Posts from health care

What Happened In 2015

Last year in my What Just Happened post, I said:

the social media phase of the Internet ended

I think we can go further than that now and say that sometime in the past year or two the consumer internet/social/mobile gold rush ended.

Look  at the top 25 apps in the US:

top 25 apps

The top 6 mobile apps and 8 of the top 9 are owned by Facebook and Google. 10 of the top 12 mobile apps are owned by Apple, Facebook, and Google.

There isn’t a single “startup” on that list and the youngest company on that list is Snapchat which is now over four years old.

We are now well into a consolidation phase where the strong are getting stronger and it is harder than ever to build a large consumer user base. It is reminiscent of the late 80s/early 90s after Windows emerged as the dominant desktop environment and Microsoft started to use that dominant market position to move up the stack and take share in all of the important application categories. Apple and Google are doing that now in mobile, along with Facebook which figured out how to be as critical on your phone as your operating system.

I am certain that something will come along, like the Internet did in the mid 90s, to bust up this oligopoly (which is way better than a monopoly). But it is not yet clear what that thing is.

2015 saw some of the candidates for the next big thing underwhelm. VR is having a hard time getting out of the gates. Wearables and IoT have yet to go mainstream. Bitcoin and the Blockchain have yet to give us a killer app. AI/machine learning has great potential but also gives incumbents with large data sets (Facebook and Google) scale advantages over newcomers.

The most exciting things that have happened in tech in 2015 are happening in verticals like transportation, hospitality, education, healthcare, and maybe more than anything else, finance, where the lessons and playbooks of the consumer gold rush are being used with great effectiveness to disrupt incumbents and shake up industries.

The same is true of the enterprise which also had a great year in 2015. Slack, and Dropbox before it, shows how powerful a consumerish approach to the enterprise can be. But there aren’t many broad horizontal plays in the enterprise and verticals seems to be where most of the action was in 2015.

I’m hopeful that 2015 will also go down as the year we buried the Unicorn. The whole notion that getting a billion dollar price tag on your company was something necessary to matter, to be able to recruit, to be able to get press, etc, etc, is worshiping a false god. And we all know what happens to those who do that.

As I look back over 2014 and 2015, I feel like these two years were an inflection point, where the underlying fundamentals of opportunity in tech slowed down but the capital rushing to get invested in tech did not. That resulted in the Unicorn phase, which if it indeed is over, will be followed by an unwinding phase where the capital flows will need to line up more tightly to the opportunity curve.

I’m now moving into “What Will Happen” which is for tomorrow, so I will end this post now by saying goodbye to 2015 and hopefully to much of the nonsense that came with it.

I did not touch on the many important things that happened outside of tech in 2015, like the rise of terrorism in the western world, and the reaction of the body politic to it, particularly here in the US with the 2016 Presidential campaign getting into full swing. That certainly touches the world of tech and will touch it even more in the future. Again, something to talk about tomorrow.

I wish everyone a happy and healthy new year and we will talk about the future, not the past, tomorrow.

What Didn’t Happen

Last year, I ended 2014 with What Just Happened and started 2015 with What Is Going To Happen.

I’ll do the same tomorrow and friday, but today I’d like to talk about What Didn’t Happen, specifically which of my predictions in What Is Going To Happen did not come to be.

  1. I said that the big companies that were started in the second half of the last decade (Uber, Airbnb, Dropbox, etc) would start going public in 2015. That did not happen. Not one of them has even filed confidentially (to my knowledge). This is personally disappointing to me. I realize that every company should decide how and when and if they want to go public. But I believe the entire startup sector would benefit a lot from seeing where these big companies will trade as public companies. The VC backed companies that were started in the latter half of that last decade that did go public in 2015, like Square, Box, and Etsy (where I am on the board) trade at 2.5x to 5x revenues, a far cry from what companies get financed at in the late stage private markets. As long as the biggest venture backed companies stay private, this dichotomy in valuations may well persist and that’s unfortunate in my view.
  2. I said that we would see the big Chinese consumer electronics company Xiaomi come to the US. That also did not happen, although Xiaomi has expanded its business outside of China and I think they will enter the US at some point. I have a Xiaomi TV in my home office and it is a really good product.
  3. I predicted that asian messengers like WeChat and Line would make strong gains in the US messenger market. That most certainly did not happen. The only third party messengers (not texting apps) that seem to have taken off in the US are Facebook Messenger, WhatsApp and our portfolio company Kik. top social apps year end 2015Here’s a shot of the app store a couple days after the kids got new phones for Christmas.
  4. I said that the Republicans and Democrats would find common ground on challenging issues that impact the tech/startup sector like immigration and net neutrality. That most certainly did not happen and the two parties are as far apart as ever and now we are in an election year where nothing will get done.

So I got four out of eleven dead wrong.

Here’s what I got right:

  1. VR has hit headwinds. Oculus still has not shipped the Rift (which I predicted) and I think we will see less consumer adoption than many think when it does ship. I’m not long term bearish on VR but I think the early implementations will disappoint.
  2. The Apple Watch was a flop. This is the one I took the most heat on. So I feel a bit vindicated on this point. Interestingly another device you wear on your wrist, the Fitbit, was the real story in wearables in 2015. In full disclosure own a lot of Fitbit stock via my friends at Foundry.
  3. Enterprise and Security were hot in 2015. They will continue to be hot in 2016 and as far as this eye can see.
  4. There was a flight to safety in 2015 and big tech (Google, Apple, Facebook, Amazon) are the new blue chips. Amazon was up ~125% in 2015. Google (which I own a lot of) was up ~50% in 2015. Facebook was up ~30% in 2015.  Only Apple among the big four was down in 2015 and barely so. Oil on the other hand, was down something like 30% in 2015 and gold was down something like 15-20% in 2015.

Here’s what is less clear:

  1. Bitcoin had a big comeback in 2015. If you look at the price of Bitcoin as one measure, it was up almost 40% in 2015. However, we still have not see the “real decentralized applications” of Bitcoin and its blockchain emerge, as I predicted a year ago, so I’m not entirely sure what to make of this one. And to make matters worse, we now seem to be in a phase where investors believe you can have blockchain without Bitcoin, which to my mind is nonsense.
  2. Healthcare is, slowly, emerging as the next big sector to be disrupted by tech. The “trifecta” I predict will usher in an entirely new healthcare system (smartphone becomes the EMR, p2p medicine, and a market economy in healthcare) has not yet arrived in full force. But it will. It’s only a matter and question of when.

So, I feel like I hit .500 for the year. Not bad, but not particularly impressive either. But when you are investing, batting .500 is great because you can double down on your winners and stop out your losers. That’s why it is important to have a point of view, ideally one that is not shared by others, and to put money where your mouth is.

Health Care’s Inflection Point

The Gotham Gal looked up from her laptop yesterday and said to me “I’m seeing a ton of health care deals right now.” I looked up from my Kindle app and nodded.

Mary Meeker’s slide deck addressed this is bit. Here are a few of the big points from it:

Healthcare is now $2.8 trillion in the US, which represents 17% of GDP

Healthcare is being consumerized

Healthcare is being digitized

Digital Health Venture Investment was $1.9bn in 2013 (out of a total of $24bn)

I listed health care as one of four “sectors” in my LeWeb talk last fall and when asked recently what excites me most, I mentioned the “mobilization of health care”.

The Gotham Gal has been making a bunch of these kinds of angel investments this year. She’s closed two and has a third in her pipeline. That’s somewhere between 25% and 33% of her investment activity right now. As Mary’s data shows, digital health is approaching 10% of all VC activity.

At USV, we’ve been looking hard at this sector but have only made one investment so far, in HumanDX. Albert explained the investment thesis behind HumanDX here.

We’ve made a few other offers but got outbid pretty badly on them. There is a lot of heat around this sector right now.

We are looking for networks of users, patients, doctors, and other stakeholders in our health care who can transform the way health care is delivered. We only have one game plan at USV and look to play it in every market opportunity we see.

I am pretty certain the intersection of the Internet and mobile, the digitization of the health care system, and a desire for people to take more control over their health is going to be one of the biggest investment opportunities we will see in my lifetime. And its game on.

Open Source and Our Government

A couple days ago, I saw a tweet by Henry Blodget and replied:

I am really upset by the problems with Leaving aside all the issues with Obamacare, and I hope and pray this discussion does not downgrade into a debate about that, I am very excited about the potential of marketplaces and marketplace economics on the price, availability, and transparency of healthcare insurance. It is way too complicated to buy healthcare insurance today and it costs way too much. The Internet and the power of marketplace economics has the potential to change that.

But our government has badly botched the construction of and is now proposing a tech surge to fix it. More people, more money, and more promises thrown at a badly broken process. This will end about as well as Afghanistan and Iraq.

I'd like to suggest another way. Open source the project, or at least all the components that easily lend themselves to open source. I think that some of it may already be open sourced. But instead of hiring an army of contract developers who will cost us so much money, harness an army of volunteers, who are likely better engineers, who will do the work for free.

That's what is increasingly done by technology companies and so much of the software that runs the web these days is open source. Why can't the software that runs our government be open sourced too? If you think this is a good idea, you can sign this petition. I signed it yesterday.

There is a lot going on in this area. My colleague Nick posted this link on today. GitHub now has a "subgit" on government projects. That's awesome and I hope we see the codebase show up there soon.

Withings Scale

As I've gotten into my 50s, something has occurred that has never been an issue for me, I've put on some weight. Nothing earth shattering but enough to get me focused on my weight for the first time ever.

So in the spirit of "you can't manage what you can't measure", I decided to get a scale. And because my friend Naveen is such a fan of the Withings scale, I went for that.

The Withings scale is a thing of beauty. It is sleek and looks great in my closet.

The scale measures your weight, body fat %, pulse rate, temperature, and CO2 levels in your home.

It connects to the wifi in your home and communicates with the Withings app on your iPhone and Android. You never have to connect anything to anything. The data flows over the air from scale to phone. The app provides a timeline of your key stats and gives you goal settings for them.

It's geek and chic at the same time. I'm into it and thought that some of you might be as well. Like most things, it is available at Amazon.


There are all sorts of wellness apps for mobile. Some record how much you workout. Some record how much you eat. And so on and so forth. In the aggregate, I think wellness is a great category for mobile. Your phone is a watchdog and a reminder and recommender. I think wellness apps can and will make a difference in living healthier lives.

But there aren't many wellness apps that are focused on the impact of mobile phones on our health. There are a number of things that mobile phones bring into the equation that may not be good for us. Listening to loud music on our headphones may be harmful to our hearing. Texting while driving, biking, or walking may be harmful to us and others. And then there's the issue of the radiation that mobile phones produce.

This last issue is where Tawkon has been focused. Tawkon is a bunch of smart Israeli scientists and engineers who have built algorithms that run on a mobile phone and predict the amount of radiation your phone is emitting in real time (and over time). They've been around for a few years and they have correlated their algorithms with real laboratory testing to insure that their predictions are accurate.

I met with the founder, Gil Friedlander, last week and during our meeting I downloaded Tawkon to my Android phone. I've been using it since. Most of the time it just runs in the background and I forget it is there. But every once in a while, it wakes up and alerts me to take the phone away from my head, put it on speaker, or put on a headset.

On friday afternoon, I was in my apartment where I get poor reception, and I was doing a few conference calls. In each case, Tawkon alerted me to the fact that I should not do the call without a headset and I took  the advice.

Tawkon also aggregates my radiation exposure and phone activity over time and keeps a record of it. This is what last week looked like for me:


You can also track family members so you can be a nagging spouse or parent. I suggested that the Gotham Gal download Tawkon for that exact reason.

Unfortunately Tawkon is not available on iOS. Take what you want from that fact. So I can't get my kids on Tawkon as much as I'd like to. I really can't understand why Apple would not approve a wellness app like this but iOS is Apple's world and they can decide who gets to play in it and who doesn't.

As with any app that runs in the background, I've been concerned about its impact on battery life. I look at what apps are using battery regularly and have not seen Tawkon on that list and I also have not noticed any difference in battery life since I have installed Tawkon. Of course, I've only been using it for a week so I can't say with 100% confidence that this is not an issue.

Here's a picture of me in the meeting with Gil practicing good cell phone hygiene. I have one of those handsets in my office and my home. I use them all the time.

Fred on headset

Tawkon is available on Android and most Blackberry phones. You can also put it on jailbroken iPhones. Give it a try and let me know what you think. 

The Rise Of Consumer Centric Healthcare

Nearly three years ago, we talked about Consumer Centric Healthcare here at AVC. I keep coming back to this central idea:

a guiding principle of any reform should be to put the consumer, not the insurer or the government, at the center of the system.

So when I read this morning in the NY Times that medical costs have been leveling off over the past few years, it got my attention.

I particularly like this part of the Times article:

Many experts — and the Medicare and Medicaid center itself — point to the explosion of high-deductible plans, in which consumers have lower premiums but pay more out of pocket, as one main factor. The share of employees enrolled in high-deductible plans surged to 13 percent in 2011 from 3 percent in 2006, according to Mercer Consulting.

I’m a huge fan of high deductible plans and think that they, along with some sort of health savings account that rolls over unused account balances, is a big step in the right direction to put consumers in control of their own medical expenses and decision making.

There are other things that would be part of a comprehensive consumer centric approach, including wellness incentives (ideally driven by self monitoring/reporting technology), accountable care, and efforts around education and transparency so consumers can make their own decisions. Clearly the Internet can make big contributions in all of these efforts.

It is ironic that consumers are starting to take control of their own medical spending at a time when our country and our courts are debating the wisdom of a large expansion of our government’s role in our medical care. It reminds me of the adoption of the open source model in software at the same time as the government’s case against Microsoft. Guess which one had the bigger impact?

None of this should suggest that I am against providing for those who cannot afford their own care. We can and should do that. But there is a difference between the funding mechanism and the decision mechanism in health care. The latter should be in the hands of the consumer as much as possible in order to restrain health care costs and maintain/improve the quality of care in this country.