Steve Krupa, Managing Member, Psilos
"We are about to have a significant flip in the competitive dynamics of healthcare," Steve Krupa, managing member and Chief Operating Officer, of healthcare investment firm Psilos told MobiHealthNews in a recent interview. "It’s going to be quite severe and shocking across the board for the big and small players delivering health insurance, providers, and consumers, ultimately. This is a result of ObamaCare, really, but also of everything that is going on in healthcare today."
Krupa explains that how businesses -- employers -- react to these change will have ramifications on the overall competitive dynamics in healthcare. He said that in the not too recent past, businesses really had only one course to pursue, but now they have four.
"They could continue the way they are going, which is providing some kind of group insurance program to their employees," Krupa said. "They could try to impact the type of group insurance they offer and move to a more value-based plan design, but have a very hands-on approach with respect to how the health insurance is delivered. Thirdly, they could incorporate a private exchange, which Aon, Towers, Mercer and others are very actively marketing. And lastly they can begin a strategy -- that we are hearing a lot of companies are doing -- that would eventually get them out of being the provider of healthcare altogether. Of course, the individual markets being established are providing them with that exit. Maybe not this year, but in future years."
Krupa argues that these individual public exchanges change everything for healthcare, because for the first time there will be a greater emphasis on the individual needs of the consumer in healthcare, which he says hasn't received much emphasis at all up until this point.
"What we have been into for the past 15 years on the software side and the digital health side is how to use data analytics and applications to improve the quality and lower the cost of healthcare," he said. "It's a simple idea, but it was tougher to do back then than it is today. The other thing we have been interested in is getting competitive forces to begin to work in the healthcare industry. Certainly that wasn’t the case 15 years ago either."
In the past decade Psilos' portfolio companies have seen a number of exits, including the sale of consumer directed health plan Definity Health to UnitedHealth Group; Extend Health, a large private health insurance exchange company, to Towers Watson; and ActiveHealth to Aetna 10 years ago.
"ActiveHealth began to take data that is not that different than the data Castlight is getting its hands on, but instead of thinking about that data from a transparency point of view, they thought about it from a care point of view," Krupa said. "They are trying to create health records out of claims data and then run it through a smart engine to find instances when people weren’t being cared for well."
Two of the companies in Psilos' portfolio today include SeeChange Health and PatientSafe Solutions. SeeChange is focused on value-based health plans that provides consumers with incentives for their healthy behaviors that actually improve their insurance benefits, instead of just rewarding them with, say, a pair of tickets to a baseball game, Krupa said. For SeeChange members, healthy behavior changes really affect the way their insurance works in terms of their deductibles and copayments, he said.
While Krupa said that many of the major changes in healthcare have helped marched the industry toward the consumer, many consumer-facing health services are still largely irrelevant.
"When I look at digital health applications this is the first question I ask: 'How relevant is this?' and 'Does it really matter?' The testing point, from my perspective, is that most consumers don’t want to be engaged in health if they don’t have to be," Krupa said. "I think that is why Castlight is pretty cool, because it is a highly relevant interaction. It is an interaction that everybody is apt to face now. As I said before, the movement now is to put the dollars and the responsibility into the individual’s hands. [That is the] beginning of people really wanting to engage outside of a niche wellness market."
Krupa calls the prospect of a Castlight Health IPO a "Kitty Hawk Moment" for digital health, referring to the first Wright Brothers' flight that demonstrated that flying in airplanes was possible.
"Castlight's platform is not going to be the only one, there are health plans building similar platforms to this one, but I think they are the first ones that are saying ‘I’m going to build a platform to help consumers with some of the burdens that are already here in some ways, but that is coming in a more significant manner down the road.’ I think it is great for digital health. I think it is the beginning of taking it from a niche spot where maybe you can collect 5 percent or 10 percent of the people that care, and broaden it to where everyone will begin to care."
One of the focus areas in digital health today that Krupa pointed to as particularly misguided is social.
"I think we are a few generations away from social," he said. "I know I’m going to sound like I’m a grumpy old man by saying that, but what I mean is, you can’t be social until you are relevant. That is a simple idea, but I keep seeing these ideas for large social networks built around healthcare. I think they are going to come, but I think they are going to come to people much differently than the media social networks got to people, because let’s face it: there is nothing entertaining about healthcare, nothing fascinating about it, and it’s a responsibility that you probably don’t want. Before you can get to the point where it is social, you have to get to the point where it matters."
Krupa said while many digital health startups are onto great ideas the market might not be ready for them for a few more years.
"I look at a lot of startups where I say, the capital requirement to build up this business to get it to where there is a great product, there may not be a market there right away until a lot of these great changes really take place," he said. "Where it stands today, only 10 or 15 percent if people buy their own health insurance. We haven’t had this huge waves of people to jump on these public health exchanges – yet. Maybe because they don’t work or because people don’t think they are valuable at this stage of the game, but over time that will change. It will change out of necessity. That will make people be more [engaged with their own] healthcare just like they are into whatever else they are doing as a regular part of their lives."
While Krupa said social networks focused on particular communities of patients are finding traction, the bigger opportunities for social networks for the broader population that gets sick and then well again or injured and then well again won't take hold unless there is a culture change where the average person is more concerned about their own health.
Similarly, Krupa said the fitness market is growing but it is still includes a small percentage of people.
"What the data backs up is very odd," Krupa said. "The data backs up that people don’t value their health – at all – in terms of the average person. There have been all these great studies where people have paid patients to take their drugs and they are very compliant when they are getting paid but when they stop paying them they become noncompliant. No one can explain that."
While there have been many startups approaching employee health and wellness platforms with an emphasis on fitness and activity levels, Krupa sees opportunities for areas where the consumer is already very focused on a good outcome, like stress management and fertility.
"MeQuilibrium is one that I really like. They can walk into the door of an employer's HR department and make the case that they can reduce absenteeism by x percent, improve productivity by y percent, and have a model that is a no-brainer for the corporation to distribute out to their employees," Krupa said. "They are using cognitive behavioral therapy to deliver stress management to employees over the internet and via mobile devices. It starts with a survey and assessment and then leads to an educational curriculum and games."
With most health issues you have to sacrifice something to start managing them, Krupa said. With stress it's different because managing stress will make everyone in your life like you more and help you like your job more. The sacrifice is just participating in the educational program at work: "That’s an example of a company that opened my eyes and makes me think that [meQuilibrium] could be a powerful company in the next three or four years."
Similarly, Krupa is impressed with digital fertility companies like Glow that aim to help users get pregnant.
"This is an application I can get behind. It's digital, it's got crowdfunding, mobile, big science, new insurance models -- it's got everything. And it is concentrated on an area where the consumer is really focused on a good outcome: ‘I want to get pregnant. I want to have a family,’" he said.
When we talk about issues like stress and fertility, this is a small category of issues where a change in healthcare behavior is not a sacrifice, but an expansion, according to Krupa.
"Digital health has a long job in front of it -- an ongoing inculcation -- to a consumer market that is sometimes not willing to pay attention," Krupa said. "There is an opportunity to use the tools of modern life to live longer and happier. It will happen but not at the rate that most other consumer technologies get adopted."
Krupa said that just because it takes a while, though, it doesn't mean investments in digital health aren't worth doing.
"Many of these digital health applications will require behavior change, so you have to look at it and say should I build it today and own it for a long time or should I wait two or three years and go after it then. We had the same issue way back in the day when everyone was talking about how Palm Pilots and PDAs were changing the way medicine was practiced. The amount of money that went into e-prescribing on Palm Pilots in order to build that technology was unbelievable. We tried to count it once and it was in the billions. The market just wasn’t ready. The market is probably just about ready for that now, right?"
