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2019年美国医疗行业十大预言

Bob Kocher, Bryan Roberts 2018年12月19日

虽然眼下经济和政治的不确定性与日俱增,但我们依然不会放弃一年一度的预测活动。

又到了预测明年行业形式的时候了。虽然眼下经济和政治的不确定性与日俱增,但我们依然不会放弃一年一度的预测活动。我们已经对2019年的医疗行业做出了十大预测,而且也做好了被现实啪啪打脸的准备。不过首先,我们还是应该回顾一下去年我们预测的那些东西都实现了没有。

去年我们的十大预测已经实现了5个,还有两个貌似有望在2019年实现。首先,我们正确地预测了Outcome Health公司的融资骗局;其次,我们正确预言了在药品市场上,亚马逊将不会通过B2C模式颠覆PBM行业,而是会选择B2B模式,结果亚马逊果然与摩根大通和伯克希尔-哈撒韦公司联合成立了一家合资公司,并任命知名外科医生、作家阿图·葛文德担任这家公司的CEO。

去年,我们还正确预测了一些创业公司会成功进行资本退出,Flatiron、Landmark和Pillpak等公司的例子可以佐证。此外,随着美国医疗保险和医疗补助服务中心(CMS)出台了更加利好的规则,美国的联邦医保优惠计划(Medicare Advantage)也获得了广泛欢迎,近50%的联邦医保受益人都选了优惠计划。最后,我们还预测了各大医保平台会积极收购那些利润更高但监管更少的公司,2018年,安泰并购CVS、信诺并购ESI,以及不久后哈门那(Humana)可能与沃尔格林公司的合并,都证明了我们的预测是正确的。

当然,去年我们也有一些预测落了空。一是关于医院招聘放缓。2018年美国各大医院新增工作岗位约25万个,同时医院行业通过提高价格抵消了劳动成本的上涨。二是对人工智能的影响过于乐观。虽然人工智能具有很大的潜力,甚至说不定有一天会横扫一切,但目前我们还没看到任何有吸引力的商业应用,除了每个创新产品在产品描述中都鼓吹自己用上了人工智能技术。三是错误地预言了大型制药公司会变得越来越大(不过明年就说不定了)。四是关于基因编辑技术(CRISPR)的商业化,不过我们对此还是充满希望的,今年11月,中国成功对一名婴儿进行了基因编辑的消息就充分说明了它的前景。五是关于《平价医保法案》的修改。考虑到民主党正在渐渐夺取国会控制权,奥巴马医改被废除的可能性几乎不复存在,而该法案的修订很可能会在明年实现。

现在再来说说我们对2019年的十大预测。

1. 医保机构加速整合

美国医疗保险行业的竞争已趋于白热化,首先是强势的联合健保公司(United Healthcare),它以低管理成本和高利润著称;其次是有了PBM业务加持后利润更高的安泰和信诺等保险公司。在这些巨无霸的挤压下,业内的很多小玩家很难阻止全国居民账户的流失,也无力在Medicare Advantage和Medicaid这种公立医保市场上与专业玩家竞争。为扩大自身体量,家底还算雄厚的医保公司便会谋求并购。另外,美国已有数个州投票同意扩大Medicaid医保计划的参保范围,加之Medicare Advantage计划的火热,各大医保公司也会考虑通过并购来进入这些快速增长且利润越来越高的细分市场。

2. 医生主导的责任医疗组织将快速增长

这里首先要解释一下什么叫责任医疗组织(ACO)。责任医疗组织是奥巴马医改的核心元素之一,是指不同的医疗机构(包括不同层级的医生)自愿组织起来成为一个协同合作的整体,为患者提供协同的医疗服务,以达到提高医疗质量、控制医疗成本的目的。责任医疗组织首先在美国联邦医保Medicare中试行。Medicare的2.0版医疗责任组织规则强烈倾向由医生主导的ACO,而不是由医院主导的ACO。这样一来,医生很快就会意识到,他们可以独立于医院赚取更高的工资。另外,有了资金、管理良好的医疗协议和低成本的分析工具,医生们也更容易享受到规模效益的好处,同时保持自身的独立性。我们预计,一旦初级保健医师们意识到,没有了大机构的枷锁,他们可以做得更好,那么一些大型医疗平台雇佣的医师团体便会破裂。另外我们认为,由医生主导的ACO和由医院主导的ACO在绩效上的差距也会愈发明显。

3. 医生的不满有所降低

电子病历系统糟糕的用户体验和繁琐的操作负担,使它早已成为医生们的吐槽对象,我们相信,医疗系统已经听到了医生们的呼声。如果医生们以辞职或退休相要挟,任何一家医院都是吃不消的。因此,他们肯定要做出一些投资来提高医生们的士气。我们认为,下一代的电子病历系统肯定会把提升医生的用户体验当成优先要务,在这方面,语音界面和机器学习等创新技术是大有可为的。谷歌以及很多创业公司都在大力开发语音识别技术,以减轻医生们打字、点击和搜索的负担。有意思的是,在医疗行业应用语音识别系统,其实要比在消费电子产品上应用更容易,因为医疗行业的术语库更小,上下文和语境也更容易预测。另外,亚马逊公司最新发布的用于挖掘临床数据的工具也有助于提高这些系统的效率。

4. 平台互通终成现实

在宣布获得成功五年后,各方力量终于将汇聚在一起,在跨平台操作方面取得实际突破。目前已有多家做电子病历系统的公司正在联合商定数据交换标准(HL7 FHIR)。美国医疗保险和医疗补助服务中心也表示,愿意动用行政权力推动所谓的“患者比文书优先”倡议。美国各州也在积极推进电子病历系统的互联互通,以更好地应对阿片类药物滥用和(貌似越来越频繁的)自然灾害。而在地方层面,由于各个医疗系统中的医生越来越积极管理风险,不同医疗系统之间的“囚徒博弈”也就没意义了。

5. 数字健康行业迎来整合

对于产品与市场尚未完成匹配的公司,2019年留给它们的增长空间将会更少。而这将带来一系列的平台整合。过去五年,医疗行业成立了很多创业公司,而现在我们差不多已经能分辨谁是成功的公司,谁是“还算凑合”的公司了。同时,就业市场上的很多大雇主已经度过了“早期采用者”的阶段,它们更喜欢的合作伙伴,是那些能够把市面上流行的各种单点解决方案纳入标准化设计的医保方案伙伴。这意味着很多处于早期阶段的创业公司都要进行艰难转型,因为对于付费方来说,它们的销售周期要长于那些大雇主,证明有效性的标准也要高于它们。

6. 保险技术的发展不会一帆风顺

我们认为,我们已经接近保险技术的炒作周期的顶峰了,2019年将是很多公司踢到铁板的一年。其中,利用计算机编码骗保是一个值得关注的风险领域,事实已经证明,它是在Medicare Advantage项目中骗取保金最快的一种方式。由于利用计算机编码骗保的行为十分猖獗,“猫捉老鼠”的游戏时时都在上演,支付方总是在寻找还没被编码的疾病,美国医疗保险和医疗补助服务中心则对其进行审计,而且CMS几乎总能发现错误,并处以罚款。这种骗保方式之猖獗,以至于CMS每年都要进行“编码强度专项调整 ”,来砍掉Medicare Advantage的一部分报销金额。有些作为支付方的创业公司虽然在融资上获得了巨大的成功,但他们很快会发现,实际业务运营之复杂,以及规模化之艰难,要比他们在融资PPT中畅想的艰难得多。

7. 透析中心将被颠覆

在一般人的印象里,一名病人如果要做透析,那么他通常每周有三天要去透析中心,每次要在一张椅子里躺三个小时。然而正如快递行业的崛起葬送了西尔斯百货,透析中心被新技术取代也只是迟早的事。对于病人来说,每天在家中接受透析显然更有利于康复,成本也更会便宜得多。瑞典已经推广自助式透析很多年了,实践证明,自助式透析比透析中心更加安全和可靠。随着美国医保制度向风险型支付转型,注重管理风险的医生们显然也会更青睐效果更好、更便宜的医疗方法。

8. 远程医学迎来大发展

我们认为,2019年,各个医保支付方将终于认识到,应该充分鼓励和利用远程医疗技术,而不是把它埋没在无人问津的网站和难用的手机应用里。医疗健康应用Oscar公司表示,目前,该公司有半数以上会员在使用远程医疗服务,并依赖Oscar应用指导他们就医。凯撒医疗(Kaiser)半数以上的就诊即将通过虚拟技术完成。医保公司多年积累的数据早已表明,远程医疗要比去实体医院就诊更省钱,而且也能让患者感到更加轻松。目前,就连Medicare也增加了远程医疗费用的报销编码。因此,我们预计,2019年远程医疗的使用量至少将翻一番,同时它的使用将不再局限于感冒或流感等小病,而是扩展到临床疾病管理等领域。

9. 药品市场迎来颠覆

特朗普关于降低药价的豪言壮语被啪啪打脸,制药公司最近甚至涨价涨得更猛了。目前,美国有关部门正在对药品流通环节的涨价进行审查。在美国,平均来说,药品离开制药公司后,在经销环节会涨价40%左右。由于经销环节不透明,患者为药品支付了不合理的高价,而大量利润都被中间商赚走了。我们预计,改革药品供应生态系统的努力或将在2019年获得实际进展。

10. 新的DNA测序平台或将涌现

DNA测序是一个非常庞大且不断增长的商机。过去两年间,以单细胞基因组为代表的一些新应用有力推动了这个领域的增长。我们认为,新的测序平台(或者是它们的影子)将在2019年悄然出现,这将导致该技术的定价下降(但同时依然能提供健康的利润)。新平台必将带来新应用和更多的业务量,同时也会侵蚀Illumina的市场主导地位。

我们很期待新的一年将发生什么,也很期待明年年底向读者报告我们的预测是否灵验。(财富中文网)

本文作者鲍勃·科克和布莱恩·罗伯茨都是医疗行业的投资人,也是风投机构Venrock的合伙人。

译者:朴成奎

It is soothsaying time again. Our annual plunge into the choppy waters of predicting the future, amid increasing economic and political uncertainty. Ever gluttons for punishment, we are ready to make 10 new predictions for 2019. But first, we should look back on how we did predicting what happened in 2018…

In 2018, five of our 10 predictions came true and two more seem on-track to become true in 2019. We correctly predicted another Theranos with the implosion of Outcome Health. We were correct that Amazon would not disrupt PBMs, rather they launched their Atul Gawande led collaboration with JPMorgan and Berkshire Hathaway.

Our successful exits prediction was validated by Flatiron, Landmark, and Pillpak. Also, Medicare Advantage gained in popularity with Centers for Medicare and Medicaid Services (CMS) issuing favorable rules and nearly 50% of new Medicare beneficiaries choosing a Medicare Advantage plan. Finally, we were correct that payers would aggressively acquire higher margin, less regulated businesses with Aetna merging with CVS, Cigna merging with ESI, and perhaps, soon, Humana merging with Walgreens.

We missed on our predictions that hospitals would slow hiring. In 2018, hospitals added about 250,000 jobs and were able to keep raising prices to offset rising labor costs. We were overly optimistic that AI would make a big impact. While AI has lots of potential and may eventually warrant “Intel Inside” status, we are yet to see meaningful commercial traction, outside of it being included in every innovative product description. We were also wrong about big pharma getting bigger (but next year…). We remain hopeful that our predictions about CRISPR commoditizing, as demonstrated by China’s gene editing of a baby in November, and the Affordable Care Act (ACA) being repaired, since we will soon have a Democratically controlled Congress that will no longer contemplate repeal, will both come true in 2019.

Now, onward with our 10 predictions for 2019.

1. More payer consolidation

There is stiff competition from not only stalwart United Healthcare, who boasts much lower administrative costs and higher margins, but also the rejuvenated higher margin PBM-enabled versions of Aetna and Cigna. As a result, many smaller payers will struggle to retain national accounts as well as compete against pure plays in the Medicare Advantage and Medicaid markets making them use their strong balance sheets to become acquirers. We also think the growth of Medicaid, with several states electing to expand, and Medicare Advantage will also trigger M&A in order to enter these growing and more profitable market segments.

2. Physician-led Accountable Care Organizations will grow rapidly

Medicare’s Accountable Care Organization (ACO) 2.0 regulations strongly favor doctor-led ACOs over hospital-led ACOs. Doctors will quickly realize that they can earn much higher wages independent from hospitals. Moreover, access to capital, managed care contracts, and low-cost analytical tools will make it easier to doctors to gain the benefits of scale while retaining independence. We anticipate the fracturing of some large health system’s employed groups, when the primary care doctors realize that they can do better if they break free. We also expect the performance gap between doctor-led ACOs versus hospital-led ACOs to become even more dramatic.

3. Doctors get less dissatisfied

We believe health systems have heard the cries from doctors about terrible user experience and administrative burden of electronic health records. Since health systems cannot afford to replace doctors who make credible threats of retiring or resigning, they will make investments to improve morale. We are bullish that electronic health records will move doctor user experience up the product roadmap priority list and that innovations like voice interfaces and machine learning will help a great deal. Teams at Google and many start-ups are making large strides in building voice technology to reduce typing, electronic medical record clicking, and searching burdens for doctors. Interestingly, it may be easier to use voice for healthcare than for consumer applications since the vocabulary is smaller and context is far more predictable. Amazon’s newly released tools to mine clinical data will help make these systems work better too.

4. Interoperability becomes interoperable

Five years after being declared successful, forces will finally come together to lead breakthroughs on cross health system and platform interoperability. Electronic health record firms are coalescing around standards for exchanging data (HL7 FHIR) and CMS is expressing willingness to use regulatory power to drive adoption with the “patients over paperwork” initiative. States are pushing for connectivity as one tactic to address the opioid epidemic and to improve resiliency from (seemingly more frequent) natural disasters, necessitating the need to access data. At the local level, the prisoner’s dilemma of health systems leveraging market power to impose three-week turnarounds and PDFs no longer makes sense when physicians on both sides of the transaction are increasingly trying to manage risk.

5. Consolidation in digital health

Growth equity will get tighter in 2019 for small companies that have not achieved product market fit. This will lead to a flurry of consolidation into platforms. Many new companies have been started over the last five years, and it is time to sort the true successes from the “just OKs”. Compounding this trend is large employers going from being the early adopters, to more willing to rely on their health plan partners who have responded to the proliferation of point solutions by incorporating many of them into their standard benefit designs. This will be a rough transition for many early stage companies since payers have even longer sales cycles and higher standards for proving effectiveness than large employers.

6. InsureTech takes a lump or two

We think that we are near peak hype cycle for insurance technology. 2019 is likely to be a year of toe stubbing for many. Upcoding is one area of risk since it has proven to be the fastest way to make money in Medicare Advantage. Coding has led to a cat-and-mouse game of payers mining charts for uncoded diseases and CMS auditing them and nearly always finding errors and levying fines. Upcoding is so pervasive that CMS actually cuts Medicare Advantage reimbursement annually using a “coding intensity adjustment.” Start-up payers that have enjoyed great fundraising success are likely to find the very complex operations and scaling required for their actual businesses much harder than investor PowerPoint pitch creation.

7. Dialysis disrupted

It is Norman Rockwell-esque that patients drive to brick-and-mortar dialysis centers three days a week and lay in a chair for three hours at a time. Just as Sears has been replaced by home delivery, dialysis centers will be supplanted too. It is far better for patients to have their blood cleansed daily and it is cheaper to have patients do it themselves daily at home. Sweden has embraced patient self-serve dialysis for years and it has proven to be both safer and more reliable than dialysis centers. As we move to risk-based payments, better and cheaper approaches to care will be embraced by doctors managing risk.

8. Telemedicine takes off

We think that 2019 will be the year that payers finally realize that it is far better to fully embrace and encourage telemedicine usage as opposed to burying it in their unengaging member portals and clunky mobile apps. Oscar compellingly reports that more than half of their members use telemedicine and rely on Oscar to route them to care, increasingly telemedicine. Kaiser will do more than half of all visits virtually. Health plans now have enough years of claims data to discover that telemedicine saves a bunch of money and makes members far happier than going to a doctor’s office. Even Medicare is adding codes to reimburse telemedicine. As a result, we expect telemedicine usage to more than double in 2019, while making substantive inroads beyond flu & cold into areas such as chronic disease management.

9. PBM disruption talk becomes reality

While Trump’s proclamations about lower drug prices have backfired, with drug companies raising prices even more aggressively, a byproduct of Executive branch rhetoric has been scrutiny over drugs getting marked up a bunch, after they leave the drug maker. Drugs are marked-up, on average, 40% by the distribution system. The current opacity about how money flows, leads to patients paying more for drugs and excessively large margins being captured by intermediaries. We expect next generation pharmacy supply ecosystem efforts to gain real traction in 2019.

10. Real progress with new DNA sequencing platforms

DNA sequencing is a very large, and growing, opportunity. New applications, such as single cell genomics, have driven growth over the last 24 months. We believe that new sequencing platforms (or at least the specter of them) will enter the fray in 2019, leading to decreasing per Gb pricing (while still providing healthy margins) which will both open up additional applications and volume as well as erode Illumina’s market dominance.

We look forward to seeing what happens and reporting back to you next year.

Bob Kocher and Bryan Roberts are both health care investors and partners at the venture capital firm Venrock.

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