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The Reckoning: What Happens to Digital Health After COVID?

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By JEFF GOLDSMITH and ERIC LARSEN

It has been a rough year so far for digital health. After an astonishing $45 billion poured into new digital health companies in 2020 and 2021, and an early 2021 peak in market valuations of publicly-traded digital health providers, valuations and multiples have collapsed. Once high-flying Teladoc, which traded at an eye-watering 42x revenues and commanded a $45 billion market capitalization, is now trading around 2.7X at about $5.7 billion. AmWell, the next largest telehealth player, has seen its stock drop more 90% from its high.

Nor is the evaporation in market value is confined to just a few highly visible incumbents. The 29 healthtech companies to go public (either via IPO or SPAC) in 2021 were collectively trading 45% lower than their opening day price by the end of the year, according to STAT. Among the privately held firms, re-valuation of digital health is getting underway. Bearish market signals portend a sharp correction in digital health, characterized by brutal price competition, widening (and less tolerated) operating losses, layoffs, and ultimately, widespread consolidation. 

However, there is also major pushback from the ‘demand side’ of the digital health equation. With the explosion of digital health players, potential customers are confused and frustrated. There is a fundamental disconnect between the exuberant (and as yet largely unsubstantiated) promises of digital health startups and the needs of the four ‘phenotypes’ of health care customers. How digital health firms respond to those customers’ needs will ultimately determine the shape and size of the digital health market.

Why is the Digital Health Market Correcting?

Let’s start with the supply side. It is not difficult to identify the source of the digital health boom: hyper liquidity in the market fueled by expansive COVID-related fiscal and monetary policy. In the heat of COVID, Congress enacted three enormous stimulus/relief packages in eighteen months. The Federal Reserve also turned deeply dovish, keeping interest rates near zero and embracing epic quantitative easing – pumping $120 billion a month into the economy and expanding its balance sheet by more than $6 trillion. Much of this newly printed cash found its way into the coffers of private investors. Private equity, growth equity, and venture capital collectively raised $733 billion in new capital across 2021.  Globally, private equity firms alone invested $151 billion in healthcare in 2021.

Telehealth Ignition

The spark to ignite the digital health explosion came from the surprise growth in telehealth visits in the spring of 2020. In the wake of the spring 2020 lockdown and freeze on elective hospital care that accompanied the COVID public health emergency, telehealth visits went from less than 1% of total Medicare Part B patient visits in 2019 to nearly 13% during the spring of 2020 (and nearly 38% of all behavioral health visits), according to an analysis by DHHS’s ASPE. Private insurers saw 50-70% of behavioral health visits turn virtual.

This surge was not caused by a spontaneous surge of consumer activism but rather by hospital systems desperate to remain in touch with existing patients during the spring COVID lockdown. These systems saw plummeting visit volumes not only due to service closures but to patient reluctance to visit hospital ERs and outpatient clinics crowded with contagious COVID patients. Larger systems with extensive IT infrastructure were able to stand up far more robust telehealth offerings than smaller systems. As Bob Wachter, Chair of Medicine at University of California at San Francisco said, “We made 20 years’ worth of progress in twenty days.”

The sudden multi-thousand percent rise in telehealth volumes led to breathless estimates of future growth in telehealth volumes and revenues. In July 2020, McKinsey estimated a total addressable market (TAM) of $250 billion for telehealth services — this from a business with a revenue base McKinsey itself estimated at $3 billion in 2019-2020, and $5.5 billion in 2020-2021. This risible TAM estimate assumed that 24% of all physician and outpatient visits (a 1.8 billion visit “universe”) and 25% of Emergency Department visits would be addressed through telehealth alternatives.

However, more than 90% of telehealth visits during the spring of 2020 were with physicians patients already knew, not random, anonymous physicians signed on to cover telehealth services by vendors. And 47% of those visits were one-time users, according to a recent Trilliant analysis. Visit volume growth was also materially aided by Congressional approval of temporary Medicare coverage for telehealth visits as part of the COVID Public Health Emergency declaration. 

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Does Digital Health Technology Have a “Famous Trio” in the Making?

By MIKE MAGEE

Yale historian, Frank M. Snowden wisely notes in his 2020 book, “Epidemics and Society”, that “We must avoid the pitfall of believing the driver of scientific knowledge is ever a single genius working alone.”

His insight came to mind this week as I was reviewing the January 11, 2020 Forbes article by Seth Joseph, health tech policy correspondent, titled “What Bubble? Digital Health Funding Year in Review 2021.”

By one measure of success – dollars invested – it’s been a banner year. According to Joseph, there was over $29 billion funded, and 729 digital health US-based startups in 2021. But according to Scott Barclay, Managing Director at Insight Partners, who is quoted generously in the Forbes piece, “digital health is still in its relative infancy.”

This level of churn, passion, and (some might say) financial frenzy is reminiscent of another moment in scientific history – the latter half of the 19th century. Over a few decades, “The Germ Theory” was fleshed out with unprecedented and remarkable human progress following in its wake.

The breakthroughs were not the result of 729 often-repetitive and unoriginal ideas, but rather the work of three successive innovators whose work built on each other, combining innovation, technology and health.

Snowden termed the three “The Famous Trio.”

The first was Louis Pasteur (1822-1895) a chemist with a sharp eye and mind. He had been hired to find a solution for wine and milk that was spoiling too fast. The tools he wielded were mostly observational, including a still primitive microscope. With it, Pasteur was able to identify putrefying microbes as causal but went two steps further. He noted that a heating process killed the microbes and halted the product putrefaction, and tied the microscopic organisms to specific human diseases. With this knowledge, he unveiled a commercial process of serial attenuation of disease-causing microbes that allowed safe inoculation of humans and acquired immunity.

The second of the trio was Robert Koch (1834-1910), a physician 20 years younger than Pasteur. While studying Anthrax at the University of Gottingen, he visualized the large causative bacteria, introduced it into a lab animal, and reproduced the disease. Going one step further, he described resistant spores of the bacteria, identified them in grazing fields, and proved that eating grass laden with spores could spread Anthrax between animals. His careful investigative approach led to the uncovering of the etiology of tuberculosis and to “Koch’s Postulates”, four steps still in place today, which when followed, constitute laboratory-based scientific proof of a theory. Beyond this, Koch was a technology innovator, teaming up with the Carl Zeiss optical company, whose lenses, in combination with specialized tissue stains and fixed culture mediums, allowed Koch to visualize and describe M. tuberculosis.

The third innovator was Joseph Lister (1827-1912), a professor of surgery at Edinburgh.  Thanks to the development of ether and nitrous oxide in the 1840s, pain management intra-operatively was under partial control. Improving techniques and tools helped control blood loss. But post-operative infection remained a persistent and deadly threat. Viewing the work of Pasteur and Koch, Lister recognized the possibility that contamination with microbes might be the cause. In carefully designed studies, employing hand scrubbing, sterilization of tools, and spraying the patient with carbolic acid, rates of post-operative sepsis declined. Other colleagues added sterile gowns, gloves, and masks, merging these added measures with Lister’s support.

 Arguably, the life-saving “Germ Theory” was the work product of complementary insights and serial incremental progress. It might then be reasonable to ask, of the $29 billion funded 729 digital health tech US-based startups in 2021, how many represent additive and progressive insights that might eventually lead to game-changing advances in the health of America?

Scott Barclay appears to be mining this same territory. In Forbes, he says, “The green shoots of the past 10 years are turning into new vibrant ecosystems that are growing, but young. We are early in what may turn out to be a two-decade epoch of super innovative ideas, strong founders with execution experience bringing change to a $4T sector of the economy that has been sclerotic and in many parts oligopolistic. The majority of the largest digital health companies in 2040 public markets have not yet been started.”

Does Digital Health Technology have a “Famous Trio” in the making to link infrastructure, AI diagnostics, and evidence-based health? Who are they, and how do they complement each other?

Mike Magee, MD is a Medical Historian and Health Economist, and author of  “CodeBlue: Inside the Medical Industrial Complex.“

Matthew’s health care tidbits: #DigitalHealth valuations

Each week I’ve been adding a brief tidbits section to the THCB Reader, our weekly newsletter that summarizes the best of THCB that week (Sign up here!). Then I had the brainwave to add them to the blog. They’re short and usually not too sweet! –Matthew Holt

For my health care tidbits this week, it’s time to bring up the disconnect between the continual collapse of #DigitalHealth stock prices and the continued increase in private sector investment and valuation in the same sector.

All of nine months ago, way way back in March 2021 market leader Teladoc hit a stock price of $308. Last week it hit a low of just under $90. Meanwhile several companies have IPOed or SPACed this year and almost all of them have seen their stock fall dramatically. For example, pioneer online mental health company Talkspace is now at a market cap of under $300m. This week a different mental health company Cerebral which was only founded in January 2020 raised $300m at a private valuation of over $4 billion. Yes they could have bought out Talkspace for that amount! In October Medicare Advantage plan Devoted Health raised money at a $12 billion valuation which exceeded the market cap of rivals Clover, Bright Health and Oscar–each of which has more members.

So what’s going on? Part of this is the wash of money still going into venture funds. Interest rates are historically low, while inflation is picking up, so that money has to go somewhere. Additionally some of the companies that SPACed out were probably unable to get such a good valuation in a private round. But it can’t be that all the 50 or so public companies are lower quality than the private ones. That indicates that either the private valuations aren’t real (because there are so many protections built into the deal for investors), or that the private and public valuations are going to get closer together. There is of course one more possibility–some of the private companies may pursue M&A and buy out some of the public ones. But in any event, this current arbitrage cannot last forever.

It’s not unlikely the public stocks may pick up. But we’ve seen private and public market bubbles before and the aftermath isn’t usually pretty.

Digital Health: A Promise of Health for All

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SPONSORED POST

In this interview Sophie Park, Chief Strategist at Bayer G4A, talks about the pandemic’s effect on the digital health landscape, digital health’s promise of Health Equity and Bayer G4A’s upcoming Digital Health Forum.

G4A is Bayer’s digital health partnerships and investments team dedicated to scaling digital health companies to change the experience of health. To attain this goal, G4A works with startups, innovation groups, commercial partners, thought leaders, health systems, and public institutions to accelerate and expand digital health innovations. In that context, G4A is offering opportunities for early stage to advance digital health companies to partner with Bayer.

Sophie, Covid-19 has clearly opened everyone eyes on the need to better our healthcare systems and raised awareness for digital health solutions. From your perspective, did the pandemic accelerate digital health on a long-term basis?

Clearly, the Covid-19 crisis spurred a momentum for digital health. During the crisis, I have observed two dynamics which advanced digital health in a never before seen pace.

On the one side, the needed adoption of digital health tools led to a mindset shift and more openness among health consumers and providers. The pandemic was a great chance for many people to get familiar with digital health tools and acknowledge their value. Covid-19 made it clear to individuals that their own health is a personal responsibility as well. Therefore, people more actively took care of their own health(care) and became more open to collect and securely share healthcare data. I believe that all these factors will lead to increasing use of digital health tools also in post-Covid times.

On the other hand, the pandemic exposed the pain points of our healthcare systems. The quality of care one gets is determined by social determinants- where you live, where you are from, what education you receive and what job you have. The pandemic left no doubt that there is still a long way to go to reach health equity and better health access. At Bayer G4A we believe that digital health can and should play a vital role in closing existing care gaps and ensuring health for all.

“Health for All” – that is the goal. Not only is it Bayer G4A’s leading vision it also is the title of this year’s Digital Health Forum hosted by G4A on September 9th. Why did you choose that theme for this year’s event?

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What’s the Latest with Evidation Health?

An email interview with the Co-CEO’s of Evidation Health

Over the last few weeks I’ve been conducting a back & forth email interview with Christine Lemke (L) & Deb Kilpatrick (R), the co-CEOs of Evidation Health. They raised $153 million in a Series E back in March (almost a small round these days!) but I wanted to understand a bit more about what the “new” Evidation was doing—Matthew Holt

Matthew Holt: Congrats on the latest funding. Clearly Evidation has evolved since its founding, but focusing first on the clinical trial study aspect, can you explain how the Achievement panel is structured? How was it put together? What are the typical ways that your clients use it, and what is the member experience?

Deb Kilpatrick: Our Achievement platform is the largest virtual connected research cohort in the United States, with more than 4 million users across all 50 states and representing nine out of every 10 ZIP codes. Through the platform, accessible via our app or through a browser, individuals have the opportunity to contribute to ground-breaking medical research in a number of ways: they can connect smartphones, wearables, and connected devices—think Apple Watches, Fitbits, CGMs, etc—that generate heart rate, activity, sleep quality, and other health-related data; they can connect health apps like Strava and MapMyFitness; and they can participate in surveys and provide patient-reported outcomes (PROs) of many forms. 

And they do so with strong privacy protections for both data collection and data use, including use-case specific consents that can be sequential over time. This goes for new Achievers and those who have used the platform for years. And Achievers always have the option to remove themselves from any research project, and/or the platform altogether, at any time.

What do we do with that data? Evidation partners with leading health care companies, including nine of the top 10 biopharma companies in the world, to understand health and disease outside the clinic walls while measuring real world product impact. We’ve conducted virtual trials for almost a decade now, totaling more than 100 real-world studies across therapeutic areas. 

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The Catalyst @ Health 2.0/Wipfli State of Digital Health Survey

By MATTHEW HOLT & ELIZABETH BROWN

Last year was a remarkable time for digital health. Obviously it was pretty unusual and tragic for the world in general as the COVID-19 pandemic continued to wreak havoc. We mourn those lost, and we praise our front line health workers and scientists. But for digital health companies, in almost no time 2020 changed from fear of a market collapse to what became a massive funding boom.

But no-one has reported from the ground what this means for digital health companies, of which there are perhaps 10-15,000 worldwide with maybe 6-8,000 based in the United States. Despite the headlines, most are not pulling down $200m funding rounds or SPACing out. So working with professional services firm Wipfli, we at Catalyst @ Health 2.0 decided to find out what digital health companies experienced in this most extraordinary year. 

Between Thanksgiving 2020 and mid-March 2021, we surveyed more than 300 members of the digital health ecosystem, focusing on leaders from more than 180 private (and a few public) digital health companies. We asked them about their market, their experience during COVID-19, and what they thought of the environment. We also asked them about the mechanics of running their businesses. The results are pretty interesting.

The Key Message: COVID-19 was very good for digital health companies–on average. Most are very optimistic but, despite the massive increase in funding since the brief (but real) post-lockdown crash, most digital health companies remain small and struggling for funding, revenue, and customers.

We also heard from investors, and a bigger group we called “users” (mostly payers, providers, pharma, non-healthcare tech companies, e-patients & consultants). While these “users” also saw a big trend towards the use of (and, to a lesser extent, paying for) digital health tools and services, they were not as gung-ho as were digital health companies or investors, who were even more optimistic.

The summary deck containing the key findings is below and there is more analysis and commentary below the jump.

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Special Event: The Catalyst @ Health 2.0/Wipfli Survey on the State of Digital Health Results Presentation

TODAY Tuesday, May 11th at 2pm ET/11am PT — RSVP here

Back in November of last year, Catalyst @ Health 2.0, supported by professional services firm Wipfli, launched the Survey on the State of Digital Health, with the goal of creating a comprehensive analysis of the impact of COVID-19 on digital health companies and the rest of the ecosystem. Between the end of 2020 and thru March 2021 we received detailed responses from 300+ digital health aficionados including 180 digital health companies. We’re sure this is the most detailed assessment of what’s happening on the ground in digital health companies you’ll find anywhere.

Join us at 2pm ET/11am PT on Tuesday, May 11th for The Catalyst @ Health 2.0/Wipfli Survey on the State of Digital Health Results Presentation, you’ll see the full results from me & Catalyst’s Elizabeth Brown, hear from Wipfli’s Paul Johnson & Girish Ramachandra, and get reaction to the results from our guests Ryan Johnson, lawyer at Fredrikson & Byron; Sunny Kumar, investor at GSR Ventures;, and digital health CEOs Helena Plater-Zyberk, Supportiv; and Mudit Garg, Qventus.

I think the zoom is full, but you can see it livestreamed below at 11 am PT – 2pm ET – Matthew Holt

Can You Trust Digital Health Firms To Trust You?

By MICHAEL MILLENSON

What kind of health care organization would let a 10-year-old child make an instructional video for patients? And what might that decision teach health tech companies trying to gain the trust of consumers? 

I found myself pondering those questions while listening to Dr. Peter Margolis, co-chair of a National Academy of Medicine committee on health data sharing and stakeholder trust and a speaker at the recent (virtual) Health Datapalooza annual conference. Margolis is also co-director of the Anderson Center for Health Systems Excellence at Cincinnati Children’s, the institution that allowed 10-year old kids with a condition necessitating a feeding tube to create videos showing other children how to insert one. Parents, meanwhile, were recruited to help develop new technology to help their child.

The payoff for this and similar efforts by the shared learning communities Cincinnati Children’s has birthed has been significantly improved outcomes and national renown. But for this type of initiative to succeed, Margolis told me when I visited a few years ago, clinicians and administrators “have to be comfortable with a very different kind of role.” 

As consumers gain access to information once limited to medical insiders, that advice seems increasingly prescient. Federal rules requiring providers to make electronic health data available to patients at no cost take effect April 5.  Meanwhile, voluntary electronic sharing of physician clinical notes is rapidly morphing from the unthinkable to the unremarkable, while apps to make all this data actionable are proliferating. As a result, long-simmering issues related to transparency and trust and are coming to the fore.

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The Catalyst @ Health 2.0/Wipfli Survey on the State of Digital Health

By MATTHEW HOLT

Catalyst @ Health 2.0, supported by professional services firm Wipfli, is launching a survey about the state of Digital Health. We hope to get a comprehensive analysis of the impact of COVID-19 on digital health companies and the rest of the ecosystem. This survey should take under 8 minutes to complete (and probably less). For your time we will get you a copy of the results when they are released. As an added bonus TWO respondents drawn at random who complete the survey will get advertising for their company for 6 months on The Health Care Blog (worth $5,000).

We are interested in hearing from leaders working in digital health companies, or those connected to digital health in health systems, payers, life sciences, consulting or investment companies.

To take the survey CLICK HERE

NOTE–None of the data from this survey will be shared by Catalyst @ Health 2.0 (even with our friends at Wipfli) other than as aggregate survey results. So you can be assured that your answers are completely confidential.

Matthew Holt is Co-Chairman of Catalyst @ Health 2.0 & Publisher of THCB

Call for Applications: Bayer G4A Partnerships 2020

SPONSORED POST

By BAYER G4A

Digital health is changing the world

From chronic disease management to prevention, G4A’s goal is to empower people with the tools and access they need to take control of their health. G4A does this through fostering a diverse and vibrant ecosystem of digital health partners to support their growth and impact.

On April 20th, G4A launched its 2020 Partnership Program with an open call for applications. The aim of the Partnerships Program is to work with companies across the globe on healthcare’s toughest challenges and innovate together towards a future of integrated care. This year G4A is seeking to collaborate with companies that are making an impact in the following areas:

  • Cardiometabolic and Renal Diseases – Heart health requires a 360-approach that encompasses lifestyle behaviors, remote monitoring, biomarker review, risk stratification, and more
  • Oncology – Utilizing targeted therapies and patient performance technologies can identify patients efficiently and slow disease progression
  • Women’s Health – Novel approaches are needed to manage gynecological conditions such as PCOS and Endometriosis, as well as Menopause, and provide answers to the unique needs of women’s health
  • Pharmacovigilance – The opportunity for innovation in drug safety is huge, specifically as it relates to adverse event detection
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