Jake Halpert

Hot take on a lot of early-stage digital health companies out there: You're not a tech company. Most tech-enabled care companies I've seen over the past two years are only tech-enabled in the sense that they use telehealth as their delivery mechanism for care. There are exceptions to this, of course - companies who build computer vision and applied AI tools to better the doctor-patient experience, companies who build tooling around risk scoring and stratification to enable more personalized medicine, companies who build truly novel intakes to better route patients to the appropriate care, etc. These companies have real technology chops and, if they sell it right to the market, can get credit for this from investors. But if you're truly a telehealth provider, you need to realize now that the goal post has shifted dramatically from 2021 and you're going to be valued at maturity at something like 3x EBITDA. That's profit. Not revenue. Throw a revenue multiple out the window. That's not the world we live in if you're a virtual doctor's office. Think of how that impacts venture math. If you're raising a seed round at $15M post-money (or $12M pre-money), it means you'll have to generate something like $150-200M in annual EBITDA to be a fund returner for your seed investors. Maybe even more with dilution, since telehealth businesses are not traditionally capital efficient and will likely need to raise material additional capital to reach that scale. You need to be ridiculously profitable (probably on $800M-$1B in annual revenue since you're likely going to be a 40% gross margin business). Here's the good news: you can set yourself up well (and probably be a contrarian founder relative to your peers), by talking about EBITDA growth and how you can grow into a fund-returning outcome based on realistic mature market comps. This will stand out for the investors you're pitching, even at the early stage. This is how you can beat the malaise of the tech-enabled care market. Focus on the right metrics and the right type of growth. You don't have to have all the answers (no founder does), but you need to make sure the ship is headed in the right direction. A focus on profitability for "tech-enabled care" (*ahem* telehealth) businesses is a good first step.

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Some VC investors believe that brick and mortar - referring to a physical presence of some kind - should be avoided at all costs. Yet, the track record of clinic and hybrid care businesses in health care indicates otherwise. ==> One Medical (sold for $3.9 billion to Amazon), Oak Street (bought by CVS for $10.6 billion), Lifestance (IPO at $7.5 billion market cap), and PE-backed Premise Health (acquired by OMERS Private Equity for $1.1 billion) If a clinic is indicated as the optimal way to deliver care for that patient population, there are creative ways to build and operate them. Full article below with advice and strategies on how to build and operate hybrid clinics from my teammate Anarghya Vardhana from Maveron, Amir Dan Rubin from OneMedical Group, Steven Eidelman from Modern Animal and more!

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The (Healthcare) Ground Beneath Our Feet… This year it is likely that over $10 billion will be invested in the digital health sector – a robust amount, no doubt, but inconsequential when compared to the amount of capital tied up in healthcare real estate assets, which is estimated to be $1.2 trillion by Jones Lang Lasalle. Of that amount, approximately $790 billion is in the hospital sector while the remaining $490 billion is in medical office assets. It is estimated that there are 48.6k facilities with 3.4 billion square feet of healthcare real estate, 42% of which are owned by REITs and another 33% held by other private investment vehicles. Much of the digital health investment is meant to make the physical healthcare infrastructure more productive: greater operating efficiencies, greater patient throughput, more relevant personalized care models with better outcomes. As the healthcare system is being pushed to be more distributed to lower cost sites of care, accelerated now by the rapid proliferation of automation and AI capabilities, the potential impact on healthcare infrastructure assets will be profound. Thoughts on what that might look like... https://lnkd.in/eTfAdUbS #digitalhealth Flare Capital Partners

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One key reason why healthcare technologies like AI, telemedicine, and software haven't structurally lowered costs or broadened access for the entire system after decades of experimentation (excluding pure financial engineering of payer contracts) is the limited reimagining of care delivery itself, with asynchronous telemedicine as a notable exception. In the same way that digitizing physical paper failed to exploit the capabilities of a new computing medium for word processing, hosting physician-patient conversations over video does not transform the actual delivery of care. In telemedicine, many of the inputs (e.g., clinician time) and therefore cost structures of in-person care persist, which is why we often see fee-for-service telemedicine companies struggle to achieve economies of scale (i.e., growing revenues non-linearly while growing costs linearly). Until we deconstruct the components of a medical appointment – from intake and triage, to chart review, history gathering, physical examination, diagnosis, treatment, and follow-up – we will continue to be underwhelmed by the disconnect between the transformative potential of these technologies and real-world patient/system impact. I’m optimistic that the emergence of reliable and performant medical AI agents will urge us to perform this deconstruction and redesign the fundamental building blocks of a “medical appointment.”

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Today’s healthcare policymakers are focused on their favorite boogeymen: physician compensation, biopharma, and new medical technologies. The real villains are ‘benefit managers’ and administrators’ who lurk in the shadows extracting 25 cents of every healthcare dollar. The reality is, in fact, in plain view if you look: administrators have grown 3200% while physicians have grown 200% over the last two decades; physician compensation is down, net of inflation. Admin comp is up, way up. PBM (pharmacy ‘benefit’ ‘management’) revenue has outstripped Pharma revenue growth in the last 20 years. Pharma extends life and improves quality of life, and extends working lives of taxpayers. PBMs - who knows… People grasp onto things they understand like doctors and drug companies. ‘Administrators’, ACOs, VBC, VBC, PBMs, spread pricing are more challenging to grasp and are allowed to obsfucate people about what they do from the shadows. America’s healthcare landscape is burdened by ‘administrators’ and ‘managers’ who extract rents from an otherwise highly innovative system. https://lnkd.in/gK3mCme4 https://lnkd.in/gPC9vKB9 DocVader puts it aptly: ‘thoughts and prayers’ https://lnkd.in/gUfnSXGV Technology is one answer. Physician and nurse leaders are another. If your company is about literally decimating administrative costs in the back office or front office of healthcare, I applaud you. As Americans we need this. Return care to the people and shrink administration and management bloat across the system. Medicare deserves this and so do the commercially ‘insured’.

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One of my proudest moments as an investor occurred today as Alaffia Health announced its series A because it shows how the Aperture® Venture Capital vision of multi-level, multi-generational #impactinvesting is succeeding in the marketplace. Here’s the model in its most basic form : ✅As diverse fund managers with meaningful capital to allocate, we are changing the VC landscape every day just by doing our day jobs. ✅As Black/Brown investors with ~40 years experience collectively, Aperture GPs have access to talent /excellence that others do not, so our portfolio *organically* is more inclusive by race, gender and geography even while optimizing for financial outcomes (all about the alpha). ✅Our most successful portco’s are using financial #innovation to solve market problems that impact underrepresented demographics and underserved communities. Alaffia Health is a shining example of the impact portion of our overall fund thesis, and we couldn’t be prouder of TJ Ademiluyi and Adun Akanni, MPH, PMP - the dynamic brother-sister founder duo whose vision we have steadfastly supported on their journey. Congratulations to TJ and Adun from William Crowder and myself, as well as the whole Aperture team- Marjorie King Philip McKenzie Yves Louis-Jacques Tanvi Lal Michelle Dhansinghani Lisha Bell Katie Kelly Amy Chung Cindy Chong, CFA Brian Fernandes-Halloran Monroe France Jayden Pantel Darren Herman Evan Wladis Neal Triplett Thomas Scriven Peter Ammon Irina Bit-Babik Tim Milanich Rob Rahbari

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Platforms are in, point solutions are out as the healthcare AI category leaders come into focus this year. In conversation with Shelby Livingston at Endpoints News, I shared: 1. Why AI-first companies have the greatest platform potential and heuristics for identifying these opportunities at the earliest stages, 2. How companies are differentiating through co-development and distribution partnerships with leading healthcare institutions, and 3. Strategies for navigating anemic budgets and constrained market sizes through business model innovation such as AI-enabled services and pay for performance models Read more here: https://lnkd.in/dJWqv_zC Bessemer Venture Partners Abridge #healthcare #lifesciences #AI #generativeAI

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There is a misconception emerging that AI agents will lead to immediate reductions in healthcare labor costs. While AI agents can automate end-to-end workflows such as booking appointments, answering basic patient questions, and performing form completion for prior authorizations, automating a single task is not equivalent to automating an entire job. Nurses are a prime example. Certain nursing tasks, such as care coordination and patient documentation, are highly automatable by AI agents; however, there is a tremendous amount of work nurses perform on the ground that cannot be fully automated with current technologies such as direct patient care, physical examinations, medication administration, wound care, patient support, and clinical assessments. These nuances make full role elimination less likely with current technologies. When articulating the ROI of an AI agent, we need to be both precise and accurate. Automating a task is more often not automating an entire profession. For roles that encompass many functions, such as nursing, AI agents can be invaluable tools for unburdening staff, increasing efficiency, and boosting throughput—benefits that are particularly valuable given current healthcare staffing and resource shortages. The most promising job candidates for full role elimination through AI remain positions with monolithic task structures, of which there are relatively few in healthcare today—scribes, medical coders, and data entry specialists for example. It is therefore unsurprising then that the most progress has been made in these categories.

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Thank you, Sumit Nagpal, for shining a light on two incredibly important movements in what can often feel like a challenging healthcare startup environment. This is a huge win for women's health and signals the dawn of a new era for consumer health. I firmly believe in moving away from a one-size-fits-all solution for men and women, and recognizing the need for a completely different approach – sometimes in obvious ways, and sometimes not. People have access to more knowledge and data about their health than ever before, enabling them to make informed decisions about their well-being. Consumer health is ripe for a comeback! #consumerhealth #digitalhealth #menshealth

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M13 is thrilled to lead the Series A in RadiantGraph which is focused on personalization in healthcare. As we continue to invest in early stage companies it is abundantly clear that the biggest indicator of success is the founder and his or her ability to execute on their vision of the future. In this case, I don't think I have seen much better founder-market fit than we have with founder and CEO Anmol Madan. We believe in his vision: in order to have the best patient outcomes in healthcare we need increased personalization and AI is the breakthrough to get us there. Anmol started one of the pioneering digital health companies Ginger and then was Chief Data Scientist at Livongo and Teledoc. He has done it all: early stage, late stage, public company. And he deeply understands the nuances of the healthcare market from all angles which is critical for success. While there are many players building healthcare-specific AI capabilities, RadiantGraph is focused on outcomes: The platform is already processing personalization models for more than 3.5 million people, despite launching just last year. Excited to partner with my friend Adam D'Augelli and the great True Ventures again and Morgan Blumberg who has been deep in the healthcare market with me for many years. More on our thesis in the blog below. https://lnkd.in/evDDmC3W

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Presenting at the Senate as part of the Coalition for Health AI (CHAI) "Day on the Hill" wasn't on my 2024 bingo card, but I'm feeling energized by the bipartisan discussions on healthcare AI. The numbers tell a compelling story: while nearly 2,000 healthcare AI startups have received funding over the last two decades, only 1 in 20 provider-facing companies reach late-stage maturity. Beyond natural market dynamics, two critical barriers are holding back AI's full potential in healthcare: unsustainable payment models and inadequate evaluation infrastructure – only 5% of research studies on LLMs in medicine utilize real patient care data, and studies advancing our understanding of performance beyond medical licensing exam benchmarks remain anemic at best. At CHAI, we're advocating for essential foundations: • Rigorous technical model performance evaluations • Comprehensive bias assessments across diverse patient populations • Thorough pre-deployment simulations and prospective studies • Robust ongoing local monitoring The path forward demands strong reporting infrastructure, advanced healthcare AI benchmarks, and meaningful public-private partnerships to drive real-world AI deployment in healthcare. Stay tuned for CHAI's upcoming initiatives in 2025 as we expand our engagements with the startup and investment ecosystem. https://lnkd.in/enw-GQcA

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I recently sat down with Michael Batko, CEO at Startmate and Founder of Puddle Pod for Episode 11 of Insane Ambition. Startmate has invested in 230+ startups, much of it under Michael's leadership, and now has $3.5b in value across its portfolio companies. In this episode, we discussed: - Michael's journey from consulting, then living in the Amazon rainforest, to leading Australia's biggest startup accelerator - The future of Australia's startup ecosystem - The labour government's very stupid plan to make it harder for people to qualify as sophisticated investors (now thankfully shelved) - Startmate City! Startmate's plan to build Australia's first startup city. Probably the most ambitious idea I've ever heard from a startup accelerator. - The balance between visionary thinking and traditional startup advice (think Elon Musk's plan to colonise Mars, vs Y Combinator's problem/customer obsession) - "The Courage to Be Disliked", and its influence on Michael's approach to life and business. Links in the description below 👇

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On the latest Vital Signs, Nikhil Krishnan and I had a ton of fun chatting with Dr. Atul Butte. Dr. Butte is a professor at UCSF, Chief Data Scientist of the UC Health System, and a co-founder of numerous healthcare startups. In our conversation, Dr. Butte shared his takes on healthcare AI opportunities, challenges, hype, and more. A few highlights: ⚡LLM use cases, data, and growth LLMs are already helping to solve the “drudgery” aspects of medicine, such as automatically drafting SOAP notes and patient messages. Dr. Butte is excited about future applications of LLMs that can help with the “cognitive” aspects: with difficult medical problems an LLM might be able to stitch together disparate pieces of information to generate a potentially novel solution. He also highlights that prompt engineering will become the next “coding language” as so much of leveraging LLMs is knowing how to ask them the right questions. Additionally, Dr. Butte discusses how since 2016, UCSF has been working to deidentify its patient notes so that it can query them to answer clinical questions and ultimately enhance patient care. ⚡The need for patient-facing AI As patients are increasingly able to access their own personal health data in nicely structured formats (e.g., EHRs, wearables), they desperately need more tools to help them interpret and make decisions using that data. Dr. Butte understands that these patient-facing solutions are challenging to get funded but he emphasizes that patients need to receive the benefits of AI sooner. ⚡Evaluating healthcare AI solutions In order to evaluate AI solutions, we often put human specialists – such as medical professionals – on the same tasks. Understanding that specialists often disagree with each other, a significant challenge arises in figuring out how we can evaluate AI considering we can’t just “average” all the specialist opinions. Dr. Butte points out that there still remains a massive gap in AI evaluation tools. Additionally, there are so many organizations that want to have a say in how healthcare AI is regulated that the landscape is uncertain. An awesome conversation with an expert on all things AI meets healthcare. Listen to the full episode below: Spotify: https://spoti.fi/3Wr3643 Apple: https://apple.co/4acwgan

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💡Benchmarks in the investment industry serve as a standard for measuring the performance of securities, mutual funds, or investment managers. They provide a reference point for analyzing allocation, risk, and return of a portfolio, enabling investors to make informed decisions. Thanks Peter Walker for keeping us all informed!! Can’t wait for this!! Follow and get on the waitlist for this one! #benchmarks #fundraising #Capitalraise #founders #womenshealth #femhealth #medtech #wellness

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This was a question investors asked us early on in our Health Tech journey. Because the hospital sales cycle was notorious for being very long. And we started the company in the era of Uber, Airbnb, Instagram, etc. where direct-to-consumer apps were the big trend. So why not circumvent that strenuous sales process by just taking digital care journeys direct to patients? Surely patients who were undergoing a complex care journey (e.g. surgery, cancer, etc.) would be thrilled to get SeamlessMD on their own? And believe me, as we struggled through those long hospital sales cycles, we would sometimes come back to this question. But every time we thought about it, we came back to the same conclusions: → Every healthcare team provides slightly different instructions to patients (e.g. how to prepare for surgery). Delivering education to patients that potentially conflicts with what a patient’s own care team is telling them is confusing and could put patient safety at risk. → If patients are using this on their own, then there’s no connection to the healthcare team. Which means no opportunity for clinicians to leverage the data collected on the platform to take better care of patients (e.g. via remote monitoring). → How would patients even learn about SeamlessMD and why would they trust us? Realistically, how many patients are looking for a digital health tool every time they have a journey? Especially older patients? Not many. → How would we know if we are actually improving patient outcomes (and also not making things worse)? Without partnering with health systems who can measure the impact of our product we simply have no idea. So ultimately we doubled down on partnering with health systems because it solved those four issues: → Ensured patient safety by aligning what patients received on SeamlessMD with what their care teams were telling them. → Drove even better patient outcomes because care teams could remotely monitor patients and catch problems earlier - with dashboards and tools directly embedded within their EHR. → Provided a trusted distribution channel to patients. Who better to promote a digital health tool than your own care team? → Produced studies and evaluations which proved we were actually making an impact on cost and quality (40+ studies/evaluations and counting!) As I reflect on those decisions, I truly believe the strong clinical DNA in our company is what led us down this path. Without it, we may not have had the thoughtfulness to consider the patient safety risks or to care about measuring real impact on outcomes. If we had just focused on “exponential growth of users” like the traditional venture-backed, direct-to-consumer models… I really don’t think we’d still be here today. That might work for some very specific aspects of healthcare (e.g. low acuity direct-to-patient telemedicine). But navigating patients through complex care journeys? I believe we made the right call. What do you think?

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Great article from PitchBook on why domain expertise amongst VCs matters. TL;DR -- in verticals like healthcare, having investors with high amount of domain expertise can result in up to 40% higher odds of achieving an IPO, 20% higher chance of being acquired and 30% higher chance of an overall successful exit. Importantly, the marginal value of having investors with domain expertise varies by sector and stage, and is not uniform, so your mileage may vary, and generalist investors still have a very important role to play in the venture ecosystem. https://lnkd.in/dXpi8gzm Curious to hear from founders: Do you have examples of seeing specialist investors be helpful in unique ways that you can share? Or alternatively, do you have an experience with a generalist investor who has been more helpful than the specialists?

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CareMax and Steward Health Care are besties What is CareMax you ask? But of course a value based care provider that went public via SPAC in 2021 $297 open price at IPO $487 high price post IPO $3.00 current trading price Notably, CareMaxbought Steward's Medicare VBC business in 2022 for $135M As part of that transaction, double yacht owning Ralph de la Torre became a board member of CareMax Solid foreshadowing Here's what CareMax recently said in it's 10-Q related to its business: "These conditions raise substantial doubt regarding the Company’s ability to continue as a going concern..." Meaning, it may file for bankruptcy if it can't turn things around Some numbers from the quarter: $156M current assets $507M current liabilities $232M revenue ($21.7M) op loss ($23.8M) cash from ops 1:30 reverse stock split recently issued Translation, you had 30 shares and now you have 1 Some more numbers: 55 centers 218,000 covered members 99% under VBC arrangements And last interesting bit of info: "Our principal sources of liquidity have been cash generated by our centers and MSO operations, and borrowings under our credit facilities." When your third key source of liquidity is borrowing, that's an issue Sorry, sorry, one more thing... Apparently, after the acquisition of Steward's VBC business, Steward doctors continued to serve these patients, though they would then be paid from CareMax... which didn't happen What's going on at CareMax? P.S. If you liked this mystery breakdown, you'll love The Healthcare Breakdown, where I breakdown the business of healthcare and all these wheelings and dealings so you can see what's really going on Check it out here: https://buff.ly/47NeASx See you out there!

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99% of tech startup advice is WRONG for Health Tech serving health systems. Here’s what outside advisors or entrepreneurs might tell you… that you should IGNORE: ⛔ 𝗟𝗮𝘂𝗻𝗰𝗵 𝗮 𝗺𝗶𝗻𝗶𝗺𝗮𝗹𝗹𝘆 𝘃𝗶𝗮𝗯𝗹𝗲 𝗽𝗿𝗼𝗱𝘂𝗰𝘁 (𝗠𝗩𝗣) When it comes to tech that touches direct patient care (e.g. digitally guiding patients pre and post-surgery), a MVP isn’t good enough. It has to be fully functional. It has to be safe. It has to be HIPAA / PHIPA-compliant. From Day 1. ⛔ 𝗠𝗼𝘃𝗲 𝗳𝗮𝘀𝘁 𝗮𝗻𝗱 𝗯𝗿𝗲𝗮𝗸 𝘁𝗵𝗶𝗻𝗴𝘀 I like fast… but not if it puts patient safety at risk. It’s not OK if you moved so fast it broke a mission critical feature patients were using to manage their health or providers were using to manage sick patients. Beyond risk of harm, frequently broken products erode trust with patients and providers. Once you lose a patient or provider’s trust, it might be gone forever. ⛔ 𝗗𝗿𝗶𝘃𝗲 𝗽𝗿𝗼𝗱𝘂𝗰𝘁-𝗹𝗲𝗱 𝗴𝗿𝗼𝘄𝘁𝗵 𝘃𝗶𝗮 𝘀𝗲𝗹𝗳-𝗽𝘂𝗿𝗰𝗵𝗮𝘀𝗲 If someone convinces you to “do to healthcare what Dropbox did to businesses with viral bottoms-up viral growth”... I’ll stop you right there. If you’re managing Protected Health Information (PHI), there’s no way an individual clinician can (or should!) just sign up without getting approval from IT/security/privacy. Just won’t happen. ⛔ 𝟭𝟬𝟬% 𝘀𝗲𝗹𝗳-𝘀𝗲𝗿𝘃𝗲 𝘄𝗶𝘁𝗵 𝗻𝗼 𝗰𝗵𝗮𝗻𝗴𝗲 𝗺𝗮𝗻𝗮𝗴𝗲𝗺𝗲𝗻𝘁 𝗵𝗲𝗹𝗽 Maybe this works for the simplest of solutions. But the closer you are to direct clinical care, the more likely you’re dealing with complex patient and provider workflows. E.g. trying to embed remote monitoring workflows and dashboards into the clinician workflow. In those cases, you must invest in Customer Success and professional services to ensure the right change management support is in place to make it successful. Otherwise… expect low user adoption → low impact. ⛔ 𝗚𝗲𝘁 𝘂𝗽 𝗼𝗻 𝘀𝘁𝗮𝗴𝗲 𝗮𝘁 𝗰𝗼𝗻𝗳𝗲𝗿𝗲𝗻𝗰𝗲𝘀 𝘁𝗼 𝗽𝗿𝗼𝗺𝗼𝘁𝗲 𝘆𝗼𝘂𝗿 𝗰𝗼𝗺𝗽𝗮𝗻𝘆 Healthcare folks are WAY more skeptical of industry. This isn’t a general “B2B software-as-a-service” industry where it’s normal for vendors to get up and pitch to each other at Salesforce’s Dreamforce conference. Especially for medical specialty conferences, vendors are almost never on stage. Clinicians want to hear from their clinician peers, not vendors (yes, even if the vendor is a subject matter expert…!) Some exceptions for health-tech focused conferences… still the minority situation though. Focus on making your health system partners successful and earn their public praises. For clarity: if you get a spot on stage... do it! Just don't expect it. 𝗔𝗴𝗿𝗲𝗲 𝗼𝗿 𝗱𝗶𝘀𝗮𝗴𝗿𝗲𝗲? #digitalhealth #healthcareinnovation

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I've received a ton of BAD advice about building a Health Tech startup. Advice that makes sense for many Tech startups… but NOT for Healthcare 👇 Here were the worst ones: 1️⃣ “You (the CEO) should stop spending so much time with health system customers. Delegate that to other people.” → Turns out that actually hurts companies in highly verticalized, complex spaces (and I think it’s actually bad advice in general). Being in the details matters, and that includes being in the details on what matters to health systems. 2️⃣ “You’re bringing too many team members into meetings with health systems.” → Turns out healthcare is complex, and being able to have subject matter experts across clinical, change management and integrations who can get into the weeds of clinical scenarios and workflows helps build trust with health systems. 3️⃣ “Why are you creating all this clinical content? Just be a pure tech platform where health systems can create their own content.” → Turns out clinicians don’t have time to create content, workflows and algorithms from scratch. Plus, if there are templates, they need to be super high quality and evidence-based for clinicians to use them. 4️⃣ “You’re providing too many services for health systems (e.g. high-touch clinical content and change management support). You should be more of a tech-only platform.” → Turns out those “tech-only” platforms collect dust on the shelf. Yes our support is more resource-intensive and yes we go above and beyond for our health system partners… but it gets the best results in the industry. 5️⃣ “You should go direct-to-consumer and not work with hospitals and health systems.” → Turns out that works great for low-complexity situations (e.g. walk-in telemedicine), but how does that work for highly complex care with lots of clinicians involved (e.g. navigating patients through a cancer journey)? It doesn’t. 6️⃣ “You should hire mostly seasoned folks with decades of experience in healthcare and business.” → Turns out many of our most impactful team members (including many of those that our health system partners love working with) were relatively early in their careers when they joined SeamlessMD. I’ve realized that someone’s self-motivation and potential are far better indicators of success here than years of experience (of course, easy to say and hard to evaluate for!). What would you add?

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