2019年美國醫療行業十大預言

又到了預測明年行業形式的時候了。雖然眼下經濟和政治的不確定性與日俱增，但我們依然不會放棄一年一度的預測活動。我們已經對2019年的醫療行業做出了十大預測，而且也做好了被現實啪啪打臉的準備。不過首先，我們還是應該回顧一下去年我們預測的那些東西都實現了沒有。

去年我們的十大預測已經實現了5個，還有兩個貌似有望在2019年實現。首先，我們正確地預測了Outcome Health公司的融資騙局；其次，我們正確預言了在藥品市場上，亞馬遜將不會通過B2C模式顛覆PBM行業，而是會選擇B2B模式，結果亞馬遜果然與摩根大通和伯克希爾-哈撒韋公司聯合成立了一家合資公司，并任命知名外科醫生、作家阿圖·葛文德擔任這家公司的CEO。

去年，我們還正確預測了一些創業公司會成功進行資本退出，Flatiron、Landmark和Pillpak等公司的例子可以佐證。此外，隨著美國醫療保險和醫療補助服務中心（CMS）出臺了更加利好的規則，美國的聯邦醫保優惠計劃（Medicare Advantage）也獲得了廣泛歡迎，近50%的聯邦醫保受益人都選了優惠計劃。最后，我們還預測了各大醫保平臺會積極收購那些利潤更高但監管更少的公司，2018年，安泰并購CVS、信諾并購ESI，以及不久后哈門那（Humana）可能與沃爾格林公司的合并，都證明了我們的預測是正確的。

當然，去年我們也有一些預測落了空。一是關于醫院招聘放緩。2018年美國各大醫院新增工作崗位約25萬個，同時醫院行業通過提高價格抵消了勞動成本的上漲。二是對人工智能的影響過于樂觀。雖然人工智能具有很大的潛力，甚至說不定有一天會橫掃一切，但目前我們還沒看到任何有吸引力的商業應用，除了每個創新產品在產品描述中都鼓吹自己用上了人工智能技術。三是錯誤地預言了大型制藥公司會變得越來越大（不過明年就說不定了）。四是關于基因編輯技術（CRISPR）的商業化，不過我們對此還是充滿希望的，今年11月，中國成功對一名嬰兒進行了基因編輯的消息就充分說明了它的前景。五是關于《平價醫保法案》的修改。考慮到民主黨正在漸漸奪取國會控制權，奧巴馬醫改被廢除的可能性幾乎不復存在，而該法案的修訂很可能會在明年實現。

現在再來說說我們對2019年的十大預測。

1. 醫保機構加速整合

美國醫療保險行業的競爭已趨于白熱化，首先是強勢的聯合健保公司（United Healthcare），它以低管理成本和高利潤著稱；其次是有了PBM業務加持后利潤更高的安泰和信諾等保險公司。在這些巨無霸的擠壓下，業內的很多小玩家很難阻止全國居民賬戶的流失，也無力在Medicare Advantage和Medicaid這種公立醫保市場上與專業玩家競爭。為擴大自身體量，家底還算雄厚的醫保公司便會謀求并購。另外，美國已有數個州投票同意擴大Medicaid醫保計劃的參保范圍，加之Medicare Advantage計劃的火熱，各大醫保公司也會考慮通過并購來進入這些快速增長且利潤越來越高的細分市場。

2. 醫生主導的責任醫療組織將快速增長

這里首先要解釋一下什么叫責任醫療組織（ACO）。責任醫療組織是奧巴馬醫改的核心元素之一，是指不同的醫療機構（包括不同層級的醫生）自愿組織起來成為一個協同合作的整體，為患者提供協同的醫療服務，以達到提高醫療質量、控制醫療成本的目的。責任醫療組織首先在美國聯邦醫保Medicare中試行。Medicare的2.0版醫療責任組織規則強烈傾向由醫生主導的ACO，而不是由醫院主導的ACO。這樣一來，醫生很快就會意識到，他們可以獨立于醫院賺取更高的工資。另外，有了資金、管理良好的醫療協議和低成本的分析工具，醫生們也更容易享受到規模效益的好處，同時保持自身的獨立性。我們預計，一旦初級保健醫師們意識到，沒有了大機構的枷鎖，他們可以做得更好，那么一些大型醫療平臺雇傭的醫師團體便會破裂。另外我們認為，由醫生主導的ACO和由醫院主導的ACO在績效上的差距也會愈發明顯。

3. 醫生的不滿有所降低

電子病歷系統糟糕的用戶體驗和繁瑣的操作負擔，使它早已成為醫生們的吐槽對象，我們相信，醫療系統已經聽到了醫生們的呼聲。如果醫生們以辭職或退休相要挾，任何一家醫院都是吃不消的。因此，他們肯定要做出一些投資來提高醫生們的士氣。我們認為，下一代的電子病歷系統肯定會把提升醫生的用戶體驗當成優先要務，在這方面，語音界面和機器學習等創新技術是大有可為的。谷歌以及很多創業公司都在大力開發語音識別技術，以減輕醫生們打字、點擊和搜索的負擔。有意思的是，在醫療行業應用語音識別系統，其實要比在消費電子產品上應用更容易，因為醫療行業的術語庫更小，上下文和語境也更容易預測。另外，亞馬遜公司最新發布的用于挖掘臨床數據的工具也有助于提高這些系統的效率。

4. 平臺互通終成現實

在宣布獲得成功五年后，各方力量終于將匯聚在一起，在跨平臺操作方面取得實際突破。目前已有多家做電子病歷系統的公司正在聯合商定數據交換標準（HL7 FHIR）。美國醫療保險和醫療補助服務中心也表示，愿意動用行政權力推動所謂的“患者比文書優先”倡議。美國各州也在積極推進電子病歷系統的互聯互通，以更好地應對阿片類藥物濫用和（貌似越來越頻繁的）自然災害。而在地方層面，由于各個醫療系統中的醫生越來越積極管理風險，不同醫療系統之間的“囚徒博弈”也就沒意義了。

5. 數字健康行業迎來整合

對于產品與市場尚未完成匹配的公司，2019年留給它們的增長空間將會更少。而這將帶來一系列的平臺整合。過去五年，醫療行業成立了很多創業公司，而現在我們差不多已經能分辨誰是成功的公司，誰是“還算湊合”的公司了。同時，就業市場上的很多大雇主已經度過了“早期采用者”的階段，它們更喜歡的合作伙伴，是那些能夠把市面上流行的各種單點解決方案納入標準化設計的醫保方案伙伴。這意味著很多處于早期階段的創業公司都要進行艱難轉型，因為對于付費方來說，它們的銷售周期要長于那些大雇主，證明有效性的標準也要高于它們。

6. 保險技術的發展不會一帆風順

我們認為，我們已經接近保險技術的炒作周期的頂峰了，2019年將是很多公司踢到鐵板的一年。其中，利用計算機編碼騙保是一個值得關注的風險領域，事實已經證明，它是在Medicare Advantage項目中騙取保金最快的一種方式。由于利用計算機編碼騙保的行為十分猖獗，“貓捉老鼠”的游戲時時都在上演，支付方總是在尋找還沒被編碼的疾病，美國醫療保險和醫療補助服務中心則對其進行審計，而且CMS幾乎總能發現錯誤，并處以罰款。這種騙保方式之猖獗，以至于CMS每年都要進行“編碼強度專項調整 ”，來砍掉Medicare Advantage的一部分報銷金額。有些作為支付方的創業公司雖然在融資上獲得了巨大的成功，但他們很快會發現，實際業務運營之復雜，以及規模化之艱難，要比他們在融資PPT中暢想的艱難得多。

7. 透析中心將被顛覆

在一般人的印象里，一名病人如果要做透析，那么他通常每周有三天要去透析中心，每次要在一張椅子里躺三個小時。然而正如快遞行業的崛起葬送了西爾斯百貨，透析中心被新技術取代也只是遲早的事。對于病人來說，每天在家中接受透析顯然更有利于康復，成本也更會便宜得多。瑞典已經推廣自助式透析很多年了，實踐證明，自助式透析比透析中心更加安全和可靠。隨著美國醫保制度向風險型支付轉型，注重管理風險的醫生們顯然也會更青睞效果更好、更便宜的醫療方法。

8. 遠程醫學迎來大發展

我們認為，2019年，各個醫保支付方將終于認識到，應該充分鼓勵和利用遠程醫療技術，而不是把它埋沒在無人問津的網站和難用的手機應用里。醫療健康應用Oscar公司表示，目前，該公司有半數以上會員在使用遠程醫療服務，并依賴Oscar應用指導他們就醫。凱撒醫療（Kaiser）半數以上的就診即將通過虛擬技術完成。醫保公司多年積累的數據早已表明，遠程醫療要比去實體醫院就診更省錢，而且也能讓患者感到更加輕松。目前，就連Medicare也增加了遠程醫療費用的報銷編碼。因此，我們預計，2019年遠程醫療的使用量至少將翻一番，同時它的使用將不再局限于感冒或流感等小病，而是擴展到臨床疾病管理等領域。

9. 藥品市場迎來顛覆

特朗普關于降低藥價的豪言壯語被啪啪打臉，制藥公司最近甚至漲價漲得更猛了。目前，美國有關部門正在對藥品流通環節的漲價進行審查。在美國，平均來說，藥品離開制藥公司后，在經銷環節會漲價40%左右。由于經銷環節不透明，患者為藥品支付了不合理的高價，而大量利潤都被中間商賺走了。我們預計，改革藥品供應生態系統的努力或將在2019年獲得實際進展。

10. 新的DNA測序平臺或將涌現

DNA測序是一個非常龐大且不斷增長的商機。過去兩年間，以單細胞基因組為代表的一些新應用有力推動了這個領域的增長。我們認為，新的測序平臺（或者是它們的影子）將在2019年悄然出現，這將導致該技術的定價下降（但同時依然能提供健康的利潤）。新平臺必將帶來新應用和更多的業務量，同時也會侵蝕Illumina的市場主導地位。

我們很期待新的一年將發生什么，也很期待明年年底向讀者報告我們的預測是否靈驗。（財富中文網）

本文作者鮑勃·科克和布萊恩·羅伯茨都是醫療行業的投資人，也是風投機構Venrock的合伙人。

譯者：樸成奎

It is soothsaying time again. Our annual plunge into the choppy waters of predicting the future, amid increasing economic and political uncertainty. Ever gluttons for punishment, we are ready to make 10 new predictions for 2019. But first, we should look back on how we did predicting what happened in 2018…

In 2018, five of our 10 predictions came true and two more seem on-track to become true in 2019. We correctly predicted another Theranos with the implosion of Outcome Health. We were correct that Amazon would not disrupt PBMs, rather they launched their Atul Gawande led collaboration with JPMorgan and Berkshire Hathaway.

Our successful exits prediction was validated by Flatiron, Landmark, and Pillpak. Also, Medicare Advantage gained in popularity with Centers for Medicare and Medicaid Services (CMS) issuing favorable rules and nearly 50% of new Medicare beneficiaries choosing a Medicare Advantage plan. Finally, we were correct that payers would aggressively acquire higher margin, less regulated businesses with Aetna merging with CVS, Cigna merging with ESI, and perhaps, soon, Humana merging with Walgreens.

We missed on our predictions that hospitals would slow hiring. In 2018, hospitals added about 250,000 jobs and were able to keep raising prices to offset rising labor costs. We were overly optimistic that AI would make a big impact. While AI has lots of potential and may eventually warrant “Intel Inside” status, we are yet to see meaningful commercial traction, outside of it being included in every innovative product description. We were also wrong about big pharma getting bigger (but next year…). We remain hopeful that our predictions about CRISPR commoditizing, as demonstrated by China’s gene editing of a baby in November, and the Affordable Care Act (ACA) being repaired, since we will soon have a Democratically controlled Congress that will no longer contemplate repeal, will both come true in 2019.

Now, onward with our 10 predictions for 2019.

1. More payer consolidation

There is stiff competition from not only stalwart United Healthcare, who boasts much lower administrative costs and higher margins, but also the rejuvenated higher margin PBM-enabled versions of Aetna and Cigna. As a result, many smaller payers will struggle to retain national accounts as well as compete against pure plays in the Medicare Advantage and Medicaid markets making them use their strong balance sheets to become acquirers. We also think the growth of Medicaid, with several states electing to expand, and Medicare Advantage will also trigger M&A in order to enter these growing and more profitable market segments.

2. Physician-led Accountable Care Organizations will grow rapidly

Medicare’s Accountable Care Organization (ACO) 2.0 regulations strongly favor doctor-led ACOs over hospital-led ACOs. Doctors will quickly realize that they can earn much higher wages independent from hospitals. Moreover, access to capital, managed care contracts, and low-cost analytical tools will make it easier to doctors to gain the benefits of scale while retaining independence. We anticipate the fracturing of some large health system’s employed groups, when the primary care doctors realize that they can do better if they break free. We also expect the performance gap between doctor-led ACOs versus hospital-led ACOs to become even more dramatic.

3. Doctors get less dissatisfied

We believe health systems have heard the cries from doctors about terrible user experience and administrative burden of electronic health records. Since health systems cannot afford to replace doctors who make credible threats of retiring or resigning, they will make investments to improve morale. We are bullish that electronic health records will move doctor user experience up the product roadmap priority list and that innovations like voice interfaces and machine learning will help a great deal. Teams at Google and many start-ups are making large strides in building voice technology to reduce typing, electronic medical record clicking, and searching burdens for doctors. Interestingly, it may be easier to use voice for healthcare than for consumer applications since the vocabulary is smaller and context is far more predictable. Amazon’s newly released tools to mine clinical data will help make these systems work better too.

4. Interoperability becomes interoperable

Five years after being declared successful, forces will finally come together to lead breakthroughs on cross health system and platform interoperability. Electronic health record firms are coalescing around standards for exchanging data (HL7 FHIR) and CMS is expressing willingness to use regulatory power to drive adoption with the “patients over paperwork” initiative. States are pushing for connectivity as one tactic to address the opioid epidemic and to improve resiliency from (seemingly more frequent) natural disasters, necessitating the need to access data. At the local level, the prisoner’s dilemma of health systems leveraging market power to impose three-week turnarounds and PDFs no longer makes sense when physicians on both sides of the transaction are increasingly trying to manage risk.

5. Consolidation in digital health

Growth equity will get tighter in 2019 for small companies that have not achieved product market fit. This will lead to a flurry of consolidation into platforms. Many new companies have been started over the last five years, and it is time to sort the true successes from the “just OKs”. Compounding this trend is large employers going from being the early adopters, to more willing to rely on their health plan partners who have responded to the proliferation of point solutions by incorporating many of them into their standard benefit designs. This will be a rough transition for many early stage companies since payers have even longer sales cycles and higher standards for proving effectiveness than large employers.

6. InsureTech takes a lump or two

We think that we are near peak hype cycle for insurance technology. 2019 is likely to be a year of toe stubbing for many. Upcoding is one area of risk since it has proven to be the fastest way to make money in Medicare Advantage. Coding has led to a cat-and-mouse game of payers mining charts for uncoded diseases and CMS auditing them and nearly always finding errors and levying fines. Upcoding is so pervasive that CMS actually cuts Medicare Advantage reimbursement annually using a “coding intensity adjustment.” Start-up payers that have enjoyed great fundraising success are likely to find the very complex operations and scaling required for their actual businesses much harder than investor PowerPoint pitch creation.

7. Dialysis disrupted

It is Norman Rockwell-esque that patients drive to brick-and-mortar dialysis centers three days a week and lay in a chair for three hours at a time. Just as Sears has been replaced by home delivery, dialysis centers will be supplanted too. It is far better for patients to have their blood cleansed daily and it is cheaper to have patients do it themselves daily at home. Sweden has embraced patient self-serve dialysis for years and it has proven to be both safer and more reliable than dialysis centers. As we move to risk-based payments, better and cheaper approaches to care will be embraced by doctors managing risk.

8. Telemedicine takes off

We think that 2019 will be the year that payers finally realize that it is far better to fully embrace and encourage telemedicine usage as opposed to burying it in their unengaging member portals and clunky mobile apps. Oscar compellingly reports that more than half of their members use telemedicine and rely on Oscar to route them to care, increasingly telemedicine. Kaiser will do more than half of all visits virtually. Health plans now have enough years of claims data to discover that telemedicine saves a bunch of money and makes members far happier than going to a doctor’s office. Even Medicare is adding codes to reimburse telemedicine. As a result, we expect telemedicine usage to more than double in 2019, while making substantive inroads beyond flu & cold into areas such as chronic disease management.

9. PBM disruption talk becomes reality

While Trump’s proclamations about lower drug prices have backfired, with drug companies raising prices even more aggressively, a byproduct of Executive branch rhetoric has been scrutiny over drugs getting marked up a bunch, after they leave the drug maker. Drugs are marked-up, on average, 40% by the distribution system. The current opacity about how money flows, leads to patients paying more for drugs and excessively large margins being captured by intermediaries. We expect next generation pharmacy supply ecosystem efforts to gain real traction in 2019.

10. Real progress with new DNA sequencing platforms

DNA sequencing is a very large, and growing, opportunity. New applications, such as single cell genomics, have driven growth over the last 24 months. We believe that new sequencing platforms (or at least the specter of them) will enter the fray in 2019, leading to decreasing per Gb pricing (while still providing healthy margins) which will both open up additional applications and volume as well as erode Illumina’s market dominance.

We look forward to seeing what happens and reporting back to you next year.

Bob Kocher and Bryan Roberts are both health care investors and partners at the venture capital firm Venrock.