Weekly Health Tech Reads |1/24/21

News:

• Good old-fashioned IPO Alert!! Signify Health filed its S-1 this week. Signify has two arms to its business: 1. a home health evaluation platform and 2. a platform that manages episodes of care, primarily through BPCI Advanced (the business it acquired via Remedy Partners). A couple of notes on the S-1 follow below. Link (S-1). Link (Article).

  • For the first 9 months of 2020, Signify did $417 million of revenue, $302 million of which came from the home health platform, $115 million coming from episodes of care.

  • The home health platform has grown from 390k home health evals in 2015 to 1.1 million in 2019, and their BPCI episodes under management have grown from 24k in 2014 to 215k in 2019 (pg 138).

  • Signify gets into the details of its BPCI-A program on page 147. It had $6.1 billion of spend under management in 2019 across 85 provider organizations, generating $327 million of savings. Worth checking out this section of the S-1 if you’re interested in details on how bundles are administered.

  • Signify introduced a model in 2020 to help patients in bundles successfully transition from acute settings to the home and avoid readmissions, which they estimate at a cost of $17k per readmission. (pg 150).

  • It’s interesting to see them talk about pharma as a source of revenue, leveraging the in home health platform to support decentralized clinical trials. (pg 146).

  • The S-1 provides a nice overview of different insurance markets (pg 139) and types of value based payment models for those looking for quick explainers of each. (pg 141).

• K Health, a chat-based virtual primary care platform, raised $132 million at a $1.4 billion valuation. It’s planning to use the cash to expand into spaces like pediatrics, diabetes, and hypertension. It’s revenue has grown 10x in 2020, although still is below $100 million (the article doesn’t quote an exact number). With 180 docs currently on staff and 300k members, that equates to around 1,700 patients per doc on average - will be curious to watch what that patients per doc number grows to over time (for the unit economics to work out I’d imagine it has to at least double). Link.

• UHG posted earnings this week. Among notable news, they’re expecting growth of ~900k members in their Medicare Advantage / D-SNP plans, which is bonkers (I think thats the technical term). Check out the data section below for some context as to the magnitude of that growth (hint: it appears UHC membership outgrew the entire group of startup MA insurers by around something like ten times this year). OptumCare entered the year with 50k physicians and expects to add an additional 10k physicians this year (compare that to an entity like HCA, which has 46,000 physicians). The comments from UHG leaders about the OptumCare growth strategy of acquiring providers and then flipping them from FFS to Global Cap arrangements over time are fascinating, particularly when you think about the PMPM of Global Cap arrangements and that OptumHealth’s revenue per consumer is currently $34. There’s a lot of upside there if they can capture that. Link (Earnings Transcript).

• Aledade, a value based care platform for independent primary care, raised $100 million. It’s impressive to see how Aledade has scaled its model - working with over 800 independent primary care practices across 31 states, managing $12 billion of healthcare spend for 1.2 million patients. It appears they’re shifting their sights more directly on Medicare Advantage for growth moving forward - they doubled the lives in MA contracts to 100,000 in 2020, which still represents <10% of their patients under management. Link.

• Medtronic’s former CEO is launching a SPAC looking for targets at the intersection of computation and healthcare. Medtronic is purchasing a stake in the SPAC as well. Will be interesting to watch what kind of AI / medical device startup this SPAC purchases. The thesis sounds very similar to what Lux Capital articulated a few months back behind their health + tech thesis. Link.

• Boston Scientific acquired cardiac remote monitoring company Preventice for $925 million with an additional $300 million in milestone payments. Link.

• Philips acquired Capsule Technologies, a spin out of the old Qualcomm Life business that’s focused on medical device data management, for $635 million. Link.

• Conversa, a virtual care platform for health systems, raised $8 million. Link.

Opinions:

• This is a interesting Business Insider article on Humana’s response to Medicare Advantage startups, claiming it has internally built a startup similar to Clover. The concept is called Author, and it apparently gained over 15,000 lives in South Carolina its first year. Which, if you’ve been tracking the startup growth in the space - 15,000 lives in the first year would be really impressive. The challenge with that comparison though, is that it isn’t quite apples-to-apples. It looks as though Humana is adding Author as a product feature to its Humana plans in South Carolina, rather than its own standalone insurance offering. Individuals are still signing up for their HumanaChoice or Humana Gold Plus plans that have the Author care team as part of the Humana product. If it were literally a NewCo branded “Author”, I’m guessing it would have the same enrollment growth challenges of other startups in the space. Regardless, it’s a cool new add to Humana’s portfolio and I’d imagine that if this South Carolina pilot goes well that Humana would be scaling the Author offering quickly. Link.

• Modern Healthcare featured a piece on how regional payers are adopting virtual first plan designs. The article focuses on Priority Health in Michigan among other plans, which saw 5,000 members sign up for the virtual plan in 2020 after only expecting 3,000 members. The 5% - 10% cost savings offered versus other plans certainly will help drive enrollment! The mention in here of the parallels between the adoption of virtual-first insurance with HMOs of ‘yester-year’ is thought provoking. Lots of tailwinds behind this trend at the moment, but how are we going to look back on it in 10 years? Link.

• Some excellent Substack posts from the past week:

  • Nikhil Krishnan on the food as medicine space. The Geisinger Fresh Food Farmacy referenced provides a really interesting example of where a payer / provider can have the right incentives to invest in programs like these. For a $2,400 investment per member they saw costs per member decrease from $240,000 to $48,000 per member per year. Link.

  • Joe Connolly wrote a fascinating piece on the rise of digital care delivery models and how the next phase of growth will come from companies targeting consumers directly. He presents some interesting thoughts on different approaches companies are taking to owning consumer relationship using Hinge and Teladoc as good examples. Link.

• Ginger’s CEO, Karan Singh, shared some really good perspective on the Ginger journey and how it’s found its footing as a mental health startup over the last decade. It looks like this is just Part 1 of a multipart series exploring many aspects of the journey - business model pivots, leadership changes, etc. - which I’m quite excited to check out. The context he provides around the board conversation at difficult moments and the different perspectives of the different VCs is quite interesting. So is the journey they went on from being a tech platform to a provider of care. Quite indicative of the last 10 years of evolution in the space more generally. Link.

Data:

• CMS posted its January 2021 membership file for Medicare Advantage and Part D plans, providing an early glimpse into how the MA plans grew from 2020 - 2021. Note this doesn’t cover the full open enrollment period (it’s represents sign-ups through Dec 4th so misses a few days of open enrollment that the February file will capture), but it does start to provide a picture of how membership is shaking out for the next year. The picture it paints is a reminder of how important brand is for individuals selecting their MA benefits as the big incumbent players dominate the growth in the space. Link (CMS enrollment file). Link (the quick Google Doc analysis below).

  • I’ll caveat this analysis by saying that the plan type distinctions in the CMS enrollment file are as confusing to me as anyone else, and I’m sure there are a lot of folks subscribed here who know this stuff better than I and I am always happy to take feedback on ways to do this kind of analysis better :).

  • The analysis below isn’t a perfect apples to apples comparison, as you’ll note some organizations in the chart below like Welbe are focused on PACE plans, not Medicare Advantage. The numbers include PACE, Cost, and Demo plans (I excluded the Prescription Drug Plan enrollment). The size of PACE, Cost, and Demo plan enrollment don’t seem to change the overall picture here.

  • Bright Health’s membership illustrates the differences in growing via acquisition versus organic growth. Brand New Day grew significantly more than Bright - with growth that rivals any other MA startup. Meanwhile Bright’s membership grew by less than 1,000 members. That acquisition continues to look really dang smart on their part.

  • All the startup MA plans have solid year-over-year growth percentages, in particular Devoted. But in aggregate all of the startups combined have only grown something like 75k lives. Compare that to UHG, which grew by ~800k lives. In total the seven BigCos listed grew membership by 2 million out of the 2.2 million in growth over last year. Wild

  • Clover had solid growth on the whole adding 12k members, although Clover’s Walmart plans currently only have 1,100 members, with 998 members in one plan and 102 members on the other plan.

• A 100+ page annual report was published on the Comprehensive Primary Care Plus program and I’m not even gonna pretend like I read this whole thing. The report cites some small improvements in quality from the program thus far, but increased costs. A section towards the end discusses the cost increases (see pg 92). CPC+ had basically no impact on better managing spend, and so the additional payments CPC+ made to practices were just a net addition to overall spending.

• KFF took a look at the coverage gap that exists in the twelve states that have chosen not to expand Medicaid. Of the 2.2 million people in this country who fall in that coverage gap, 97% of them are in the South. Link.