There are few challenges messier and more fraught than the U.S. healthcare system, but a growing number of startups are looking at ways to address shortcomings in standards of care through tech. We had three such companies share our virtual stage at TechCrunch Disrupt 2021 this year, including Cityblock Health president and co-founder Toyin Ajayi, Forward CEO and founder Adrian Aoun, and Carbon Health‘s Eren Bali.
Let’s just say this conversation got heated — fast.
The main point of contention arose around defining what constitutes customer-centric healthcare and Aoun’s stance that, regardless of what else is involved in a company’s approach, starting from a point of working with insurers disqualifies a company from making any consumer-centricity claims.
“We keep saying that these companies are kind of consumer-centric,” Aoun said, referring to the panelists. “But in many ways I think one of the things that you realize is that when you get in bed with the insurance companies, which, whether it’s a Carbon or a Cityblock, at the end of the day, [if] you get in bed with the insurance companies, unfortunately, your incentive is basically not to go build a good consumer product.”
“Your incentives are actually not the right thing — they’re not what the consumer needs,” he added. “So at the end of the day, you’re [referring to Eren and Carbon] launching a scheduling feature. We’re launching a heart health program that eliminates high blood pressure for 40% of our members. You’re launching a new way to bill; I’m launching cancer prevention.”
Ajayi took issue with the binary Aoun was trying to establish and explained why it’s actually not such a clear-cut division between working with insurers and having a real and meaningful focus on patient outcomes.
“Adrian has said, either you get reimbursed by insurance, or you build a consumer or patient-centered company. And you know, in parentheses, that only very wealthy people can afford. What we found is actually that’s not binary; there is another path, which is partner with insurers, but take risk on the total cost of care and outcomes. So we do not bill for a community health worker coming to your home, holding your hand, telling you that you matter and helping understand what goes on in your life. But we absolutely are incentivized to do that and to innovate in that space, because that allows us to earn the right to provide healthcare to people that make them healthier.”
“There’s an approach that says: ‘Let’s go all for the consumer experience, and let’s cut out the insurer, and let’s just have pure incentives around delighting our customer.’ But the reality is, I’ve never, not once, seen a product that is built for that cohort trickle down to serving marginalized people,” Ajayi added.
Bali followed up by drawing attention to what cutting out insurers means in terms of the numbers of people who are left out when it comes to healthcare delivery.
“There are maybe 150 million people, if you’re being generous, that would be applicable for a concierge healthcare offering, like they can pay out of pocket,” he said. “Because most people are covered by some sort of insurance, even if they’re poorly insured, they probably don’t have the means to [ … ] spend thousands of dollars every year for their basic primary care. There’s also the high-risk Medicaid, Medicare dual-eligible class that can’t take risk. I mean, that’s maybe another 20 million or 40 million people. So you can call it like 60 million to be generous, and the realty is that like 300 million people are neither so sick that the government’s gonna pay a premium for their care even if you are taking risk, nor they are so rich that they can pay out of pocket.”
Aoun continued to make the case that there’s essentially no effective path forward short of razing the current system to the ground and starting over again fresh. He used Elon Musk and his approach with Tesla as the model to look to.
“So my argument, my posit is that we need to rebuild the entire healthcare system from the ground up,” he said. “You name it, it’s time to redo it — literally from open heart surgery, to delivering babies to oncology.”
“Now, you have to start asking yourself, what does that look like? When Elon talks about a carbon-free world, we know that he’s at the beginning, right? He needs infrastructure, needs cheaper cars, he needs time. When we talk about an insurance-free world, we need the exact same three: We need infrastructure, we need cheaper care and we need time. When you think of infrastructure, I want you to think of things like body scanners and sensors. When you think of cheaper care, I want you to think of things like AI and algorithms. When you think of time, it’s time to build a brand new healthcare system, built right for me, not the insurance companies, and built once and for all.”
Regardless of what is and isn’t an ideal end state, Ajayi countered, there are realities that need to be dealt with today, and in healthcare more than in maybe any other industry, ignoring the existing realities means leaving people behind, which means risking their health.
“I think saying look, actually flawed as they are — and none of us is going to say that insurance is not flawed — flawed as it is, we have a payment mechanism today that is operating in effect as a market failure. We’ve not leveraged and deployed the resources that we have today into the places that we can actually drive the maximum impact from.”
Aoun had earlier compared the moment in healthcare today to the iPhone’s entry into the scene, and the subsequent thriving of the App Store and platform as the desired future state, but Ajayi rejected that parallel.
“I’m not talking about the iPhone here — I’m talking about how do I make the world better today for people,” she said. “We can take the tools and the flawed systems we have and make much better things out of them. And in so doing have, I think, a vast, vast impact on others. Maybe those curves converge one day, and maybe we find ourselves in a world in which your technology in the future can be applied to the types of numbers I serve today. And that would be a beautiful thing.”
Ajayi further contested the way in which Aoun presented the problem as an oversimplification that omitted huge portions of the population, and particularly those in most need.
“I think the fundamental question is, what are we trying to solve for? And you [Aoun] may vision yourself the Elon Musk of healthcare; I vision myself as a human who is trying to make the world better today, for people who are sick and suffering, who do not have access to the types of technology and tools and systems that we may aspire to, for the future,” she said.
“Specifically, [I’m trying to help] people for whom the vast majority of their health outcomes, the factors that drive whether they will live or die, whether they will live to see their grandchildren, actually have nothing to do with your body scanners [and] have everything to do with do they have enough food to eat?” Ajayi said. “Do they have transportation to get to that doctor’s office? Did they experience profound trauma in their lives every day? Do they have access to green, nutritious foods to eat? Those types of factors, as we know, are the major drivers of health outcomes, particularly for lower-income individuals.”
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