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.

#health care

Comments (Archived):

  1. David Semeria

    Rigor on investment thesis and rigor on price.It’s remarkable how many professional investors have neither.

    1. fredwilson

      Its painful to be under invested right now in a sector that we know is going to be huge

      1. David Semeria

        That, as you know, is the (temporary) price one sometimes has to pay for being disciplined.

      2. jason wright

        “We only have one game plan at USV…”what’s your review process for the thesis?

        1. fredwilson

          every minute of every day

      3. Dave Chase (@chasedave)

        Fortunately (and unfortunately), healthcare moves slowly. The opportunity window will be open longer in healthcare than most other sectors.

      4. William Mougayar

        How many HC investments roughly would you like to make, to cover your bases?

        1. fredwilson

          i think four to five would be good. maybe more

      5. Anne Libby

        I have been noodging one of these firms to reach out to you again.

      6. PhilipSugar

        More painful to be invested in deals that won’t work out.

        1. fredwilson

          maybe. but we do a lot of that. it’s part of our business model

      7. LE

        Its painful to be under invested right now in a sector that we know is going to be hugeI think you have to be careful not to make investment decisions simply because of the pain you might be experiencing.I know you will say that you won’t. And didn’t. And don’t. However your emotion doesn’t show that. [1]Look at it this way. “Warren” didn’t want to invest in any tech companies because he didn’t understand tech and things (in 1999 and today) don’t feel right for what he is all about. But he has still made a shitload of money by concentrating on what he does know and what he does believe in. The key to investing is not assessing how much an industry is going to affect society, or how much it will grow, but rather determining the competitive advantage of any given company and, above all, the durability of that advantageI almost didn’t want to put the above quote because I hate to focus on the theories of survivorship bias and “oracles” who the media drools over.http://www.businessinsider….[1] This is really quite similar to when the market goes up and people feel they have missed out and then they wait 6 more months or a year and the market goes up more and they finally jump in. And sometimes it works and sometimes it doesn’t work. (Same thing happens with real estate).

  2. jason wright

    i recall receiving an unsolicited letter from a branch of the UK’s NHS (National Health Service), asking me to participate in a ‘blind’ national health study. The letter made it explicitly clear that i would receive no personal health benefit from the study, even if the study revealed an undiagnosed condition or ailment. i declined.

  3. awaldstein

    The wellness sector (some $2T in the US) is moving up from exercise and fashion to food and lifestyle and will very soon start to touch the medical changes from the ground up.It is no longer a corner case for doctors offices to not only have Xray facilities on site now but also accupuncture, Reiki and yoga in their open spaces.Healthcare is no longer just about doctors and insurance, it’s about a change in lifestyle and consumer beliefs. It is also no longer strictly about the well-to-do, but about how people choose to spend their ‘play’ dollars.

    1. Dale Allyn

      Quite true, Arnold. Even Kaiser Health is advertising the value of these alternative methods; and the Mayo Clinic has long supported the value of yoga as an important means to better health. This area is finally getting real traction.

      1. sigmaalgebra

        A whole clinic devoted just to mayo? I didn’t think that mayo was that bad! Maybe it should be Extra Mayo Clinic?I’ve never heard this before, but it has to be an old joke!

      2. ShanaC

        Meanwhile, these are still luxury itemd

    2. William Mougayar

      True. An ounce of prevention is worth a pound of cure later.

      1. awaldstein

        This is about a complete and total life style change.Trust me–with one company and one client, this is the real deal.When tens of thousands, no hundreds of thousands of women adopt slogans like “strong is the new skinny’ and spend Billions (yes that is with a B) on books, coaches, gyms, clothes, nutritionists, retreats, communities, and more–this is a societal change.

        1. Dave Pinsen

          A short video about a 67 year old woman’s success with strength training at this link:…That video is by Jonathan Sullivan, who’s an MD/PhD who moonlights as a Starting Strength coach.Incidentally, the main book on the Starting Strength method of barbell training was mentioned in an NYT op/ed last weekend (… ). That article drive the book into the top-25 on Amazon.

        2. Anne Libby

          And like Pinterest (at first) one that’s been surprisingly under the radar. What we’re seeing today began in the mid-90s, and was the second — maybe third — wave of this movement.

          1. awaldstein

            Agree–I spend a bit of my time in this sector and it is a groundswell of change being driven mostly by women consumers but broadening quickly.What’s fascinating is that huge companies in the fashion and body care industry are circling around.And a new type of nutritionists and exercise and life coach celebs are surfacing.

        3. sigmaalgebra

          Maybe what Fred wrote here is correct, but I can’t see how to support his conclusions. Maybe there can be some means of support one project proposal at a time. Maybe you are saying that this hot field will be heavily about medical fads, food fads, diet fads, and quaktopractic? We’re all going to get our spines straightened? Is THAT what Obamacare is about? I’ve been wondering. Or, maybe all the hot, new medical stuff is protecting us against all of Obama’s dangerous CO2, methane, etc.?The company Albert just invested in is running ads for people, and for one of them they want someone good with “machine learning/AI” to attack problems of sparse high dimensional data. Okay: Congratulations, guys, you just rediscovered one more time “the curse of dimensionality” already well known and explained by Richard Bellman way back there, ballpark 50+ years ago. I published a paper that did some good things with sparse, high dimensional data, but, sorry, the paper is super tough to read! You see, we take a measure space and do something like ergodic theory does …. Oh well.”Machine learning”? Sure: Statistics done badly. Statistics done well is much more powerful.AI? 99 44/100% irresponsible hype and the rest water, including the papers I published in the field.And “machine learning/AI” are the best attacks on “the curse of dimensionality”? The mind boggles!

    3. Otis Funkmeyer

      Not to derail the conversation, but your comment made me think to share that going gluten-free two years ago was by far the most obviously positive health change I’ve ever made, and lord knows I’ve tried ’em all.Whether or not it’s a fad, whether or not it’s “real,” I can say from personal experience that it has had a massively positive impact on my life. I highly recommend to everyone.The way I started was giving it up for 30 days. After *3* days, it was so obvious how much better I felt that I haven’t looked back… Give it a shot! A/B test and pivot as needed 😉

      1. awaldstein

        Thanks for the share.My way of doing this–granted I own a green blend company on the side–is-at home, no dairy, no gluten, no bad stuff.-3 days a week I do blends-til-dinner (can explain another time)-go out a few times a week and eat what I want, including yes Pizza!But its becoming more and more true that when I go out I also eat healthy as the choices here in NY are quite astounding.All natural wine, only farm vegies usually, never industrial produced meat or eggs.And I’m not an extremist 😉

        1. William Mougayar

          “only farm vegies usually, never industrial produced meat or eggs.” How is the status of labelling these products so you know exactly what you’re buying? of course, in the spring/summer when produce is being grown locally it’s easier, but I find it harder to be pure during the winter months if you don’t live in warmer climates where they can grown almost anything all year long.

          1. awaldstein

            Great questionIn season, I shop at farmers markets for all greens, dairy and meat.Out of season, for greens, I have connections to wholesales through Luli so its easy for me.I’m not a fanatic nor religious about this–just with clear intent.Labeling and certs an entirely different topic. I’ll post on it one of these days. Know it very well from both the food and wine industries. Somewhere between compromise and downright BS.

      2. Matt Zagaja

        The nice thing about the placebo effect is that it often works. 🙂

      3. Salt Shaker

        I’m a glutton for gluten (free). Six months in, perhaps psychological or perhaps not, but bottom line I too feel better without.

        1. Richard

          Give my sister a call at 718 877 2297. She founded a gluten free specialty retail store (Fit Foods Market) back in 2001. If there is a gluten free version of “it”, we have it. The foods are (gluten) free and the advice is also Free

          1. awaldstein

            gluten free is everywhere in nyc..from pizza to bagels to challah–simply a choice.

          2. ShanaC

            I’m freaked out by the extent of gluten free. I think we treat wheat badly, not that gluten is bad….

          3. awaldstein

            we need an expert, not I, to wade in on this.

          4. ShanaC

            there has been some research that unless you have celiacs or another autoimmune disease, the gluten thing is overhyped – but that the sensitivity comes from the pesticides instead.

          5. awaldstein

            you are going to need more proof than that Shana!

          6. Dennis Mykytyn

            There is no proof gluten is bad for anybody except celiac patients, less than 1% of the population. The original study showing gluten was bad has recently been retracted and the researcher now thinks it is not a problem. Gluten is the MSG fad of the 2010s, with no scientific evidence to back up the beliefs.http://www.realclearscience

          7. awaldstein

            I’ll share your links to some medical friends.I will also most likely make–>’MSG is good for you’ my tweet of the morning’ with attribution.

          8. Donald E. Foss

            MSG still triggers bad headaches, so I avoid it when possible. When I don’t have a choice or don’t know that MSG was in something I ate, I drink an extra liter of water to help flush it out. Same thing with regular soy sauce or Tamari.

          9. Dennis Mykytyn

            There is no evidence MSG is a problem. “Although the stigma of this additive may still persist, the use of MSG and other related glutamates are generally perceived by the scientific community to be harmless.” http://www.yalescientific.o…MSG and gluten are just 2 examples of entire diets/lifestyles/multi-billion $ businesses being build on anecdotal experiences unsupported by science. Basically, fads.

          10. Donald E. Foss

            The issue, for me anyway, is not the glutamates, but the sodium in each. MSG will probably always bother me, even if they took all the gluten out of it, because not my problem.

          11. Salt Shaker

            Rich, where is your sister’s store located?

          12. Richard

            Staten Island – But if you have questions about products, she loves to talk shop and is a nurse as well.

    4. Matt Zagaja

      Exercise seems to have transformed from this miserable thing you “had” to do or be part of an off-putting jock culture to being something that people are trying to make more accessible (themed runs and other events that don’t require you to be a super athlete) and social. Meanwhile healthy foods and cooking is getting a new cachet. Weight watchers isn’t “cool” but quinoa is sexy as is Paleo and as we see this gluten-free trend.

      1. awaldstein

        Yup–this is a horizontal change in the culture of wellness.I’m considering building out a practice in this field. Really love it.

      2. LE

        (themed runs and other events that don’t require you to be a super athlete) and social.The only thing that matters about exercise is doing it on a repeated regular basis. If you don’t do it regularly then all you are doing is entertaining yourself with an “event”. Further by doing “events” you can injure yourself which leads to not being able to exercise at all and losing any momentum (while you are healing) and needed to get back on track. And by spending to much time exercising you are making it much harder to keep up all that work multiple days a week. Like meaning just about all days a week.Meanwhile healthy foods and cooking is getting a new cachet.Counter that with all this food culture, and worship of food and restaurants. And the belief that every meal has to be about pleasure instead of about just getting reasonably nutritious things in your stomach.Hard to believe people would be overeating if part of the meal was boiled potatoes and steamed green beans along with a small piece of meat.

        1. Matt Zagaja

          In college potatoes with green beans and a piece of chicken was basically what I cooked for dinner most weekdays. Sometimes I went wild and made rice or corn.

    5. fredwilson

      mary touched on this in her deck. staying healthy is probably the single best way to change healthcare

      1. awaldstein

        perfectly said Fred.

  4. Matt A. Myers

    Preventative and proactive health care is the future in terms of value. It costs much less to keep a person healthy than fixing them – especially when the service provided is teaching people the tools they need to care for themselves, and when that knowledge is easily transferable and will trickle into other lives. It also keeps people being more productive and for a longer period of time.Group learning, say like a yoga class, is also more efficient and therefore cheaper to deliver than one-on-one – though one-on-one is still needed for certain situations.

    1. Dale Allyn

      Right, Matt. As I mentioned to Arnold above (or below?), established healthcare brands are accepting and investing in these important approaches; and preventative lifestyle choices present great long-term value.

    2. Tyler Hayes

      I think Rock Health has invested in some cool companies for group organization of healthcare related stuff.

  5. Jan Schultink

    My wife is a partner in a healthcare-only focussed VC covering health tech, getting up the learning curve about “tech” as fast as she can, the inverse position of you 🙂

  6. WA

    What about creating health care tech focused incubators in the teaching hospitals and developing synergies with their other schools in each university for the portfolio. Your relationships across the academic system and credentialed success in creating wealth should already have them opening the doors as this is read. Perhaps I’m a bit too simplistic. But a good sell should be.

  7. jason wright

    i need something solid to wrap my mind around.what do you envision a digital healthcare consumer service being like?

  8. William Mougayar

    There are 3 emerging areas I like in HC:1) healthcare consumer engagement 2) analytics and big data3) wearables and biosensorsAnything that empowers the patient or the doctor/care provider, and simplifies the relationship between them is up for grabs.

    1. awaldstein

      The largest and greatest changes are happening on the ground at the community level. They will force the change on top.

    2. pointsnfigures

      I see deals in this all the time. Investors like them because they skirt the FDA.

      1. William Mougayar

        Well, it has to start somewhere. As MLK said – “Take the first step, even if you don’t see the whole staircase.”

        1. Tyler Hayes

          Neat quote hadn’t heard it before

          1. William Mougayar

            He was talking about faith, but faith applies to anything you believe in.

          2. LE

            All of that goes counter-intuitive to my thinking which is to question everything and not take something on blind faith if it doesn’t make sense. And religion if anything is about blind faith.

          3. William Mougayar

            I was trying to take religion out of that context, i.e. faith as a belief system in yourself, your goals, your aspirations, etc…

    3. Richard

      It seems that way from the outside, but in actuality, these are healthcare rowboats in a sea of freightliners and cruise ships.

      1. William Mougayar

        You are quite involved in a healthcare company, right?

      2. Tyler Hayes

        Needs to be both top and bottom and also sideswiping

  9. pointsnfigures

    Except, most of the health care deals all focus on the same shit. It’s all software and it’s all designed to handle problems that need to be handled in the operational side of the health care system. I am seeing lots of health care deals as well. Some are pretty cool. In Peoria, they have the most cutting edge simulation center in the US: and in Chicago we are building a huge collaboration space dedicated to medical startups: We also have a group of 180 mentors that mentor for free-take no equity etc at concentrate on therapeutics and other tough stuff.What we need is more startups dedicated to devices and drugs-but because of the FDA it’s impossible to fund them.Investors (LP’s) are also reticent to invest in seed funds dedicated to healthcare.

    1. Dave Pinsen

      One approach would be to develop innovative drugs and devices in a country with lighter regulation.

      1. pointsnfigures

        They still need to go through a FDA testing process even if it comes out of another country. I know scientists developing stuff here, and then using them in China or Europe because of lighter regulation.It really pains me to say, “I’d love to do your startup but can’t because of the FDA. If I were you, I’d move to China and do it over there.”

        1. Dave Pinsen

          Sure, to be used in the US. But if they have clinical success overseas, that could give them a tailwind here.

          1. pointsnfigures

            It might, but if you are a US VC it creates operational issues. Much easier to solve with software than hard science issues.

          2. Dave Pinsen

            True. Would this sort of device need FDA approval here?:…Not medical exactly, but sort of in the ballpark (caring for elderly).

          3. pointsnfigures

            I don’t know if that one would or not, gut says no. What was revealing was the Japan innovation in robots-labor costs high, no immigration. Interesting.

          4. Dave Pinsen

            Robots won’t require health care, policing, schooling for their kids, welfare, etc. Makes a lot if sense fiscally.

          5. Dave Pinsen

            I hadn’t. Interesting.The first paragraph overstates the case a bit, but the automatic transmission analogy reminds me of something WSJ columnist Holman Jenkins said about medicine years ago: physicians ought to become more like pilots overseeing a plane on autopilot. He felt that would lead to fewer mistakes & better care.

          6. opit

            You think ? People bodies vary on an individual basis : and they make choices which affect their health. Plus some are made for them, like GM foods and pesticides or fluoridation…. or even the proliferation of pasteurization in the food chain following the model it is safer to use toxins ( slow poisons ) for ‘sanitation’ than continue the conditions in which we evolved and proliferated. ( The perfect food – milk – is a classic example : ‘clarified’,homogenized,skimmed,heated,powdered,sweetened. What happened to “If it Works, Don’t Fix It”? ) So you are dealing with a poorly understood operating system in constant motion using weird ‘food’ dreamed up by marketing and you cannot really tell what is happening. But your attitude is good for selling more tests. Getting useful results might be a tad more complicated.

          7. Dan

            Nope, not a regulated type device. That would be exempt from any sort of fda oversight.

      2. SubstrateUndertow

        Would you council any of your friends or family to join those foreign test groups ?

        1. LE

          Or keep the dollars in this country! Make prisoners the guinea pigs in exchange for reduction of their sentence.

          1. opit

            That should go over big with the private prison industry. People put in prison for what they choose to put in their bodies should also be subjected to deliberate abuse ? Why not ? ( Satire for the caustically disadvantaged ) Torture is already common ! Part of a proper ‘Just Us’ system for the rich.BTW Scientists who are so silly as to point out laws and regulation are based on Scientism ( perverted scientific representations to meet an Agenda ) are fired as consultants. See the example of Dr. Nutt in the UK.In any case : experimentation is suppressed by outlawing substances in the first place.

        2. Dave Pinsen

          If it was their / our best hope for treatment, why not? Medical tourism is already a big business.

    2. Richard

      Yep, This is a different kind of space . Between the VA, Medicare and Medicare, we are in a top down medical model. These agencies pay for 40% healthcare. Private Insurance which are becoming indexed to medicare pays for 30%. Copays etc are about 20%. This is a top down model.

      1. pointsnfigures

        Yup, totally top down, bureaucratic and made worse by Obamacare. People are disassociated with the concept of price in medicine. Should be like going to a hot dog stand. See transparent price and pay for what you get. Third party payment system screws it all up.

        1. PhilipSugar

          Milton Freedman said it best, four ways to pay for things.1. You for you: You care about quality and cost2. You for somebody else: You don’t care about quality, care about cost3. Somebody else for you: You care about quality not cost4. Somebody else on somebody else: Government: care about neither.

          1. Aaron Fyke

            Is there no agency with government? Why is it not possible to act responsibly for a third party? I spend my employer’s money and I care a lot about cost and a lot about quality, and yet I’m spending not my money on not my stuff. Yes…there is this vague effect that if it is done poorly I’ll be out of a job, but that has zero influence on why I do a great job.

        2. Richard

          Yes (primary care) and No (hospitalization).We live in a RX system.

        3. LE

          See transparent price and pay for what you get.I don’t know about that. Do you choose your physicians based on pricing? And in theory if there was a perfect way to find the best value (and I don’t think there is but let’s assume it can be done) those providers (like top schools rated by US News) would simply get overwhelmed by patients. At that point they could either raise pricing (and take less from plans that didn’t pay them much) or simply cut off from seeing new patients.If you want to choose physicians on price you may as well choose based on those who advertise on billboards or in magazines for patients. Or who build these big mega practices by hiring docs to work under them that are recently minted. (Same model as law firms use in a way I guess.)

      2. LE

        Between the VANightly News Report (NBC) the other night about the VA scandal interviewed vets as far as what they thought of the whole situation with VA healthcare.The interview was at a veterans post, at the bar, with the vets drinking, and one guy (on camera) was even smoking. And they all looked like worn out unhealthy older guy types. (Women were there and didn’t look good either don’t know if they were vets or wives.)I wish everyone would stop laying the blame on healthcare on the medical community and government as being the de facto bogeyman.There are many parts to this problem and guess what they aren’t going to be solved by giving people some app and wrist pulse monitor from the apple store.

    3. PhilipSugar

      It would be awesome to see somebody try and upset the whole model start to finish.

      1. pointsnfigures

        Yup-totally agree. would help if the govt dismantled the bureaucracy.

      2. Tyler Hayes

        That’s like saying someone should dismantle banking 😉 (very big, hence the need to focus on individual pieces and problems)

        1. PhilipSugar

          See dwolla

    4. Tyler Hayes

      Not impossible to find them. Look to the health focused accelerators this year and you’ll see a lot more happening now. People are learning to navigate the system.

  10. RDC

    We will move from reactive (see a doctor when not well) to maintenance (feedback through devices that detect potential issues). This will happen through data analytics and sensors combined with the ever increasing rate of knowledge about the genome. Your DNA may not change however what we know about it will and that will trigger additional insight. This is a significant part of the equation and will be transformative. Really exciting.

  11. testtest123

    Its always strike me as odd that pretty much anything that can be tracked can except for our personal health history. I could easily tell you what I spent last year or what my digital footprint was…but the minute you ask me how many times I went to the doc or what meds i took it would be a hazy blackhole.Does anyone know of a company currently that aggregates personal health history well? Nothing like Google Health or Microsoft Healthvault which is never going to work as too dependent on manual entry by consumers.

  12. Dave Chase (@chasedave)

    Employer-based healthcare is both the “original sin” and likely the best hope for healthcare going through radical transformation. The “sin” is in the issue of the consumptive user being disconnected from the money flow (with the providers, insurers & employers all playing a key role). Thus, it’s why the market isn’t changing as fast as we’d hope.At the same time, some of the most interesting things I see going on are catalyzed by employers (and unions, believe it or not). CEOs/CFOs increasingly are understanding they are failing in their fiduciary responsibility if they don’t purchase h/c in a smarter way (IBM is an exception…there are others). As they buy smarter, it enables bit by bit to be carved out (e.g., high cost procedures via domestic medical tourism is one of many examples).As with another local oligopoly/monopoly (newspapers), the death-by-a-thousand-papercuts phenomena is easy to ignore early on and then crushes incumbents. Like newspapers, health systems over-focus on cross-town competition when it’s easy-to-dismiss new national-scale entrants (e.g., craiglist, ebay,,, etc.) that progressively chipped away bit by bit. By the time incumbents react, it’s too late.The most interesting thing I’ve seen is employers in a given geography collecting their buying power (over $1B in local spend can make for an attractive market). By doing so, they can create a new marketspace that new entrants can sell to that buys much more rationally than traditional players (ask anyone who has done enterprise selling into health systems what that is like — e.g., 100 people who can say NO and seemingly no one who can say YES). These new marketspaces advantage new entrants over the incumbents who are benefitting from the norm of long, excruciating decision processes that kill startups who can’t wait that long.My sense is that as the healthcare delivery side gets disrupted, that’s when the real tech opportunities open up. Until then, there are tech-enabled services that will chip away at slivers of the pie (e.g., a16z’s investment in Omada is an example of that). It’s worth noting that Omada is selling to employers. Enabling the tech-enabled healthcare services is another opportunity.

    1. Matt Zagaja

      The State of Connecticut is trying some new things to drive down healthcare costs by requiring visits to dentists and doctors (no co-pays, etc.) to catch conditions before they become worse and also encourage management of conditions. Lots of libertarian backlash with these programs from people concerned about “big brother” type intrusions into their lives so they offered an option for employees to buy-out of the program with an additional surcharge on their insurance. The hope was many would opt-out and give a short-term revenue burst, but the participation rate was almost 100%. Seems like those concerns go away when people realize it’s good for their health and they are willing to sell a bit of their privacy away. Of course the other hope is the state sees the upside in decreased healthcare costs in the future, so hopefully that pans out.

    2. ErikSchwartz

      I am a bit skeptical of employer funded tools for wellness programs and chronic diseases. In an era where people don’t work for the same company for a career (or even more than just a few years) I don’t see how the employers are going to see strong ROI on that kind of employee investment.

      1. Dave Chase (@chasedave)

        There’s long been a debate on wellness program ROI but it’s a multi-billion dollar market today so there’s no question some employers are investing money that way.Chronic disease management is different. The ROI is extremely clear when it is done well. Organizations such as Iora Health, Qliance and others are showing they can reduce costs (while improving outcomes) in under a year. The status quo is so inefficient, they can typically see double-digit (%) savings in costs while also reducing unnecessary surgeries, ER visits, etc. between 40-80%. It’s important to say that they don’t do it by denying claims. If anything, the “claim” is self-denied. When people are well-informed, they often choose the less invasive path. With >200,000 deaths per year in hospitals due to avoidable errors, etc. choosing invasive paths isn’t without significant risk.

      2. Ron

        Erik,I share your skepticism about wellness tools, although I don’t think your point about career switching is strong enough to dismiss all forms of value for employer based health prevention efforts. It does mean, of course, that employers should discount the savings when calculating ROI. After all, a pretty significant portion of prevention ultimately only shows up in healthcare costs quite a few years down the road.But in some cases, costs are much more elastic in the short term. Diabetic employees who don’t manage their blood sugar are extremely expensive and when they start managing it better, their costs come way down. Any condition (COPD, heart failure, kids with severe Asthma, etc.) that is likely to lead to tertiary care and can be managed can have huge ROI in the here and now.That said, the problem is not only that some employees quit their jobs before the benefits show up, it’s that most wellness programs don’t actually change behavior or improve health. Read the fine print in white papers or ask wellness executives at top companies and they will readily admit they don’t change behavior. Wellness programs are a perk consumed by people who would otherwise consume them. The greatest impact they have on healthcare costs for companies is likely to show up in which employees the companies attract and retain. Not in improving health.I think the solution isn’t to dismiss prevention at the corporate level, however. It’s to rethink it. My own company is using a method validated in a randomized trial, with a control group, and shown to actually change behavior. But even that still leaves hard questions like “to what effect on what time horizon?”Our solution is to think about it is other tangible benefits of these interventions, and to move away from HR. If you actually improve employee quality of life, it’s true that your effect on cancer may not show up for twenty years. But there is a significant body of research that suggests it does show up in retention and productivity. Changes to retention and productivity are more likely to show up more quickly and often involve significant dollar figures. And there are certain operations departments in certain industries that live or die by their retention and productivity metrics. Our plan is to sell to them. We refocused this way and in just a few weeks five significant companies have committed to pay for pilots at rates HR would have blanched at.We believe the key is to find the real benefit, and then get the people with the real pain point to pay for it.

  13. Richard

    Is humandx a nonprofit? What is their product?

    1. LE

      Yeah they own the .com but it redirects to the .org.I’m curious why they are doing that as well. You can use .org for anything you want but most people (source: me) associate it with non profits, organizations etc.By the writeup Albert has “enabling the medical community to collectively contribute knowledge to an open machine learning system that could benefit people everywhere” that seems to be the case.I’d also like to know why they are collecting email addresses but don’t even have a summary on their web page as far as what they are trying to do. Or why it should be interesting to any particular target participant. “If you are a researcher, if you are a physician, if you are a medical student” etc.Even the “join our team” lacks any information on the company. How would someone even know if they wanted to “join the team” if they happened to hit this page? “Hi I don’t know what you do but you look cool and USV invested in you so I thought I’d spam you my resume”.And if I thought I knew someone who was interested in this (based on something that Fred or Albert said somewhere) I couldn’t send them to the website (as a word of mouth) because the website doesn’t give any info. It would be foolish.Hopefully there are well thought out reasons for all of this because this is exactly the type of thing that really bothers me about startups.

    2. fredwilson

      machine learning for medicine. yes, they are for profit

  14. muratcannoyan

    Interestingly, there are still no great platforms connecting patient and provider.We are working on simplifying how providers connect their patients to the right products from product discovery to home delivery. I believe reducing complexity is the key to enabling new value added services.While the enthusiasm for innovation in healthcare is exciting changing life long habits and perceptions is going to remain a challenge. It seems we are at a tipping point of sorts but only time will tell.

  15. Richard

    I went through Gotham Gals crunchbase investments, I don’t see a pure healthcare deal?

    1. pointsnfigures I would have invested too but was full up on seed companies.

      1. Richard

        Hope their product is better than their pitch.Remove the perception from the progression of the healing process and disease stateThis means what?

      2. LE

        How far along with funding are they if this (from their web page) exists:captureproof is in the running for a $15,000 grant and can use your help.

        1. pointsnfigures

          they came out of Chicago Tech Stars and raised seed money.… She is HIPPA compliant, and as anyone in the angel space knows, when you are raising money for a medically focused company, it’s really hard to raise money.I know well established VC funds that have been successful, and around for years in the med space that could only raise 80% of the money they wanted because of their focus. LP’s cross their hands when you talk about medical.I tried to start a fund with a little medical focus, three GPs were highly experienced in medical innovation with years of experience. We weren’t going to do therapeutics. Couldn’t raise.People bitch that VC doesn’t invest in ground breaking things, just “appy” stuff. Instead of blaming the VCs-look instead to the LP’s that don’t want them there, and the US govt which makes it almost impossible to be there.

    2. fredwilson

      her portfolio page is more accurate…

  16. panterosa,

    Hospitals and doctors still use the fax, and 10 year old software as well as handwrite things which need to be digitized. Having a resident doctor as a cofounder he rips his hair out on this stuff, and custom builds digital ways around to save time. He’s the first one out the door by several hours.This is a ground up problem whose solution will revolutionize medical practice.Do you see any movement in this area?

    1. awaldstein

      Not all.My doctors group is all digitzed.Sure they still struggle with security of information exchange, but this is changing and quickly.

      1. panterosa,

        Not at all meaning any movement?Your, my, and I bet 99% of AVC readers have smart and mostly digitized medical care.We’re not the problem.

        1. Dave Pinsen

          Digitized is nice, but it’s not the same as smart care. If I need to se a doctor on short notice, I’ll go to a local drop in clinic where every doc has a tablet computer. But my GP’s office still uses old fashioned Manila folders for patients’ charts. He’s a Mayo Clinic-trained, crackerjack doc though. He can keep using pens and paper if he wants.

    2. pointsnfigures

      I have seen this. One of the problems is hospital software is organized in a vertical stack. Epic, Cerner, Mckesson. Not unlike the phone ecosystem. CFOs of hospitals love systems like Epic because it’s great billing software. Doctors trying to innovate hate it. They have an inferior software development tool inside the system that is basically unusable. Here are three companies trying to go around some of it:,,

    3. Richard

      most hospital have one form of EHR or another. Its not exactly moving the “revolution needle”.

    4. PhilipSugar

      They do that to CYA.Had a long discussion with my wife about that.

    5. LE

      He’s the first one out the door by several hours.Hah. Well that helps by giving him more free time but not the medical community or patients! To wit “He’s the first one out the door by several hours.” (I’m assuming of course that you are implying it gives him more free time sorry if that is not the case.)Anyway reminds me of something that I learned when I was a kid.The mailman came to the door (nb, “that’s all he wanted out of life” ) and told my mom that his supervisor would be coming around with him the next day and he might be late. Reason was that if he went at his normal speed they would simply give him more blocks to do. Very possible that the supervisor even knew this.When my wife is on call she gets messages by text including the phone number which she can click on (obviously) to make the call. When I first met her she would get a page, have to return the page, write down the phone number and call. The text now contains some vital relevant info that is needed. At another job they had this really strange “sign out” procedure for patient hand off. Sometimes it would take 20 minutes by phone to discuss all the patients. I asked her many times why they couldn’t just send a summary in writing (or automate somehow) and she gave me a good answer but I don’t remember enough to quote it here.That said pagers work everywhere and iphone’s don’t.I owned a device in the mid 90’s which was essentially a Apple Newton clone that I used to make sure my systems were running. It was a small pad but it communicated over the same network that beepers ran on so it had “deep in building coverage” it would work anywhere. There was an entire developers program going at the time and I considered getting involved in it (not as a developer but seemed like an opportunity somehow). Of course now I’m glad I didn’t bet on that horse. (Lest you think that everything that seems like it’s the thing works out having tracked things over the years that of course is not close to being the case..)

  17. Adrian Scott

    It’s the new Greentech! Gov’t regulation & interference in the market, etc… The angel/VC investor needs to be careful they don’t get caught in deals that are either gov’t-screwed-up or vitamin pills. It’ll be great for consumers internationally/globally though.

  18. Semil Shah

    Two points: (1) I agree with everything you’ve written, but when I see people starting out I get stuck on how easy it may or may not be to onboard the average consumer into a new system or be cool with the privacy angle. (2) Keep an eye on Prime (iOS now) in TechStars KC – founded by a former long time Disqus engineer, who is on a personal mission with this product.

    1. awaldstein

      Is that Tyler’s gig?

      1. Semil Shah


  19. Richard

    In the short run, the low hanging fruit is the home healthcare agency, post hospitalization skilled nursing facilities, and nursing homes. They are ripe for disruption.In the long run, personalized medicine via data and biotechnology will be the biggest table pounder the world has ever seen.

    1. awaldstein

      You’ve said this before Rich.Why and how? I support someone within that system but this is basically the housing market and not seeing this low hanging at all.

      1. Dave Pinsen

        The only sort of innovation I can think of there is increasing automation while increasing the welfare & dignity of the residents. That Japanese washing machine for the elderly I linked to earlier would seem to be an example of that, but as long as nursing homes can hire cheap aides instead, they probably won’t pony up for it.As long as it stays a labor intensive business, I don’t see how it’s “ripe for disruption”.

        1. awaldstein

          You and I both.It’s a mess. But it’s a real estate model and i don’t see the in for disruption.

    2. fredwilson

      kind of like home schooling in education. go where the bureaucracy isn’t

  20. Pete Griffiths

    Fraud is a depressingly rich area in this sector. Current estimates are that the amount of fraud in the US system is 4X the budget of the UK’s National Health Service.This suggests a huge opportunity.

    1. Richard

      most of this work is being done via government grants to academia.

  21. Brian Manning

    I was at a healthcare innovator’s conference recently and someone told me that there are now more than 1,000 apps for diabetes patients and that less than 1% of patients use them.To build a large network of engaged ‘patients’ a service is going to need a very simple and practical utility. The “next big thing will start out as a toy” theory applies here. Google Health failed because they couldn’t engage patients. For most patients it’s a lot of work to upload a bunch of health information when it’s not clear what value you’ll derive from it. Google tried to do something big and important — instead of giving patients something that they want or need.There’s a ton of heat in healthcare tech right now and a lot of cool services emerging. But very few of them have that small but instant, no-brainer practical utility that’s needed to build a successful network.

    1. Richard

      Yep and diabetes (type 2) may be the one disease that the patient can actually treat and cure.

    2. Tyler Hayes

      Good analysis on Google Health. All about solving a real pain point for people in the easiest way possible.I wrote some more on that here too:

      1. Brian Manning

        Great answer. We’re seeing this now with all of the patient portals that are rolling out — providers are struggling to get to that 5% patient engagement number because patients just don’t want to use them…

    3. fredwilson

      what a great comment. we’ve looked at a few of those diabetes apps. i wonder if we are just waiting for someone to implement transdermal blood glucose monitoring and then there will be a reason to use them?

      1. Brian Manning

        Yes, I think that’s right. Though it might even be something simpler and less bold. Too often the healthcare apps I see are focused on solving a big problem rather than serving a small and simple consumer need. I really think the big patient networks are going to come from services that do a small and seemingly trivial thing. This is almost a requirement to avoid the regulators.

  22. george

    I’m so glad to see the tech industry taking a stab at changing health care, we all know it’s a problem in our country on several levels. For me, productive reform (change) is about defining a problem(s), building a plan, enabling a process and creating an alliance of people that can make many good things happen; tech has become an instrumental part of the recipe for redefining and reshaping markets.We are in a truly in a seminal era…

  23. TKList

    Get the federal government completely out of the healthcare business.Obamacare/(ACA), Medicaid, Medicare and VA hospitals should be abolished.People under these programs should be given a yearly amount that they could use to purchase health insurance.Allow people to purchase insurance from any state.Deregulate state health insurance markets.Unhinge medical insurance from employers in the tax code.Getting government out and increasing competition in this way will lower healthcare costs. It cuts the bureaucracy costs, cuts the fraud costs and improves competition and quality of care.Yes, no or something in between?

  24. sigmaalgebra

    Okay, I’ll try: One of the more important aspects of health is the performance of the collection of feedback control systems in the body. With sleep, foods, work, stress, sex, exercise, etc., we keep hitting the system with ‘impulses’, and then the feedback control systems respond.Well, in real time we are a bit ignorant on what impulses we should give to get the control system responses and system states we want. Okay, collect some data, that is, inputs and corresponding outputs. Then estimate the response function of the feedback control system. Then work backwards and say what the inputs should be for the output state we want. In simple, terms, say what the heck to eat for lunch so that don’t go to sleep right after lunch or get too hungry before 5 PM. Or, if we just did some exercise, just what the heck should we do with water, rest, and food to get the system state back to where we want it.For this project would want to be able to read the relevant variables, e.g., blood sugar, and track inputs, calories, sugar content, fat content, etc., of foods, up to the current second.Role for mobile: The system to collect the data should be mobile.Role for a network: For better estimates of the system response functions, share data across similar people.Problem: Getting the data, e.g., nearly a continuous, real time blood test and more. Also, inputting some of the data, e.g., on foods eaten; for this would want some ‘calibrated’ foods, that is, with the nutritional content available, if only from the cloud.Ah, heck: I’ve got a better project than that!

  25. Ashish Bhatia

    One fundamental problem with the way US health care works is that “user” is employee (and his/her family) and “customer” (payer) is employer.IMHO, that itself creates a slight mismatch where user can reap the benefit at customer’s expense (of course, things like HDHP are changing this field a bit). As long as user and customer is not the same, I don’t think the system will improve drastically.

  26. Ben Kinnard

    I recently just finished “The New New Thing” by Michael Lewis, which follows Jim Clarke. In the late 90’s he was convinced Healthcare would be the next big thing to be attacked by Silicon Valley, and created Healtheon, which somehow reached a $bn valuation even though no one really knew what it was.Interesting to see history repeating itself, but with the rise of mobile etc. maybe this time genuinely is different?

  27. Brad Inman

    The Kaiser Permanente system in Northern California is an amazing story of transformation. My kids were born in Oakland Kaiser and 30 years later my grandson. Today, it is a complete digital experience reinforcing prevention and patient control. Amazing, how a legacy bureaucratic institution truly refocused.

  28. ErikSchwartz

    I spent a year working on consumer products for Healthline I saw a ton of stuff come by. I have to say that in my opinion patient engagement and medication adherence apps are one of the biggest scams out there.Who know who uses pt engagement platforms? Patients who are already well engaged. You know who doesn’t use them? Patients who are not engaged. They do not move the needle at all at a population level. Giving them a different tool to do something they do not want to do is never going to change behavior.Why don’t people want to take their meds? Top 4 from most research are:1. They can’t afford them.2. Denial. Only sick people take pills, if I do not take my pills I am not sick.3. They feel better already.4. They do not like the side effects.None of these apps address any of these issues.You really want to make a difference in healthcare? Deal with the over treatment and over diagnoses areas. That is about changing physician behavior, not patient behavior.

  29. Jeff Ruby

    We’ve found that the best way to engage people and change behavior – especially those at risk – is to really get to know them. There is no one-size-fits-all solution, but leveraging genetic testing and the latest behavioral science, we can understand people – what they’ve inherited from their parents, personality, motivation and readiness to change – and leverage that information to curate a personalized experience online to inspire them to make the right lifestyle decisions to live healthier lives. Results – engagement, clinical, costs savings – have been awesome and the economics for employers, insurers and ourselves are terrific.

  30. andrewstuart81

    letter made it explicitly clear that i would receive no personal health benefit from the study, even if the study revealed an

  31. Alphaskater

    Health low, death high…

  32. Bob Summers

    Apples release of HealthKit today validates opportunity, with client side data repository as the design. at we see a clear path to mobile tech delivering on a promise of enabling consumers to take charge of their health.

  33. Dennis Mykytyn

    @fredwilson:disqus I tried concierge medicine with the Mayo Clinic for $8,000 a year a few years ago. Not worth it, pretty much all they do is over test you at your expense. I just had an annual physical after signing up with One Medical which charges a fee of $200 per year. They have an app to schedule appointments (no waiting on phone!), same day appointments, 6 offices in NYC including 14th St and 9th Ave, where I signed up with a primary doctor I chose. Other offices around the country, so when I am in LA they have access to my records and will see me there also. They take my health insurance. They even have nicely designed offices and hipster looking doctors, who all seem young. It is really a different experience from any medical practice I have ever been to before.Google Ventures seems to be funding them (hence the 14th and 9th office I am sure). All in all, I’d say it is a very well designed experience, and worth checking out. Appears to be a popular perk with tech companies to offer their employees:

    1. fredwilson

      i will check them out. thanks Dennis

      1. Charlene Ngamwajasat MD

        One Medical is great. I met the founder Tom X Lee (serial entrepreneur, co-founder of epocrates-all med people know what that is) last month. Really different kind of experience for consumers and providers.

  34. Charlene Ngamwajasat MD

    I agree that healthcare is an incredibly hot field right now, in particular health information technology (HIT). The costs are huge. The market is big both on enterprise and consumer side (esp as Millenials, GenX, GenY, Boomers age). There are a lot of issues though because there are so many players and even doctors aren’t homogenous (specialists which have their own breakdown vs PCP and also allied health). The technology is way behind other fields and doctors are not taught the basics of tech as part of their education (not one class except for in places like Harvard, Stanford, UCSF or Tufts). (I am teaching myself by slowly learning to code, watching MOOC’s and Youtube videos, engaging with thought leaders on Twitter and in person and rolling up my sleeves and digging into the space for real world experience).Big trends are value-based care over fee-for-service, patient satisfaction (hospitals and physicians are ding’ed if these are low), Big Data, sensor technology, telehealth, machine learning/artificial intelligence/algorithms/ natural language processing/clinical decision support), social networks, home healthcare/post-acute care/seniorcare, direct primary care/retail clinics/concierge medicine and now the integration of the ‘omics (genomics, proteinomics etc), an example of which is the IBM Watson project at the recently opened NY Genome Center, personalized medicine and empowered patient movements. (I actually see digital health as the intersection of health+design+tech+social+pharma/lifesci).Healthcare is definitely undergoing a consumerization which reflects changing attitudes as well as the natural progression of technology, and a mandatory digitization under government meaningful use requirements where institutions and practitioners were incentivized to convert to EMR (electronic medical records) first with monetary awards and later, there will be penalties (carrot and stick approach). On the consumer side, Samsung’s recent announcement as well as Apple’s Healthkit will further accelerate consumerization.I break up wearables into those used more for fitness and those that have potential to go further 1) fitness tracking 2) medical monitoring 3) possible public health and clinical trial recruitment . I see a lot of platforms working to integrate data from different devices which I think is nice because it’s annoying to have to open so many apps at once. Whatever consumer tech exists, it has to be easy to use and people need to get something out of it. Recent articles that a lot of people buy wearables but it ends up in a drawer 6 months later.Issues in healthcare are:1) Still a disconnect of tech from users for which it would make the most sense. There is no across the board clinical informatics fellowship for physicians until 2018 (strange because all of the foundations are being built now). There are few ways for physicians to find out about tech that potentially is more connected and even cheaper than other traditional tools in the long run. For example, there is Alivecor for EKG monitoring, Kinsa thermometer, StethIO, Cellscope etc. Few of my young physician friends have heard of these technologies though all own a smartphone. On the patient side, they often end up using tech that is developed in isolation from their real world experience and daily trials and tribulations. Basic literacy, health literacy, language, socioecomics, access to tech and information are issues that need to be addressed and that a 20 year old developer might not think about but a 78 year old elderly person with 3 chronic diseases on 5 meds who speaks Spanish and lives in the projects might be affected by. I am a proponent of possibly having policy people and developers visit hospitals and clinics and talk to patients/providers about their needs. I also think that docs need some baseline knowledge of tech as everything becomes digital and 99% mobile-based.2) Walled gardens or walled kingdoms. Healthcare is afflicted by closely guarded silos of information. There are initiatives to liberate the data: open mhealth, PCORI, open FDA (just announced), NYS open data and NYDOH data.3) Complexity. There are so many layers to go through to get something done. Players in space all have their own incentives which need to be aligned. It also has the classic battle of innovation vs regulation. Plus tech complexity, one hospital alone might have one system for labs, one for radiology, one for ER, one for medical notes for doctors, medication record that only nurses can access etc.4) Some believing that tech can solve everything. No it can’t. Just like a pill won’t solve everything. Health is affected by socioeconomics, behavior, what we eat, environment etc.5) Need for curation. Went from paucity of apps to tons for the most common disease. Which are the best ones? In the future we might start prescribing apps or asking patients what apps they use.6. Backlog of entering/scanning all the files that are paper into the new digital system.I think networks are interesting as a way of connecting people, accessing information, and harnessing the sum total of those connections. Twitter is actually used by a lot of docs and other providers in the digital health, med device, social medicine, behavioral medicine and life science and research fields. There are also a lot of social media patient support groups. There was a recent article on Twitter used to track flu and Yelp being used by the health department to track cases of food poisoning.Chronic disease apps are interesting because there is a high disease and cost burden. Hypertension, cholesterol, obesity, diabetes. Someone mentioned diabetes below. Work is being done in microfluidics as well as other point of care testing. I also am aware that people are trying to work on bloodless blood draw. There is also a pen that checks the glucose in tears but not sure how well it correlates to a blood draw (though I do like the no needles aspect).This is important because we use the hemoglobin alc to check how well a diabetic is doing and that literally is glycosylated hemoglobin (RBC component). Google contact thing was interesting but some people don’t like wearing contacts. Also both diabetics and contact lens wearers are more susceptible to a nasty bug called pseudomonas which requires higher level antibiotics to treat.EHR’s. First off, there are so many of them and a couple of incumbents (walled gardens). There really is a lack of interoperability and that affects patient care. If your regular doctor is across the street from the hospital and they use different systems, it’s a no go. They also were not initially designed for the transmission of patient care and were actually designed for billing so there are checklists and bullet points that often do not give a cohesive view of what’s going on compared to a well-written, thoughtful assessment and plan.Let me illustrate: Age: 52BP: 190/110Chest painVersus: 52 yo male patient on hypertensive meds brought in by ambulance with chief complaint of non-radiating sub-sternal chest pressure-like pain with an 8/10 pain scale rating that began this morning. No history of recent chest trauma. Admission BP 190/110. Differential diagnosis includes myocardial infarction, hypertensive emergency, aortc dissection. Troponins (enzymes heart releases when damaged) and routine labs drawn. Patient placed on continuous monitoring. Will re-check levels in 4 hours.New York is interesting because the nonprofit NYeC (NY ehealth collaborative) and NYS has come together to develop the SHIN-NY network which will connect all 10 RHIOS (regional health information networks) prob by 2015, if you live in NYS and go anywhere in the state and you opt-in you will be able to access your own medical information via a patient portal. There is also an element of the SHIN-NY known as the “digital sandbox” where developers can go to test things out on dummy data.In terms of the federal government, there is something called the Blue Button Initiative that is all about medical record portabillity which comes out of ONC.Someone mentioned low engagement and patient portals. You need to show at least 5% meaningful use of a patient portal for meaningful use purposes. I think there was low engagement because the UX/UI wasn’t there, access was an issue, and people were like “Why should I use this?”. We need to make things accessible, convenient, simple to use, nice to look at, and meaningful for people. Create something of value that people value.Here are some resources that I recommend to learn more about what is going on in the space:NYC Health and Business Leaders (I have organized an event for them June 17 and you are welcome to come. Topic is 3D-printing and its application to healthcare (Healthcare is the fastest growing segment of 3DP). Attendees come from all sub-sectors of healthcare).NY e-health collaborativeOpen MhealthHealthIT.govLink on architecture of the SHIN-NY:…PublicationsMedCityNewsMobihealthnewsHealthcareITnewsFierceHealthITHIT ConsultantForbes (Dave Shaywitz, Dan Munro, John Nosta, Robert Szcerbab, Matthew Herper)MedgadgetConferences:HIMSSNYEC Digital Health ConferenceHealth DatapaloozaConsumer Electronics show (now a lot of consumer health stuff)Paul Sonnier has the best comprehensive web site on digital health: Pretty much has archived all the companies in the space, incubators, and events etchttp://storyofdigitalhealth…

  35. Tyler Hayes

    Re: StackExchange for patient side of medicine, have you seen Inspire, PatientsLikeMe, and PatientsKnowBest? They’re all working on that and all great.Re: large networks of users in healthcare, Doximity pretty much has that on lock on the doctor side. The above companies are working on the patient journaling and third-degree connections patient side. We (Prime) are getting there on the patient medical data and first- and second-degree connections patient side.

  36. William Mougayar

    You’re sure it’s not allergies ? just sayin’Try Healthtap- it might be useful:

  37. fredwilson

    we’ve looked at a few “stack for healthcare” companies. i agree that its needed.

  38. Tyler Hayes

    Thanks Charlie. Email me anytime with thoughts — we love ruthless feedback 🙂

  39. William Mougayar

    yep- you got to navigate the local scene. it’s like know your fishmonger – good luck. i tried that many times, but they aren’t honest enough to tell me which fish arrived today vs. 3 days ago. they favour restaurants and give them their best fish, while the average consumer gets the rest, most of the times. unless you live in a coastal city, or close to one, it’s difficult to get fresh fish. at least i’m speaking from my experience in Toronto. Vancouver is much better for fish, and sushi for that matter.

  40. Anna Nicole Smith

    part of the issue is that the average consumer doesn’t know the difference between the fish that arrived today vs. the fish that arrived three days ago, even if told honestly.