Latest / StartUp Health NOW Podcast / Investing in AI-Native Healthcare with Venrock's Bob Kocher and Unity Stoakes
Transcript
- 0:00[chimes] Why did they quit their day job and start this company? I mean, there's always a really fascinating story because every founder I met was doing something different before they started their business,
- 0:15and it is a scary, giant leap of faith to go start a company, and it's like having a child. You have to bring it to life and bring people to it.
- 0:22It's, like, the hardest job that exists, I think, is starting a company, 'cause you have to make something out of nothing. Mm-hmm. So understanding why.
- 0:28Like, why was this the problem that they quit their proper job and s- spent their life on is, like, really interesting to me. [upbeat music] My name is Unity Stoakes, co-founder of StartUp Health.
- 0:43I'm really happy to welcome Dr. Bob Kocher back to StartUp Health. We go back a long way, I think over 15 years. In fact, Bob was there when we launched StartUp Health- Yes... at Health Datapalooza, I think, in 2011.
- 1:00Right around then, yeah. And, and you taught us something very early on that has stuck with us ever since.
- 1:06In fact, we've designed it right into everything we always coach to founders ever since, which is, in healthcare, the person who pays, the person who buys, and the person who actually benefits are often three completely different people.
- 1:24If you're building a healthcare company, understanding that dynamic can be really the difference between building something people love and building an actual business.
- 1:35Bob has one of those rare vantage points on healthcare. He helped shape national healthcare policy during the Obama administration, helping architect the ACA, in fact.
- 1:47He spent years at McKinsey, trained and still practices today as a physician, and really today is one of the world's great healthcare investors as a partner at Venrock, where he's backed and helped build some of the most important companies in healthcare, including Devoted Health and Virta Health, companies we're very proud to have invested in at StartUp Health.
- 2:13So today is really our opportunity to learn from Bob and we hope, as always, you post your questions in the chat. After Bob and I have a conversation, we'll open it up for questions.
- 2:27Ask your questions early and I will do my best to call on you and welcome you to the conversation. Bob, great to have you back with the StartUp Health community. Welcome. Unity, it's great to see you.
- 2:40I so appreciate the work that you and StartUp Health do. You've created a tremendous movement and ecosystem and so many great companies. It's always fun to talk with you, and I'm glad to be back to talk with you again.
- 2:50Thank you so much for that. So to kick things off, I thought we'd start macro to better understand what world are founders actually building into. How would you describe the landscape from your
- 3:06vast vantage point today? [laughs] Well, I think we're building into a great opportunity, which is nearly every aspect of healthcare in America can be made better. Access is a giant problem.
- 3:18Quality can be greatly improved, and affordability is really a critical issue for us to tackle as a nation. With the magic of AI, I think we can make things faster and better than we could before.
- 3:30And in many ways, I think it's gonna become tougher because with HR1 going into effect next year with many people losing Medicaid, it's gonna create a lot of demand for lower cost ways to provide care and a bunch of disruption.
- 3:41So I think we're at a moment where, like maybe we've been for the last 15 years, again, it's never been a better time to start a healthcare company than, than today. And that remains true.
- 3:50I'm also pleased that the funding environment, I think, is positive.
- 3:52So if you have an idea, the TAMs are so big and the demand is so great, and this is kind of a counter-cyclical area, then I think it's a good time to start a business.
- 4:01We couldn't agree more, as these windows of opportunity sometimes open up as they did at the dawn of the internet and World Wide Web and mobile and other moments, ACA being one.
- 4:13One thing I think is interesting from things I've heard you speak about or write about recently is you have a somewhat contrarian argument right now about AI that while it may make healthcare better in so many ways and more accessible, but not necessarily cheaper.
- 4:32Yes. So [laughs] tell us more and what you think that means for innovators today who are building. Well, AI is gonna make healthcare better for sure.
- 4:41As a doctor, I can tell you AI is better at evidence-based medicine than I am, and I think probably any doctor, because it knows all the evidence and it updates all the time. So it's incredible.
- 4:50You can engage patients in dialogue. Gr- patient-reported outcomes are easier to capture. I mean, it's amazing. But AI will work in the system and system incentives that exist for the people in healthcare.
- 5:03And since most healthcare today is fee for service, most people using AI are gonna be using it in a fee for service context, and AI creates productivity. AI can allow you to do more virtual care.
- 5:13With scribing, see more patients a day because you don't take notes. And so it will create more visits, and visits are expensive.
- 5:19And so since most of healthcare's fee for service and AI's gonna create productivity, it's gonna lead to more activity, it's gonna be more expensive. Now, it might be good. It might improve access.
- 5:27It might improve quality. But I don't think it by itself will lower cost of care. We have no mechanism to actually lower prices in our system if the care gets more efficient.
- 5:36And so I think it's gonna not have a deflationary effect. In value-based care, it's gonna help people in value-based care do that care more cost-effectively.
- 5:44And again, they'll make more money in value-based care, but it won't lower the prices or lower what people pay. Because, uh, outside of LASIKs, I know of no examples of he- the prices falling.
- 5:53LASIKs and generic medicines, I suppose. It's great that there's more access, but, uh, you know, it, we still gotta solve the cost, cost issue. Yeah.
- 6:02I mean, I was talking to a large employer who was, like, talking to me saying, "Bob, I wish my employees would all get primary care doctors and go to the doctor."
- 6:11And I said, "I would like them all to have primary care doctors. I think it's good for people to have a way to access healthcare." And then they said, "Half my employees don't go to the doctor in a given year,
- 6:21and if they all went to the doctor, we would spend a couple hundred dollars more per p- more per p- employee, and that would be more expensive." And so then you kind of have a debate about should they?
- 6:29Like, is that good or bad? And that's a good debate to have. And is primary care lower cost or... Like, and the answer is maybe, [laughs] but it doesn't make it cheaper this year.
- 6:39It may make it cheaper in a couple years because primary care will identify things and treat them, but in the year that you begin care, it maybe isn't cheaper.
- 6:46That's why preventative care also is so tough, is that I can help all of us, I think, you know, sleep better, eat more healthy, be more active, stop habits that are dangerous, and that'll be good for us, but it costs something to do that,
- 6:59and the payback may not be for a while. And our health system thinks in one year increments, and so it makes it really hard. Yeah, I wanted to dig into that in a minute because I, I, I want to tackle some
- 7:10creative business models around prevention, something near and dear- Yeah... to both our hearts for, for so long.
- 7:16But as you really look across the landscape today of healthcare, are there two or three places where innovators or startups can still create enormous value?
- 7:30Or I guess, where would you advise them to focus first to create that enormous value over, say, the next five years?
- 7:37Is it, is it- Well, I, I go back and say I think almost everything can be made better, [laughs] and the TAMs are big everywhere, so I think there's a lot of spots. Maybe do the inverse. Where would I not do it? Hmm.
- 7:46I think what we're really good at in America is intensive care in hospitals, so I think ICU care is hard to do better than what we're doing today at the hospital.
- 7:55I think, frankly, surgery centers and operative procedures are done awfully well and quite efficiently, so I probably wouldn't start there.
- 8:03I probably wouldn't do generic tele- new directions for telemedicine because I think there's so many players in that space. So that would leave you with everything else.
- 8:10Nobody's figured out value-based specialty care, and so that remains an area I think a lot about how one might do that.
- 8:16I think geriatric behavioral health is done very poorly and so there's probably ways to do that a lot better. I think medication adjustments are often not done very effectively.
- 8:25A lot of people are taking medicines for their blood pressure, for their cholesterol, as examples, and they're not controlled, and so there's probably a way to improve the titration [laughs] and usage of those medicines.
- 8:35And then de-prescribing is one thing that at Devoted we spend a lot of time figuring out how to do properly because people are on medicines that no longer are needed. Yeah.
- 8:43And I know you've also talked about moving healthcare from episodic visits toward more of a continuous care.
- 8:51Yeah, I mean, it'd be better not to have me see you once, twice, or three times a year, but to actually be in dialogue with you so when you have a question, you can ask it.
- 8:59Now, with AI, that's much more practical, but obviously things like blood pressure control, it's silly to come back to an office every s- eight weeks and have somebody measure your blood pressure once and be like, "Okay, we're gonna change it."
- 9:09You should just check it multiple times a day and we can change the medicine tomorrow. We should just get these things done a lot more.
- 9:15That's why CGMs for diabetes is mu- so much better than, again, a finger prick a couple times a day and going to the doctor in three months. We should be able to do much more rapid adjustment of medications.
- 9:25So do you see the, the winners there being not primarily software opportunities, but more they have to own some portion of the care delivery as well to, to really win there?
- 9:37I prefer having more control over the care delivery. There are gonna be autonomous software things also that could be interesting.
- 9:44UpDoc, as an example, is a company that has an FDA approval to do titration of medicines for diabetes, and soon probably other things.
- 9:52And so there could be software only, but I think it's easier still to have a clinician who can just change an EMR, the order for a medicine so you can close the loop. Yeah.
- 10:02And, you know, obviously, and you started to go there on this, there's the big debate for many years about AI replacing doctors or pieces of the clinician versus augmenting the clinician. Yeah.
- 10:15Where does- I think, I think we're not replacing most doctors. I think we're augmenting. AI will allow you to be in that constant dialogue. It c- can allow you to not have to...
- 10:23Like, for, in the past, for remote patient monitoring or chronic care management, we'd spent a lot of time trying to stratify patients to make sure we did it just for the right ones, where we'd have an impact.
- 10:33And so we could only do it for high-risk people, but then we missed people who could benefit because it was cumbersome and costly and hard to do. With AI, I can offer that to anybody potentially.
- 10:42And we can find stuff and educate people and engage them in their care, and that's probably really good for them and good for care. And so I think it's nice to have...
- 10:51Like, software can make a lot of things more possible, but I think it augments the clinician, 'cause ultimately care works better, I believe, when you have a patient goal that you and the patient are working to achieve.
- 11:02And when you have software, it may treat every disease as if it's the most important thing in your life, and that maybe isn't practical if you have more than one disease or a life. [laughs] Mm-hmm. Yeah, totally.
- 11:11And obviously, so you're still seeing patients- Periodically, yeah... periodically. And so what's something in your actual clinical workflow where you think, "I can't believe someone hasn't solved this yet"?
- 11:27God, I mean, so many things. Well, first- [laughs]... I think transcribing is the greatest thing since sliced bread because I don't have to type notes or dictate into Dragon anymore, so that's magic. But
- 11:35one thing that's super annoying, I had to do it today, so it's top of mind, is credentialing.
- 11:39Every two years or three years, depending on the insurance company and the hospital, you actually have to resubmit all this paperwork to get re-credentialed, and I cannot believe, like, that I'm still sending PDF pictures of
- 11:53diplomas and things. It's just, it's, it's shocking. And, like, there seems like there's so many ways one can actually...
- 11:58That they should know all this information because it's easy to know if I've been sued, and if my licenses are active, and if my CME is done. And so that's one where it just drives me nuts.
- 12:07I was just answering a question about sending a copy of a certificate that I'm like, "This from 22 years ago. Are you serious? It was, you had it three years ago and it was fine, so why are we asking for it again?"
- 12:16That's super annoying. Yeah. I think, you know, referrals Are still more complicated than they should be.
- 12:23Getting a question formulated and the information shared with the clinician and the, and the patient scheduled and the information back, that's cumbersome.
- 12:31There's all these tools that aren't connected to actual practice around, like, how to do this more optimally, but it's very hard in practice to sort of use that.
- 12:39I think decision support, like every note should automatically be bounced off of an evidence-based resource from the open evidence to check it for accuracy. It doesn't do that automatically. There's, you know...
- 12:50I think there's so many ways to make it better for sure. Yeah. And so y- let's talk a bit about what you think is actually investable. So put, keep that hat on.
- 13:01You, you've probably see hundreds of companies, for example, claiming to be AI native or claiming to reduce costs or whatever the case may be. What really separates...
- 13:12Let's start with the AI, I guess, since it's where all the money's going. What separates an AI healthcare company you might seriously consider looking at or investing in from just something that's a wrapper or a feature?
- 13:28What has to be proprietary? What makes something investable, I guess, is the real question. I think if it's an AI thing, it comes down to distribution. So
- 13:37unfortunately for AI creators, anything that you create in AI, AI can be created by other people in AI probably quicker.
- 13:43And so your time to defend the invest- you know, to build a moat is so short that the key thing with AI is distribution.
- 13:50So if you're one of our growth stage businesses like a Devoted or an Aledade, applying AI to your business can be awesome because you already have an installed base that you can then push it through and do things.
- 14:01That's why in healthcare EMRs are in a pole position for AI because they have users and they can push it out.
- 14:07And so I think a lot about when I see AI, what is the way to distribute this thing so you get it into the workflow and people habituated to it, that you're not gonna then have people just switch off of it?
- 14:17I think AI by itself is really hard to invest in because it's so easy to copy.
- 14:20I feel like a lot of companies that I saw a year ago, six months later are free features of OpenAI or Anthropic, and so they just evaporate these companies. I like
- 14:31things that are full stack, so they are doing the care and they can use AI to make the care better. I like things that bear risk.
- 14:37I like things that have gone through thorny, long, hard contracting cycles with payers because those end up being the things that are defensible or things that have distribution already.
- 14:46But AI by itself is wonderful, again, but I think it's more wonderful for our growth stage business to add 10 points of gross margin to their business and new features than to be a startup today trying to compete in AI.
- 14:58Yeah. I mean, it's just amazing to watch how quickly, say, OpenAI is improving with their new health product.
- 15:06It's really quite- I mean, their new health product without training appears to me to be as good as any decision support tool I've ever seen. So that's a problem if you built a predictor of sepsis. [laughs] Yeah.
- 15:18Gosh, so, you know, interesting time when things literally are changing by the week as you're a founder, as you're pitching someone like you, as you're building.
- 15:28So take us inside your head when a founder pitches you, and let's just, you know, assume they have a good idea, I guess. But in the first 10 or 15 minutes, what are you trying to figure out?
- 15:42What gets you leaning forward or vice versa? When do you check out? Like, how does that go? [laughs] I try... I try to listen and learn. For me, the most exciting part of meeting a founder, I guess, are two things.
- 15:56One is why did they quit their day job and start this company? I mean, there's always a really fascinating story because every founder I met was doing something different before they started their business,
- 16:06and it is a scary, giant leap of faith to go start a company, and it's like having a child. You have to bring it to life and bring people to it.
- 16:14It's like the hardest job that exists, I think, is starting a company because you have to make something out of nothing. So understanding why.
- 16:20Like, why was this the problem that they quit their proper job and spent their life on is, like, really interesting to me. Second thing is, and probably where I spend the most time, is how big is the impact?
- 16:30How big is the effect size of the invention that they have? I think a early stage business, you have to be able to see from Jupiter that is a better approach that emits photons of value to people who are using it.
- 16:41It can't be like a p-value of 0.05. It has to be like, "Oh my God, it's obviously better."
- 16:47And so I'm focusing on, like, how much better is the innovation than what people are doing today, and then how many dollars does that generate for the person who's gonna be paying for it? And it better be big.
- 16:57[laughs] That's... But that's sort of number one. Companies that I pass on quickly are ones where the effect size isn't that big, so they're never gonna get over the inertia of, like, whatever the status quo is.
- 17:09So effect size, number one. After I think the effect size is big and awesome, then I go into, like, all the versions of the questions you just asked around what's defensible about this?
- 17:17How do you prevent it being copied? Is there a network effect? Like, why can't... You know, once you show people this is awesome, why can't every MBA student just make one? Like, then what?
- 17:28But the first thing is really effect size. And what's cool about early stage startups is sometimes the people have really imaginative approaches to problems that are hard, and they have really big effect sizes.
- 17:39I remember when I met Sami Inkinen, the Virta founder and CEO, he's like, "Bob, did you know that we can cure type 2 diabetes?" And I'm like, "I didn't know that."
- 17:47Like, I wasn't taught that in medical school or residency. I worked at Joslin Diabetes Center, like that's like the best diabetes center in the world. They never talk about reversing diabetes.
- 17:55And he's like, "Well, here's the data." And I'm like, "Oh, it's a big effect size." Yeah.
- 18:00And so you can't not like that impact, and then you spend all the rest of the time on, well, how do I build a business that works to do this thing because for some reason we haven't chosen to do this thing as our clinical practice?
- 18:12But effect size is the thing that I get really excited about. And is Benrock doing... What stages are you starting? Yeah, we invest at company formation at the beginning.
- 18:22Like, we co-founded Acompany Health and Devoted Health and-
- 18:26To validate from the beginning or the A or the B, but like kind of the earliest stage out of the venture fund, then we have a growth fund that will invest later stage in the portfolio too.
- 18:36And, you know, obviously things have evolved a lot from seed and A from when you started to, to today. What,
- 18:47what do you think founders really need to have proven today that might have been different from years past where y- you really need to show up with, with more today?
- 18:58Well, certainly on the have, have more software built at the beginning because when we were seeding things, when you and I were starting StartUp Health and I joined Venrock, we were looking at, you know, screenshots on a PowerPoint of like what our product might look like.
- 19:13And then they'd be like, "You invest the money and give me a year, and I'll build the thing that you looked at on this PowerPoint."
- 19:18Today, people can arrive with prototypes of the product, and ideally they've had customers try it and give it feedback. And so you're not limited so much by a very hard to build software product.
- 19:28A- and now the product roadmap is like whatever the customer wants, you can build it pretty quickly.
- 19:33We spent tens of millions of dollars at Devoted building Orinoco, which is the name of the claim system and the operating system for Devoted. I heard that companies have built claim stacks now with like six people.
- 19:44Software is the biggest difference, that you can have a lot more of it, it can be a lot more ready, and probably even at the seed you have at least a very good prototype you can show. And that's why
- 19:55then you go up to the real hard challenges of actually closing those big contracts that might take- Yeah... might be impossible to close.
- 20:03If you get the A done, you need to get somebody to pay you money [laughs] for the software. Right. Have some contracts that look like they're sticky.
- 20:08Or if you're selling to consumers, that you have CAC, ARR, and churn data so one can make an assertation... You know, discern, discern like is this a business that actually grows or is the churn gonna kill it? Yeah.
- 20:20Well, let's shift gears a little going back to prevention. And you've spent so much of your career thinking about business models around prevention or policy changes to try to improve prevention.
- 20:35There's a lot of founders building or trying to build things in the prevention or longevity or continuous health businesses, but it's just not clear that the business models can work or what they are.
- 20:50So if someone in the room or watching were building a prevention company today, what business model would you tell them to pursue, I guess? Or how would you advise they think about this challenge?
- 21:06I think it's the hardest problem because the incentives are most misaligned for prevention.
- 21:10I think the two business models that can work are direct to consumer, where you engage people because they find it entertaining or they get a great deal of joy from prevention, or in Medicare Advantage,
- 21:24where members typically stay with their Medicare Advantage plan for five to seven years, and so you have some time to do it. But that's less prevention. It's more, I'd say, like
- 21:32making the diseases you have not get worse. [laughs] It's, it's, it's less prevention. But those are the two populations or the two dis- business models I've seen.
- 21:40You need to have somebody in your population for prevention for several years for the prevention to pay back. So that's why Medicare Advantage is where I think of, because those people stay longer.
- 21:51Otherwise, if you're doing it for people under 65, I think it's DTC.
- 21:54And if it's DTC, it needs to either give people really great joy from the experience or a lot of entertainment or, you know, be super engaging 'cause otherwise your churn's gonna be a problem in that business.
- 22:04Churn's- Like Aura, like what Aura's doing. Aura, yeah. I'm wearing Aura right now. Yeah. You are too. Yep. I find it entertaining and it gives me joy.
- 22:12And so I'm not buying it for prevention, I'm buying it as a consumer entertainment device, basically. I think most people are.
- 22:18I don't think of Aura as a healthcare provider, like they can try to pitch me on telemedicine. I'm not gonna buy it because I'm, you know, intrigued [laughs] by my data. And so that's why I pay for it. I...
- 22:28But to me, it's the entertainment product. I do not think insurance will pay for Aura data or that doctors are gonna have a desire to have an API to it.
- 22:36I think function health and, and, you know, other consumer health business are gonna be DTC because they're... Again, they're not, they're not gonna have a ROI for an insurance company to pay for these things.
- 22:46And so they're gonna be entertainment businesses or bus- you know, business for the curious. But they're gonna, all of them struggle with CAC and churn. Mm-hmm. Yeah. Interesting. Well, we...
- 22:59You know, my, my dream is your... Like we gotta crack the code on this one.
- 23:03So I'm, I'm an author on a National Aca- Academy of Medicine paper coming out for like ways to better align incentives, and one of the centerpieces of what we're recommending is multi-year insurance products.
- 23:14So if we had five-year insurance products in the commercial segment, we'd have five years at least to show [laughs] payback from prevention.
- 23:21So that would make a bunch of things possible that probably aren't possible today. So that would make things like weight loss cost effective, mental healthcare access and screening and better treatment.
- 23:32Certainly nutrition counseling would become much more cost effect- like would make more sense. And so it would unlock a lot of business models. Sleep would be actually something that we could pay money to improve.
- 23:42And so I'm excited about the idea. Unfortunately, it's an idea still. We need legislative action to do it. It's not possible [laughs] to do it today.
- 23:49But we make a compelling argument that it'd be good for Americans in the long term, make healthcare, we think, the cost grow less. We're gonna shift gears to audience questions in just one second.
- 24:01So if you've got a question, there's some good ones coming in. Please post now.
- 24:05But while people are posting more questions, just for the founders who want Venrock as an investor, a lot of them do, what's the best way to get on your radar?
- 24:15What makes you want to even look at their email, or is it coming in through someone else? Or how do you get on your radar? Believe it or not, I read every email I get, and I respond to most of them.
- 24:26But it's always nice if you Come referred through a friend, that's nice too. I think the most important thing is that we begin getting to know you before you're doing your fundraising.
- 24:35Because when somebody invests in your business, they're investing in that business until that business is done. [laughs] And that's like a marriage. I mean, that's like a relationship that you're entering into.
- 24:45And if I'm only meeting you for the first time when you're meeting 25 other people in a one-week long sprint to go pitch investors,
- 24:53it's probably not enough time for you and I to decide if we should spend the next 15 years together, like, talking all the time.
- 24:59And so for me, most of the investments I make, I've known the founder for somewhere between six months and years, and we've spent time talking about their business.
- 25:07And for me, it's the dialogue around the business, why they started it, the effect size, the business model, what we're learning along the way, what could we do better or different.
- 25:17Like, that's actually how you decide if you wanna work with somebody. Because if I invest in your business, I'm going on your board, and we're gonna be on a Slack channel and a text chain and talking
- 25:27at least once a week until you're done. And you better like me, I better like you. [laughs] We better have a good way of working together.
- 25:34And so if you're just looking for money, which I know is what you want, then I'm not a good fit for you. But also, like, I only make a couple investments a year, and I only spend much time on them.
- 25:45And so I have to make sure that it's gonna be a mutually good fit. And that's, I think, that'd be advice I'd give any founder, is that the time, really your best time for fundraising is not when you're fundraising.
- 25:55It's getting to know the people before, so that when you actually fundraise, you can be like, "Now's your opportunity to invest in the business."
- 26:00And then we- we've done the work, we know you, we understand the business, and then it doesn't take long to figure that out. Great. Great wisdom. Thank you.
- 26:08And thanks to all the Health Transformers for your great questions.
- 26:11And most of all, thank you, Bob Kocher, and, and really just what you and Venrock have done in building so many extraordinary companies and supporting and investing in so many great founders.
- 26:23In fact, one of our next Fireside Chats is with Todd and Ed Park. Mm-hmm. So we're excited about that. But just wanted to thank you again, Bob, for sharing your wisdom, and spending the time with us. Thank you so much.
- 26:36Thank you for having me, and I thank you so much for the work that you do and all the wonderful businesses that you're building. So I can't wait to learn more about them. Have a great day. Thank you.
- 26:44Everyone, see you soon. Bye. [upbeat music] And finally, an invitation to all of the extraordinary Health Transformers.
- 26:54Whether you are a startup, someone building the future of health, or whether you are an investor, funder, or buyer of the solutions out there in the marketplace, this is an invitation to you to join the StartUp Health member community.
- 27:09Learn more at startuphealth.com. Look forward to hopefully seeing you soon. [upbeat music] [outro jingle]