The InSITE Talk Last Monday Night

The folks from InSITE filmed my talk last monday night. Their YouTube channel is here.

In this 15 minute section of the talk, I talk a bit about how we are looking at healthcare, payments, and work markets, which are three of the big themes we are working on this year.


Comments (Archived):

  1. Shaun Dakin

    Thanks for sharing.   Haven’t payments been on the top of people’s radar since the first dot com boom.  Flooz anyone ? 🙂…I was part of the dot com boom in the 90’s as one of the team members that put tracking on the internet at… My memory is that much of what we talked about in those good “old days” is exactly what we are talking about today.Shaun DakinCo-Founder@ReverseRobocall:twitter – Giving the power of the robocall to the citizen.  If politicians can robocall us, why can’t we robocall them?

    1. fredwilson

      back to the future!

    2. Carl J. Mistlebauer

      The first boom was a different time, credit was easy no one ever dreamed that things would change.  Now we have OWS and everyone hates bankers and finance folks so using cash as a payment (different processing methods not different currencies) is obviously an idea who’s time has come.  The reality is today we do have reverse robocalls, examples would be the Tea Party and the internet battle over SOPA.  Robocalls to politicians have been replaced by online movements.Healthcare will be the “biggie” that will resist the outside “disruption” that Fred is so enamored with.Not really sure about the “work” theme; still don’t understand that one.  I would think that it would involve something that changes the thought process from employers as “job creators” and moves the focus to employees as “value creators” or sort of taking the ideas of consumer centric retail, where the consumer is the leader rather than the retailer to the workplace (at least beyond the niche of programmers).

      1. William Mougayar

        Carl- See the transaction costs theories of Coase, and there lies the potential for WorkMarket. 

        1. Carl J. Mistlebauer

          William, that is what I have been reading since you posted it and I am trying to get my thoughts around the idea using my own experience. The sticking point for me is that some tasks, payroll, accounting, software/tech, art/design can be contracted out and the cost/benefits are easy to list. Then you have tasks such as sales that are contracted out (salespeople as independent contractors) that really can be nightmares from my perspective and then I have to do something with managing contracted out production. The big sticking point is that in an information economy contractors make sense but in a manufacturing economy contractors have split loyalties.

          1. William Mougayar

            I’m sure there are complexities involved, but with disruption, everything is up for grabs I think.

          2. Carl J. Mistlebauer

            I think sometimes “disruption” is more an opinion than a fact:http://www.businessinsider….

  2. testtest

    open source business models are based around value-added.E.g RedHat linux based on CentOS linux. RedHat being the commercially supported distribution.Wordpress. With services such as ValutPress for backup.   to denigrate free in information businesses is a mistake. the most compelling companies often have a free component.they also work at scale. it’s tough to make a ton of money without scale.

    1. fredwilson

      yup, agree with all of this. but of course, free is a great way to get scale

  3. Rohan

    Particularly interested in Dwolla’s progress.Nice point about Facebook and what’s ‘hot’ now vs what’s hot in the future.Reminds me of the Wayne Gretzky quote ‘I skate to where the puck is going to be, not where it has been. ‘

  4. JimHirshfield

    Work markets…hmm…haven’t heard you mention that before. Examples in your portfolio already?

      1. JimHirshfield

        I think they got the right domain name. ;-)On Mar 4, 2012 9:15 AM, “Disqus” <>

        1. fredwilson

          yes they did

          1. skysurfer172

             I was the CTO for Evan Sohn’s Salesconx in 2008/9. We raised  an initial round and was looked at by Spark (Mo spent some time with us). Jeffrey was involved in some way financially  before Workmarket took off. I’m wondering if Salesconx was too early to gain traction or just too niched in the sales vertical??

          2. fredwilson

            Getting a lot of adoption on the demand side is the key

          3. skysurfer172

            Agreed, the demand seemed to be there, it was just difficult to get them to commit (and pay). Very frustrating but also enlightening experience overall.

        2. Donna Brewington White

          I love that name.  Really brilliant.

      2. Carl J. Mistlebauer

        I looked at this the first time you mentioned it and I am so tempted to explore it but as they say, “my plate is full,” and right now my desire to explore and learn new things has to take a backseat to a whole host of other priorities.How many companies “managing” work are non tech?

    1. William Mougayar

      Jim….where have you been 🙂 There was at least one blog post on them.

      1. JimHirshfield

        The memory banks ain’t what they used to be.Also, as a category I was looking for multiple examples …wasn’t thinking that was actually the company name.

        1. fredwilson

          Mine aren’t what they used to be either

          1. JimHirshfield

            Can we move to the cloud as we age?

          2. fredwilson

            I’m gonna need some solution!

          3. Richard

            Tongue in Cheek remarks on memory? Age related memeory loss (particularly at 50) is a preventable and reversalable. If the group is interested in taking part in a protocol (supplements and food selection), let me know.

          4. William Mougayar

            Huh? If that is preventable and reversable, that’s the biggest invention of the century, ref: Alzheimers. 

          5. LE

            “Barleans Omega Swirl”I’m not sure exactly what else this stuff is good for (attached photo) I don’t take any vitamins or do any wacky holistic stuff.But I saw this story on NBC the other day about fish oil (and yes I know they have one of these reports everyday and often it’s reversed by another report):…So when I was in  Whole Foods the other day I decided to pick up some fish oil. To my surprise this tastes great. It’s almost like desert. I highly recommend it (even for the placebo value).It’s pretty expensive at Whole Foods. If you end up liking it Amazon is much cheaper. (I calculated it would cost $50 per month I think ..)Edit: (per @waldstein comments below):Holistic = wackyVitamins = who needs themfish oil = something new that is good for you.1) Word “wacky” before holistic isn’t mean to imply that everything holistic is wacky. I mean “wacky” holistic like “wacky wife”. Not all are wacky.2) “Vitamins” I try to get appropriate vitamins in food. Just my personal leaning. Have seen people who take vitamins with 20 bottles though. (To me I would apply the word “wacky” to that behavior.)3) “Fish Oil”. I’ve known about this for years. I used to take these little fish oil packets but stopped doing that.My mother is in her mid 80’s and super healthy. I remember her reading Rodale Press (prevention) back in the 70’s. But she is minimalist with this stuff. She also does the treadmill every day. Was in the hospital the first time last month for something minor. Never before since child birth (AFAICR)Sorry if I gave the wrong impression.

          6. fredwilson

            Hmm. Might have to try it

          7. awaldstein

            Holistic = wackyVitamins = who needs themfish oil = something new that is good for you.We need to chat my friend 😉

          8. JLM

            I have been using this stuff in my daily smoothie for years and it is also good for your joints.  I also use it for salad dressing along with flax seed oil.

          9. awaldstein

            LEI was trying to find a bit of humor. My bad.I should stick to community and marketing and swear off comedy ;)Just a huge believer in exercise, nutrition and that we need to define the world each day with us in the center of it.

          10. LE

            We need more comedy. Don’t stop that.Truth is you definitely uncovered my bias in what I wrote even though I defended myself.  

          11. Curiousgeorgette

            Rich is correct. Even Top Tier medical schools are exploring treating disease with nutrition.   There are numerous MD PhDs subscribing to the theory that there are far fewer causes to disease than we originally thought,  number one on all their lists is inflammation.  See below for an example: Curcumin inhibits formation of amyloid beta oligomers and fibrils, binds plaques, and reduces amyloid in vivo.AuthorsYang F, et al. Show all JournalJ Biol Chem. 2005 Feb 18;280(7):5892-901. Epub 2004 Dec 7.AffiliationDepartment of Medicine, UCLA, Los Angeles, CA 90095, USA.

          12. John Revay

            Vitamins = both my grandmother ( I think 98 yrs old before she died) & my wife’s grand mother (90+ and still living)….both consumed many vitamins and swore by them.When I mention vitamins to my DR – he said the jury is still out.

          13. FAKE GRIMLOCK


          14. Matt A. Myers

            I can’t stand fish oil – mainly fish burbs.I take flaxseed oil.I just replied a bit deeper into it here,…

          15. Rohan

            Check out 😉 Might help.I love the service simply for adding some variety to my breaks.. 🙂

        2. John Revay

          I just turned 50 a little while ago …last few years…when talking w/ DRs during annual physical…I try to describe my memory loss by telling the DR, I feel like my memory is on a hard drive, and the program knows that data is located on the drive somewhere…but it like there is a mssing sector on the drive and the program can not access the data.I just get a blank look back – I don’t use that analogy any more when talking w/ DRs – they don’t get it.Last time – the DR just said – John you are getting older!Agree w/ you re: great domain name.

          1. JLM

            High brain activity “games” such as bridge, chess, FreeCell, etc apparently have a beneficial impact on short term memory.I read an article — can’t remember where haha — that people who create memories in a multi-sensory manner (reading, writing, speaking simultaneously such as taking notes while speaking on the phone) retain their memories longer and better.

          2. John Revay

            YUP – as I age, I hope it is not too late to start playing some of these, my father in law always does cross word puzzles…

          3. leigh

            Agree with John below — crossword puzzles are suppose to have huge benefit to short term memory.  

          4. JimHirshfield

            Scares me to think what aging doctors have forgotten.

          5. Donna Brewington White

            John — to your comment below re vitamins — I would encourage you to think more in terms of “supplements” than “vitamins” per se.  And surprisingly being an MD does not necessarily make someone knowledgeable about diet and nutrition.  You may have to seek that advice elsewhere.  In fact, you most likely will.  I have a lot of experience with this because I have a son with a gastrointestinal illness.  I have been aghast at the medical advice that we have received that has not included a nutrition component and has only involved a medical or surgical solution.Physicians and nurse-practitioners with a nutritional or more holistic focus can be found.

          6. Matt A. Myers

            Try flaxseed oil. Take a teaspoonful initially for 5-7 days.If it doesn’t cause you to have so much mental energy that you’re exhausted by the end of the week, then go up to a tablespoon per day.Flaxseed oil is very good for focus – increases your ability to focus and process information.I used to take a tablespoon every day but that gave me more energy than I could handle at the time. I’d take it in the morning – meant to try taking it at night but haven’t tried.And if you try it, let me know how it goes! 🙂

          7. LE

            “I used to take a tablespoon every day but that gave me more energy than I could handle at the time.”No shit. I’ll have to try that.

          8. Matt A. Myers

            @domainregistry:disqus – Just to clarify, that’s take a teaspoonful Daily for 5-7 days. 🙂

  5. William Mougayar

    Ronald Coase is the name you were trying to remember. His theories on the nature of the firm and transactions costs and social cost are even so much truer now. I can see how his theories are front and center in Dwolla, WorkMarket and the next Healthcare company you’ll invest in.… He’s still alive and age 101. If one understands Coase’s theories, it’s really powerful stuff.

    1. fredwilson

      wow. he’s still alive. that’s awesome

      1. William Mougayar

        A recent interview from a year ago, on China…. Here’s a quote from him “You don’t know what you can learn until you try to learn.” Where is Rohan?

        1. ShanaC

          sleeping in?

          1. William Mougayar

            Or travelling? 

          2. Rohan

            Hahaha.That’s a really nice quote, William.Entered into my quote-o-pedia 😉

          3. Rohan

            Lol.More like working all through Sunday afternoon! 😀

          4. ShanaC


      2. Robert Thuston

        would enjoy hearing more on Coase’s theory

      3. Robert Thuston

        especially how it applies to USV’s investment portfolio.

    2. JamesHRH

      William – really really fantastic stuff. Thanks for the link.

    3. laurie kalmanson

       coase is awesomesee also free riders, tragedy of the commonsold suburban developments were allowed to build without planning for sewers, schoolssmarter development would apply math: x number of people would require y$ in new infrastructure and education facilities

    4. laurie kalmanson

       also generally credited with being the foundation for a lot of markets that didn’t used to be markets — carbon credits, etc

  6. ShanaC

    It’s sunday?

  7. ShanaC

    Wouldn’t Coase’s theorem also work with issues of time – time gets expensive in transactions?

    1. laurie kalmanson

       fedex is the perfect example — nobody knew they needed it absolutely positively overnite until they did

      1. ShanaC

        right, but I keep thinking that as transaction costs go lower, time transaction costs go higher. Just because computers offload some of the work doesn’t mean the cost of the time spent is equal to the costs that dropped away with a computer

        1. laurie kalmanson

          the time cost is dispersed. we book our own tickets now; we used to call travel agents. except, of course, the new openings for highend travel agents.

  8. Tom Labus

    Maybe core wellness should be a “free transaction”and build out from there for specific aliments.Incentive medicine is being used in England.  Docs can get bonus bucks if they get their customers off smokes, in shape, etc.

  9. jason wright

    I’ve read that the Russian government has been looking at encouraging an international payments system to rival Visa and Mastercard. Perhaps something new will emerge from Moscow for frictionless money transfer. Clearly they see a downside to having a percentage of their wealth being ‘extracted’ by an American system.This is somewhat similar to the current petrodollar standoff between the US, Israel, and the usual suspects on the one side, and the ‘dissidents’ on the other. Iran’s oil bourse disruption model has certainly got the incumbents worried, worried enough to risk a tactical military strike to protect their financial interests.

  10. ShanaC

    I wanted to address something you said about healthcare….Right now I am planning a web app for myself to take down my family history.  There isn’t anything currently available, and I have to do a complex one for a specific doctor.  I was given an 8 page form initially to do this, which I know will be typed up anyway.To release it to the public would require me to become HIPPA compliant which is extremely complicated and requires knowing people who know all sorts of things about cyber security (which is fine, I happen to have a friend getting a masters in that part of CS at NYU-Poly who may help). Forget the fact that this would be a great tool for genetic counselors – how do you deal with government regulations for just person to person healthcare/diy forms is incredibly complicated. It’s a humongous cost that I can’t figure out how to hack my way around (from a legal perspective). And it is probably turning people away from trying.

    1. fredwilson

      I need to understand HIPPA and to whom it applies

      1. JamesHRH

        The issue with attacking Energy, Payments or Healthcare is that you are not able to just connect the buyer/seller on a platform.You need to keep Uncle Sam happy to – and that’s a big difference, IMO. 

      2. Antony Evans

        HIPPA applies when you are either managing information for or providing information to a healthcare provider, eg a doctor. Specifically your information must meet all of the following criteria:1. Information relates to an individuals health2. The information relates to the provision of health care3. A covered entity is involvedIf you are just collecting health information and not sharing it with a provider, eg sharing it peer-to-peer, then it doesn’t apply.

    2. LE

      A great opportunity.  I don’t see this as insurmountable in any way (as opposed to fighting the entertainment industry which is a well oiled machine).The barrier to entry is “effort” and it will/has scared off many people. I see that as a good thing not a bad thing (assuming you can assemble the right team of course).I attended a show last year which was established vendors selling EMR systems to Physicians and practices. The vendors and sales approaches were so quaint it reminded me of the early 80’s and PC software.

    3. laurie kalmanson

       it might be simple as long as the app doesn’t hold the datamake the app something to walk the user thru filling out the equivalent of a spreadsheet, which exports to a doc that the user keepsthe user is free to print it, email it, etcthe app is just a framework; it never holds data, just the equivalent of a formatted xls with local storagedoes that help?

      1. ShanaC

        Yes, unfortunately, the biggest value comes from storing the data (you could resell the data back to research institutions for research reasons if you have a large enough sample set)There are also issues of user experience (I don’t know the answer to some family history question, so I email a relative and come back to the form later)If it weren’t for that, I would totally agree with you.

        1. laurie kalmanson

          email is private

        2. laurie kalmanson

          revenues from reselling data raises the confidentiality issuessubscription service/fee for service: private

          1. ShanaC

            I know, but I also feel morally compelled – you don’t realize how bad the state of research is for these areas until you start talking to people getting phds in these areas – they use statistical approximations instead of large bodies of data

    4. Kasi Viswanathan Agilandam

      I am not very sure what you are talking about (your requirement)… but there are abundant no. of tools available as open source software in healthcare (EMR, HIS, RIS, PACS). and there are hundreds of vendors making similar software. You can download one of the open source software and modify to your requirement. You don’t have to start from scratch. In my opinion there already exists a software with 80% of your requirement!!! Yes. Regulations will be a big hurdle to cross and also you may have to learn about HIPAA and HL7 and IHE protocols. Let me know if you need any links.

      1. ShanaC

        Got a name of a very simple medical software package to look at, considering I don’t need to deal with full health records, medications, anything of that sort?

    5. leigh

      I forgot Shana — but i have a friend who is working on healthcare forms for emergency rooms on the ipad.  Maybe i can put you in touch with him about what you are trying to do?  There is a great use case for it and in particular there is a huge research project in Toronto that is looking at genetics around specific populations.  It would be interesting to connect all three of you.  

      1. ShanaC

        I’m still planning out this form (it started from a very particular use case to realizing it could be more generalized). I’d love to hear their thoughts.

        1. leigh

          i’ll reach out to him and ping you back 🙂

          1. ShanaC


    6. ShanaC

      apologies to everyone – its HIPAA, not HIPPA (damn names)

  11. RyanComfort

    USV’s investment thesis of large, engaged networks dovetails well with Clayton Christensen’s theory that the creation of “facilitated networks” will play an instrumental role in the disruption of healthcare.  And, like the comment in the video about competing with existing establishments, Christensen also suggests that the disruption has to come from outside the system.  He has a whole book dedicated to healthcare, The Innovator’s Prescription… which applies his theories on disruptive innovation to health care.  A fantastic read.  

    1. fredwilson

      He’s one of my gurus

      1. RyanComfort

        Not surprised to hear that. I actually thought about USV’s investment thesis quite a bit as I read his book.In my view, the “job” that technology can be hired for is to help consumers understand, coordinate & manage their health care. The current system and structure makes that extremely challenging and has created a massive pain point for everyone (and not just consumers, but also many of the other stakeholders).I think the most exciting opportunity lies in the creation of facilitated networks. This network would (at least, initially) include many of the existing establishments andinstitutions. However, they way the consumer interacts with each of them would change the dynamic of the delivery of care and services.Like you, I believe disruptive change will be driven by a large group of engaged users. For health care, these users need to be empowered with information and tools that helpthem “quarterback” their care more effectively. Creating and establishing this platform is no doubt a bold task. However, initially focusing on a niche issue would not only prove out this model, but also help build out the facilitated network.

    2. laurie kalmanson

       going to buy that right nowcreate “groups” that sell to anyone “group” insurance at “group” ratesso many large employers are already the equivalent of self-insured; they’ve created their own groups

  12. Mike Kijewski

    Really glad to see you talking about healthcare again. It’s prime for disruption from people with an “internet mindset.” Glad to see USV, First Round, etc. talking about it seriously.

  13. Patrick Campi

    Great talk Fred. I was excited to hear your input and explanation about Dwolla and the POV on the disruptions that are coming to the payments area. I’m a merchant/innovator who has been coming at this from a pain position. Processing costs are just to damn high for most small businesses. Citigroup did a recent field study in Mumbai where paying with your phone has been in operation for some time. The study found an increase in usage at 6X that of traditional CC usage. 6 times more usage means far more processing costs. More pain. My team and I have been building our model for close to a year now and have been talking with the people at Dwolla for some time. 

  14. John Revay

    Fred, thanks for sharing the video – I enjoy watching these/watching you think and comment about investment thesis, start up community ( World, US & NYC) etc. – as I think you said ad lib w/o any prepared comments.Two questions1. FB – company has been in existence for 8 years…now might be the wrong time to start a company that competes w/ FB ( or at least one that might be funded w/ USV)….Would you include companies/apps like Instagram, & Pinterest in that comment…..Maybe thesis does not allow you to do deals like these any more> more 8 to 10 years out.  2. Dwolla – it sounded like you made a comment ” we got sucked into Dwolla” talking about their biz model – $$ transfers for free and making money on the value added services….It sounded like buyers remorse?  So there are 5 GPs @ USV do you all vote on each deal – majority wins

    1. fredwilson

      No buyers remorse at all. It was an attempt at humor that failed apparently Instagram Pinterest as well as Path Foursquare and others are examples of the fragmentation of social networks and Facebook. There are going to be some interesting companies created in that theme

      1. laurie kalmanson

         fragmentation can become channels on a platform that allows, to use metaphors from entertainment, sports/cooking shows to be streamed separately but a user might still like both

      2. John Revay

        I started signing up for Dwolla after reading your “payments day” post. i chickened out after they started asking me for credentials of my life – re: much more than name, rank & serialDOB, Soc#, …..I was worried I didn’t know this company well enough to share this much data about me.I was also taken back a little when reading about the company…it sounded like all transactions were processed through some mid west credit union…just wondering how well that will scale.I probably will go back & share my data, sign up & give it a try.



        1. fredwilson

          i don’t like to invest in the consolidation phasethat means investing in big companiesi’m a startup investor

          1. FAKE GRIMLOCK


          2. fredwilson


          3. jason wright

            Has anyone dipped their toe in this ocean yet? I have the feeling that everyone is gathering on the shore but waiting for someone else to be the first to pluck up courage.The problem with healthcare is that the players in that industry have no incentive to change – it’s too profitable. Who would have the inside knowledge of how it works but be willing to take that knowledge and disrupt? In the web tech sector investors naturally seem to want people with some knowledge of coding or other useful skills like that. Someone from outside healthcare, how are they going to be able to convince a VC that they have the insight, the knowledge, the relevant skills to successfully deploy a revolutionary disruption model?

  15. jimmystone

    Hi Fred, new to the blog. You briefly mentioned energy as a vertical with a lot of opportunity. Is USV looking at making any energy investments in the short- to medium-term? Have you written any recent blog posts with your view on the industry? Thank you!

    1. fredwilson

      I think cleanweb is interesting. Still coming up the learning curve though

      1. jimmystone

        Thanks! Look forward to reading more of the blog.

  16. Aviah Laor

    This is huge. We had engaged social networks.Now payments, healthcare, work! Next year government…. Job done

    1. fredwilson

      We are very interested in government innovation. We are doing a “sessions event” next month to dig deeper on that

  17. Richard

    thanks fred! Thougts on the folllowing?Healthcare – the area for disruption seems to be the first $4000 of individual expenditures (which doesn’t require an intermediary with high deductible insurance. ) This meets all of Fred’s incestment criteria, large market of engaged users …..The next level of expenditure 4k-15k is our healthcare premiums. Only better lifestyles will change this (not likely).The next level 15k + is spent on hospitalization. This area is ripe for disruption too, thouhh u needs participation from the current healthcare system.

    1. fredwilson

      That’s a good framework. I like it!

    2. laurie kalmanson

       prevention is the thing to find a way to fund; it’s something that benefits everyonevaccines are generally well accepted; if my neighbor is vaccinated it helps me, tooscreening/treatment early for chronic preventable and treatable diseases prevents illness and reduces costs later — but there has to be a mechanism to fund it. right now, the economic game is to pass the potato. if health/healthcare is viewed as one pot, instead of a pot that insurers can skim off healthy people and deny sick people, then overall health becomes more economically important and less something that can be excluded from the model by saying, well, sick people are just out of the game

      1. Richard

        You would think that the evidence supports your position on screening, but the data isn’t so clear. See Dr. Gilbert Welch’s Editorial (New York Times, Feb 28, 2012) arguing that screening the healthy does NOT promote health.

  18. Matthew Lenhard

    It seems as if the middle man or distribution system is being replaced in most industries. I’m guessing and I’m sure others have said this as well that the next ones to be replaced will be the movie and music distribution systems.Dwolla sounds like it could be quite the disruption if it does reach the goals you mentioned.  A free payment system would have seemed crazy to me before, but you learn something new every day.Anyway loved the talk, it was all very interesting.

  19. DonRyan

    Outstanding. I always look forward to watching this. 

  20. zschwarz

    Thanks for coming to spend the evening with us Fred! The “InSITE State of the Union” was a total highlight.

  21. Ori. B

    About HC, and better understanding the product we buy.Here’s an idea..Like you credit-score , oneshould have a health score ( or a “wellness score” , and all health expenses should be attached tothat.( the insurance companies do have something like this – but it should be exposed and open to everyone) Strong motivator.A lot of new wellness ventures and gizmos could tie into it such as  withings to runkeeper + of course all the traditional info… There are quiet a lot of new startups with a gaming theory approach to motivating you, but if one could actually calculate a score that would de facto be able to impact your cost of HC… that could be quite powerful.BTW, it ties into another point you talked about … a new kind of insurance company.It should be adaptive and relative.i.e how much you haveimproved vs. your starting condition. For example if you are a Diabetic, andkeep sugar levels low, that counts as much as a healthy person running amarathon. Etc…Love to hear what everyone thinks.

    1. fredwilson

      I’ve been talking about that idea to lots of entrepreneurs lately. Haven’t convinced anyone to do it yet

      1. Ori.B

        maybe we should talk :-), I’m one myself and am starting to be very passionate about the subject.

        1. fredwilson

          send me an email

          1. Aviah Laor

            same idea for taxation: a corporate with low health score (for employees/environment) pay higher taxes, and vice versa

      2. Richard

        I’ve been working on this, my approach is to reframe the score to “stopping/ending illness” (people’s eyes seem to glaze over when it comes to health scores). The score starts at a mean baseline, increases with positive activities but also reverts to the mean with each unit of time (i dont know of anyone doing this) unless the user provides a positive event. There good reversion to the mean algorithms that I am working with.

      3. William Mougayar

        But that idea is not very disruptive by itself. Wellness management on the Internet has been tackled since the late 90’s. Something new is needed, and whoever figures it out would be a winner.

        1. Carl J. Mistlebauer

          I think if one could find a way to development a “wellness” management program that would capture and store a person’s test results every time they visited a doctor or had an annual physical and then would provide some basic analysis of the data would be a great place to start.This program would be of benefit to not only the consumer but also the doctor and the insurance industry.

          1. William Mougayar

            I think Microsoft & Google were trying to tackle parts of this problem with varrying degrees of failure. But it’s very possible the solution lies with more direct empowerment of the consumer. My health info in the cloud.

          2. John Revay

            And Google cancelled their project in this space a few months   

          3. Carl J. Mistlebauer

            To truly grasp healthcare and the concept of “direct empowerment of the consumer” we need to realize that the consumer is not the decision maker in the healthcare matrix; but rather almost a commodity.If you have health insurance that is provided by your employer then what incentive does the insurer have to satisfy the demands of the patient? Most health insurance companies see either the insurance agent or the employer as their “consumer.”Who is the “consumer” from the prospective of a healthcare provider? Its not the patient.That is why I always refer to the patient as a “commodity” in our healthcare system.Thus Microsoft and Google failed in their attempts because they were thinking “direct empowerment of the patient” who is, for all practical purposes not the “consumer” in our way of thinking.

          4. leigh

            as in I own my data not the gov’t/doctors?could you imagine?  malpractice insurance would go through the roof.  

          5. Carl J. Mistlebauer

            Oh, its not only malpractice, its also the fact that doctors do not really like being second guessed by patients.

          6. William Mougayar

            And they don’t get paid for answering their emails or tons of questions either. There’s prob a secondary market for medical advice that take the time to Q&A with the patient.

          7. Carl J. Mistlebauer

            I have been involved in health insurance for 20 years as an employer and not once has a health insurance company ever sent me anything that resembled a “…we want you back” advertisement; its easy come easy go.I do agree that the secondary market for medical advice is a real need, but once again, it is only going to be successful with actual data. I remember when my doctor wanted me to have an annual physical so we would have a “baseline” to refer to (I have gone to the same doctor for 21 years) and every year I have another physical but yet I as the patient have no clue what the baseline was or is and I have no idea, after testing, where I stand, for better or worse. The only things I know is that my weight has not changed in 21 years, my blood pressure and pulse are the same. Because all of that data is gathered before the doctor comes into the room….I really want to work with or partner with my doctor to manage my wellness but I really can’t without data.I even promised my doctor I would never sue him and that just brought a smile to his face (we are personal friends) but he still has the stereotypical mindset of doctors.

          8. leigh

            No kidding. i was helping out a friend with an issue at an Emergency waiting room and the nurse told me “not to bother the doctor bc he was in a bad mood” — I informed her that my dad, step dad and all my uncles are all doctors, and their bad moods – ha par for the course. As my step dad says, if you are going to go to the hospital alone (meaning without an advocate to jump up and down on your behalf) these days, you might as well order the hurst to pick you instead of a cab.

          9. Carl J. Mistlebauer

            I am quite knowledgeable of nutrition and exercise, I am also quite knowledgeable about our healthcare system and our insurance system, but with all this knowledge I really have no clue as to what my overall “wellness” is.THAT is the flaw of our system and for all the talk about “diet,” “lifestyle,” and “DNA” is actually meaningless unless one has the diagnostics, the test results, to which one can measure ones improvement.

          10. William Mougayar

            Don’t get me started there. Like when you ask the doctor or the hospital Can I have a copy of my results or x-ray or whatever. And the answer is “Why”? Or “the doctor has to approve releasing it to you”.

          11. Carl J. Mistlebauer

            This is exactly why I believe the key to “empowering” the patient and or “disrupting” the status quo will actually take a partnership, maybe health care providers and patients.Whatever it is it has to start with the acknowledgement that the patient is an active participant in their own healthcare.

        2. raghuhavaldar

          it just may be possible to “crowd source” the data and results to develop a score and quickly iterate to refine it. Both processes and outcomes need to be included to make it valuable.The wellness scoring models can be used as a start, but we need to rethink the score from a “value” perspective (costs, # of sick days, pain levels, etc.) The factors may vary.

          1. William Mougayar

            that’s probably part of it, yes.

    2. Cam MacRae

      It’s an interesting idea. The primary advantage of credit scores is that they’re cheap; their predictive value is only fair, and if you believe the literature, is decreasing. The better financial institutions are moving away from credit scores and towards more detailed risk assessment in an attempt to keep their book clean. This will no doubt trickle down.A wellness score would need to have a proven predictive value or else it will simply be another well intentioned, but otherwise bullshit number to which insurers will tether your claim.

  22. Luke Chamberlin

    I changed doctors a few years ago and during my first visit the doctor pulled out his palm pilot, wrote a prescription and submitted electronically it to my local pharmacy. I had never seen this before and was very impressed.On my second visit about six months later, he wrote a paper script and handed it to me. I asked what happened to the electronic system and he told me that the local pharmacy chain canceled the system because it was full of bugs and there were concerns about complying with HIPAA.So we were back to illegible paper scripts. Progress!

  23. Modernist

    The opinion leadership in healthcare is itself a hierarchy that should be disrupted.  “White Coat, Black Hat” by Carl Elliot is an incredibly disturbing read.

    1. Modernist

      I get that wellness would more readily embrace progression, but medicine currently dominates the authoritative capital of opinion leadership.

    2. jason wright

      Every institution is a conspiracy (but I don’t like the way the meaning and sentiment of that word has been twisted in modern usage) against the public interest for private benefit.

      1. Modernist

        Yeah, when you start looking at things from a sociological, systematic point of view, it’s going to come across as conspiracy thinking.  Is it a conspiracy if it lacks a central instigator?

  24. Bala

    http://www.washingtonpost.c…I think the simplest solution to this is bring price transparency to healthcare services, force everyone to publish their prices.

    1. jason wright

      What force is that though?

      1. Bala

        The market force, I think if we could just hack a directory of Healthcare services in the US localized and publish the different prices offered by the providers vs those paid by the insurance companies. The truth comes out, my wife used to audit the hospitals and believe me some of the invoices that the hospitals send to Insurance companies makes no sense, $150 for a Syringe, $50 for Gauze used in surgery! 

        1. jason wright

          The word syringe has always made me feel a little light headed.Seven marathons – knee surgery is not cheap.I see the former PM of Iceland has his day in court starting today. Do you think it’s fair to try to hold him legally responsible for Iceland’s problems?

          1. Bala

            Well we all need out Witch Hunts, Icelanders have theirs… there are many who feel it is not fair but then again who am I to judge.I am investing in a Hip and Knee replacement hospital/hotel in Iceland so when my knee gives way I will not have to travel long to get it replaced.yes, especially those that cost $150

          2. jason wright

            I’m sure preventative is cheaper 🙂

  25. John Revay

    Sounds like a continuation of the influence that Carlota Perez had w/ you & Brad –  initial USV investment thesis.

  26. Donna Brewington White

    It’s exciting to hear you talk about work markets in USV’s future.  If ever there was a set of markets begging for disruption and a VC firm to help promote this disruption…I strongly believe that there are ways to merge the developments in social media/networking and online communities with how people find work and work finds people.  Sometimes I feel like I am right on the verge of an epiphany but am so busy doing the work that I can’t break through the curtain.  Someday I want to pick the brain of a certain large dino robot who seems to have some interesting thoughts on this.One of the reasons I have remained in executive search (besides loving what it accomplishes) is that done rightly, it is one of the methods of recruiting that retains the relational element in the hiring and recruiting process and doesn’t reduce people into being part of a cattle call.  Even those who aren’t hired often experience some benefit from the process.  But it is time-consuming, strenuous work which makes it expensive — which means that it is cost prohibitive for many of the companies — like startups — that could most benefit from the consultative approach involved. This troubles me.The way that USV handled its recruiting process a couple of years ago sparked my imagination. Still more of a cattle call, but transparent and fun — and there was some sense of community involvement to an extent.  The most recent hire didn’t have as strong a sense of this, but this may be because I felt more distant from it.   Wait…did you ever hire anyone?

    1. fredwilson

      yes, we hired two young people who will be joining our firm after they graduate from college

      1. Donna Brewington White

        Fantastic! Congratulations! When you hire people it feels like an investment in something larger than USV.

      2. jason wright

        This is the outcome of that process you embarked upon last year is it, where you had applicants send short video clips of themselves?So these two students now study for a few years knowing exactly where they will be working after they enter the world of work. Interesting. Are there any conditions attached  to this agreement? Do they need to reach a certain level of educational attainment?  

        1. fredwilson

          yes, that was the processboth are seniors in college. they will be joining us shortly and are working with us part time as their academic schedules permit

  27. Donna Brewington White

    Do I detect a shift of sorts when you talk about some of the markets that USV is moving toward?  Not so much in investment thesis, but in how these markets interact with essential aspects of everyday life for massive numbers of people.  If this is a shift, is it intentional?

    1. fredwilson

      we are looking for industries that large networks of engaged users can impact besides media/entertainment

      1. Carl J. Mistlebauer

        The reality is in regards to healthcare “large networks of engaged users” might actually be referring to government or employers as they are the ones that make the decisions in regards to coverage and pay the bills…..

        1. Donna Brewington White

          Ripe for disruption.

  28. jason wright

    I’d love to see education disrupted… big time. I can’t stomach elitism and ivy towers. Healthcare is a little different. Yes, it can be very expensive, and people are marginalized, but so many people bring about their own downfall due to poor dietary and lifestyle choices. One can’t do much about genetics (and we haven’t reached that new therapeutic paradigm quite yet) but one can do a lot by taking greater personal responsibility for health.If I was going to fall ill when traveling then I would hope to be in France at the time.

  29. Dave Pinsen

    Just got around to watching this video clip. Kind of a cliff hanger ending…

  30. Carl J. Mistlebauer

    Fred,This is interesting:… Etsy is the second most popular source of content on Pinterest…..

    1. fredwilson

      the demographic overlap is nearly perfect

      1. Carl J. Mistlebauer

        Has it translated into increased sales?I use Facebook for family and close friends and two months ago I posted about Pinterest and before I knew it all of my female cousins and close friends were on Pinterest, not one male friend or family.  One of my female cousins commented, “…I don’t know what Pinterest is all about but it sure is fun…..”Which pretty much sums it up.Since I read that article I have posted a couple of links to Etsy, now it will be interesting to see what the Facebook friends and family network think of it (I call it market research of the middle age rural America market)  🙂

        1. fredwilson

          Yes. It does translate into sales.

  31. hungrygardener

    Our take on your thesis “large networks of engaged users” and how it pertains to Africa

  32. Carl J. Mistlebauer

    This might be a good place to start looking at “disrupting” healthcare: 

    1. fredwilson


      1. Carl J. Mistlebauer

        You might also want to check in with the Nashville Entrepreneur Center, last time I went to one of their meetings it was all healthcare of course Nashville is home to HCA and with Vanderbilt Medical Center and a few more healthcare related corporate headquarters there is alot of activity investing in healthcare start ups.