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2020年醫療業10大變化

Bob Kocher, Bryan Roberts 2019年12月30日

展望2020年,醫療行業的專業人士做出了這10項預測。

2019年即將結束,應該做個展望并告訴大家我們覺得2020年的醫療保健生態系統情況如何。但首先讓我們回頭看看,評估一下我們的2019年預測表現。

總的來說,我們對了大概一半(10項預測中有5、6項是正確的,具體要看大家是否把北卡羅萊納州的醫保組織Blue Cross Blue Shield試圖與Cambia整合計算在內)。我們準確預測的包括Accountable Care Organizations的增長,數字醫療領域整合增多,透析療法被顛覆,遠程醫療限制增長、以及DNA排序平臺的突破。

看錯的有電子健康記錄(EHRs),在用戶界面的明顯改善和政府在互操作性上的突破兩個方面都是如此。

雖然這兩個問題得到了廣泛討論,但我們覺得2019年沒有取得多大進展。我們同樣看錯的還有對藥品福利管理的顛覆,雖然說了很多,但美國醫療保險和醫療補助服務中心撤回取消藥物退費的建議后就沒了動靜。

我們確實認為互操作性和藥品福利管理會出現變化,但和我們的生態系統中的大多數變化一樣,它們需要較長的時間才能夠取得成果。其他預測失誤還包括保險科技被列為初創公司,或者至少初創公司的估值仍然會有非常好的表現。

展望2020年,我們做了下列10項預測:

1. 實際情況證明“不計代價的增長”存在極限

WeWork的IPO遭遇滑鐵盧后,軟銀隨即投入89億美元予以援助(太大所以不能失???)。此前許多估值飆升的非上市公司在2019年登陸股市后也都跌破了發行價。成長型投資者需要提高對最終能否財務獨立,甚至是短期內能否財務獨立的辨別能力。

要知道,由于其他種類的資產回報率低,仍然有大量可用資金。但這些數額巨大而且正在尋找目標的資金將重點關注增長快、毛利高,而且必要時有可能產生正現金流的公司。這或許會推動更多成熟公司退出私募市場(通過并購或者IPO),因為這個市場將不再那么寬容。

2. 癌癥免疫療法獲得認可,行業很擁擠

在經過生物科技投資者這些年的關注和投資后,等待下一個免疫療法重磅產品的市場已經拿不出與眾不同的點子,而且目前的這批免疫抗癌項目也開始放緩腳步,因此其革命性還不足以支撐它們昂貴的生產。這種情況下,投資者將把資金轉移到中樞神經系統和自體免疫失調等其他領域。

3. 人人都喜歡聯邦醫保優惠計劃

CMS將繼續讓聯邦醫保優惠計劃變成對新參保人來說較好的醫保方案。我們認為CMS將繼續提高該計劃的報銷比例,從而讓相應的醫保服務降低所分攤的成本,同時在藥品、牙科和眼科方面提供更多福利。

聯邦醫保優惠計劃仍然會和傳統醫保存在差異——它給患者的體驗更好,比如遠程醫療、基于文本的醫療互動以及改善影響健康的社會因素。

聯邦醫保優惠計劃參保人數隨后的增長將促進更多投資進入以該計劃為導向的初創公司中,而且和大多數凈利潤都來自該計劃(所以確實關心該計劃)的大型老牌企業相比,其中大多數初創公司的執行都會很糟糕。

4. 數據隱私得到認真對待

長期以來,醫療記錄一直被醫院視為待開采的金礦。過去幾年,一批初創企業和谷歌都和醫療機構接觸過,提出將其數據進行匿名處理,并在整理之后賣給制藥公司。

問題在于數據匿名化的難度非常大,而且大多數情況下這樣做都沒有取得患者同意,所以涉嫌侵犯患者隱私的反作用已經出現。相關爭論會因為人工智能迫切需要大量數據而變得更為激烈,而且我們認為會曝光許多患者身份被重新識別出來的事件。

5. 生物醫藥慈善活動增加

也許是受到了沃倫和桑德斯的競選活動以及長達10年的牛市影響,或者更有可能是35歲時膝蓋就出了問題,更多億萬富翁將追隨扎克伯格夫婦以及肖恩·帕克的腳步來設立生物醫藥研究機構,特別是最近這一代科技界人士。用新工具和計算力來接觸生物學并治愈疾病的潛力會讓成功的創業者著迷。

6. AI的用處得到證實

經過了幾年的純炒作后,人工智能除了可以識圖外,還將開始在臨床上發揮作用。

雖然我們對人工智能在非臨床領域的應用同樣感到欣喜,比如更有效地計費、編碼、提供憑證和求醫問藥,但我們認為在支持生物醫藥研究和臨床診斷方面,人工智能的參與將變得更有效、更實用。

我們還認為人工智能永不滿足的數據胃口對大多數臨床應用來說都將是限制因素,原因是訓練數據受到了醫療失誤和傾向的不利影響。

7. 更多丑聞曝光

就在投資者傾向于更嚴格的審查程序之際,為了更快地成長而選擇鋌而走險的初創公司將再次讓投資者受到困擾——面對偽造的用戶增長、虛假的單位經濟以及監管機構的漠視,有些人會緊張不安,有些人則會幸災樂禍。

8. 大型科技公司無重大顛覆行為

雖然一直有令人瞠目的文章談到亞馬遜、Haven、谷歌、Facebook和蘋果公司正在顛覆醫療保健行業,但我們認為2020年外界對它們更多的關注將轉向其他方面。

明年大型科技公司將把顛覆醫療保健的工作置于次要位置,轉而去應對公眾信任和隱私危機,同時迎接消費科技的其他機遇。雖有眾多關于打造消費健康產品和顛覆藥品福利管理和付費機構的消息,但我們認為最好的情況只是繼續進行的小規模試驗和對小公司的收購。

9. 大選年政策癱瘓

我們認為在意外計費、就藥價取得實質性進展以及改進平價醫保法案等問題上,國會的合作局面不會持續太久,盡管這會讓人感到失望。

在大選和彈劾遮掩了其他一切的情況下,任何一方都不想讓對方宣稱取得了任何勝利。對于已經制定的政策,行動將出現在聯邦政府層面(我們覺得這挺有意思)。

10. 基層醫師脫離醫院

2020年基層醫師將覺醒,他們將意識到脫離醫療系統去工作可以賺得更多,而且更開心。

因此,付費機構將設法引誘基層醫師獨立,它們會為后者提供更多的報銷和啟動資金,甚至為這些醫師提供辦公場地和技術補貼。

我們還認為,20世紀90年代的情況將再次出現,即利潤率較低的醫療系統會厭倦所聘醫生帶來虧損的局面,并提出以低價將相應業務退還給這些醫生。

希望本文可以讓大家了解我們的想法并激起大家的好奇心。我們期待看到明年的實際情況。在此之前,祝大家節日以及2020年快樂。(財富中文網)

本文作者鮑勃·科克和布萊恩·羅伯茨都是醫療保健行業投資人,兩人均在風投機構Venrock擔任合伙人。

譯者:Charlie

審校: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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