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2020年医疗业10大变化

Bob Kocher, Bryan Roberts 2019年12月30日

展望2020年,医疗行业的专业人士做出了这10项预测。

2019年即将结束,应该做个展望并告诉大家我们觉得2020年的医疗保健生态系统情况如何。但首先让我们回头看看,评估一下我们的2019年预测表现。

总的来说,我们对了大概一半(10项预测中有5、6项是正确的,具体要看大家是否把北卡罗莱纳州的医保组织Blue Cross Blue Shield试图与Cambia整合计算在内)。我们准确预测的包括Accountable Care Organizations的增长,数字医疗领域整合增多,透析疗法被颠覆,远程医疗限制增长、以及DNA排序平台的突破。

看错的有电子健康记录(EHRs),在用户界面的明显改善和政府在互操作性上的突破两个方面都是如此。

虽然这两个问题得到了广泛讨论,但我们觉得2019年没有取得多大进展。我们同样看错的还有对药品福利管理的颠覆,虽然说了很多,但美国医疗保险和医疗补助服务中心撤回取消药物退费的建议后就没了动静。

我们确实认为互操作性和药品福利管理会出现变化,但和我们的生态系统中的大多数变化一样,它们需要较长的时间才能够取得成果。其他预测失误还包括保险科技被列为初创公司,或者至少初创公司的估值仍然会有非常好的表现。

展望2020年,我们做了下列10项预测:

1. 实际情况证明“不计代价的增长”存在极限

WeWork的IPO遭遇滑铁卢后,软银随即投入89亿美元予以援助(太大所以不能失败?)。此前许多估值飙升的非上市公司在2019年登陆股市后也都跌破了发行价。成长型投资者需要提高对最终能否财务独立,甚至是短期内能否财务独立的辨别能力。

要知道,由于其他种类的资产回报率低,仍然有大量可用资金。但这些数额巨大而且正在寻找目标的资金将重点关注增长快、毛利高,而且必要时有可能产生正现金流的公司。这或许会推动更多成熟公司退出私募市场(通过并购或者IPO),因为这个市场将不再那么宽容。

2. 癌症免疫疗法获得认可,行业很拥挤

在经过生物科技投资者这些年的关注和投资后,等待下一个免疫疗法重磅产品的市场已经拿不出与众不同的点子,而且目前的这批免疫抗癌项目也开始放缓脚步,因此其革命性还不足以支撑它们昂贵的生产。这种情况下,投资者将把资金转移到中枢神经系统和自体免疫失调等其他领域。

3. 人人都喜欢联邦医保优惠计划

CMS将继续让联邦医保优惠计划变成对新参保人来说较好的医保方案。我们认为CMS将继续提高该计划的报销比例,从而让相应的医保服务降低所分摊的成本,同时在药品、牙科和眼科方面提供更多福利。

联邦医保优惠计划仍然会和传统医保存在差异——它给患者的体验更好,比如远程医疗、基于文本的医疗互动以及改善影响健康的社会因素。

联邦医保优惠计划参保人数随后的增长将促进更多投资进入以该计划为导向的初创公司中,而且和大多数净利润都来自该计划(所以确实关心该计划)的大型老牌企业相比,其中大多数初创公司的执行都会很糟糕。

4. 数据隐私得到认真对待

长期以来,医疗记录一直被医院视为待开采的金矿。过去几年,一批初创企业和谷歌都和医疗机构接触过,提出将其数据进行匿名处理,并在整理之后卖给制药公司。

问题在于数据匿名化的难度非常大,而且大多数情况下这样做都没有取得患者同意,所以涉嫌侵犯患者隐私的反作用已经出现。相关争论会因为人工智能迫切需要大量数据而变得更为激烈,而且我们认为会曝光许多患者身份被重新识别出来的事件。

5. 生物医药慈善活动增加

也许是受到了沃伦和桑德斯的竞选活动以及长达10年的牛市影响,或者更有可能是35岁时膝盖就出了问题,更多亿万富翁将追随扎克伯格夫妇以及肖恩·帕克的脚步来设立生物医药研究机构,特别是最近这一代科技界人士。用新工具和计算力来接触生物学并治愈疾病的潜力会让成功的创业者着迷。

6. AI的用处得到证实

经过了几年的纯炒作后,人工智能除了可以识图外,还将开始在临床上发挥作用。

虽然我们对人工智能在非临床领域的应用同样感到欣喜,比如更有效地计费、编码、提供凭证和求医问药,但我们认为在支持生物医药研究和临床诊断方面,人工智能的参与将变得更有效、更实用。

我们还认为人工智能永不满足的数据胃口对大多数临床应用来说都将是限制因素,原因是训练数据受到了医疗失误和倾向的不利影响。

7. 更多丑闻曝光

就在投资者倾向于更严格的审查程序之际,为了更快地成长而选择铤而走险的初创公司将再次让投资者受到困扰——面对伪造的用户增长、虚假的单位经济以及监管机构的漠视,有些人会紧张不安,有些人则会幸灾乐祸。

8. 大型科技公司无重大颠覆行为

虽然一直有令人瞠目的文章谈到亚马逊、Haven、谷歌、Facebook和苹果公司正在颠覆医疗保健行业,但我们认为2020年外界对它们更多的关注将转向其他方面。

明年大型科技公司将把颠覆医疗保健的工作置于次要位置,转而去应对公众信任和隐私危机,同时迎接消费科技的其他机遇。虽有众多关于打造消费健康产品和颠覆药品福利管理和付费机构的消息,但我们认为最好的情况只是继续进行的小规模试验和对小公司的收购。

9. 大选年政策瘫痪

我们认为在意外计费、就药价取得实质性进展以及改进平价医保法案等问题上,国会的合作局面不会持续太久,尽管这会让人感到失望。

在大选和弹劾遮掩了其他一切的情况下,任何一方都不想让对方宣称取得了任何胜利。对于已经制定的政策,行动将出现在联邦政府层面(我们觉得这挺有意思)。

10. 基层医师脱离医院

2020年基层医师将觉醒,他们将意识到脱离医疗系统去工作可以赚得更多,而且更开心。

因此,付费机构将设法引诱基层医师独立,它们会为后者提供更多的报销和启动资金,甚至为这些医师提供办公场地和技术补贴。

我们还认为,20世纪90年代的情况将再次出现,即利润率较低的医疗系统会厌倦所聘医生带来亏损的局面,并提出以低价将相应业务退还给这些医生。

希望本文可以让大家了解我们的想法并激起大家的好奇心。我们期待看到明年的实际情况。在此之前,祝大家节日以及2020年快乐。(财富中文网)

本文作者鲍勃·科克和布莱恩·罗伯茨都是医疗保健行业投资人,两人均在风投机构Venrock担任合伙人。

译者:Charlie

审校:夏林

As we near the end of 2019, it is time for us to look ahead and share what we believe 2020 has in store for the health care ecosystem. But first, let’s look back and assess how we did with our 2019 predictions.

Overall, we got about half correct (five or six out of 10 depending on whether you count Blue Cross Blue Shield of North Carolina’s attempt to consolidate with Cambia). What we got right was growth of Accountable Care Organizations, more digital health consolidation, dialysis disrupted, dramatic growth in telemedicine, and breakthroughs in DNA sequencing platforms.

We were wrong about electronic health records (EHRs)—both about any meaningful improvement in the UI and that the government would break the ice on interoperability.

While there has been lots of talk about both of these topics, we do not think much progress was made in 2019. We were equally wrong about pharmacy benefit manager (PBM) disruption, with lots of talk but no action after the Centers for Medicare and Medicaid Services (CMS) withdrew their proposal to eliminate drug rebates.

We do think interoperability and PBM changes will happen but, like most changes in our ecosystem, they will take longer to come to fruition. We were also wrong about insuretech getting tarnished as start-ups, or at least start-up valuations, continue to do very well.

As we look ahead to 2020, here are 10 predictions that are shaping our thinking:

1. Turns Out “Growth at All Costs” Has a Limit

After the debacle of WeWork’s unsuccessful IPO, SoftBank’s subsequent $8.9 billion bailout (Too Big to Fail?) and many formerly high-flying private companies trading below their 2019 IPO prices, growth investors are going to become more discerning regarding eventual, or even near term, financial independence.

To be clear, there will still be way too much money available given the low rates of return in other asset classes, but that sea of cash seeking a home will focus on high growth, high gross margin businesses that could be cash flow positive if necessary. This could push more mature companies to exit (whether M&A or IPO) since the private markets will no longer be so permissive.

2. Cancer Immunotherapy Is Recognized—As Crowded

After multiple years of focus and investment from biotech investors, the market for the next blockbuster immunotherapy runs dry of differentiated ideas and the current batch of immune oncology programs starts to look incremental, therefore not revolutionary enough to command the high prices required for their production. As a result, investors’ cash rotates toward other areas like CNS and autoimmune disorders.

3. Medicare Advantage is Everyone’s Favorite. Uh Oh…

CMS will continue to make Medicare Advantage (MA) a better deal for new Medicare beneficiaries. We think CMS will continue raising rates for MA, thereby allowing plans to lower cost sharing as well as offer more generous drug, dental, and vision benefits.

MA plans will continue to differentiate from traditional Medicare—offering patients better experiences like telemedicine, text-based care interactions, and help with social determinants of health.

The ensuing growth in MA membership will drive even more investment in MA oriented start-ups, most of which will succumb to poor execution compared to the large incumbents that receive most of their net Income from MA (so they really care).

4. Data Privacy Taken Seriously

Hospitals have long viewed their medical records as gold waiting to be mined. For the last few years, a slew of start-ups and Google have come to health systems offering to anonymize, organize, and sell their data to pharma.

The hitch is, it’s very hard to anonymize data and most of the time this was done without patient consent, so a backlash around violating patient privacy is coming. These debates will be intensified by the hunger of AI for large datasets and, we think, the discovery of many examples of patients being re-identified.

5. More Biomedical Philanthropy

Perhaps a by-product of the Warren and Sanders campaigns, the decade long bull market or more likely turning 35 years old with bad knees… more billionaires, especially from the recent generation of tech companies, will follow the lead of Chan-Zuckerberg and Sean Parker and set up biomedical research institutes. Successful entrepreneurs will be entranced by the potential of using new tools and computing power to tackle biology and cure disease.

6. AI Begins to Prove Useful

After several years of pure hype, beyond being able to recognize images, AI will begin to become useful clinically.

While we remain equally excited about non-clinical use cases like more efficient billing, coding, credentialing, and provider directories, we think that AI use cases to support biomedical research and clinical decision support will begin to become useful and practical.

We also think that AI’s insatiable appetite for data will be rate limiting for most clinical use cases since the training data is contaminated with medical errors and bias.

7. More Skeletons Come Out, a la uBiome

As investors pivot towards more rigorous diligence processes, we think it is inevitable that cut corners, made by startups to grow faster, will come back to haunt them—tales of artificial user growth, phantom unit economics, and regulatory disregard will lead to hand wringing and schadenfreude.

8. No Disruption Bogeyman from Big Tech

Despite a steady stream of breathless articles about Amazon and Haven, Google, Facebook, and Apple disrupting health care, we think that they will shift much of that attention to other things in 2020.

Next year big tech is going to deprioritize health care disruption to deal with crises in public trust, privacy, and other consumer technology opportunities. For all the talk about building consumer health products and disrupting PBMs and payers, we think the best we can hope for are continued small experiments and acquihire acquisitions.

9. Election Year Policy Paralysis

While disappointing, we do not believe Congress is going to be able to cooperate long enough to solve problems like surprise billing, make any meaningful progress on drug prices, or to improve the Affordable Care Act.

With a presidential election and impeachment overshadowing everything, neither side will want the other to declare any sort of victory. To the extent policy is developed, the action will happen at the State level (which we think is interesting).

10. Primary Care Physicians (PCPs) Break Free from Hospitals

2020 will be the year the PCPs wake up and realize that they can earn more and be happier working independently of health systems.

As a result, payers will try to tempt PCPs to break free by offering them higher reimbursement, start-up capital, and even subsidized office space and technology.

We also think that we will begin to see a reprise of the 1990s with lower margin health systems tiring of losing money on their employed doctors and offer to sell them back their practices for peanuts.

We hope that this gave you a glimpse into our minds and piqued your curiosity. We look forward to seeing what happens. Until then, wishing you all a happy holiday season and 2020.

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

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