Elizabeth Burstein

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

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

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Someone broke down the estimated costs of a $15 Sweetgreen salad. We need these cost graphics for digital health to help future founders. Especially for tech enabled cos, the greatest cost is labor. Much of the "value created" is in curation and matching, which means the gross margins are reliant on labor arbitrage. Pay someone $X, but get paid $X+Y% per visit. The challenge with healthcare is that you often have to pick one of two business models: 1. specialized, low volume, high cost, low gross margin % 2. generalized, high volume, low cost, high gross margin % I'd argue founders should focus on gross dollars over the lifetime of the customer (like Jeff Bezos said) instead of gross margin %'s, but we'll leave that for another time. The challenge is that many tech enabled digital health cos have high cost of goods sold (labor) and moderately high product, design, and engineering budgets. We must build differentiated solutions for patients, clinicians, and clients to be out incumbents, however, we're realizing that companies are ultimately valued on the discounted value of future cash flows. And the high SG&A costs at most organizations might be inbalanced to the unit economics of the business. I'm not sure the math pencils out for everyone unfortunately. But I'm just a guy on the internet, would love to hear the thoughts from those smarter than I (you!). Comment below. --- p.s. I have no idea the accuracy of the graphic and not an investor in Sweetgreen. Cheers. Credit: David Crowther

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

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

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Here’s your recap of last week’s healthcare technology news 🗞️ 👇 🤖 AI Clinician Assistant • Carle Health is beginning a full-scale adoption of Nabla through their Epic integration.    • UVM Health Network signed an enterprise-wide agreement with Abridge.    • Regard closed a $61M Series B with an investment from Cedars-Sinai Health Ventures among others.    • Mass General Brigham published a Q&A discussing the results of its initial AI ambient scribe pilot and plans to roll out a wider implementation.    🔁 RCM • Greenway Health released a patient payment solution that integrates cost estimates, patient payments, and payment plans.    💼 Provider and Practice Administration • Kontakt.io released a new wearable tag that aims to enable understanding of patient journey, estimated wait times, room availability, physician time with patient, and more.    📋 Patient Administration • Cone Health is partnering with Lirio on an AI-driven intervention for patients with diabetes.    • SAIGroup acquired Get Well, giving it access to the firm’s AI platform. 🍎 VBC • P3 Health Partners is partnering with Innovaccer to leverage its physician engagement solution as well as its AI-driven analytics.    • HSBlox, Inc released an update to its CureAlign platform that includes tooling for improved care coordination and patient outreach.    • GrayHawk Health is implementing Innovaccer to optimize operations and improve efficiency. 🧠 Food for Thought • We’ve covered numerous studies in our newsletter highlighting the impact of tech on reducing physician burnout. It appears we’re finally seeing signs of widespread impact from these workflow and workload interventions: physician burnout dropped below 50% for the first time since 2020, according to the AMA. https://lnkd.in/eWhj94NB    • ONC released the new, proposed rule HTI-2 to advance interoperability and patient information access and sharing. We're looking forward to more expert takes in the coming days—feel free to send any good ones our way! https://lnkd.in/eyM7eDyq --- Reminder: you can sign up for the Elion Briefing to get the latest healthcare tech news delivered to your inbox each week 📬 👉 https://lnkd.in/e2UJ3ckP

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Excited to announce Frist Cressey Ventures' investment in Qualified Health and privileged to partner w/ SignalFire, Healthier Capital, Town Hall Ventures and others!   Healthcare costs are increasing at a faster rate than ever before, with the US spending nearly twice as other wealthy countries and still ranking bottom in outcomes. It's a story you've all heard - - US healthcare is known for astronomical inefficiencies, waste, workforce supply constraints, fragmented access, appalling patient experiences, and driving patients and businesses into debt.   Yes these problems present opportunities. But opportunities are limited to the system's appetite for change, desire and incentive to try something new and the innovation available. At FCV we believe we've hit the trifecta with Generative AI. Generative AI has given us truly transformational tools in the toolkit and the healthcare ecosystem is demanding to absorb its benefits. This perfect collision of supply and demand means healthcare is poised for big change.   Generative AI is everywhere, it's buzzy, it dangles hope and opportunity. But many things need to be true for the Gen AI transformation in healthcare to take hold, such as but not limited to:   💡 Patient lives and data need to remain safe: We believe in a highly regulated and human life-touching sector such as healthcare we must ensure Gen AI can drive to unrivalled savings and improvements in the quality of care WHILE not putting patient lives or data at risk.   💡 Systems need to own their utilization of Gen AI: We believe systems will use some hybrid of external partners and homegrown solutions but importantly will want full control of data provisioning and utilization as well as the ability to solve an unlimited number of nuanced issues and not cookie cutter algorithms.   💡 Costs need to be looked at on an enterprise level: We believe the speed of innovation in Gen AI means costs will continue decreasing dramatically but at an enterprise level this will still not be a small detail. Systems will want the ability to understand costs and delegate as needed for the outcomes desired at the organizational level.   Enter Qualified.   We knew when we met Justin Norden, MD, MBA, MPhil and team we were standing in front of changemakers. These individuals have lived and breathed the true application and implementation of Generative AI far before we were asking ChatGPT to write our emails. In fact, if you’ve ever driven in a Waymo you’ve benefited from past products this team has built.   Qualified Health is on a mission to enforce governance in Gen AI, allow systems to rapidly build for their needs, monitor and make decisions for all GenAI (homegrown and external) and accelerate the value the sector can glean from these new technologies.   Huge shout out to William T., Tommaso Auerbach and Jamie Kuntz for their hard work!

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The biggest topics in healthcare last year? The two Gs. GPT and GLP-1s. We’re continuing to innovate our GLP-1 care track, which includes personalized care from care teams supported by AI tools, that can help maximize outcomes for someone on a GLP-1. And what’s to come? I expect this year we’ll see: ⭐ Measuring digital health programs will shift (check out Omada’s VOI report for more on this) ⭐ Consolidation in the market - not all digital health companies will survive ⭐ An uptick in PBM and health plan partners to help employers offer GLP-1s with sustainable coverage plans Anything I missed?

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The challenges of healthtech innovation follows a pattern. The more I speak to companies and founders, The more I see a recurring theme. It goes like this: 0. Crystallizing their initial idea. 1. Validating their idea clinically. 2. Scoping out the market size and business model. 3. Figuring out how to build the initial MVP (Agency / Self build). 4. Deciding on the first few key hires. 5. Fundraising or grant application to develop the product further. 6. Finding end users to test the product and provide feedback. 7. Navigating NHS compliance and regulations. 8. Finding a clinical partner or pilot site. 9. Generating early evidence to prove their solution works. 10. Selling, selling, selling. Every single step is critical and you can tell how mature a company is based on where they are. It does not have to happen linearly as many things do happen simultaneously. ______________________________ As the vast majority of founders we help are non-clinical, I find myself helping more at 0, 1, 2, 4, 6. But I often signpost founders to awesome people in my network for the rest. If you are a founder, which challenges do you find particularly vexing? If you are a supporter, which challenges can you help with? 👇 Do let us know below! Liam Cahill | Phil Evans | Laura Johnson | Michael Watts | Victoria Burnip |

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Alot of bad actors and a few good actors. $2.5T HC capital raised & $1T invested by PE in last decade. $31B in 2013 vs. $217B in 2021. We know the story. Misaligned incentives - unrealistic multiples, short-term profit focus, aggressive cost-cutting, unrealistic scaling, misunderstood market dynamics, just to name a few. However, our industry needs money. But our industry is more infrastructure asset class than tech start-up (James Nicholls gave me that epiphany). Mic drop on the lyrical genius of Alex Fair of MedStartr Ventures as he literally gives the whole story poetic justice as he reads HIS POEM on this "On The Road at VIVE" episode of The Reverse Mullet Healthcare Podcast w/BP2 Health. This is the perfect episode for a Friday afternoon! He and Paulo J Machado donned the actual reverse mullets and joined us back in February at #VIVE2024 to talk about the need for REAL change in healthcare, startup focus and investor expectations. It was one to remember and one that is in desperate need of a full-length follow-up episode. Give us a like and a watch or a listen https://lnkd.in/e4w4mjkv https://lnkd.in/egmK3kMB

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📈 Demand for fertility services is rising -> 💼 PE recognizes this and wants in -> 🏜 but opportunities are scarce (https://lnkd.in/g6zXEVZh). Highly recommend anyone who wants a deeper understanding of what's going with fertility and fertility tech read Aya Spencer's *2024 State of fertility tech report* (https://lnkd.in/gVjK_UpX) - it's a great summary

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This 👂 podcast episode and insight’s from a16z Bio + Health's Julie Yoo spoke so clearly to the fundamental challenge facing both 🩺 clinicians and 🏥 healthcare systems.  There is a huge disconnect between supply, in the availability of clinicians, and demand, in the increasing volume and complexity of healthcare needs. -     36% of physicians plan to reduce their hours next year according to the AMA -     48% of physicians reported feeling burned out in a 2024 Medscape survey At the same time, the demographic baby boomer bubble and steady increase in the prevalence of major chronic disease, which consumes up to 90% of healthcare expenditures according to some estimates, is driving demand. With this context, Yoo points to a major opportunity for AI adoption in healthcare in 2025. Yeah, a VC hyping a wave of new AI companies that will replace the decades of training and experience of clinicians, the skeptic would say.  But Yoo is thoughtful in pointing to the role AI can play, and is already playing, through solutions such as ambient, autonomous scribe solutions (of which local star Abridge is leading the pack) in not replacing, but freeing up productivity for clinicians. There is so much unstructured context in both the complexity of disease and treatment options and the social/emotional considerations that we shouldn't be looking for AI to *replace* clinicians. But companies are getting better at finding the structured, repetitive and time-consuming places where AI tools can *help* clinicians. Nearly two-thirds of doctors cited bureaucratic tasks as the leading contributor to burnout. Rigorously trained-AI driven solutions can be a force multiplier for clinicians, and I’ve seen several interviews where nurses and doctors go as far as to say some of these solutions are ”restoring their joy in practicing medicine”. Our health is precious; and we rightly want any technology engaging with it to be developed thoughtfully and thoroughly tested. This requires top AI talent and diverse and realistic training data. Pittsburgh’s strengths in both areas is why we are an emerging hub for data-driven healthcare. #AIinhealthcare #clinicianburnout #healthinnovation #digitalhealth

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What's been happening in mental health? ⏺ Vitalic Health raised a $4M seed round for its geriatric behavioural health care platform. ⏺ Kooth Digital Health landed a $1.45 million pilot contract to provide their Soluna platform to over 50,000 students across New Jersey. ⏺ Peer support startup Fello , led by former Uber Eats executive Alyssa Pollack, raised $10.4M for virtual, app-based peer support designed to combat the loneliness epidemic. ⏺ Oceans Healthcare acquired Haven Behavioral Healthcare , expanding to 5 new U.S. states and adding 7 new locations. ⏺ Mabel raised a €600K pre-seed round to help improve women's mental health through microdosing programs and mushroom-based supplements ⏺ Wysa published a paper on the impact of their early stage digital mental health interventions for Singaporeans. ⏺ Applications for the KHP Ventures Mental Health immersion programme close tomorrow (Jan 7th) (All links below) __ If you liked this and want insights on the mental health industry in your inbox every week, subscribe to The Hemingway Report newsletter and follow me Steve Duke 📩 #MentalHealth #BehavioralHealth

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Q1 2024 was big for Digital Health, with $1.1B in VC funding. A large portion came from major deals like $126M for Transcarent and $108.8M for Rightway. Despite some challenges in digital therapeutics and telehealth, investments in general care ($213.4M) and health benefits navigation ($140.7M) are promising. Read what’s driving the shift from direct-to-consumer to enterprise telehealth models here: https://ow.ly/uNYs50SpXGh

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Hot off the pre-print server – an important publication authored by the Atropos Health team exploring the performance of LLMs in answering real-world clinical questions. LLMs excel at summarizing and contextualizing existing literature, but cannot generate de novo medical evidence today. The results of the study highlight performance gains attributable to injecting novel, relevant, and up-to-date medical evidence into LLM-powered clinical decision support systems. Brigham Hyde Nigam Shah Saurabh Gombar Read the study here: https://lnkd.in/ecuU25Pq

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Today was a big win for consumer health, with Flo Health Inc.'s valuation at $1 billion. We're hearing talk about the market becoming frothy again, but I’d argue—without seeing the detailed financials—that this valuation could be entirely warranted. Flo has built an impressive business, with 5 million paid subscribers and 70 million monthly active users. At $60 per year for users to access the product, this business has hundreds of millions in revenue and plenty of room to grow. It's increasingly clear to me that innovators focused on healthcare have been wildly underestimating consumer business models for years, believing that patients would only opt for solutions covered by their health plans and prescribed or recommended by their doctors. That thesis needs updating, particularly given high deductible plans and soaring co-pays. Innovators building solutions that users genuinely love will win - even in healthcare. These businesses also have the potential to move into B2B channels, which is far easier to do when you have an engaged, loyal user base. I expect we’ll see many more consumer health businesses “pop” in the years to come, further proving that consumers are ready and willing to pay for such solutions. We're watching closely at Cherish Kudos to the team at Flo for this impressive milestone. Lainie Muller Charlotte Yeh Aashima Gupta Avanlee Christine Esther Dyson Alexandra Drane Jessica Kamada Vin Gupta, MD MPA Asheesh Saksena Paul Crnkovich Josh Kampel Steve Chazin Lee Wagner #agingwithattitude #independentliving #consumerdrivencare

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Couple of weeks ago had the pleasure of sharing my story to Alexander Benkendorf about starting CastPrint and later moving on to join Verge HealthTech Fund and the learning along the way. Some topics we discussed: 💡What does it take to bring innvation in healthcare 💡How did my startup background help me better prepare for VC work 💡How founders can better engage with VCs and what are the tips and tricks from the "other side" Thanks Alexander for having me!

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Incredibly excited to share our updated Healthcare AI thesis. This is not a market map – in 4,000 words, we dive deeply into the research, products, business models, and market entry points that are reimagining healthcare with AI. More specifically, we cover: • Translating AI research into real-world products • Mapping modalities (software, copilots, agents, services, diagnostics, therapeutics) to problems in healthcare • Designing AI business models that unlock billion-dollar markets • Closing current gaps in healthcare AI infrastructure • Distinguishing AI platforms from point solutions Let us know what you think ⤵️

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