video visit; Care Innovations Health Harmony also providing video capability.

Of particular interest to our international readers would be the high rate of US growth in telemedicine utilization from 7 to 22 percent (Rock Health survey). Teladoc, the largest and publicly traded provider, passed the milestone of 100,000 monthly visits in November and the ATA estimates 1.25 million from all providers for 2016 (Teladoc release). Other US competitors include the aforementioned American Well, MDLive, and Doctor on Demand, the latter two also selling direct to consumer. They also compete against doctor-on-house call services like Pager and Heal. Reimbursement remains an issue both privately and publicly (Medicare and Medicaid) on a state-by-state level, with telehealth experiencing significant difficulties, as well as internet access, speed, and usage by older adults.

The NHS, tech, and the next 10 years – soapbox, event & call for posters

February 22, 2015 | by

As a distraction from the things that, before the advent of handheld technology, little boys used to do in the school playground when this editor was young, once in a while we would engage in the pointless debate of what would happen if an irresistible force met an immovable object.

Those debates came to mind when Graham De’Ath kindly drew this editor’s attention to the recently published Labour Ten Year Plan for Health & Care. Now Telehealth & TelecareAware knows better than to indulge in politics, however the document was notable in that it did not make any significant reference either to the demographic reality of the next ten years, or the likely role of ‘technology’ in assisting with the resultant increase in care required (the word is mentioned just once, in the commitment to: “Set up a wide–ranging review of NICE which will look at reforming the  NICE technology  appraisal process…” [actually already underway by the NIB]).  The Labour Party is far from being alone in this – readers with long memories will recall our amusement as the RCGP’s ten year forecast of the changes in GP practice where the biggest role technology was expected to play in 2022 was in remote delivery of test results.

The reality, TTA believes, will be very different: (more…)

A boffo week for telemedicine. Will 2015 be online visits’ Big Year?

December 18, 2014 | by

(Boffo: extremely good or successful, sensational–Webster)

Adding to Monday’s news of ATA’s telemedicine accreditation program was American Well‘s near-simultaneous announcement of an $81 million Series C funding.  This brings total funding for the eight year-old Boston-based company to over $128 million, though it is not yet profitable. According to Modern Healthcare, “The capital injection will be used to serve a number of big projects the firm has underway, company co-CEO Dr. Ido Schoenberg said in an interview. Among those are campaigning to ease regulatory constraints, scaling its provider networks and customer outreach, working with insurers to secure more favorable reimbursement and working on its technology, he said.” The institutional, private equity, and corporate investors alluded to in the company release were not disclosed. Its mobile app, Amwell, claims over 1 million downloads with a year-to-year 1,000 percent increase. Major partners include payers Anthem Health, EmblemHealth, the Blue Cross Blue Shields of Massachusetts and Louisiana, Optum Health as well as corporate clients. American Well press release, BostonInno, SEC filing. (Note to American Well: you’re telemedicine, not telehealth)

If this round of funding represents a substantial bet on American Well’s future, another is the new relationship between Walgreens‘ and rival MDLIVE. (more…)

Verizon’s ‘white label’ telemedicine service debuts

June 30, 2014 | by | 2 Comments

Verizon is evidently sticking with its strategy of enterprise marketing when it comes to digital health. The Verizon Virtual Visits service released last week enables a video chat with a clinician via smartphone app (3G/4G OK as well as Wi-Fi; the full mobile enablement Verizon states as a key differentiator versus competitors such as American Well, MDLive and Teladoc) or alternatively, web portal. Prior to the average 30 minute chat, the service verifies eligibility and co-pay information, presents patients’ self-reported histories, symptoms, medication allergies and other information, then collects the co-pay; at the close if needed, an e-prescription via SureScripts is sent to the patient’s pharmacies. Verizon presents this as as a ‘white label’ service for groups such as health systems, insurers and health plans who will determine their unique co-pay and clinician mix. Clinicians can be contracted through Verizon’s provider network or, in a health system, their own or an in-house/contract mix. Neither clients nor third-party medical provider(s) have been announced yet, but VentureBeat states that the clients will be publicized in the next few months, which is deflating. Information Week, The IHCC. Verizon release.