MD Next | Q4 2022

DIGITAL HEALTH

By Julie Fanning

ORAL HEALTH CONTINUED 46 / ORAL HEALTH STARTUPS Revere’s Top Picks Companies to watch in the oral health sector 48

Oral Health from Ed to Z Adopting new technology in a clinical practice 50

Investor Outlook

The oral health space is proving to be an exciting arena for investments, innovation and change

By Revere Partners EVENTS 58

A Physician’s Guide to HLTH

Sometimes what happens in Vegas doesn’t stay there

By John Dayton, MD, FACEP, FAAEM 66

2022 MedTech Conference

A wicked good show in Boston

By Vicki Farrar

FINANCE & POLICY

70 / FINANCE

It’s Not What You Make, It’s What You Keep Selling business interests, tax-free

By Alliance Bernstein 74 / FINANCE The Independent Physician Practices need to grow and evolve

By Oppenheimer

77 / FINANCE

Where Do We Go Now?

Market trends change, but informed investors ride the ever-changing waves

By Michael Schmanske

79 / FINANCE Startup Funds and the Funding Gap

Why early and small investment rounds are difficult to raise

By Michael Schmanske

81 / POLICY Healthcare and a Divided Government

What can and cannot get done and what it means for VCs

By Jones Point 83 / POLICY Policy Innovation

The physician’s important role in driving healthcare policy

By Tommy Barletta

ABOUT THE COVER

Columns

A few entrepreneurs who inspire us 60 Calendar of Events 87 / PROFILE Jaffar Raza, MD, FACC 88 / PROFILE Yvonne Bokelman 99 / ANGELMD ACADEMY Seven P’s to Evaluate Healthcare Companies A framework for physicians to determine the strengths and weaknesses of startups

By John R. Dayton, MD, FACEP, FAAEM 100 / ANGELMD ACADEMY Grow to Thrive Strengthen your practice’s core with this four-step methodology to scale growth

Innovation leads to a universe of infinite possibilities. To explore it, you just need a really good map.

Photo by Greg Rakozy

By Pariksith Singh, MD 102 / SIDE HUSTLE Hustle and Bustle

The financial rewards of a side hustle can be just the beginning 103 / NEWS OF THE WEIRD The Last Laugh

CHAIRMAN | PUBLISHER Tobin Arthur

EVP OMNICHANNEL MEDIA | MANAGING EDITOR Berry Brunk

CHIEF CREATIVE OFFICER Julie Fanning

ASSOCIATE EDITOR | HEAD OF RESEARCH Michael Schmanske

CHIEF MEDICAL OFFICER Mark Foimson, MD

HEAD OF COMMUNITY Katie Richardson, MD

EXECUTIVE MEDICAL DIRECTOR, WRITER Ramesh Donepudi, M.D., MRCP

EXECUTIVE DIRECTOR, ANGELMD ACADEMY Saya Nagori, MD

WRITER Amir Baluch, MD

TECHNOLOGY ARCHITECT Yuri Sernande

CONTRIBUTORS

WRITER Sam Kessel, MD

WRITER Manish Bhandari, MD

PRODUCTION ASSOCIATE Cam Douglas

ADVISORS

Nirv Amin, MD Amir Baluch, MD

Thomas Biggs, MD

Asheesh Gupta, MD

Aaron Kaplan, MD James Lee, MD

Luke Oh, MD Nitin Patel, MD

Ramin Rafie, MD Jaffar Raza, MD Harneet Singh, MD DJ Verett, MD David Yakobi, MD

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Berry Brunk 757.340.3625 berry@angelmd.co

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© 2022 | Vol 1, No. 2

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FROM

A New Year and a World of Opportunities.

When we launched MD Next we knew it would be a good compliment to the other media channels AngelMD produces for education and entertainment of our clinician membership. What we did not anticipate was the extent of the response.

From medical societies to sponsors to members with ideas for future articles, the magazine has taken on a life of its own. Keep it coming. Response like this validates the hard work that goes into producing content for the community.

Like most individuals and companies, we have our own New Year’s resolutions:

Tobin Arthur

Tobin Arthur, a 25-year startup, investment, technology and operations expert, is founder of AngelMD and publisher of MD Next.

• We want to double membership. The larger the membership gets, the more advertising revenue we generate. The more ad revenue we generate, the more content and events we can produce to serve healthcare innovation stakeholders.

• We want to highlight your contributions. If you have content ideas, interest in engaging a large community of clinicians or have other ideas for us, we’re all ears.

• We want to serve you with the best content in healthcare innovation. Articles, podcasts, events and education are just the beginning. Become a CAB member to sign up for evaluations, side gigs and advisory roles.

In this issue, we continue to highlight innovative startups. This is core to our DNA. We also highlight intriguing developments in digital health, orthopedics, oral health and more. We are especially excited about the one-on-one conversation with Ed Zuckerberg, DDS. Dr. Zuckerberg and his wife are tremendous advocates for innovation and dedicate time to helping startups that could otherwise be spent on plenty of other things at this stage in their lives. It’s this kind of dedication to advancing healthcare that we are honored to witness everyday and showcase for you in MD Next. Happy New Year!

Sincerely, Tobin

FROM

I Left My Business Cards in San Francisco

As the internet was establishing more mainstream status in 1999, I first attended the Volpe Brown Whelan Internet & Communications Conference in San Francisco. Already it was the epicenter of matchmaking for entrepreneurs who needed to access capital to grow their fledgling start-ups. The JP Morgan Healthcare conference continues in the same vein as the earlier meetings and for 2023 celebrates its 41st convening of this symposium.

Berry Brunk

Berry Brunk is the EVP, Omnichannel Media and the managing editor of MD Next. He has an extensive background in publishing along with healthcare and technology ventures.

The lobby at the St. Francis Hotel has hosted more deal-making handshakes and seen more term sheets fly around than probably any other venue in the U.S. The global focus provides Angel MD with an opportunity to debut our second issue of MD Next—the crown jewel in our omnichannel platform—that connects earlystage companies with physician investors who have entrepreneurial interests. The MD Next team will be there, and we look forward to your feedback on the exciting new magazine we have launched.

Event details

The JP Morgan 41st Annual Healthcare Conference (JPM 2023) will take place January 9–12, 2023 in San Francisco, California. We hope to see you there.

The annual event is back in person this year; it is the largest and most informative healthcare investment symposium in the industry, bringing together industry leaders, emerging fast-growth companies, innovative technology creators and members of the investment community.

JPM Healthcare Conference: its history

What is today known as the annual J.P. Morgan Healthcare Conference began in 1983 and was hosted by Hambrecht & Quist (H&Q). H&Q was acquired by Chase in 2000 and a year later Chase was acquired by J.P. Morgan. At its infancy, the conference featured just 20 companies, had about 200 attendees and focused on the biotech industry.

Anyone who has been in San Francisco the second week of January knows that the JP Morgan Healthcare Conference is the event everyone references. But in reality there are over a dozen parallel events all focused on various aspects of healthcare innovation and financing. JPM 2023 is an exciting way to begin the year, and AngelMD remains the nucleus where these relationships and the focus on healthcare innovation continue all year long.

All the best, Berry

Advanced Scanners

Surgical planning and procedure has become ever more integrated with machine vision and robotic assistance. The FDA has recognized the significant vision gap that leads to “patient deaths, life-threatening injuries, and failed, aborted, and prolonged medical procedures.”

Advanced Scanners has developed an optical machine vision platform to track anatomy during surgery. Utilizing cutting edge lighting and imaging techniques their scanner maps the anatomy and provides realtime tracking updates (corrections) to navigation, robotic, and AR/VR visualization platforms so they present accurate information to surgeons during a procedure.

Advanced Scanners is one of very few companies addressing this issue and developing commercial solutions with market-leading companies across a spectrum of applications.

They are currently raising a Series A round with commitments from a global medical device company and the founder of one of the largest and most published neurosurgery groups in the United States. They are looking for a colead and fill-in investors.

The Bleeding Edge

Innovation is a global force. At AngelMD we are proud to support entrepreneurs and clinicians from all around the world. This issue we bring you some cuttingedge concepts from Australia, Europe, the Middle East and even far-away Canada. If you or your peers know of any international startups looking for support or introductions into the world’s largest healthcare marketplaces, make sure they register their companies at AngelMD.

Also don’t miss out on the upcoming Pitch Madness contest coming this spring. Make sure your favorite startups are represented!

If you have any questions about these companies or would like to recommend any “gee whiz” technology yourself, please contact us at MDNext@AngelMD.com.

Micro Pacemakers

Via Physics Today—Scientists have fabricated and successfully tested an ultrathin patch-type cardiac device that can monitor a heartbeat and apply stimulations as necessary.

Currently, these functions are performed by bulky and intrusive devices such as pacemakers. While these were miracle machines for many decades, the surgery required to implant pacemakers is complicated and can be risky. This new device, on the other hand, has a unique adhesive that allows it to stick directly to a wet organ such as the heart.

The researchers, from Yonsei University in Korea, believe that the platform they have developed may one day replace pacemakers and therefore avoid unnecessary surgical risks. The team has so far only tested the device on a live rabbit model and an artificial heart, but successful results suggest that this is a promising new technology that bears further investigation.

NeuroGeneces

Neurodegenerative diseases are associated with accelerated brain aging, and as a result the concept of Brain Age has gained attention as a measurement of brain function. Current methods for Brain Age rely on MRI scans which limits their accessibility and scalability.

NeuroGeneces’ innovative approach for determining Brain Age analyzes the electrophysiology of the brain during sleep with an at-home EEG sleep headband and AI algorithms. Macro and micro features of sleep capture how well the brain’s key processes—such as memory consolidation, hormone activation, inflammatory response and glymphatic cleansing—are operating. When mapped to a reference range, these electrophysical patterns provide an objective measure of overall brain function which is summarized in the biological Brain Age.

Changes in brain function occur up to 20 years before cognitive symptoms become apparent. This enables early detection and risk assessment for neurodegeneration in presymptomatic individuals—at a time when interventions and behavioral changes can be most effective.

NeuroGeneces is transforming brain wellness—while we sleep. Their platform integrates neuroscience, sleep science and AI to create a suite of braincare solutions, from proactive screening and brain health assessment to targeted neuromodulation to enhance brain function.

SFA Terapeutics

SFA Therapeutics is reimagining the treatment of autoimmune disease.TM

Autoimmune disease affects over 350 million people and remains a field with serious unmet medical needs. Major autoimmune diseases include psoriasis, rheumatoid arthritis, lupus, and MS. Current treatments focus on symptoms, using drugs that have major side effects due to immunosuppression.

SFA is focused on treating the root causes of autoimmune disease, with a novel class of oral drugs that target key inflammatory cytokines and return them to normal levels. The method of action for these oral drugs downregulates TNFa, IL17, IL23 and IFNg. SFA has six drugs in their pipeline.

Psoriasis is the initial indication for proving their platform, with their lead drug, SFA002. In a previous phase 1a clinical trial, 6 out of 6 patients with psoriasis showed significant responses. A second trial is now underway in 30 patients with mild and moderate psoriasis.

Enrollment is underway at four clinical sites, and SFA expects preliminary data in early 2023. For more information, contact Dr. Ira Spector, CEO, at iraspector@ sfatherapeutics.com.

Sonosine

Currently, patients presenting with soft tissue disturbances in a wide variety of disease conditions are difficult to diagnose. Current medical imaging such as MRI, CT and ultrasound are either expensive, complex, have long-waiting times or often produce non-diagnostic images. This is particularly the case with musculoskeletal (MSK) or sports injuries where long waiting times and inconclusive images hinder getting the correct treatment fast.

Sonosine has developed a point-

of-care modality which can detect these soft tissue disturbances using a patented radio frequency-based technology called Electromagnetic Acoustics (EMA). The company’s Pulsar 1 device will enable point-of-care medical

BEFORE AFTER BEFORE AFTER

Human data show treatment effect with SFA002 in a new patient with moderate-to-severe psoriasis

diagnostic imaging that is cost-effective, safer and more comfortable.

The Pulsar 1 device is an ‘addon’ to existing ultrasound machines to create images with advanced tissue differentiation detection with pathological features such as increased blood perfusion, calcification, and inflammation clearly visible. This portable device can be used to monitor healing and effectiveness of treatment with no restrictions on frequency of use.

Pulsar 1 will initially be used to image MSK conditions, with clinical trials set to begin in early 2023. Sonosine plans to expand the use of its technology to other applications such as breast, liver and kidney with an initial NIH-funded trial scheduled for late 2023. Contact: info@sonosine.com.

Hylid Diagnostics

While diabetes outcomes and costs have improved—particularly with internet-connected glucometers and engagement-enhancing remote care (aka digital health)—Chronic Kidney Disease (CKD) outcomes and costs have steadily worsened. We need a ‘glucometer for CKD’, ie a simple at-home system for measuring biomarker levels important to CKD, such as potassium, creatinine, and hemoglobin.

Hylid Diagnostics (HyliDx) is developing the first cloud-connected home blood-testing system able to measure multiple disease markers in a finger-prick drop of blood, to enable a vast expansion of Remote Care capabilities. Their first target is chronic kidney disease (CKD). CKD often develops from diabetes and has approximately the same number of sufferers and Medicare treatment costs as diabetes.

With its patent-pending optical sensor technology, HyliDx is the only company that can provide lab-accurate biomarker measurements in the hands of any user. It can also do so at a fraction of the cost of similar devices designed for hospitals, which use more complex and difficult-to-manufacture electrochemical sensors for their measurements.

HyliDx has a working prototype instrument and single-use test cartridge— containing biomarker sensors that demonstrate tight precision in benchmarking against central laboratory equipment. With a completed system—including manufacturing and EMR-connected eHealth app—HyliDx is poised to start disrupting the $400B US/EU CKD market in 2024. n

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Alyve Medical Inc.

Have you had shoulder pain, a shoulder injury, or had a family member with a shoulder injury? Know someone who has had shoulder surgery? Nearly everyone that the team from Alyve Medical talks to about their products responds with their own story, and wishes the solutions from Alyve had been available to them.

Today, there are currently no rehabilitation or stimulation devices that retrain the brain to achieve long term outcomes. Current therapies do not provide dynamic stimulation or biofeedback or generate a neuroplastic response. Additionally, in orthopedics, assessing motion and outcomes is generally subjective. Adding to these issues, 75% of patients do not comply with their physical therapy as prescribed. This is a huge problem with significant cost implications.

Alyve Medical has developed two technologies that are FDA cleared, registered and CE Marked that solve these problems.

The first is Neuralign System™ S (shown at right), a substantially differentiated neuromuscular electrical stimulation (NMES) device, treating the vast majority of shoulder pathologies. The key to the technology is the patented Motion Activated Stimulation that provides dynamic interaction inducing neuroplasticity. Patients follow a customizable series of therapeutic exercises on a tablet-based app, which rounds out the trimodal biofeedback—visual, auditory and

Healthcare Startups

MDNext is the magazine for healthcare innovation. But breakthroughs do not spring wholly formed from a vacuum. Successful entrepreneurs are assisted by a robust innovation ecosystem and central to that ecosystem is expertise. AngelMD’s clinical experts have proven ability to winnow those solutions most likely to overcome development and adoption hurdles from the chaff of ideas that will never reach the finish line. The AngelMD network is proud to support a wide range of promising healthcare startups. Many of our featured startups are actively seeking investors, advisors and early adopters as beta sites.

For more information on any of the startups featured here or elsewhere in the magazine, contact us at MDNext@AngelMD.com for more information or an introduction to company management.

sensory—and augments the treatment of the stimulation itself. This is a unique and proprietary innovation.

The second product, ShowMotion™, is a kinematic sensor kit which objectively documents normal and abnormal movement in joint function in 5-7 minutes. It is noninvasive, mobile and provides instant graphic results. The two products can be used independently or together.

Both products have peerreviewed publications documenting their utilization and effectiveness, with more expected near-term, and multiple studies ongoing around the globe. The results of a recent multicenter randomized controlled trial, demonstrated statistically significant and sustained results in WOSI scores when comparing six weeks of physical therapy using Neuralign S (formerly known as Shoulder Pacemaker), to six weeks of standard physical therapy. (see graph at right.)

Both technologies are available in the U.S. and EU, and target shoulder/ upper extremity applications. ShowMotion’s capabilities have recently expanded to allow analysis of the lower extremity. The Neuralign platform’s pipeline development is now underway to create a device for the knee, with spine to follow.

Alyve Medical is a commercial stage medtech company focused on reimagining the management of musculoskeletal care. Headquartered in Denver, Colorado, with R&D and manufacturing in Carpi, Italy, they develop, create and market noninvasive and wearable technologies that represent revolutionary technological advancements in motion analysis and functional restoration driving improved outcomes and satisfaction for both patients and healthcare professionals.

Alyve Medical is actively fundraising and has opened a managed SPV using AngelMD Capital’s new syndicate platform. To learn more, contact Michael Schmanske at michael. schmanske@angelmd.co or Yvonne Bokelman, CEO of Alyve Medical, at ybokelman@alyvemedical.com

Comparison of the change from baseline Western Ontario Shoulder Instability Index (WOSI) between the physiotherapy (PT) and Shoulder Pacemaker enhanced physiotherapy (SPM-PT) group including cross-over from PT to SPMPT after 3 months. Mean and standard error of the mean are presented.

Alyve Medical Inc. CEO—Yvonne Bokelman is a results-driven life sciences executive with a unique leadership background and executive experience in medical device, hospital, consulting and healthcare information technology. Recognized as an astute business operations and financial executive, market access expert, transformational leader and mentor and strategic thinker. Extensive experience in executing strategic/tactical plans to support optimal commercialization and reimbursement of devices and therapies. Before joining Alyve Medical in 2022, Yvonne spent more than a decade with Zimmer Biomet in a variety of leadership positions, including global president and GM for a diverse group of functions and businesses; she was with Medtronic Spine & Biologics for six years prior to that. Earlier in her career, she was in hospital administration, spent several years as executive vice president at QuadraMed. Yvonne has served as a board director, holds an MBA and is a fellow in the American College of Healthcare Executives. [See p. 88 for a Q&A with Bokelman]

Wave Therapeutics

Pressure injuries kill 50% more Americans than automobile accidents, but Wave Therapeutics has a plan to change that. CEO Jessica Bussert came up with the idea for her smart cushioning technology while working as an emergency room nurse.

“A veteran who had lost his legs came into the ER with the worst infected pressure injuries I’d ever seen. He was septic and nearly dead, and you could clearly see his ischials below his glutes. After we stabilized him, he told me that his doctor had prescribed a $4,000 alternating pressure wheelchair cushion to help treat his wounds, but he just couldn’t afford the product. His story really motivated me. I’ve always been

an inventor and techie, and I challenged myself to create a more effective solution that could be manufactured and sold affordably.”

At first she was just working on an interesting challenge, and Jessica had no intention of setting up a company or manufacturing her idea. That changed when she learned more about the number of people impacted every year and the cost to the U.S. economy. “I realized that one of the reasons so many people die from pressure injury is that affordable preventatives just don’t exist. People have to be seriously sick before insurance will act, and that’s just wrong.” She left nursing and began working full time on the technology, convinced that she was onto something important.

Today Wave Therapeutics is on the brink of bringing their first

product to market. The Surf Wheelchair Cushion is a soft robotics platform paired with advanced analytics, all in a self-contained package expected to cost the user between $450 and $600 dollars. Wave’s patented technology combines alternating pressure with sequential compression to create a rolling wave of low pressure beneath the user, constantly changing pressure points and working with the body’s circulatory system to deliver fresh, oxygenated blood back to at-risk tissues. Additionally, the on-board analytics will provide real time data and alerts as well as remote patient monitoring and compliance with care documentation.

Bussert says, “The patient is not the only one whose life will be improved. Overworked nursing staff and family caregivers will be freed from the ineffective drudgery of endless turning schedules. Our devices will do the job for them.” Wave’s technology will next be applied to mattress toppers, hospital beds and products for the surgical suite. They will eventually expand to foreign healthcare markets as well as license their technology in consumer, automotive, and airline products.

Wave Therapeutics is based in southern Indiana, but the company is making waves across the U.S. In recent months they have won several pitch events including at the Aging 2.0 conference in Boston, the National Women’s Fast Pitch in San Diego and the Crossroads Seed Pitch in Indiana. “We’ve already secured nearly a million dollars of funding and we’re currently pursuing grants and additional private investment to help accelerate our path to market,” Bussert said.

They’ve got a contract with

the Veterans Health Administration, were recently awarded their first U.S. patent and are in discussions with the University of Colorado, Denver, to deliver their first clinical studies.

Wave is actively looking for partners to host additional pilots and clinical studies and the company has recently begun initial manufacturing to support a soft launch of the product as early as Q1, 2023.

To learn more, please email wave@wavetherapeuticsinc.com

Wave Therapeutics founder, president & CEO—Jessica Bussert, RN, has been a lifelong maker/hacker since her early teens. She was a computer game publisher at 15, a robotics programmer at 17, an entrepreneur at 20 consulting with Indiana businesses and a successful Fortune 100 business leader running EMEA consulting division. She has also been a volunteer firefighter, an Emergency Medical Technician (EMT), an emergency room nurse, and an inventor/ entrepreneur. Bussert is a Purdue University Alumnus, an active community volunteer, a public speaker, a diversity community organizer, and a member of The Startup Ladies, SONSIEL, The Female Founders Alliance, Women In Bio and an IYG leader.

Happyr Health

Chronic pain is not an ‘old-peopleproblem’. A shocking 25% of children and teenagers live with chronic pain. So does Nicola, co-founder of Happyr Health, who has lived with migraine since her childhood. The pain takes its toll on our future generations. They miss 2.5x more school days than their peers and are twice as likely to develop mental health conditions such as anxiety or depression.

Based on Nicola’s and her cofounder’s struggles with chronic pain when growing up, they founded Happyr Health. Happyr believes in a happier life with chronic pain. Their products are uniquely designed for young people and their families. How? Happyr combines behavioural and mindfulness-based self-care techniques with engaging and interactive app design suitable for the young audience. Their core product, the Tamer App, builds on the scientific discoveries that cognitive, behavioural and mindfulness-based interventions can change our pain perception.

Become a member of AngelMD and get startup advice from our community of expert clinicians.

Happyr Health

Nicola Filzmoser Co-founder and Product Lead

happyrhealth.com

A. Chronic pain is not just physical pain, as many people believe, it also includes a lot of emotional and social challenges. There is a strong psychological aspect to it. But unfortunately, there is hardly any treatment for the psychological, emotional and social issues particularly challenging for children.

At HappyR our goal is to let people have a happier life with migraines. We help them with techniques from positive psychology, cognitive behavioral therapy and coping techniques used in psychological settings. By helping them to cope better with their disease, it also has an impact on their physical wellbeing and on the actual pain intensity they experience.

Q. You have a lot of personal experience as a sufferer, but what about your experience gives you insight into the proposed solution?

A. I have been living with migraines since I was four years old. I looked for a solution based on science that would help me manage both my pain and my life. I approached it from the medical expert’s side and integrated my personal experience along with many other migraine, chronic pain sufferers and their families. I tried the techniques myself. And they helped, they really helped.

Although the techniques came from evidence-based care, I didn’t know back then just how much research was behind it. There is a large base of accumulated research, especially for the pediatric community, showing it can help better than even pharmaceutical approaches. For young people, for children, adolescents, a lot of medications are not advised or available yet. So we saw in some studies, better effects of, for example, cognitive behavioral therapy, in reducing pain intensity than pharmaceuticals.

And we’re not meaning to take away the physical pain entirely. We believe this is a complementary approach, and significant research shows that by addressing all aspects of pain we can dramatically reduce the levels of medication required. Addiction risks are diminished as well.

A. We’ve been focused on the UK at the moment. We’re working with different universities and NHS Trust grants to perform our first studies with our phone app rollout. We have very good preliminary results from a recent pilot project we did with a target group containing children and adolescents, specifically with migraine living in the UK. They had a significant improvement in their functionality in professional settings (at work, at school or university). Those moments make up the bulk of our days. If you can deal better with a disease in those situations, it immediately has an impact on your emotional and social wellbeing. We got first indications of a decrease in pain intensity and frequency of distraction as well.

We are now looking for a larger pilot project with a broader participant base, so we’re also looking for sites in the U.S. If you know anybody who works with the pediatric chronic pain population, any pain clinics, any charities who would like to help beta test our apps that can actually improve pain intensity, please reach out.

Q. Are you saying

could

replacement for opioids entirely? That would be a pretty dramatic statement.

A. We aren’t looking to completely replace the pharmacological approach. For now, we prefer to focus on supplementing it. We acknowledge that pain is not only physical, it’s psychological, emotional and it’s social. So we have to treat all the four aspects.

Happyr Health co-founder—Nicola Filzmoser developed the app to help young people manage chronic pain. Based on her own experience with migraines since her childhood, Nicola is dedicated to transforming access to personalised and engaging pain-coping support. She works closely with migraine and pain experts globally as well as hospitals, pain clinics, and most importantly, Happyr Health’s patient advisory board to develop new solutions. Nicola has a background in entrepreneurship (at the University of Cambridge), and an MSc in Healthcare & Design (at Imperial College London). She has won multiple awards for her work, including the Women in Innovation Award 2021 of the UK government.

Q. Could you describe your company’s approach towards pediatric chronic pain care?

this

be a

Q. Could you tell us a little bit about the results you’ve had thus far? What has been your primary geographic focus?

Cognitive behavioural therapy is the leading intervention used in paediatric pain management. It aims to enhance a child’s adaptive functioning by teaching them how to react to pain more helpfully. The psychological techniques used are designed to alter psychological processes which underlie pain, distress, and disability by modifying situation, emotional, and behavioural factors (Palermo, 2012). As Fisher et al. (2019) found, those techniques don’t only improve a child’s coping ability but lead to a reduction in pain intensity.

With the involvement of patients, their families, and clinicians, Happyr adapts those techniques into digitally accessible tools that complement the current standard of care, treating acute symptoms with medication. A first evaluation of the Tamer App with

the University of Stirling confirms that young people find the Tamer App a valuable tool for their selfmanagement.

At present, Happyr offers three tools to its audience: the interactive Tamer App with evidence-based selfcare exercises. A parent online course to teach them about children’s migraine management. And a children’s book, explaining migraine in a story-based context. What next? Happyr is working with a diverse team of clinicians to bring all these tools together into a multidisciplinary digital clinic. They are continuously looking for pain experts, psychologists, or clinicians who too aim for making multidisciplinary

chronic pain management accessible to future generations. Find them on HappyrHealth.com if you want to get involved or learn more. n

Hippo Health is now on a mission to enable “Care Communities for All” across the country. Come join us on our free consumer-friendly care team communication portal to help restore joy to the modern day care experience. Please sign up today at hippohealth.com.

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Digital Health

Providing patient care beyond four walls

he COVID-19 pandemic and the resulting lockdowns changed some business models and accelerated others. In healthcare the changes may be transformative. The industry has long been viewed as 20 years behind the rest of the world in adopting digital solutions. During the past three years (yes, three years!) government, insurers and healthcare providers were all forced to change long-standing business practices to adapt to the new reality. By removing roadblocks to adoption, a torrent of new services and companies have been released into the market, all seeking to be a preferred service provider.

While some companies have achieved multi-billion dollar valuations, others have flopped and we believe the digital sector has not even completed gestation let alone its infancy. What will be the drivers that determine success and are there any markers we should watch for to help us support the eventual winners? “Moving fast and breaking things” doesn’t work for healthcare, and being a disruptor is less valuable when you need to integrate with an existing operating structure. We asked some of our experts to provide some insight on this topic and we think it provides a welcome enhancement to the Silicon Valley investor mentality.

Is There a Doctor in the House?

That got a chuckle from the audience and the rest of the panel, but also highlighted an issue plaguing digital health startups. Most digital health platforms are not much more than a matching engine and/or a teleconferencing platform that meets regulatory requirements. Those are the successful ones. Other product developers in operations or workflow support are frustrated because they fail to make traction critical to overcome critical mass and adoption hurdles.

To a man with a hammer all the world is a nail. And for twenty years digital developers have been fed a steady diet of blitzscaling, moving fast and breaking things and most of all being “disruptors.” They did not necessarily need experts in the development process; in some cases the fresh view of the non-expert was actually an asset. That will NOT work in medicine.

Healthcare has gatekeeping stakeholders throughout: patients, doctors, medical practices, hospital systems, policy payers (like employers) and servicepoint payers (government, insurers, etc). All have vastly different priorities and adoption models.

Sometimes those interests are at odds with one another and successful solutions must be aware of the rocky waters they are navigating. The good news is that entrepreneurs have multiple touch points that may be addressed. But elegant solutions in search of problems will be ignored unless you include the target audience from the beginning.

One audience has the institutional knowledge and the practical operational experience to provide feedback to startups at all levels of adoption. Doctors are familiar with the players and those that own their own practices control the purse strings as well.

Digital entrepreneurs in other industries operate in “stealth mode” then release their products into the market and hope for mass adoption. Strategically there is great sense in that. Unlike other life science innovations, the nature of digital technology solutions means low barriers to entry, minimal IP protections and an emphasis on traction or sector expertise. In retail and commercial use cases this makes good sense. The developers likely have some understanding of the economic

By Michael Schmanske

“The problem I have with digital healthcare is that most of the applications are not healthcare, they are websites.”

Startups in medical devices and therapeutics know how important it is to involve doctors in the innovation and development process.

~AngelMD Impact Conference Digital Roundtable

environment in which they are working.

Medical solutions need more. Startups in medical devices and therapeutics know how important it is to involve doctors in the innovation and development process. Board members and scientific advisors are drawn from the science and medical professions most relevant to the use case or scientific specialty the company is addressing. But newsflash to developers: Unless you are a healthcare professional yourself with deep knowledge of each aspect of the value and adoption chain, you need to engage that expert knowledge during development. Shrewd advice, but how does an entrepreneur implement it?

MindTrace is a funky example of the classic development model inverted. By working with facilities and practitioners in brain surgery, they gained immediate traction and feedback for their surgical planning products. They are still finalizing their Minimum Viable Product (MVP) yet multiple surgical practices have already begun adopting their technology. Other than redefining the definition of an MVP, this also highlights how valuable that early engagement can be. By the time they finalize a digital solution for the market they will already have an installed user base among the key opinion leaders in neurology.

Their example is extreme but it includes some important insights that can be generalized:

Engage the experts early. Get the NDA’s signed or whatever you need but you should have a couple reliable guides when you are still at the predevelopment phase. Don’t travel blindly down a dead end path.

Make sure that the solution for one set of stakeholders does not cause pain for any others. True innovation should be a win-win scenario, otherwise you will have a fight on your hands.

Most importantly, is this a problem the stakeholders want you to solve? Think about your innovation from the point of view of each stakeholder. Even better, go ask! Visit the actual facilities and spend time

The Bleeding Edge

MindTrace

Neurosurgical interventions to remove brain tumors or treat medically refractory epilepsy strive to not cause post-operative cognitive deficits in patients. However, as many as 4 in 5 neurosurgery patients self-report a post-operative deficit that negatively affects their quality of life.

MindTrace has developed software that protects a neurosurgery patient’s mind.

Patients want confidence they will be the same person coming out of brain surgery as they were going into surgery—and clinical teams want to quantify the tradeoffs of taking different surgical routes.

MindTrace addresses this critical need by co-registering neuroimaging and behavioral data to create a new type of evidence that reduces uncertainty associated with neurosurgery. The platform is software as a medical device (SaMD) and leverages AI/ML to support pre-operative neurosurgical planning and evidence-based projections of post-operative function (e.g., walking, talking).

Ultimately, MindTrace enhances a clinical team’s ability to visualize and iterate on its surgical plan by exploring different paths of approach to a lesion, and the consequences of being more or less aggressive with the resections at the margin between lesion and healthy brain tissue.

shadowing the professionals.

If you need help arranging a “take your developer to work day,” that is a good indication that you need to expand your advisor base. That is their purpose. The good news is that the AngelMD Expert Network is here to help. n

Michael Schmanske, associate editor of MD Next, is a 24-year Wall Street veteran

with experience on trading desks and asset managers. He graduated with degrees in Aerospace Engineering from MIT and a Masters from Princeton University. Mike is also the managing director for AngelMD Capital and chief investment officer at AngelMD where he is happy to exercise his inner nerd on a regular basis by supporting the most innovative entrepreneurs and cutting-edge medical startups.

ADOBE STOCK

The Doctor Will See You Now

Digital health platforms should try to integrate more in-person care

Ask any expert objective observer of the healthcare industry and most will agree that medicine is 10–20 years behind the industry in integrating technological solutions for care delivery. When you include that major industry itself is 10 years behind consumer electronics, you can understand why some doctor’s offices still use fax machines. Actually 20–30 years behind might be optimistic. But things are changing. Even before the pandemic there were efforts to increase home care and self monitoring. The movement towards

wellness care as a preventative to more expensive acute care has accelerated a move to workplace-provided health services—think work yoga and gym memberships. Wearable technology is expanding into ever more useful health monitoring devices. As these devices are integrated into our insurance and care delivery platforms, we may expect to see additional incentives provided by payers for wellness care. Auto insurers are rolling out tracking key fobs and other devices to promote safe driving. We can expect health insurers and selfinsured employers to follow suit.

By Michael Schmanske

The elephant

Of course the trends pre-pandemic are nothing compared to the transformation in care delivery spurred by COVID-19. The movement to home offices—required during the pandemic lockdown—accelerated the adoption of digital conference calls, integrated email, scheduling and task management. We can be certain that the workplace will never be quite the same again, but these were well-established trends that both facilitated and were facilitated by quarantine. As an analogy, compare these trends to online shopping, streaming services and gaming. Healthcare is different. Prepandemic could you have imagined a world in which a majority of check-ins or consultations were handled virtually? Innovators stepped in to fill the gap. Consider the startup Hippo Health: The company developed a platform to assist emergency responders by providing live consultations with practicing clinicians while on a call. When COVID-19 hit, they pivoted to also provide telemedicine services on that same platform. By reacting quickly they filled a need, with many other similar services following suit. Uptake was phenomenal, and rather than accelerating an existing trend, it spurred transformative innovation. Using the prior analogy, compare the pandemic impact on business travel and virtual events.

But is the current state of affairs sustainable?That was great for the past two-plus years, but misses the real need going forward if we embrace the change as permanent. Recently Congress decided not to decide when it came to extending telemedicine coverage under the CMS coding system for Medicare/ Medicaid reimbursement. They passed the buck to future legislatures by extending the existing emergency framework until policymakers can wrap their heads around how a steady state solution might be crafted. I don’t blame them. It’s a tough nut to crack.

See me, feel me, touch me, heal me

While follow-up consultations or simple care delivery can be handled remotely,

The Bleeding Edge

Hippo Health

To honor the Hippocratic Oath, the clinician- and patient-led team is working hard to revolutionize the modern day care experience. Hippo health provides consumers access to great care at a lower cost and care professionals access to a free teambased communication portal to better connect with their patients, their colleagues, and the scarce services needed in their community.

Hippo Health was founded by highly experienced emergency physicians who wanted to ease the frustrations and unnecessary costs incurred by patients and care professionals that are often seen every day on the frontlines of care in America. Their mission is to eliminate the intolerable fragmented communication that still limits consumers and local care professionals from a consistent, timely and affordable care experience. If you are someone who wants to achieve a better care experience together, please sign up and join the community to start your own Personal Care Network on Hippo today.

Amazon Clinic

Via CrunchBase—Amazon revealed a new telehealth offering in November: Amazon Clinic. After previous failed starts, the offering seems to be the health system’s answer to “a quick check in.” Doctors are juggling far too many patients every single day and patients are finding it hard to get an appointment. Funding for telehealth startups has not reverted back to pre-pandemic numbers, signaling telehealth adoption is a permanent change in the healthcare system.

Through Amazon Clinic, patients can search for a particular ailment (there are around 20 that are applicable), scroll through a list of providers and how much they cost and message with them virtually after filling out a quick intake form. “Virtual care isn’t right for every problem,” Amazon admits, which makes sense for a messaging-only application. For now the offering does not integrate with insurance providers.

Amazon has ventured back into telehealth after its flagship Amazon Care product disintegrated. It is interesting that their first new foray is a text platform at the far extremes of interaction and ease. Healthcare cannot be provided if the patients do not have access to care. So we encourage innovations that remove usage hurdles increasing availability of health care to the patient population. However, as medical professionals we await innovation that improves the quality of care delivery options rather than just focusing on removing usage hurdles.

there are some services that simply must be done in person. At AngelMD we held a series of expert roundtables on digital care delivery, mental health and equitable healthcare access. One of the items that came up across all three topics was the need for in-person care at an early stage of the patient-physician relationship. Even for cases which are fully addressable remotely, there is still a need to establish a baseline.

Mental health providers wanted an ability to meet patients in person to assess the many body cues that are obvious in person, but may be difficult to read through a video conversation. Doctors highlighted a reluctance to prescribe items like pain medication without being able to look into a patient’s eyes and consider addiction complications. There have been a series of news items to this effect. Regulators are cracking down on the business models of some telemedicine platforms with directives seeming to be damn the indications, full speed ahead.

Patients are also assisted by physical presence. Trust is a vital element in the patient-doctor relationship and an in-person meeting can go a long way to improving both patient response and care prescription adherence. This has led us to recommend hybrid care as the optimal care goal for virtual medicine. Amazon has found brick and mortar locations to be invaluable to their business model. Healthcare providers will discover the same.

Let’s be realistic; I doubt we will ever be adopting self-administered colonoscopies, but some procedures like blood tests and vaccinations can be easily handled via home visits by nurses and physician assistants. For longerterm treatment courses, a manageable mix of in-person introductory visits can then be supplemented by remote or virtual care delivery options. To facilitate this sort of integrated hybrid care we will need different kinds of telemedicine solutions.

We should move away from solutions that act simply as a dating service or a video conference platform. AngelMD is looking to support the

next generation of innovators building integrated care delivery systems that include health record management and sharing, easy referrals, integration with payer systems and other solutions that enhance the intimacy of the appointment to approach that of in-person care. A number of startups have addressed individual items of our shopping list, but the entrepreneur that provides a solid all-in-one solution will be the next hot product in this space. n

Michael Schmanske, associate editor of MD Next, is a 24-year Wall Street veteran with experience on trading desks and asset managers. He graduated with degrees in Aerospace Engineering from MIT and a Masters from Princeton University. Mike is also the managing director for AngelMD Capital and chief investment officer at AngelMD where he is happy to exercise his inner nerd on a regular basis by supporting the most innovative entrepreneurs and cutting-edge medical startups.

Mark Froimson, M.D.

MD Next discusses virtual healthcare with orthopedic surgeon and vocal advocate of physician causes, Dr. Mark Froimson

“The essence of healthcare is information exchange,” so why isn’t information technology more relevant?

Q. Digital Healthcare companies have proliferated but you are unimpressed by their impact, can you tell me why?

A. We treat digital health as though it’s some sort of independent and separate entity from the rest of healthcare. It would be like saying, I’m going to develop a drug, That drug will be a standalone entity. And patients can take it without input from physicians. Or it would be like developing a surgical robot and saying, Well, here’s a surgical robot, I don’t need to ask the physicians whether it’s solving a problem, I don’t need to figure out how it fits into their workflows.

Q. Why do you think that digital solutions go that way?

A. The digital world, Amazon or Apple, views healthcare as a direct to consumer service, and that consumers have discretion over what they want to do. Then digital health is like a fitness app or a diet app. There are things that you can do without a doctor, you can figure out what to eat, you can figure out what kind of exercise to do. Maybe you have a sore throat or a runny nose, and you want to look up the symptoms on WebMD and find out what might be the appropriate means to self treat?

That is a piece of healthcare that has always been over the counter, played by the drugstore, the pharmacy counter, etc. It would explain why those are the platforms that have seen the most success thus far, whether it’s diabetes management, or weight loss, or fertility monitoring.

Q. Sure, these are definitely OTC direct consumer products. But what is the alternative?

A. Digital health has had a hard time understanding the segmentation of the market. I can get on my CVS app. And I can reorder my meds and I can get a flu shot. But, you know, if suddenly my knee is swollen, and I can’t walk, I need a doctor. And I would like a digital health tool to be a facilitator into direct, traditional physician directed or clinician directed healthcare.

Froimson, MD continued

Q. So what does that look like? Because one of the models that I hate is this idea of treating my digital health platform as match.com. Like, I don’t just need help finding a doctor, I need help managing my entire condition.

A. Right. It’s not about finding a doctor, it’s about facilitating the interaction with your doctor. The paradox here is that health systems and providers are slow to adopt digital tools because they haven’t really seen the utility of it. And it has not been presented to them as an Augment to what they do, rather as a replacement.

Companies that I’ve seen that have the right value proposition, say: “We’re going to use these digital tools to help make you more efficient in the way you manage information and your interaction with your patients.” Improve access, improve communication, right?

Q. What do you mean by a paradox? Can you give me an example of a problem in how platforms currently manage communication in the physician-patient relationship?

A. Digital health is a tool, like a scalpel, a drug, or a stethoscope. These are things that help the doctor both obtain information from their patient, and provide either treatment or information back to them. The essence of health care is an information exchange. You call your doctor, you have questions. How bad is it? What are my options? There’s a question-answer that goes back and forth. Digital health tools are really good at facilitating that, if done right.

The essence of healthcare is information exchange. If you just hung that statement out there as a standalone, you would assume that digital health is the best possible thing that could ever happen. That’s the paradox, information technology in healthcare has become an impediment to the physician patient relationship.

Q. So where is the paradox? How should digital solutions approach the information exchange?

A. If it’s done right it can be a very important Augment. I can get all the information I need about you as a patient and have it in front of me, in normative terms, meaning where you are relative to others with a similar condition, a similar age, similar set of circumstances. Then be able to digest all the literature and all of the clinical decision support that would tell me based on my experience, and based on everything I know, here’s a set of recommendations. The doctor could provide you with videos and written statements and a way of representing that information, so you would understand it. Let’s be realistic when most patients go to the doctor, it’s like the teacher in Charlie Brown, ‘Wa wa, wa wa, waa...,’ they

walk out and the conversation with a loved one goes something like: “What did the doctor say?” “I don’t know, I think I need surgery.” “Why?” “I don’t know, he thinks I need it.”

Like that’s something that’s right at the interface of the physician patient relationship to help patients understand, to help me as a doctor understand more about you, and to help you as a patient understand more about your own condition, and what options are out in front of you.

We do a terrible job educating patients. And, and that’s the paradox of this, digital health would be perfect for that if we did this right. But we keep getting tied up in the minutia of recording and reporting.

Q. Thanks so much Dr. Froimson. As a take-away, can you give me three factors for investors and entrepreneurs in digital healthcare that you wish more people understood?

A. I’d like digital health solutions to enable better quality information exchange. I’d like to see it improve the experience of the healthcare workforce, so that delivering health care was more enjoyable, as well as more efficient.

And this is really kind of an important thing that I talked to a CEO about last week. Digital health is the equivalent of nails scratching on the chalkboard. Every physician says ‘I hate this computer in my clinic, it’s in the way, I have to do this documentation, I copy and paste.’ It’s clunky and inefficient.

When you think of somebody with their iPhone, you think of someone using digital technology to orchestrate their lives, right? It’s an artistic experience, and the art is lost in digital health. It would be beautiful to see digital health as an artistic media to make that healthcare experience more human, more accessible.

We talk about the art and science of medicine. Too often our digital health solutions are asked, ‘What’s your return on investment? Where’s the data that you’re providing better outcomes?’ We’re asking for the scientific rationale for why we should use them. We’re often willing to sacrifice the artistic rationale. I think that’s a wrong dichotomy. I want to see the digital health solution become an artistic medium, become the music that orchestrates the dance. n

Mark Froimson, MD, MBA is the Quality Review Officer for the Orthopaedic and Rheumatologic Institute, charged with initiating and monitoring quality improvement efforts for the entire institute. He joined the Section of Adult Reconstruction Surgery in 1999, after serving as Director of Joint Reconstruction at another Cleveland academic center. He specializes in the surgical care of the hip and knee, with particular emphasis on primary and revision joint replacement and arthroscopy.

Mark

CRMs and EHRs

Digital interfaces manage patient care while connecting providers to proactive healthcare management

As of 2021, roughly 78% of United States office-based physicians—nearly 4 out of 5 medical professionals—have adopted Electronic Health Records (EHR); about 78% have adopted a certified EHR and nearly all non-federal acute care hospitals (96%) have adopted a certified EHR. This data is according to healthit.gov.

Essentially an EHR is a digital version of a patient’s paper chart and their use has become integral for moving work along in a provider organization. The system’s native guardrails allow the information including medical and treatment history

and plans to be accessible to authorized users. Depending on the system, the patient should also be able to access their medical information including clinical summaries, lab results, medications, and even communicate with clinical teams. EHR platforms are a necessary reality for our modern healthcare system. The first step to integrating the disparate data from hundreds of sources is to get the data in the system in the first place. Unfortunately that means converting some of the most highly trained professionals in the world

By Sindhu Pandit, MD, MBA

DIGITAL HEALTH

into data entry clerks—not exactly an efficient use of their time. Most health care professionals are familiar with these banes of their existence: EMRs. The Electronic Medical Record (EMR) is an order entry module with a prescription management system that is usually included as an out of the box offering. The module facilitates billing and support claims, payments as well other components of financial management. The good news is that data entry and client tracking systems are widely used across a number of other professions. Ideally we can learn from our experiences there.

Customer Relationship Management (CRM) systems allow for a more sophisticated way of managing relationships. Department or business units from marketing, sales, commerce and service can benefit from CRM tools with design specifications to support agent workflows, sales management, customer communications to name a few. By allowing management of individual relationships—suppliers, partners, customers, employees—at

scale, data can drive more productivity, and enhance collaboration.

According to Salesforce (NYSE: CRM), worldwide spending on CRM is expected to reach $114Billion USD by 2027.

CRM systems and solutions are newer in healthcare. The concepts are not new of course, as these functions are conducted to some degree in all businesses. Historically in healthcare it is generally accomplished via the more manual processes familiar to our clinician members. Integrating and automating data entry workflow is therefore our first development requirement.

However there could be much more. Consider that managing relationships has been reactive in most healthcare organizations, often siloed and disconnected. CRM systems are optimized to provide agile and scalable options to manage communication preferences, reconcile demographics across systems (EHRs typically), and connect to other data sources like social determinants information. Beyond the

potential positive impact on patient outcomes and doctor workflow, a properly designed system could provide holistic views of populations via comprehensive analytics. By original design, EHRs look at patients from a clinical lens. CRMs start with the client (patient) relationship and if layered around EHRs and other systems, allows for a view of individuals and populations from a holistic perspective.

As we look to the evolution of solutions leveraged across an enterprise, CRM platforms along with EHRs will continue to become more common as the ecosystem moves to whole person care, and remains with a north star to keep the patient at the center, and drive to better outcomes. n

Sindhu Pandit, MD, MBA, is a clinical leader on the Healthcare and Life Sciences team at Salesforce. Most recently, Dr. Pandit was the Medical Director for the Ochsner Rehabilitation Hospital in New Orleans, Louisiana, and her clinical practice included both inpatient and outpatient responsibilities. She is a boardcertified physician in Physical Medicine and Rehabilitation and continues to practice.

Skywriter MD

Skywriter MD is an innovative and impactful solution to alleviate the excessive burden of EMR documentation that erodes physicians’ work-life balance, limits the quality (and quantity) of patient care, and ultimately contributes to dissatisfaction and burnout.

Skywriter MD offers virtual medical scribe solutions giving providers all the benefits of an in-person scribe without the high cost, intrusiveness, and HR headaches.

Skywriter MD’s simple-to-use technology and highly skilled scribes combine into a nearly perfect “sweet spot” delivering the speed and efficiency of AI automation with the quality of human decision-making and quality assurance. Entirely U.S.-based, Skywriter MD solutions are highly personalized for

providers from a consistent small team of scribes who serve them, to specific documentation preferences within the EMR, to choices of mode from real-time ‘live’ to encounter recordings.

Reduce after-hours ‘pajama time’ charting. Improved work-life balance and satisfaction. Greater patient engagement and increased billings.

Higher documentation quality and timeliness. It takes only a few weeks to realize the tangible, sustainable ROI of Skywriter MD.

Contact Bill Leander, CEO at WLeander@SkywriterMD.com.

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Oral Health

Word of mouth: the newest opportunities and innovations

ncology, cardiology and orthopedics get a lion’s share of attention amongst life sciences investors. While the dentist’s office may not seem to be a hotbed of innovation to casual observers, there are many technological advances that are impactful to the sector. Dental practices are embracing advances in operational efficiency as well as the most cutting-edge technology like robotics, laser, and 3D printing. MD Next covers the innovators, startups and entrepreneurs with editorial content highlighting oral health.

Our clinical experts have provided us with both insights and referrals to those breakthroughs they believe will be most influential in the coming years.

Innovation in Oral Health Specialties

Annual spending on dental care in the United States will be more than $230 billion in 2023. Much of this spending is self-directed and/or paid to largely independent operators. And yet the dental industry continues to lag behind traditional healthcare with antiquated products and systems. Innovative solutions try to come to market, yet a lack of capital flow hinders their development. However, vast changes in the oral health landscape are on the horizon, and the lack of attention historically leaves a great deal of room for opportunistic investors [1].

Today’s startups are answering both practice and patient demand.

Very often we need not look to science or engineering to find cutting-edge innovation. The breakthroughs also occur via changes to the business model and the biggest contributors to the bottom line might be those that enhance efficiency.

Dental practices are first and foremost a business. Like all service providers they rely on revenue cycle management. We place these into four buckets—payments, patient financials, insurance processing and claims verification. Startup FeatherPay, for instance, takes multiple payment methodologies from a patient, and integrates Buy Now Pay Later. Choice Payment Services, yet another startup, looks at higher acceptance and broader acceptance criteria for patients with FICO scores that rate with typical patient financing. AirPayTM is solving some of these most difficult problems across different insurers and providing deep information on what’s covered and what’s not. And Zentist, a dental billing insurance platform, leverages machine learning and robotic process automation to optimize the insurance revenue cycle management. (Refer to an overview of some of our best picks for dental startups beginning on p. 46.)

The result? The patient knows exactly how much to pay using the best

By Revere Partners

As we recognize the importance of oral health to total wellness, proper care is no longer viewed as a luxury or discretionary good.

A new frontier for investors

1. DENTAL SPEND, AS A PERCENTAGE OF HEALTHCARE, IS GROWING

Healthcare spend Dental spend

combination of methods for them, and the practice can track and optimize performance more accurately, as well as reconcile everything at the end of the year. Without this transparency, the patient is restrained from proper dental care due to financial restraints, and the practice cannot protect its revenue. Both the patient and the provider are better off with one set of

interoperable solutions with a seamless user experience.

Access to care is also a high priority. As we recognize the importance of oral health to total wellness, proper care is no longer viewed as a luxury or discretionary good. Especially amongst underserved populations, long appointment wait times, costprohibitive exams, extra fees for

cleaning or x-rays all become significant adoption hurdles for care. Patients need solutions at the top of the “care funnel” that can educate them on what’s going on in their mouths and motivate them to do something about it—driving them into the provider and using the products that precisely address their needs. And, they must be enabled to take ownership of their care and monitor it over time.[2]

The microbiome is an area ripe for innovation that is receiving a great deal of “new” attention. But don’t lose sight of the service vector of this entirely new patient experience. The challenge starts with asymmetric information. In other words, patients don’t share the same level of dental literacy.

Educating the patient, quantifying the problem, and devising a precise therapeutic—delivered in a platform they like to use—will be a needed bridge for care providers. Startup Bristle Health uses genomics to measure the “good, the bad and the ugly,” and provides coaching and personalized care plans to help improve oral health. BrickBuilt Therapeutics uses live biotherapeutic products for the prevention and treatment of periodontal disease, caries (cavities) and oral candidiasis (thrush). And Twice combines cutting-edge science and clean ingredients to create a holistic oral health system for a healthy mouth. Lastly, startup Lura Health has brought the world’s first salivary diagnostic, wearable sensor to market, allowing for ongoing biometric monitoring.

Clearly, the oral health space is rich with bright ideas and innovation, solving problems that benefit patient, practice and investor. While not the first area you might consider as an investment or startup space, this field has proven to be an especially exciting arena in which to invest, grow and bring change for the better. n

Revere Partners is changing the landscape of dental and systemic health ventures—via a mix of professionals across dentistry, DSOs, insurers, manufacturers, professional associations, academics, and more—to elevate innovations and optimize patient and provider experiences.

Startup Profile

Dentroid

Dentists have long complained of neck, shoulder and back pain. The reality is that despite advances in imaging and surgical procedures, the core activity of cavity removal still relies on handheld drills and line-of-sight procedures.

A patent and 14 months later, Dentroid was born. The dentist is Omar Zuaiter and the engineer is Alaa Habeb and both are from Australia. Dentroid (previously Emudent Technologies) is on a mission to remove barriers to quality oral health and to make dental treatment a kinder and smoother experience for dental professionals as well as their patients.

The device replaces rotary drills with a minimally invasive, laser-enabled intra-oral robotic attachment. The company leads with a novel type of laser that is unique in its ability to perform hard tissue cutting (ablation) without requiring intraoral irrigation.

Not only does this mean an ergonomic and posture-friendly mode of operation, but also an unprecedented level of visual clarity while in operation. And the lasers are so gentle that they don’t need local anaesthetic in the majority of

cases—a huge win for needle-phobic patients.

The small device packs a powerful camera, image analysis algorithms, artificial intelligence and networking capabilities. Unlike other robot systems the device sits directly on the teeth under treatment and the laser drill requires no moving parts. The stable platform and unequalled visibility assists dentists in making accurate diagnostic and surgical decisions in real time. There is less need for radiographs, and errors could be significantly intercepted. Record filing and tracking is streamlined offering an extra layer of prevention and protection from medico-legal issues.

Dentroid possesses an expansive IP profile which includes Australia, the United States, EU, Japan and has recently tested its advanced prototype. Results exceeded expectations and were featured in the textbook “Principles and Practice of Laser Dentistry” (NY, US) as well as in peerreviewed journals such as Biomedical Optics Express and Frontiers in Dental Medicine. Management is targeting to be in-market by late 2024.

The AngelMD team has had the great pleasure of getting to know doctors Ed and Karen Zuckerberg over the last several years. Despite having an uberfamous son and incredibly successful daughters, at their core they are just extremely nice people who care about making the world a better place. Ed Zuckerberg, DDS, FAGD, ran a very technology-forward dental practice in Westchester, New York, for most of his career. In addition to being a talented psychiatrist, Karen stepped in to help run the practice while also overseeing the care of the kids.

Ed co-chairs the AngelMD Dental Advisory Board and was nice enough to join us for a question and answer session while on a long travel delay.

Q. Share a bit about your formative years including when and why you decided to go into dentistry.

A. I was a good student growing up in Brooklyn with a strong affinity for math and science. In high school, an aptitude test identified that I was good with numbers, my hands (good spatial skills) and liked to help people. A number of careers were suggested including medical and dental disciplines, but also science in general, engineering and accounting.

Q. What did you enjoy most about your career in dentistry?

A. I practiced in the same location for 30+ years and enjoyed long-term relationships. I took pride in patient loyalty, especially when a young child grew up and then brought their families to see me. Along with my psychiatrist wife, Karen, who ran everything nonclinical in my office, we developed a patient caring practice that focused on phobic individuals. I had a multi-

DOCTOR

PROFILE:

Edward Zuckerberg

Support as much as you can with your skillset, but understand when it is appropriate to bring in outside professional guidance.

By Tobin Arthur

discipline background with extra training in surgery, root canals and periodontics, so I really enjoyed working with phobic patients who had not been to a dentist for a long time due to fear and needed multi-discipline work. Those patients were thrilled to have all their comprehensive care done by one dentist and it was very satisfying.

Q. You were a tech-savvy dentist from the early days. What got that started?

A. I had the vision to see which technologies made sense while also avoiding ones that would just end up in the closet gathering dust. In 1981 I was a pilot tester for the very first electronic banking developed by Citibank. Using a primitive Atari 800 computer and a 300 BAUD modem, my first banking session took an hour to pay three

bills, but showed me the future. My wife could write three checks and mail them in five minutes. But the instancy of the transmission and immediate gratification were part of a theme that made me an early adopter of digital photography and digital radiography. I put in an IBM PC XT in 1985 in my office, a rather pathetic machine at the staggering cost of $10K for computer and software that were both awful, but enabled me to work with developers and guide improved software development (I am not a programmer).

With my son-in-law, we developed our own electronic health records for my office when none were commercially available in 2005, and in 2008 adopted CAD/CAM for same day delivery of crowns, inlays and veneers. My patients came to expect to see the latest

COURTESTY ED ZUCKERBERG | ©MFOX

technology in my office and along with the gentle approach to treating dental cowards, enabled me to avoid the PPO scourge of managed care in dentistry.

Q. You are a two-doctor family—three counting your daughter-in-law. How, if at all, did this impact your lifestyle and approach to raising a family?

A. While my wife and I are both doctors, we understood that it was not entirely our own career choices. We grew up with both direct and strong subliminal influence to become doctors but the key to a happy life is loving what you do. Work comprises the bulk of the time you will spend in your life, so we were careful not to influence our children’s career choices directly—rather to help them find things they were passionate about and support them in developing those passions.

Q. Your wife and you have been a real team over the years. Even though she was a trained psychiatrist—and very talented—she stepped in to help you with your practice. Share a little about the teamwork you two forged over the years and how your offsetting skills made for a stronger partnership.

A. Karen completed medical school in 1984 and actually gave birth to our first two children during her medical school years without missing a day of school! She took a hiatus to raise our children and have two more, then returned to her career, only to be very upset that managed care had influenced the practice of psychiatry, [where] she was relegated to hospital care for extremely ill patients—not the population she wanted to work with. She also missed the family and treated many patients who were the product of broken homes or absentee parents.

At the same time, our dental practice was growing very quickly and I was overburdened with running both the clinical and nonclinical ends of the business—which was based in our home. When I proposed her running the business-end she embraced it and we worked together with mutual respect

for each other’s skills. To this day, we still collaborate on companies we both advise and we have worked together consulting for dental practices using our combined talents. Obviously not every couple can live and work together 24/7, but we are still going strong and in December will celebrate 43 years of marriage.

Q. Your family has been at the center of creating an historic company. What were your early thoughts on this as a project before it was even a company?

A. We were always supportive of our son’s passions, as well as those of all of our children. While it is hard to see a child leave college, especially as prestigious an institution as Harvard, we supported his pursuit of what looked like an opportunity that had to be explored, and viewed it as an experiment of sorts. If it didn’t pan out, he would have been allowed to return to his education at Harvard. We are believers in life experience, and open to gap years, as well as career interruptions, for great opportunities that advance the development of the person.

Q. Looking back on what you did or didn’t do to contribute to Mark’s efforts, what would you advise parents whose kids are undertaking an entrepreneurial journey?

A. If your child has a passion it should be supported. We did that and along the way brought in experts, like professional computer teachers, to help that growth. A dentist owning their own office is sort of an entrepreneur, but Mark was embarking on territory unfamiliar to either Karen or myself. He got great guidance along the way and we were smart enough to allow those with the experience and knowledge that we did not have to guide him in his journey. Support as much as you can with your skillset, but understand when it is appropriate to bring in outside professional guidance.

Q. As a parent, how did the meteoric rise of Facebook impact you and the rest of the family in the early years?

A. Instant name recognition and fame, bombardment with calls and emails from the media, and unfortunately some hate directed our way were all bi-products of this new fame. We consulted with others who had gone through these life changes and adapted as we could, but we always remained true to ourselves and our friends. Old and new will attest that we are still the same people. Our other children, all very gifted and successful in their own right, have had to adapt to dealing with comments and comparisons to their famous brother while carving out their own niche in life. We are very proud of how they have navigated their own development.

Q. As Facebook became more well known, it provided a new platform for your work. Explain.

A. In 2008, after four years of existence, Facebook rolled out Business Pages and I immediately adopted a page for my practice. A couple of years later I was solicited for help and advice with issues that some other early adopters were having, and soon I began teaching my colleagues via articles I authored in dental journals and live lectures I gave around the country and [across] the world. In 2011 after our first grandchild was born—and with three out of four of our children already living in California— we began a two-year transition to the west coast during which time we sold our New York home and dental practice. Starting in 2013 I was essentially done with clinical practice and became an educator, writer and advisor to startups in the oral care industry.

Q. Between AngelMD, Revere and your industry standing, you see a lot of innovation across lots of sectors. What gets you really excited these days in healthcare and perhaps even outside of healthcare?

A. I’ve always been a huge fan of technology and ways to improve the quality and efficiency of getting things done both clinically and nonclinically. That early adoption has given me the background to evaluate new

technologies and advise companies with their business plans, bring in professional support where needed and introduce them to Venture Capital for funding. Lately I have been focusing more on the oral-systemic connection as opposed to just clinical technology. I’m on the Clinical Advisory Board at Vivos Therapeutics, working with colleagues to develop effective methods for treating obstructive sleep apnea, as this is one area where a malady with oral origins can affect overall health.

My main passion currently, though, is my work as chief dental officer for Keystone Bio. The team at Keystone Bio has discovered the pathway through which a dental periodontal pathogen causes an inflammatory response and releases toxic proteins throughout the body (see the Keystone Bio startup profile on page 43). Incredible stuff here, and with our biologic therapeutics we may be on the threshold of a therapy which will promote the status of dentistry as the single most important healthcare discipline to prevent these maladies. Trials are ongoing in Australia and we hope to have it in offices by 2025. I am in the process of recruiting dental industry KOLs to help spread the word via educating both medical and dental practitioners, as well as the lay public.

Q. You are still very involved in the innovation space despite having busy kids, grandkids and plenty of demands on your time. As you think about your legacy, what do you want that to look like?

A. It would have been pretty easy for me to just fall into a life of grandparenting, golf and bridge back in 2013 after completing the move to California. I am not blind to the fact that my famous name has opened doors for me to get both teaching and advising gigs, but with my work with Keystone Bio the last 18 months I see a chance to really push Dentistry into #1 primary healthcare status and I am hoping that I can parlay the power of my name into helping to promote this game-changing therapeutic as perhaps the biggest legacy I can leave behind. n

Free flights to

Not Your Father’s Dental Practice

Oral health innovation is alive, well and investable

I remember visiting the dentist as a child. My dentist was pretty cool, the waiting room had a salt water aquarium and in addition to the obligatory Women’s Day and Highlights magazines he also had Ranger Rick and Popular Mechanics. Such are the things on which a child’s mind prioritizes. Throw in the bubble gum-flavored fluoride paste and that counts as pretty incredible innovation to an eleven year old in the 1980’s.

In 2023 oral health innovation is a decidedly different proposition altogether. On the one hand it is

a relatively neglected slice of the healthcare investment pie. At 5% of overall healthcare spend, it attracts less than 3% of investment dollars. Not a big number to the overall picture until you realize that means a 40% relative underinvestment.

On the other hand there are a number of technologies that are ripe for implementation:

• Artificial Intelligence (AI): Appearing everywhere and in everything.

• Intraoral scanning and imaging: Live x-rays and images for patients are the beginning.

By Michael Schmanske

• 3D printers to create dentures and implants: Naturally paired with improved imaging.

• Robotic surgery: Paired with lasers and remotely enabled.

• Regenerative dentistry: Growth factors and other methods to rebuild bone and tooth pulp.

I would argue these innovations miss the forest for the trees. I suggest that the single greatest innovation in oral health for the next decade will be its integration with total wellness. Granted, a healthy mouth has long been recognized as impactful to our well being, but with the increased research into the whole body biome we are becoming more aware of the direct causal interaction between our oral health and other members of the flora and fauna that our body supports as a part of our total biological system.

Keystone Bio is an excellent example of a company built on the importance of oral health to wide ranging indications including cardiovascular disease and Alzheimer’s.

Startup Profile

Keystone Bio

Two of the most important and unmet disease processes in medicine are those driven by inflammation/ NLRP3 (cardiovascular, stroke, cardio metabolics/type 2 diabetes and NASH) and pre- to early-dementia including Alzheimer’s. Importantly these two conditions (and others) are linked. Chronic inflammation has been shown to be the root cause of many neurodegenerative and vascular diseases affecting hundreds of millions of people.

Keystone Bio has developed a monoclonal antibody that can eradicate virulent Porphyromonas gingivalis (vPg), a chronic biofilm bacterial infection in the mouth that releases toxins throughout the body, both triggering and driving inflammation pathways that promote disease progression. The monoclonal antibody is deployed as a simple non-toxic solution every 6-12 months akin to fluoride treatments, and has been shown to prevent recolonization of vPG films at the source.

vPg is a serious, undiagnosable, currently untreatable, toxin-secreting bacterial infection in the oral cavity that drives all major systemic inflammatory pathways in the body leading to multi-end organ disease. The flow of toxins trigger, disarm, and overexpress the host’s innate immune response locally and systemically, activating pro-inflammatory NLRP1/3 inflammasomes and dysregulating the acquired immune system leading to the progression of many systemic diseases.

Oral

Or consider the inverse, utilizing the information available in our mouth to monitor total health. A startup from our community recently proposed a health monitoring device that would reside in a patient’s mouth as a small sensor attached to a molar (see Lura Health item on p. 44). From this location it is able to monitor a wide range of chemical and biological signals. Basically a wearable for every statistic you could imagine. The technology is still very early and in need of further miniaturization but the promise is clear.

I believe dentistry has an advantage that many other specialties do not. General medicine and the specialties are closely tied to either government- or insurance-based

Their proprietary research has provided strong and convincing evidence of both the etiologic agent vPg and mechanisms of action for the neuroinflammatory/degenerative disease in AD (Nara et. a. JADAIl 2021). Further the source DNA residing in AD brains is insufficient to account for the florid amounts of bacterial virulence factors present (Nara et. Al 2021). This work sheds new light on the longstanding conundrum of how the vPg bacteria/pathogen from a peripheral location (the oral cavity) is playing a direct/indirect systemic role in the pathogenesis of neuro-inflammation and Alzheimer’s disease—especially the inflammation, integrity losses and the eventual degeneration of the Brain Blood Barrier (BBB.)

By stopping the regular flow of the virulent factors and disease-causing toxins from the mouth throughout the body Keystone Bio is seeking to diagnose, treat, modify, and prevent inflammation-driven diseases including early Alzheimer’s and Cardio-metabolic diseases. Company Management is continuing preclinical and clinical development of a companion diagnostic (CDx) and precision Bio- therapeutic for the early to late treatment of this major driver of systemic inflammation in the human body.

In 2023 management expects to complete Phase 1a/b clinical trials, produce the cGMP clinical drug substance for the Phase 2/ab trials, leading to preIND and crucial pathway development/meetings. The company is currently seeking investment to further support the AUS and US Phase 2a/b clinical trial, FDA IND package and clinical studies. Primary US Phase 2 clinical trial support study sites are also being considered including Forsyth in Boston.

payers. The providers usually operate within large centralized bureaucracies.

By necessity, innovations must overcome large adoption hurdles to create use case traction. Conversely, dental practices generally rely more frequently on personal patient expenditures and while some practices may be large, there are hundreds of thousands of private practices all looking to improve their margins or increase their patient base.

Apocryphically, In the old west, dentistry was performed by barbers with a bottle of whiskey and a pair of pliers. Thankfully, that is obviously no longer the case. With the wide spectrum of new technological advances and the prospect of a clinician audience uniquely able and eager to adopt economically meaningful innovations, I hope to see a great deal of investable startups in oral health in the coming years.

Help us by nominating some of your favorites for the upcoming best in class Pitch Madness competition (see below). n

Michael Schmanske is a 24-year Wall Street veteran with experience on trading desks and asset managers. He graduated with degrees in Aerospace Engineering from MIT and a Masters from Princeton University. Mike is the managing director for AngelMD Capital and is the chief investment officer at AngelMD.

The Bleeding Edge

Lura Health

Patients and doctors are always seeking easier and less invasive wearables to accurately monitor chronic disease. Wrist and skin-based wearables are convenient to wear, but their medical accuracy is questionable for biomarker detection beyond macro-trends like temperature and heart-rate. Blood-based wearables require puncturing the skin to tap into blood or interstitial fluid and can be highly visible. Lura Health is developing a new class of medical monitoring devices, which noninvasively monitor biomarkers in saliva instead of blood.

The system consists of a small biosensor attached to the side of a tooth. The innovative biosensor design is tiny, waterproof, biocompatible, and features electrochemical transducers for biomolecular detection. Sensor data is transmitted via bluetooth to a smartphone, then synced to an EMR. Patients will check vital diagnostic information and receive real-time health alerts with preloaded medical interventions, while doctors will detect early signs of disease and monitor response to treatment. Applications include wideranging chronic conditions including diabetes, tooth decay, chronic kidney disease and heart disease.

Lura Health is currently conducting inhuman clinical trials with clinicalgrade prototypes. The company is applying the learnings from these trials to improve the system and ultimately seek FDA clearance for medical monitoring. Clinicians should contact the company if they are interested to learn more about the system or conduct a trial.

"Arguably the world's most resourceful healthcare company. Revolutionizing inflammation with a rocket ship of opportunity"

-Physicist, TEDTalk Luminary and Sen-Jam Advisor, Alexander Wissner-Gross PhD

AirPay

Dental practices are businesses, checkout automation solutions that simplify dental practices’ insurance verification, treatment plan quoting and flexible payments systems saves countless hours and increases patient case acceptance.

AirPay brings automation to antiquated checkout workflows in dental practices, enabling them to offer real-time, instant quotes to their patients. Verifying insurance and calculating treatment costs are dental RCM functions that have been the most resistant to innovation, accomplished only by brute force: phone calls, web portal visits and fax backs.

The company’s platform aggregates and standardizes wide-reaching sources of benefits verification data to provide the most comprehensive solution available today. This unique capability simplifies one of the most stubborn challenges for dental teams and enables patients to better understand their dental plans and costs prior to treatment. Founded by dentists, AirPay saves practices countless hours spent dealing with insurance carriers and leads to an incredible increase in case acceptance.

Revere’s Top Picks

AngelMD is happy to be working with Revere Partners, the first and only venture capital fund focused on oral health globally, selecting high performing and innovative startups. MD Next asked them to provide more information on some of the companies they are watching in the oral health sector.

Choice

Choice Payment Services (a.k.a. Choice) offers omnichannel lending solutions through a customizable and futuristic FinTech platform. Choice empowers provider partners to offer patients up to 100% approval and access to financing solutions in real time with a simple single application.

Choice is focused on improving the patient experience when securing a loan. This is in sharp contrast to the problematically poor online patient experience and fragmented model that exists in the market today. Choice’s easy-to-use platform directs patients to the right lending product through an algorithm-match technology and can work in conjunction with existing waterfall and practice management systems.

For providers, the company

enables a completely customizable lending ecosystem that increases patient access to care, creates an incremental interest-share and ensures stringent regulatory compliance. Choice can originate patient loans with your desired lender partners without incurring additional expense—allowing providers to serve their patients regardless of economic conditions and uncertainty.

Bristle Health

The oral microbiome is the community of bacteria, fungi and viruses that reside in the oral cavity. We are only beginning to understand the importance and complexity of this ecosystem. Bristle is reinventing oral health through oral microbiome testing and care.

Bristle analyzes the oral microbiome from a saliva sample to report on oral health status and risk for conditions including cavities, gum disease and halitosis. Based on a user’s results, Bristle provides personalized diet, hygiene and product recommendations plus 1:1 support through their team of hygienists. Oral diseases are among the most prevalent conditions on the planet.

Today’s first-line tools—x-rays and observational screenings—detect oral diseases at the latest stages when they require invasive and expensive procedures. Oral health and the microbiome are also linked to systemic conditions including diabetes, cardiovascular disease, and Alzheimer’s. Bristle’s test is affordable, non-invasive and can be performed anywhere. They work with consumers and providers interested in offering the next generation of oral health technology.

Twice

Twice is a next generation oral wellness company elevating your hygiene experience, with a holistic oral health system that combines cutting-edge science and clean ingredients for better mouth/body balance. The complete system includes the Oral Wellness toothpaste, immunity rinse, floss, and whitening pen that deliver microbiome-friendly and pH balancing solutions to support the second largest microbiome in the body. This system is rooted in the belief that a healthy mouth is a healthy self. Over 120 systemic diseases begin in the mouth—including cardiovascular disease. Twice is providing consumers with dentist-backed, better-for-you ingredients formulated into powerfully clean solutions to provide highly effective oral care that has been missing in the market. While conventional hygiene products contain active ingredients that are synthetic and oftentimes strip the oral microbiome, Twice provides wellness super ingredients such as colloidal silver, zinc, and antioxidant vitamins with clinically proven active ingredients to deliver the fastest, effective results without compromise.

Twice’s formulations are changing the way oral wellness is being approached with high-performing, powerfully clean solutions chosen with care meant to benefit the mouth and body.

Zentist

Billing can be complicated and individual practices must manage their own billing processes; dental businesses lose an estimated $2.1 billion due to legacy billing systems. Zentist’s Remit AI software leverages robotic process automation (RPA) and machine learning to place tedious dental insurance billing tasks on autopilot.

Remit AI can save practices up to 10 hours of labor per work week by addressing inefficiencies related to the management, handling and posting of Explanation of Benefits (EOB) and Electronic Remittance Advice (ERA) data.

Its intelligent denials management

feature identifies the root causes of denials and provides actionable steps for claim remediation. Fully scalable to meet the more complex billing needs of the modern dental industry, Remit AI minimizes human error, maximizes insurance payout, provides intelligent analytics on revenue, and improves the patient-provider relationship.

FeatherPay

Healthcare practices are overburdened with the proliferation of payment and billing solutions they must manage to collect out of pocket patient liabilities across all points of payment in the patient journey—before, during and after care. Additionally, because practices are unable to consolidate all credit card volume through one merchant services provider, they are unable to earn the competitive rates their aggregate card processing volume justifies.

Perhaps most importantly, frustrated patients who expect consumer-friendly digital means of making out of pocket payments are leaving their providers due to complicated payment solutions. All of this is leading to lost revenues, profits and productivity. And ultimately, reduced enterprise value for the practice.

FeatherPay is a one-stop billing and payments platform that is purposebuilt for the needs of elective health practice staff and patients. FeatherPay drives new revenue, increases operational efficiencies and lowers costs for healthcare practices of all sizes. All while delivering a world class payment experience for patients. n

Oral Health from Ed to Z

Adopting new technology in a clinical practice

MD Next goes one-on-one with Edward Zuckerberg, DDS, FAGD

A. PPOs. Insurance companies said to dentists we’ll give you a chance to fill those empty chairs, but you need to sign up to this fee schedule. It served a portion of the clientele who placed dollar cost consciousness over quality.

Many patients perceive going to the dentist like buying an appliance, I can buy it from this store or that store. And that store is cheaper, so I’ll buy it from there. Offices don’t take the time to show the beautiful work that the laboratory did, or their sterilization processes or this brand new piece of equipment that will improve your experience.

Really, the profession is guilty of not explaining to patients the quality of the care they are getting.

Q. So how does this impact innovation adoption?

A. First off, patients love this stuff. “Look at this new digital radiology, you can now see an image on the monitor a second after it is taken.” It didn’t cost more because it made me a lot more efficient, saving about an hour a day waiting for x-rays to get developed. I recovered the cost of the machine in under three years.

But the greatest benefit was in education and trust. One of the biggest problems facing dentists is convincing patients to accept their treatment plans. One of the shortcomings is the lack of visual aids. People can’t understand a very tiny dental X ray. But they can see a cavity or a lesion when you blow it up the full size of the screen.

I actually saw about $200k in additional revenue, the first year I put digital X-ray in my practice from increased treatment plan acceptance. The machine was already going to pay

Q. What are the challenges or private practices now versus in the past?

COURTESTY

ED ZUCKERBERG

for itself in Material and time savings, all that extra treatment plan conversion was great.

Q. Theoretically the size of dental practices should make them more nimble as earlier adopters of innovation. So why isn’t oral health 10 years ahead in terms of technological uptake?

A. They just are not trained with an MBA, they don’t have a business mind and don’t look at technology in the right way.

A classic example was computer assisted CAD CAM. The typical workflow for a crown can be 10 days or much longer. Sometimes the lab screws up and the patient shows up and the crown doesn’t fit properly.

With CAD CAM, we drill the tooth, we scan the tooth and we’ve got a milling machine in the office. We send the data to the milling machine, in about 15 minutes the crown is fabricated from a Ceramic block. The crown comes back, cemented in while they are still numb, they leave with their permanent restoration the same day.

I’m being totally productive on this crown and may be spending a fraction of the time I spent doing it previously. But not all dentists are trained to see that.

Q. I noticed that of the seven companies that Revere Capital chose to highlight as examples of your portfolio. Four of them were finance or operations companies. Is that a normal distribution?

A. It changes over time. At Revere Partners we have lead partners each with a different focus and vision for the future. Jeremy, who’s our CEO, definitely has a focus on the financial end of the practice. As we’ve seen, financial efficiency defines a practice’s survival.

Q. And your own focus? Has that changed over time?

A. In the beginning, I advised companies with any technology that interested me. It might be a smart toothbrush or robot

that places dental implants or anything that will help an office run efficiently.

But over the years, I’ve become involved in getting dentistry back to its rightful position as a specialty of medical care. The worst thing dental insurance did, even worse than financially is it drove dentists further away from the medical profession. Why should dental insurance be different from medical insurance?

It’s an essential part of healthcare, and companies like Keystone Bio (see startup profile on p. 43) are showing the way for dentistry to be among the leaders in reducing the occurrence and severity of systemic diseases.

Q. How would that work in practice or in a practice?

A. My crystal ball 10 years into the future shows all medical care under one facility. If someone comes in for high blood pressure or diabetes, before the physician will work them up for the disease process, they’re going to tell him the first and single most important thing is go to the dentist and get a clean bill of dental health.

If you’ve got periodontal disease, the dentist has to get that under control, because I can’t treat your diabetes unless your periodontal health is under control.

Q. I’m sorry, what does oral health have to do with treating diabetes?

A. That’s just one example. We know that the toxic proteins of P gingivalis (The bacteria that cause gingivitis) go into the liver and impair glycogen synthesis, which means that sugar is not being properly processed by the body. The pancreas is counting on the liver to perform adequate glycogen synthesis to break down the sugars and maintain homeostasis.

So things go haywire and someone with a borderline diabetic situation becomes full blown diabetic. Someone with a history of diabetes now finds their diabetes out of control. It behooves the physician to rule out the periodontal role in diabetes.

It is the same thing with cancers,

you’ve got oral cancer, esophageal cancer, stomach cancer, pancreatic cancer, rectal cancer, all with links to bacteria, and specifically the oral cavity.

Q. That sounds like tapping into a major research trend, this idea of Whole Health Wellness that the body is one giant biome that you need to treat as a system.

A. And I want to be an agent to affect this change. Everything’s intertwined and interrelated. And I really believe that dentistry is going to be leading the way to reducing the incidence of systemic diseases.

For example, I mentioned cancer. We’ve identified certain DNAs and proteins that patients who have oral cancer exhibit in their saliva so we should be able to detect cancer orally before a lesion appears. Oral cancer is terribly disfiguring, even patients who are fortunate enough to survive, may lose half their jaw, or have other disfiguring surgery which means they can never live a normal life.

But we can prevent it. And a number of companies are pioneering interesting ways to do this.

Q. So if you were a dentist fresh out of school just opening a new practice, what would be the one area of innovation you would have your eye on?

A. Mainly it isn’t a single piece of technology. I would really try and explain to the patients the role of dentistry as a specialty of medicine, that takes more of a stress on prevention. I’d just educate the hell out of it.

We didn’t know this stuff before. When I was in practice in the 80s, we knew periodontal disease was bad, the leading cause of tooth loss. We suspected you got from having a lot of bacteria in your mouth and it created some havoc in the body, but we didn’t know the pathways like we do now. So that’s my mission. It’s too late for my practice, but I want to be the leader of the army that I’m recruiting to get the word out about this. n

Currently, the oral health industry is severely underinvested with innovation opportunities often left on the table. Revere Partners is hoping to change that as first-movers in the space.

Revere invests with two major timeline-based categories in mind: short-term prospects and long-term prospects.

Short-term opportunities already have integration and are being used with significant underlying whitespace. The capital employed is primarily for growing the company and a great deal of effort is put toward sales and marketing. These companies are often derived from achievements and have some foundation.

Conversely, long-term prospects are sometimes no more than viable concepts. These types of ventures require a great deal of thought, expertise and manpower for testing the viability of innovation. They offer much greater long-term reward prospects but also hold a great deal of risk stemming from uncertainty in more milestones toward success..

Whether short or long term, the future looks especially bright in the oral health space. When the combination of industry experts is adjacent to the strategic capital and earnest deployment pace, the results are prime to perform—even during a recession. Dentistry has always fared well in economic downturns. In the 2008 recession, patients continued to visit the dentist and the industry thrived. We do not expect any different in the coming years.

What we are looking for right now

“We see gaps within the industry as well as synergies, and bring several solutions

Investor Outlook

The oral health space is proving to be an exciting arena for investments, innovation and change

By Revere Partners

together to form a more comprehensive and/or operable whole,” says Revere managing partner Dr. Jeremy Krell.

Simply put, Revere takes a thematic approach to investing— breaking oral health into subcategories that complement each other to solve a previously unsolved challenge where it believes there is big upside value creation and investment potential to this strategy.

Yet how does this thematic approach benefit investors? Essentially, Revere has to anticipate market risk—not just product risk in dentistry, that is, the go-to-market strategy and consumer/provider adoption. A recent article in the Harvard Business Review states: “Strategic opportunities for new ventures can be categorized along two dimensions: attitude toward incumbents (collaborate or compete?) and attitude toward innovation (build a

moat or storm a hill?).” Revere couldn’t agree more.

For fintech, that challenge has traditionally been payment solutions that take limited payment mechanisms, as well as the merchant processing fees shaving percentage points of the practice’s revenue. Other frustrations included financing with high interest and low approval rates, wait times of hours to weeks to confirm insurance benefits, and claims that “get lost” in the practice’s priorities, leading to lower than initially expected reimbursement without knowing it.

The microbiome is another area ripe with innovation—educating the patient, quantifying the problem, and devising a precise therapeutic, delivered in a platform they like to use. Startup Bristle Health uses genomics to measure the “good, the bad and the ugly,” and provides coaching and

personalized care plans to help improve oral health. BrickBuilt Therapeutics uses live biotherapeutic products for the prevention and treatment of periodontal disease, caries (cavities) and oral candidiasis (thrush). And, Twice combines cutting-edge science and clean ingredients to create a holistic oral health system for a healthy mouth. Lastly, startup Lura Health has brought the world’s first salivary diagnostic, wearable sensor to market, allowing for ongoing biometric monitoring (more details on some of the startups referenced above can be found in our “Top Picks” beginning on p. 46).

Being specialty focused provides an advantage as subject matter experts when selecting optimal investments. But it also helps with post-investment support and strategic partnerships.

Every situation is unique, but lately, Revere prefers collaborating and building a moat. If the company sees that a product or service is part of a set of parallel or sequential solutions, then “vertically investing” can be a strategy that pays off with an end-to-end solution that drives value to its target market across the continuum.

Clearly, the oral health space is rich with bright ideas and innovation, solving problems that benefit patient, practice and investor. While not the first area you might consider as an investment or startup space, this space has proven to be an especially exciting arena in which to invest, grow and bring change for the better. n

Revere Partners is the first Venture Capital fund exclusively focused on oral health, identifying opportunities for investors and providing capital for cutting-edge innovations in the oral and systemic health sectors. Founded by Dr. Jeremy Krell and David Arena, Revere Partners fosters strategic partnerships that improve care delivery as well as patient and provider experiences—maximizing value for investors. To learn more, visit www.reverepartnersvc.com or on LinkedIn.

Dentistry has always fared well in economic downturns. In the 2008 recession, patients continued to visit the dentist and the industry thrived.

By Julie Fanning

MOCKTAILS & COCKTAILS

The holiday season is always a good excuse to enjoy a few more celebratory specialty drinks than we normally would. But with the rollover into a new year, some may take advantage of “Dry January” in an effort to cleanse our systems from a few too many eggnogs or mulled wine or sweet cocktails with sprigs of herbs and other festive garnishes.

The team at MD Next embraces that challenge as a healthcare-related group— and I’ve created an alcohol-free drink for you to try. But for those who may want to dip their toes into more of a “dry-ish January” (cutting back from December’s libations without going completely cold turkey) I’ve got two incredible drinks to share after a visit to an award-winning artisan distiller—spending time with their equally award-winning master distiller and mixologist—in Northern Virginia. Whether your drink of choice packs a punch or simply packs flavor, cheers to you.

Virgin Cherry Mule

You may not miss the bourbon or vodka in this. The spiced cherry bitters add a subtle touch of something special in this nonalcoholic cocktail with the warm spice of ginger beer.

INGREDIENTS

• ice

• 1 tablespoon fresh lime juice

• 4 oz. ginger beer (non-alcoholic)

• 2 splashes spiced cherry bitters*

• club soda

• lime wedge

• Luxardo cherries

THE METHOD

Fill a copper Mule mug with ice

Add the lime juice, ginger beer and bitters

NOTED

Top with club soda and stir to combine

Garnish with lime wedge and a toothpick with 3 Luxardo cherries

NOTES

Luxardo gourmet cherries can be found at a variety of stores— including WalMart or Amazon. These are “candied” cherries— using Marasca cherry juice— that offer a richer taste than your basic maraschino.

* I used Woodford Reserve® Spiced Cherry bitters (bought at a specialty store, but you can find them on Amazon). While bitters have trace amounts of alcohol, it is negligent based on the use of only a drop or two in this recipe. This can be optional in the drink. Another option can be to add about half a teaspoon of the Luxardo cherry juice.

PHOTOS BY JULIE FANNING, UNLESS OTHERWISE

The following two cocktails were the creation of master mixologist and distiller George “Papi” Zwetkow, of Murlarkey Distillery in Bristow, Virginia.

My Skinny Valentine

Once we get into a new year, an attempt for self-improvement resolutions seem to lodge into our brains. Regardless of whether you want to lose a few pounds, this refreshing and very low-cal concoction is a tasty option.

INGREDIENTS

• ice

• 2 oz. hibiscus-infused vodka

• cranberry raspberry sparkling water

• 1 tablespoon fresh lime juice

• wooden skewer/ toothpick with fresh raspberries

• lime wedge

• sprig of rosemary

THE METHOD

Fill a tall glass with ice Add the vodka, lime juice and sparkling water

Stir to combine

Garnish with lime wedge, rosemary and a skewer of raspberries

SOURCES & INFO

Infusing vodka with hibiscus is easy. Hibiscus herb tea is readily available; empty four tea bags into a bottle of vodka and let sit overnight. Strain and add back to the bottle.

Papi uses Spindrift® sparkling water, which is unsweetened and made with real fruit. If you don’t have that, you can always improvise with a berry-flavored seltzer water.

The Pitmaster

Smoked is the name of the game here—perfect for sipping next to a roaring fire. Suggested pairing with this drink is a little dish of smoked, salted almonds.

INGREDIENTS

• ice

• 1 oz. smoked whiskey

• 1 oz. barrel-aged whiskey

• 1/2 oz. turbinado simple syrup*

• 4 dashes orange bitters

• orange slice

• wooden skewer/toothpick with Luxardo cherries

• beef jerkey (or bacon)

• pork rind

THE METHOD

Add ice to a rocks glass

In another large glass, pour whiskeys, simple syrup, bitters and orange slice

Stir to combine, then pour into rocks glass over ice Garnish with Luxardo cherries, jerkey and top with pork rind

SOURCES & INFO

*Turbinado sugar (aka “raw sugar”) adds a natural molasses flavor. Papi recommends a 2-to1 ratio for this simple syrup (so 1 cup sugar to 1/2 cup water as an example)—which makes a richer syrup. Combine both in a saucepan over medium heat, stirring until sugar dissolves. Remove from heat and cool before using. Stores (covered) in refrigerator for several weeks. Murlarkey has a Smokehouse whiskey—naturally cured and aged with smoke-infused wood—which was used in this cocktail. Check for similar ones near you or if you have a cocktail smoker, you could use that process with whiskey before assembling the drink.

Spirited Innovation

The appetite for artisan distilled beverages seems to have exploded since we were all on lockdown. But supply chain issues of the big brands encouraged us to consider and pivot towards local sources.

Murlarkey Distillery, in Bristow, Virginia (a short drive west from Washington, D.C.), opened its doors in 2016. But they have quickly made a niche out of three things: 1. small-batch, high-quality spirits; 2. naturally infused specialty spirits and 3. the award-winning creations served up by master mixologist and co-founder George “Papi” Swetkow (below)—consistenly ranked a top mixologist in the D.C. region.

In addition to multiple awards for their gins, vodkas and whiskeys, TAVEL+LEISURE magazine recently ranked them among “The 25 Best Distillers in the U.S.” (and the only one selected from Virginia).

Murlarkey was created from a small group of family and friends. Jim Larkin, another co-founder, explained that they strive to produce the best spirits they can using locally sourced grains, botanicals and other ingredients (such as honey) completely from Virginia. Even the barrels used to age the spirits are produced in Virginia.

If you visit the distillery it’s evident how much effort goes into every step of the process. In the tasting room there are large glass containers of fruits and botanicals infusing various spirits. There are areas outside where they grow a variety of botanicals and herbs—with fresh cuttings for the day’s use at the bar. You can see through glass behind the bar into the area where head distiller Kevin Szady works his craft. And the end product is the creativity and passion for an authentic experience customers get with an ever-evolving selection of unique cocktails crafted by Papi.

According to Jim, Papi’s palate and nose are second to none (prior to Murlarkey he was an executive corporate chef in New York City). Overall they “strive to make artisan cocktails for the senses: beautiful to see, wonderful to taste.”

What does the future hold? Murlarkey recently announced plans to expand into a larger space. Says Jim: “Expansion is on the horizon, but we will continue to maintain the experiential factor and high quality.” n

CONFERENCES

We’re Back!

Virtual conferences are efficient but not nearly as much fun

First we started seeing family again, then we started going out socially again, then we started traveling again. But it seemed that the in-person conference might have been an unfortunate casualty of the pandemic.

Fear not—the boondoggle is alive and well. Let’s be honest, we like conferences as an opportunity to step outside our weekly existence and to concentrate on aspects of our careers that can become swamped by daily responsibilities. The opportunity to network with other professionals and learn about new trends in healthcare innovation is more pleasant when you experience it in a fun or beautiful setting—which is why the rumors of their death were greatly exaggerated.

It’s also true that attendees are suffering from virtual fatigue and sponsors don’t

feel like they get full value without the ability to shake hands and make personal connections. Just think how your brain tunes out television commercials after decades of training yourself to ignore them.

So events are back in person, but back with a small caveat. Most events going forward will have a hybrid element. Virtual speakers are a plus and a virtual audience might increase total distribution. On the other hand, the hybrid option might damage in-person attendance and there is a need for innovation to help drive an integrated experience or you have a risk of a two-speed event. Is it the best of both worlds or just accepting reality and muddling through? We will have to find out.

TERREN HURST

The HLTH annual healthcare conference was back in-person this year and in Vegas and included a mix of talks, presentations, panel discussions, and a massive exhibit hall.

Unlike specialty society conferences, HLTH caters to startups, industry leaders, investors, and policymakers. There are company announcements, networking events, and parties instead of research posters, procedure labs, and CME credits. This year’s event drew over 10,000 attendees, 800 sponsors, and 300 speakers. Highlights included everything from pitch events to meditation rooms to a Ludacris concert. It was great to attend a live event!

HLTH knows that physicians are increasingly interested in investing in healthcare companies and working in advisory and consultant roles. Maddie Coffin, senior marketing manager for HLTH, said:

“HLTH’s aim is to bring the entire healthcare ecosystem together... Our goal was to make sure physician attendees received tailored value from sessions, activities, and partner programs.”

I’ll focus on physicians’ experiences at HLTH and profile three groups that led physicianfocused events: the American Medical Association (AMA), StartUp Health, and Google.

Physicians’ goals and experiences:

I spoke with several physicians who attended HLTH for education and networking. They compared their experience to typical academic and specialty society conferences.

Paulius Mui, MD, and Kenneth Qiu, MD, family physicians, wanted to learn more about health tech and

A Physician’s Guide to HLTH

Sometimes what happens in Vegas doesn’t stay there.

By John Dayton, MD, FACEP, FAAEM

shared their experience on their Solving for X Substack. They note that one downside to the conference was the focus on entertainment over evidence. However, they felt the major upside was networking and meeting with other attendees in person:

“HLTH was surreal, extravagant, and very different, but it was fun. It was a vacation with people who were all interesting. It was awesome to talk about health policy and health tech innovation, while in Vegas and doing Vegas things.”

Gerad Troutman, MD, is the national medical director of Innovative Practices for Global Response Medicine. He believes that EMTs and paramedics are underutilized in the healthcare system and attended HLTH to connect with companies focused on technology that will assist with hospital-at-home

and ED-at-home solutions. While many of the companies lacked sufficient validation he was impressed with the range and pace of new innovations being developed.

“As a provider at the local level, I had never experienced this level of innovation that is occurring behind the scenes. I don’t think most doctors realize what is likely to come to our care toolboxes in the very near future.”

Aditi U. Joshi, MD, telemedicine expert and founder of Nagamed Consulting, came to learn about startups as part of the American Medical Association’s Physician Innovation Network. Like Drs. Mui and Qiu, live networking was a major highlight of HLTH. She was also seeking companies solving pain points she was researching for her book on telehealth equity. As an

emergency physician, she notes:

“I like being able to look at the health space from a broader view while advocating for emergency medicine at HLTH. It gives me a better perspective on both. I also went to more parties at HLTH than I do at ACEP!”

Katherine Saunders, MD, cofounder of Intellihealth, was seeking investors for a Series A investment round for her company. She was also interested in learning about other companies and appreciated that HLTH was more multidisciplinary and offered more exciting opportunities than typical specialty society conferences:

“There is so much happening right now. This is a great time to be involved in healthcare innovation.”

American Medical Association (AMA):

The AMA was one of the HLTH vendors that catered to physician attendees. They highlighted their Physician Innovation Network, gave presentations about diversity, equity, and inclusion (DEI), and hosted networking receptions. Amanda Azadian, product manager for Digital Health Strategy shared:

“The goal at HLTH for the AMA was to build connections between physicians on the front line and companies building next-generation solutions, in the hope that their conversations help bring better, more integrated solutions that will be assets—rather than administrative burdens—for physicians, care teams, and their patients.”

The networking events for physicians and startups were big draws and featured companies working with MATTER’s healthcare incubator and Amazon’s AWS Healthcare Accelerator. Conversations focused on collaboration opportunities.

StartUp Health:

StartUp Health leads a healthcare innovation and investment community. They are particularly interested in working with physicians as innovators,

collaborators, and investors. They hosted talks, featured many of their startup companies, and featured panel discussions. My favorite panel focused on physicians who founded companies and included Dr. Yair Saperstein (AvoMD), Dr. Natalie Davis (Preventscripts), and Dr. Ian Madom (Mocingbird) shared lessons they’ve learned building healthcare businesses.

Google:

Google hosted several talks and made several announcements including partnerships with EPIC for the cloudbased storage of EHRs and with Hackensack Meridian Health and Lifepoint Health to build an accelerator focused on health equity, operations, and value-based payment models.

The talks were led by Dr. Michael Howell, Google’s Chief Clinical Officer. The one pictured below focused on enabling access to accurate healthcare information and also featured Dr. Austin Chiang (Medtronic), Ariel Altmanm (YouTube Health), Hema Budaraju

(Google Senior Director of Product for Health and Social Impact), and Heather Fernandez (Solv).

Physicians play a crucial role in healthcare innovation. They wear many hats as they invent, collaborate, advise, invest, research, and run companies. In addition to all of the networking, parties, and opportunities, HLTH is a unique conference for physicians because it focuses on innovation that will affect their patients’ care and their medical practice. n

John Dayton, MD, is an emergency physician and the first Medical Innovation Fellow with Stanford’s Department of Emergency Medicine. He is an advisory board member for AngelMD, a physician consultant for Zus Health, and a Venture Partner for SpringTide. He writes about healthcare innovation for several publications, including MD Next and Emergency Physicians Monthly. He also founded MedForums, a ‘Yelp’ type of resource for medical education and healthcare innovations.

AMA, from left to right, Amanda Azadian, Aditi Joshi, Katrina Naik, Nihal Naik, Anita Gupta, Rachel Villaneuva, Katherine Saunders, Chris Gibbons, Michael Penn (not pictured, Vimal Mishra).

Google, from left to right: Michael Howell, Ariel Altman, Austin Chiang, Heather Fernandez, and Hema Budaraju

Categories November

November 1–5

AMP 2022—Association for Molecular Pathology—Annual Meeting & Expo Arizona | Phoenix

AMP is the leading organization in the field of molecular diagnostics, and our annual meeting is widely considered the “premier gathering” of molecular professionals. As always, we will explore how cutting-edge technology and developments in molecular testing and diagnostics continue to have a major impact on patient care.

COST: $495–$850 amp22.amp.org

November 3–5

North American Cystic Fibrosis Conference (NACFC) Pennsylvania | Philadelphia

NACFC provides a collaborative and educational forum for all CF professionals. The educational elements of the meeting program are targeted to physicians, nurses, research scientists, respiratory therapists, physical therapists, nutritionists, social workers, and pharmacists

COST: $155–$1,090 www.nacfconference.org

November 3–6

ASN—American Society of Nephrology Kidney Week Florida | Orlando

Join ASN and approximately 10,000 other kidney professionals from across the globe at Kidney Week 2022 in Orlando, FL. The world’s premier nephrology meeting.

COST: $275–$900 www.asn-online.org

INDUSTRY CONFERENCE POLICY EDUCATION INVESTMENT/PITCHES MEDICAL ASSOCIATION

November 4–8

AASLD—The Liver Meeting Washington, DC

American Association for the Study of Liver Diseases—The Liver Meeting brings together clinicians, associates, and scientists from around the world to exchange information on the latest research, discuss new developments in liver treatment and transplantation, and network with leading experts in the field of hepatology.

COST: $545–$1,465 www.aasld.org/the-liver-meeting

November 7–10

Credit Suisse Annual Healthcare Conference California | Rancho Palos Verdes

Investment banking conferences are generally exclusive to clients and potential clients of the banking firm represented. They provide an opportunity to mingle and network with institutional investors as well and receive valuable feedback from investment funds and industry representatives. They often have a small number of free or low cost attendance options for individual investors.

COST: N/A www.credit-suisse.com/ch/en/investmentbanking/global-markets/equities/cashequities/corporate-access-calendar.html

November 7–10

Population Health Colloquium Pennsylvania | Philadelphia

Gain insights on critical business solutions from leaders across the health ecosystem and discover new approaches on the leading edge of innovation and healthcare transformation.

COST: N/A populationhealthcolloquium.com

November 8–12

SITC—Society for Immunotherapy

of Cancer—Annual Meeting

Massachusetts | Boston

The annual meeting & pre-conference programs provide a multidisciplinary educational and interactive environment focused on improving the outcome for current and future patients with cancer by incorporating strategies based on basic and applied cancer immunotherapy.

COST: $425–$1,025 www.sitcancer.org/2022/home

November 10–14

ACAAI—2022 Annual Scientific Meeting Kentucky | Louisville

Thought leaders from around the world deliver dynamic information on advancing allergy/immunology patient care. The American College of Allergy, Asthma and Immunology is committed to providing attendees with practical Podium to PracticeTM takeaways that can be implemented quickly into practice and improve patient care.

COST: $395–$645 annualmeeting.acaai.org/index.cfm

November 10–14

American

College of Rheumatology

Annual Scientific Meeting (ACR/ARP) Pennsylvania | Philadelphia

ACR Convergence 2022, the world’s premier rheumatology experience, will be held November 10–14 in Philadelphia. ACR Convergence 2022 will be hosted in person with opportunities to view content virtually and on demand.

COST: $699- $1,099 www.rheumatology.org/Annual-Meeting

November 12–16

SfN—Society for Neuroscience— Annual Meeting California | San Diego

Each year, scientists from around the world congregate to discover new ideas, share their research, and experience the best the field has to offer. Attend so you can: present research, network with scientists, attend session and events, and browse the exhibit hall.

COST: $145–$1,005 www.sfn.org/meetings/neuroscience-2022

November 13–16

HLTH 2022 Nevada | Las Vegas

Taking place on an open show floor, the fourday event will convene the entire healthcare ecosystem, connecting and developing relationships that truly move the needle— breaking down silos to unite all participants within one holistic environment. Attend for an event unlike any you have seen and be part of a movement pushing boundaries in the healthcare industry.

COST: $2,295 (discounts available) www.hlth.com/2022event

Categories

INDUSTRY CONFERENCE POLICY EDUCATION INVESTMENT/PITCHES MEDICAL ASSOCIATION

November 17–20

SNO—Society for Neuro-Oncology— Annual Scientific Meeting Florida | Tampa

The Society for Neuro-Oncology exists to advance multi-disciplinary brain tumor research, education, and collaboration to drive discovery and improve patient care.

COST: $245–$1,680 www.soc-neuro-onc.org

November 27–December 1

RSNA—Radiological Society of North America—Annual Meeting Illinois | Chicago

The most important week in radiology inspires a diverse community of professionals and industry partners from around the world. 400+ educational courses and scientific sessions from every subspecialty, in addition to 100+ industry presentations and demonstrations featuring the latest products, innovations and solutions

COST: $310–$2,095 www.rsna.org/annual-meeting

November 29–December 1

November 29–December 2

CTAD

Congress 2022

California | San Francisco

The Clinical Trials on Alzheimer’s Disease conference (CTAD) is a meeting focused entirely on Alzheimer’s Disease Therapeutic Trials with key leaders in Alzheimer Disease research from Industry and Academia getting together and forming partnerships with the objective of speeding the development of effective treatments to fight the disease.

COST: $960–$1,380 www.ctad-alzheimer.com/

November 30–December 1

Evercore ISI’s Virtual HealthCONx

Conference

Massachusetts | Boston

Investment banking conferences are generally exclusive to clients and potential clients of the banking firm represented. They provide an opportunity to mingle and network with institutional investors as well and receive valuable feedback from investment funds and industry representatives. They often have a small number of free or low cost attendance options for individual investors.

COST: N/A www.life-sciences-usa.com/product/ evercore-isi-healthconx-conference-groupinvestment-investor-financing-2001-30258. html

December

December 2–3

November 16–19

Connective Tissue Oncology Society Annual Meeting (CTOS)

Canada, BC | Vancouver

CTOS is committed to fostering all aspects of sarcoma research and treatment. This conference welcomes physicians working all disciplines that touch on sarcoma care, offering an opportunity to reconnect, to restore and strengthen networks. The program will include sessions including oral presentations, poster discussions as well as general poster sessions.

COST: $500–$800 www.ctos.org/Meeting/ 2022AnnualMeeting.aspx

CRISPR 2.0 Summit Massachusetts | Boston

The CRISPR 2.0 Summit is devoted to showcasing only the latest and greatest innovations by uncovering how the next generation of CRISPR tools are radically enhancing efficacy, minimizing off-target effects & enabling efficient tissue-specific delivery to help you progress your program into and through the clinic.

COST: $2,700–$4,000 crispr-conference.com/

Ophthalmology Innovation Summit Year in Review

California | San Diego

This new independent meeting will feature groundbreaking technologies, clinical thought leaders, industry executives and investors in a new format that will include social activities in a unique setting to have fun while learning and networking. Novel therapies for both the front and back of the eye will be showcased.

COST: $496–$895 ois.net/ois-xii/

December 2–4

ESMO Asia Congress Singapore

The ESMO (European Society for Medical Oncology) Asia Congress is recognised for its outstanding scientific programme, covering breakthroughs on the most prevalent cancer types in the region, and offering high quality multidisciplinary educational sessions, including the Pan Asian Adapted Guidelines Lectures, conceived to share best practice standards of care for cancer patients.

COST: $260–$880 www.esmo.org/meetings/esmo-asiacongress-2022

Categories

INDUSTRY CONFERENCE POLICY EDUCATION INVESTMENT/PITCHES MEDICAL ASSOCIATION

December 6–10

SABCS—San Antonio Breast Cancer Symposium

Texas | San Antonio

This symposium is designed to provide stateof-the-art information on the experimental biology, etiology, prevention, diagnosis, and therapy of breast cancer and premalignant breast disease, to an international audience of academic and private physicians and researchers.

COST: $600–$900 www.sabcs.org/2018-SABCS-sup-sup/2018Symposium-Overview

December 7–9

December 2–6

AES—American Epilepsy Society— Annual Meeting Tennessee | Nashville

The AES Annual Meeting brings together healthcare providers, scientists, advocates, industry, and other professionals dedicated to better outcomes for people with epilepsy.

COST: N/A www.aesnet.org/AES-annual-meeting

December 4–7

American College of Neuropsychopharmacology— Annual

Meeting

Arizona | Phoenix

The Annual Meeting is one of the world’s leading forums for the exchange of cutting edge scientific information about the brain, behavior, and psychotropic drugs.

COST: $180–$630 acnp.org/annual-meeting

ESMO Immuno-Oncology Congress 2022 Switzerland | Geneva

From the basics of immunotherapies to the latest research results; from understanding different treatment options to the management of toxicities and interpretation of new data, the ESMO (European Society for Medical Oncology) Immuno-Oncology Congress will cater to the diverse needs of oncology stakeholders with an interest in this topical field of cancer treatment.

COST: $300–$600 www.esmo.org/meetings/esmo-immunooncology-congress-2022

December 8

2022 Forbes Healthcare Summit Florida | Miami

The world’s most influential leaders from inside and outside the traditional healthcare sector will meet and discuss how to treat the whole person, improve access, integrate the latest tech tools and reduce costs.

COST: $1,495 www.forbes.com/connect/event/2022forbes-healthcare-summit/

December 10–December 13

ASH—American Society of Hematology

Meeting

and Exposition Louisiana | New Orleans

The 64th ASH Annual Meeting and Exposition is an in-person event which will also be broadcast virtually; access to the meeting’s virtual platform is included with registration. Sessions include scientific programs and include the prestigious Plenary Scientific Session, Best of ASH and Presidential Symposium.

COST: $700–$1,500 www.hematology.org/meetings/annualmeeting

December 14–15

Jefferies Denver Healthcare Summit Colorado | Denver

Investment banking conferences are generally exclusive to clients and potential clients of the banking firm represented. They provide an opportunity to mingle and network with institutional investors as well and receive valuable feedback from investment funds and industry representatives. They often have a small number of free or low cost attendance options for individual investors.

COST: N/A www.jefferies.com/OurFirm/ConferenceList/ Investment-Conferences/159

January

January 9–11 [In Person]

January 17–18 [Virtual]

Biotech Showcase: The Investor Conference for Innovators California | San Francisco

Biotech Showcase is an investor conference devoted to providing private and public biotechnology and life sciences companies with an opportunity to present to decisionmakers during the most important fundraising week of the year.

COST: $2,000 informaconnect.com/biotech-showcase/

January 9–11

JP Morgan Virtual Annual Healthcare Conference California | San Francisco

Investment banking conferences are generally exclusive to clients and potential clients of the banking firm represented. They provide an opportunity to mingle and network with institutional investors as well and receive valuable feedback from investment funds and industry representatives. They often have a small number of free or low cost attendance options for individual investors.

COST: N/A www.jpmorgan.com/global

January 19–21

ASCO Gastrointestinal Cancers Symposium—Hybrid California | San Francisco

A global GI meeting with dedicated multidisciplinary committees and faculty to discover the latest innovative science, solution-focused strategies, and multidisciplinary approaches in GI cancer treatment, research, and care.

COST: $375–$740 conferences.asco.org/gi/attend

January 25–27

Precision Medicine World Congress California | Silicon Valley

PMWC’s mission is to bring together recognized leaders, top global researchers and medical professionals, and innovators across healthcare and biotechnology sectors to showcase practical content that helps close the knowledge gap between different sectors.

COST: $1,250 www.pmwcintl.com

Categories

INDUSTRY CONFERENCE POLICY EDUCATION INVESTMENT/PITCHES MEDICAL ASSOCIATION

January 27–29

Advance 2023—The Anesthesiology Business Event Florida | Orlando

Formerly the ASA The PRACTICE MANAGEMENT™ conference—The Anesthesiology Business Event allows attendees to navigate the business of anesthesia, gain insights and solutions for today’s biggest challenges, and be prepared for what’s next.

COST: $995–$1,395 www.asahq.org/advance

February

February 1–3

Scripps Structural Heart Intervention and Imaging 2023 CME Conference California | San Diego

Scripps’ Structural Heart Intervention and Imaging conference is designed to provide a practical, cutting-edge, and live case-based assessment of structural heart disease interventions and cardiovascular imaging. COST: $650 www.scripps.org/events/structuralheart-intervention-and-imaging-2023february-1-2023

February 6–7

BIO CEO & Investor Conference New York | New York

The BIO CEO & Investor Conference is one of the largest investor conferences focused on established and emerging publicly traded and select private biotech companies, for institutional investors, industry analysts, and senior biotechnology executives.

COST: N/A www.bio.org/events/bio-ceo-investorconference

February 7–10

Immuno-Oncology 360° New York | New York

IO360° offers an unparalleled opportunity to hear from stakeholders representing both the science and business communities who report on the latest data impacting IO to fight a wider range of cancers.

COST: $1,995 reg.theconferenceforum.org/event/io3602023/

February 8–10

International

Stroke

Conference 2022 Texas | Dallas

This three-day in-person conference features more than 1,500 compelling presentations in 17 categories that emphasize basic, clinical and translational sciences as they evolve toward a better understanding of stroke pathophysiology with the goal of developing more effective therapies.

COST: N/A professional.heart.org/en/meetings/ international-stroke-conference

February 15–19

TCT 2023—Transplantation & Cellular Therapy Meetings of ASTCT/CIBMTR Florida | Orlando

Administrators, clinicians, data manager / clinical research professionals, fellows-intraining, investigators, laboratory technicians, MD/PhDs, nurses, nurse practitioners, pharmacists, physician assistants, and other allied health professional attendees benefit from a full scientific program that addresses the most timely issues in hematopoietic cell transplantation and cellular therapy.

COST: $395–$1,095 registration.tandemmeetings.com/ website/44579/

February 16–February 18

ASCO Gastrointestinal ASCO Genitourinary Cancers Symposium California | San Francisco

The 2023 ASCO Genitourinary (GU) Cancers Symposium offers new, innovative findings in the study, diagnosis, and treatment of GU malignancies

COST: $375–$740 conferences.asco.org/gu/attend

February 19–February 22

Conference on Retroviruses and Opportunistic Infections (CROI) Washinton | Seattle

CROI provides a forum for basic scientists and clinical investigators to present, discuss, and critique their investigations into the epidemiology and biology of human retroviruses and associated diseases. Attendance at the conference is open to researchers and clinical educators actively involved in the study and management of HIV, other retroviruses, and related medical conditions.

COST: N/A www.croiconference.org/about/

Categories

INDUSTRY CONFERENCE POLICY EDUCATION

INVESTMENT/PITCHES MEDICAL ASSOCIATION

February 19–February 23

February 22–February 26

Lysosomal Disease Annual WORLD Symposium Florida | Orlando

WORLDSymposium 2023 in Orlando will be the place to connect, collaborate, communicate and continue to make global progress in lysosomal disease research.

COST: $675–$775 worldsymposia.org

Rural

Healthcare Leadership Conference Texas | San Antonio

The Rural Healthcare Leadership conference is designed especially for rural area hospitals and other healthcare organizations that have a common goal to build a robust presence in the healthcare sector.

COST: N/A www.aha.org/education-events/2023-aharural-health-care-leadership-conference

February 22–February 25

February 23–February 25

ACTRIMS 2023—Americas Committee for Treatment & Research in Multiple Sclerosis California | San Diego

The annual ACTRIMS Forum highlights novel and rigorous scientific discoveries made in MS that advance our understanding of research and clinical care of MS patients. The ACTRIMS Forum 2023, themed “MS: Going Viral,” is your opportunity to be inspired, connect with others and move the conversation forward.

COST: N/A forum.actrims.org

International

Conference

on Advanced Technologies & Treatments for Diabetes (ATTD) Germany | Berlin

The ATTD diabetes conference is at the forefront of Innovation in diabetes medicines and treatments, the most cutting-edge technologies, and the latest research.

COST: $650–$825 attd.kenes.com

February 24–February 27

AAAAI Annual Meeting Texas

| San Antonio

American Academy of Allergy Asthma & Immunology the, Optimizing Scope of Practice, covers educational offerings on a variety of topics including: allergic disease; asthma; immunotherapy; food allergy and GI disease; skin disease; PIDD; practice management; new technologies; and healthcare reform.

COST: $570–$900 annualmeeting.aaaai.org

March

March 2–5

AAAS—American Association for the Advancement of Science—Annual Meeting Washington, DC

The American Association for the Advancement of Science is the world’s largest multi-disciplinary science society, fulfilling its mission to advance science, engineering, and innovation for the benefit of all. Each year, the community of leading scientists, educators, policymakers, and journalists gathers to discuss cutting-edge developments in science, technology, and policy.

COST: $155–$500 meetings.aaas.org

March 4–6

ACC—American College of Cardiology—Annual Scientific Session & Expo Louisiana | New Orleans

The American College of Cardiology joins with the World Heart Federation to host ACC.23 Together With WCC (ACC.23/WCC). Reunite with your colleagues from around the world, explore the latest science and innovation, and learn about practice-changing updates in care. At ACC.23/WCC, you’ll get everything you need to advance cardiovascular care for all.

COST: $399–$899 accscientificsession.acc.org

March 4–9

SIR—Society of Interventional Radiology—Annual Scientific Meeting (Oncology, Cardiology, Radiology) Arizona | Phoenix

The Society of Interventional Radiology (SIR) represents more than 8,000 practicing interventional radiology physicians, trainees, medical students, scientists and clinical associates. The society’s core purpose and mission is to work with its members to deliver patient-centered care through image-guided therapy.

COST: $790–$965 www.sirmeeting.org

Categories

INDUSTRY CONFERENCE POLICY EDUCATION INVESTMENT/PITCHES MEDICAL ASSOCIATION

March 13–17

ICAR—The International Conference on Antiviral Research France | Lyon

The International Society for Antiviral Research (ISAR) is for scientists involved in basic, applied, and clinical aspects of antiviral research. The annual International Conference on Antiviral Research (ICAR), is an interdisciplinary meeting attracting chemists, biologists, and clinicians.

COST: N/A www.isar-icar.com

March 17–21

AAD—American Academy of Dermatology

Annual Meeting

Louisiana | New Orleans

The AAD Annual Meeting is your one-stop event for education and networking. Jazz up your education with over 300 sessions, connect with over 8,000 medical personnel, and meet with over 350 exhibiting companies.

COST: N/A www.aad.org/member/meetings-education/ am23

The 2022 MedTech Conference, held this past October in Boston, Massachusetts, was a productive event for medical device start-up companies in general and for us at Light Line Medical, Inc.

The MedTech conference was a great place to meet people, companies and organizations that can provide a wide range of specialist support (e.g. product development, contract manufacturing, regulatory consultants, financial advisors, government permit assistance, etc.) to medical device startup companies.

The event was also attended by a large number of global medical device companies. The format facilitated introductions to members of the corporate business development and innovation functions. These contacts may be helpful for future partnerships and/or ultimate exit strategies.

The conference environment also facilitated great networking with other medical device start-up companies to share experience and insights regarding many topics including: fundraising, product development, regulatory agencies, and third party consultants.

In addition, there wasn’t a single panel we at Light Line attended that didn’t take great pains to answer every single question posed. That was fantastic.

Last but certainly not least, the MedTech Conference provided opportunities to meet a limited, but helpful, number of potential investors including angel investors, healthcare focused venture/private equity funds, and large medical device companies with Venture funds. Importantly, in addition to potential investors, Light Line met strategics interested in our products, U.S. Army Medical Research and Development Command, and FDA

2022 MedTech Conference

A wicked good show in Boston

By Vicki Farrar

reviewers. We also met individuals who could provide insight into the use of our product to prevent peritoneal dialysis related infections, including Kimberly Kaplan, a senior product manager at ISACA in Schaumburg, Illinois, who freely provided input and offered further discussion.

Note to sponsors: The best place to meet people was around the cappuccino machines strategically placed throughout the floors of the conference. So for maximum exposure, think about sponsoring one of the cappuccino areas! n

Vicki Farrar, CEO of Light Line Medical, Inc., has 40+ years of experience as an IP attorney and entrepreneur. Previously she founded Catheter Connections, Inc.—which was sold to Merit Medical. Light Line Medical is developing technology that will prevent catheterassociated infections. The company is currently entertaining investment interest from strategic partners to prepare for market entry.

6 Key Ways for Physicians & Dentists to Get Involved

• Learn: entrepreneur, advisor, investor

• Refer startups

• Evaluate startups (Earn)

• Advise startups (Earn)

• Network: meet like-minded peers throughout the industry

• Invest: selected and optimized opportunities to build a portfolio of early stage startup equity

PLUG IN

Finance & Policy

Second opinions from experts outside of medicine

tartups are assets, clinical practices are businesses and doctors are investors. While we focus on innovation in healthcare we also know that decisions are never made in a vacuum. If you are a startup seeking funding you are competing against other asset classes to engage investor interest. If you are an investor you are obviously thinking about the best way to leverage your expertise and maximize your return on investment.

You need to be aware of the broader macroeconomic picture and you should be aware of the decisions being made by policy makers that affect all of our lives and the industry we support. In our ongoing coverage of financial and policy issues, we hope to provide you with differentiated opinions coming from and directed towards our clinician membership.

It’s Not What You Make, It’s What You Keep

Selling business interests, tax-free

Sara and Tom founded their biopharmaceutical company in 2014 as a C-Corporation and have grown the company substantially since launch. They’ve notched several successes along the way, all while reaching multiple fundraising milestones. Now they are planning for a liquidity event, from which they expect to receive over $100 million in sale proceeds, pretax.

Assuming they land the deal, their estimated federal tax bill would come to $23.8 million. As with many successful founders and business owners, they approached a wealth planner to explore opportunities in advance of this event.

Tom and Sara wanted to know whether they could reduce the income tax burden upon sale and shield their eventual heirs from an estate tax bill of 40%. We raised the possibility that their shares might be eligible for Qualified Small Business Stock (QSBS) treatment, also known as IRC Section 1202. The collaborative effort with their tax and wealth advisors netted millions of income tax savings, and additional estate tax savings for the entrepreneurial pair.

Can you benefit from this program?

Having successfully grown your company, would you like to be able to

sell some of your shares potentially tax free? If you hold shares in a private company developing pharmaceuticals, medical devices or other products, you might be eligible. Most entrepreneurial founders and investors ultimately remit 23.8% of their long-term capital gain profits to the federal government, and many share an additional 3%–13% with their state government.

But realizing long-term capital gains tax upon selling a business could be partially or completely sidestepped? It’s a benefit written into the tax code, designed to promote the development of small businesses. Investors, founders, or employees who receive stock in small businesses may be eligible for these significant tax savings, if certain requirements are met.

IRC Section 1202, commonly referred to as Qualified Small Business Stock (or QSBS), outlines the requirements for a business to be able to exclude the greater of $10 million of gain, or 10 times cost basis, upon selling qualified small business stock. This means that shareholders can potentially avoid tax on up to $10 million of capital gain if the cost basis is less than $1 million—a figure that rises if the cost basis is greater than $1 million.

For example, an owner with a cost

By Alliance Bernstein

KEY TAKEAWAYS:

• Investors, founders, or employees who are shareholders in small businesses may be eligible for significant tax savings upon sale

• But first, certain requirements must be met

• Engage with qualified tax, legal, and financial professionals sooner rather than later to explore and maximize your opportunities

ANNA NEKRASHEVICH

basis of $3 million could be eligible to exclude up to $30 million of gains from capital gains tax.

Before you start sizing your savings, you’ll need to confirm eligibility. The rules are extensive and require advice from qualified

QSBS Eligibility at a Glance

Corporate Structure

professionals, though we share the highlights below. You can find a more detailed description in Qualifying for the QSBS Exclusion at www.bernstein.com.

A quick summary is shown below, “QSBS Eligibility at a Glance.”

Domestic C-corporations only

Active Trade or Business • Any trade or business other than: • Service Businesses

• Banking/Insurance/Leasing

• Investment Management

• Farming/Mining/Oil & Gas Extraction

• Hotels/Motels/Restaurants

Gross Assets

Issuance

Less than $50 million in gross assets between business formation and immediately after stock issuance

• Stock must be issued when corporation is deemed a qualified small business

• Stock must be issued directly from the company and received by a non-corporate taxpayer (e.g., individuals, pass-through entities, trusts)

Making the grade

How might this play out in practice?

Consider the following pass/fail scenarios.

Pass: Steve founded a small business that manufactures and distributes organic pet food. Steve formed his company as a C corporation and received his shares directly from the corporation in his revocable living trust. Steve’s shares meet the test for original issuance.

Pass: Andi invested $5 million in a fast-growing robotics company in exchange for preferred stock, bringing the gross assets of the business to $20 million. Two years later, the company’s gross assets have tripled to $60 million. Andi’s stock remains eligible for the QSBS exclusion because the company had less than $50 million of gross assets immediately after the issuance of her preferred stock.

Fail: Pavan founded an executive recruiting business that specializes in

SOURCE: ALLIANCE BERNSTEIN

placing candidates in the healthcare sector and formed his business as an S corporation. While his firm meets the “small business” test, it fails the “original issuance” test because shares were not issued from a domestic C corporation, nor would it qualify as an “active business” because it is a service business that principally relies on his expertise.

The devil is in the details

As these examples show, applying these tests to a specific company or stockholder’s stock is often more complex than it appears. The QSBS exclusion can be enormously valuable for founders, investors or employees with a stake in an emerging company. Such individuals would be well advised to understand this exclusion and the nuances of its requirements. These details may impact your decisions around initial business formation (or conversion of an existing entity), along with when to exercise options or time the sales of company stock. Keep in mind that the rules surrounding the QSBS exclusion are complex. Additional planning opportunities exist that may amplify QSBS to reduce taxes even further, while also minimizing future estate tax exposure. It is critical to partner with tax, legal and financial professionals who are familiar with these rules, who can help capture (and maximize) the opportunity. n

Alliance Bernstein authors: Daniel Brunello, Director—Bernstein Wealth Strategies Group Stephen Schilling, Director—Bernstein Private Wealth Management

Pavan W. Auman, Director—Bernstein Wealth Strategies Group

The views expressed herein do not constitute research, investment advice or trade recommendations and do not necessarily represent the views of all AB portfoliomanagement teams. Bernstein does not provide tax, legal, or accounting advice. In considering this material, you should discuss your individual circumstances with professionals in those areas before making any decisions

The Independent Physician

Practices need to grow and evolve

The industry trend for independent physicians over the last decade has been clear: More are selling or merging to become part of a larger organization. The reasons are obvious. Economic pressures, most notably costs and reimbursements, have made the power in numbers more attractive. Among those physicians still in private practice, we get some consistent questions.

1. How do we remain independent?

Retaining autonomy is the number one objective group leaders have ahead of every competing priority. The worry over losing independence is valid

across all specialties in every region of the United States. Yet the harsh reality is that practice independence is threatened now more than ever.

Health systems, publicly traded corporations and private equity funds are employing billions of dollars to consolidate independent practices. Nearly every independent physician practice in the U.S. is on an acquisition target list today. By our count, there are more than 200 private equity-backed physician platforms seeking acquisitions (and this excludes a few specialties). The chart on page 71 tells the story.

There are just over one million physicians professionally active in the

By Oppenheimer

The only viable plan for independence is a strategy focused on growth.

TIMA MIROSHNICHENKO

U.S. According to the AMA’s Physician Benchmark Survey.

2020 was the first year less than 50% of patient-facing physicians worked in private practice. The decline is dramatic compared to 54% of physicians who worked in physicianowned practices just two years ago. At this pace, independent practice ownership would effectively disappear in the next two decades, and the speed of consolidation is increasing.

In 2020, 40% of physicians worked in a group with partial or complete ownership by a hospital or health system. Perhaps most striking about the AMA survey is that 2020 was the first year private equity registered as material ownership with a 4.4% share.

Optum, the national provider group wholly owned by UnitedHealth (the nation’s largest health plan), has more than 53,000 physicians in its network—that’s about 5% of the nation’s physician workforce. In 2021, 407 physician groups announced a deal with a private equity or corporate investor, a 119% increase over the previous comparable period. These deals were valued at approximately $5.5 billion.

The only viable plan for independence is a strategy focused on growth. If your group doesn’t have a growth plan, you’re already part of someone else’s. The plan should focus on both organic and inorganic growth, making investments in capabilities for value-based care programs, and

SOURCE: PHYSICIAN GROWTH PARTNERS

proactively exploring your strategic alternatives.

2. How do we manage physician burnout?

Burnout is characterized by emotional exhaustion, depersonalization and a sense of reduced accomplishment in day-to-day work. According to a recent study, more than 50% of physicians reported suffering from at least one burnout symptom. Significant stressors include excessive workloads, significant administrative burdens, the use of electronic medical records (EMR), inefficient work processes as well as organizational factors causing physicians to feel that leadership operates with misaligned values. COVID-19 only exacerbated the existing burnout challenges faced by independent physician groups.

This is a serious issue at every professional level throughout the healthcare system. One of the strategies addressing physician burnout has been to embrace organizational changes that focus on improving the work environment. Physician groups that pursued structural alternatives such as forming a Management Services Organization (MSO) and re-allocating administrative duties to the MSO have often seen a renewed sense of energy among the practice partners. By exploring an MSO structure and growth strategy using external capital, independent practice partners are often surprised by the magnitude of the value

creation opportunity. And the resulting uplift in energy and focus has a positive impact on the practice partners and often throughout the organization.

3. How do we migrate to value-based care?

If the number one concern for group practices is remaining independent, the number one answer to that question is transition to value-based care. The payment side of the $4 Trillion+ U.S. healthcare economy—health plans, CMS, state Medicaid programs—is demanding it.

In 2019—before the pandemic— 91% of the 62 health plans and seven fee-for-service (FFS) state Medicaid programs surveyed about alternative payment models (APM) expected APM activity to increase (according to Health Care Payment Learning Action Network). CMS expects that by 2025, 100% of Medicare providers will be in a two-sided risk arrangement, and half of Medicaid contracts in some form of VBC program. Humana, the second-largest Medicare insurer in the U.S., publishes an annual VBC report detailing progress in migrating members and providers to VBC arrangements; they spotlight better outcomes. The pandemic seems to have only accelerated APM activity.

We can analyze micro-regions in the U.S. where mature provider groups operate only under VBC arrangements such as percentage of premium capitation. These groups receive (as an example) 85% of the Medicare Advantage premium that the contracted health plan receives but are responsible for 100% of the member’s medical costs. Because of the transparent value proposition, these groups have made extensive investments in their practices and boast better member outcomes and above-average operating margins.

Yet the vast majority of physician groups remain beholden to FFS models. A 2019 survey by Xtelligent Healthcare Media’s Insights indicated that 70% of physician practices still earn 75% or more of their revenue from FFS. If your practice hasn’t developed a plan and allocated investment dollars

Private-Equity Backed Physician Platforms (as of April 2022)

to position it to transition to VBC arrangements, eventually it will go by the wayside. Making investments in VBC—information systems, clinical workflows, C-suite talent—is critical today to position your practice to thrive. It’s also key to remaining independent. Maintaining your status as an independent physician has never been more complicated. But with a changing ecosystem and shifting pay landscape it is possible that by maintaining independence these private operators may turn their size into an advantage. Staying nimble in a chaotic environment is an important element of success and niche players often excel in markets overlooked by larger operators. But it takes an expertise in finance and business that is sometimes lacking in the skillset of a small practice. Educating yourself is the best first step. n

Oppenheimer Helps Independent Physician Groups Chart Their Futures

Oppenheimer’s Healthcare Investment Banking Group is one of the nation’s leading advisors to primary care, multi-specialty and single specialty physician practices. We have closed more than 40 transactions involving physician groups, including minority investments, private equity recapitalizations and strategic sales. We can add tremendous value by sharing:

• Advice on strategic alternatives

• Perspectives on valuation

• Perspectives on value-based care (VBC)

• Ideas on capital structure and financing

• Introductions to prospective partners and C-level talent

oppenheimer.com

Where Do We Go Now?

Market trends change, but informed investors ride the ever-changing waves

In the past I’ve told readers I’d give some idea of what to do next, or at least what to watch for. This is not official investment advice and I am not a financial advisor. I am an educated guy with experience and an opinion which you may or may not find helpful. That being the case, I’d like to give you some food for thought that may help drive your personal investment decisions over the next decade. Yes, decade.

It’s not the very beginning, but it’s still a very good place to start

The ‘70’s were all about stagflation, and inflation hedges outperformed in an otherwise crummy market. Agriculture, mining, gold and base materials did ok, but the best thing that could be said about the ‘70’s is that they finally ended before disco killed us all. The ‘80’s started to get interesting as high

interest rates in the beginning of the decade led to the Fed gaining control of stagflation. The newly stable financial markets led to an outperformance of classic value stocks: Consumer staples, healthcare and utilities all outperformed. Eventually that stability and leveraged buyouts created a value bubble in stable cash cows, and it ended badly with the 1987 market crash. Interestingly, the nadir actually occurred with the savings and loan crisis of the early ‘90’s and the resulting washout along with Desert Shield set the stage for the ‘90’s tech rally.

Modern markets and the world of CNBC

The 1990’s were the beginning of modern markets. Retail investors got involved and computers changed the world. Anything computer did well,

By Michael Schmanske

anything internet did even better. CNBC was on every TV, hot dog vendors became day traders, Y2K was coming and the Central Bank kept monetary policy very loose in preparation. Arguably they kept rates too low for too long leading to rampant speculative behavior and when the bubble burst in 2000 there was much weeping and gnashing of teeth. Like the ‘80’s, the actual end didn’t occur until the telecom credit market washed out. In 2002 Enron and Worldcom collapsed and we once again invaded Iraq in 2003. Iraq had better be ready for us—we don’t have another George Bush to elect, but the symmetry is impressive. Maybe we can just visit this time?

The 2000’s returned us to nontechnology companies. Biggest performers were banks, energy stocks and home builders. Note: Technology companies from the ‘90’s were persona non grata until AFTER this regime ended with the Global Financial Crisis in 2008. Instead of invading Iraq that time, we began the greatest monetary experiment in history.

The 2010’s were all about low interest rates. Globalization took over and logistics became king (the real power of Amazon wasn’t tech, it was LOGISTICS) and the anti-inflationary forces Cathy Woods loves so much meant that easy money was here to stay. Or at least it was here for a while.

“Oops I did it again”

Here we are! It’s the 2020’s and we begin the story with a crisis, monetary policy held too loose for too long and the bursting of a decidedly speculative bubble. We can’t follow the ‘70’s or the ‘90’s playbook since history doesn’t repeat—it rhymes. The pain is real for holders of spec-tech, meme stocks or crypto, but it didn’t infect the rest of the market this time. Thankfully we did

learn one lesson and the world stayed away from the leveraged finance lotus flower (we think).

Instead, watch out for government finance problems as rates go high and stay there. No guarantees one way or the other, but if you want some canaries for your debt bubble coal mining, watch municipal bond defaults and European government bond yields.

In the U.S., if things go badly it will happen first in your big blue cities in the big blue states like San Francisco, Chicago and New York. It should be remembered that the ‘80’s unwind included restructuring of Orange County California and the New York City bailout. Also pay very close attention to how the European Central Bank (that’s their “Fed”) manages its way through the inevitable debt restructuring of the PIGS: Portugal, Italy, Greece and Spain. Because of the Russian games, this time their pain will be felt in the cold countries too, so watch Germany, Poland, Slovakia etc….

“…Baby one more time” Even after the darkest night, the sun will rise again. So what do we focus on for the next cycle? Let’s look back at the common features. First of all, one cycle’s darlings are never the stars of the next. As much as the narrative may suggest that the survivors go on to rule the market, they usually have to spend some time wandering the wasteland first. Microsoft was dead money during the 2000’s as was Amazon. CSCO, Juniper Networks and Intel never regained their lofty peaks. Google, Netflix, Tesla and Facebook all started in the 2000’s. The hot companies that cycle were finance (dead money), energy (wasteland still, even with oil at $80+/barrel), and homebuilders (like rubbernecking at a car accident). Those are probably decent value sectors to watch, along with big company healthcare and mining and materials. But they won’t get the real attention. For juicy growth you need innovation. OF COURSE I’m going to say early stage healthcare! Readers will know that I’m at AngelMD for a reason—

and it is not desperation or foolishness. But what else should we be watching? Technology and innovation is a big field, and we can find areas that are interesting. I would look at the sectors that

• Have positive secular trends

• Arte still a little early, but not too early

• Haven’t been picked over or SPAC’d like crazy.

So what WILL work?

Anything that addresses the following secular trends will work:

• Aging Population—We’re all getting older, especially the population demographics of the wealthiest countries.

• On-shoring, and improved supply chain robustness—Globalization is here to stay, but the entire world now knows that we must improve the flexibility of our supply chain.

• Workforce optimization and automation—3.6% unemployment and inflation; an aging workforce increased desires for flexibility and increased wages.

• The Environment—Agree or disagree on the premise, the green movement will continue.

• The rise of “the rest”—You will be hearing more about “The Global South” and as those populations become more wealthy they’ll want stuff too.

• Tightening government spending— Maybe this should be #1. We’ve been living in a fantasy world of low interest rates. No government is prepared for what a real interest rate policy will mean to budgets.

My space is limited, so I’m not going to go into deep detail on the sectors I’m watching. Also I’m still feeling this out and the facts on the ground are always changing. But here are some sectors which meet the above conditions.

Leaning away from:

• Space companies—too early, too SPAC’d

• Electric vehicles: Too picked over, too competitive, too 2020

• Anything with “social” or web 3.0— Too picked over, too 2020

• Anything that is a real company but whose value got juiced because people decided to call it a tech company—SO 2020

• Every COVID darling—don’t make me say it.

Leaning into:

• Startup Healthcare—(Natch) Seriously folks, I’ve said it before so now I’ll just move on.

• Exotic materials fabrication—Rare earths to superconductors and graphite composites

• Bio-whatever—This may be biotech therapeutics and MRNA for everything, but also watch for biomechanical crossover, bioenergy, biocomputing, and bioengineering.

• Alternate energy sources—Yeah it’s played out—except it’s really not. From kinetic energy storage to improved networks and nuclear energy

• Alternate food sources—The stupid hype around veggie meat is only stupid in that it isn’t all that impressive, it’s too early and there is so much more work to do.

• Robotics—Implementation into daily life. I saw a cool company working on an automated fast food kitchen. So now I don’t even have “fry cook” to fall back on as a backup career.

• Artificial Intelligence—Don’t focus on the cutting edge obvious. Think about what it means in real world application.

• The next computer revolution— Includes Metaverse and Quantum Computing

Hate these ideas or love them?

Let me know what you think. I’m more confident in the reasoning than the results and intelligent investors can disagree: “It takes a market” and it makes one too. n

Michael Schmanske is a 24-year Wall Street veteran with experience on trading desks and asset managers. He is the managing director for AngelMD Capital and is the chief investment officer at AngelMD.

From a credibility standpoint it makes sense. You are transitioning from faith and belief to hard facts and delivered outcomes. Angel investors live on faith and belief which is why they live in that zone. It is also why most Angel investors don’t actually do that well if you compile all of their investments. It is easy to get distracted by the vision of the emerald city when you should be keeping your eyes on the road.

Startup Funds and the Funding Gap

By Michael Schmanske

Most startup founders have or will become familiar with the idea of the “Funding Gap.” It’s not complicated. But if you are an entrepreneur and are not familiar with the term, you are either very lucky or still too early to know what’s about to happen to you. Even writing this I am wracked by mixed feelings of envy and pity for you.

Simply put, company funding moves in phases:

• Self-funded: The company operates on owners’ capital, sweat equity and/ or some mix of research grants and or institutional support.

• Friends and Family: Your Mom, Best Man at your Wedding, College besties, and working peers that respect and know you step up to help get the company off the ground. They believe in You, so they see your Vision.

• Seed Stage: The first Stranger Funding Round. “Here be Angels.” With some

initial milestones met, you head out to find your first “Real” investors. They don’t know you, they are here to vet your product and company.

• Series A: The first big money. More milestones have been met and to take you to the next level you need some bigger checks to scale, finalize and go to market.

• Series B: More track record, more milestones. You might be in-market or generating revenue. If you are a speculative product like an oncology therapeutic you’re probably at Phase 2 trials, but at the very least you have strong visibility to an exit and your earnings projections are based on reality not imagination.

• Yada, yada, yada. Rounds C, D, preIPO, IPO, etc…

What is the most difficult stage? Trick question; it’s actually a blend of two: Seed through Early Series A.

That sounds great, and it’s the reason most experts or consultants in private equity give for the gap. But that is dismissive of the REAL reason the funding gap exists. Because of the structure of the institutional asset management profession, there is little appetite for $250,000 to $2,500,000 checks. Most of those sizes come from family offices and high net worth individuals. (We will get to them shortly.)

Family offices are groups of one or more wealthy families that manage their assets like an established hedge fund or other Asset Manager. They probably support a series of trust funds and/or charities. Think about the Waltons from WalMart, the Koch Brothers or Jeff Bezos’ private accounts. Now scale down to the local property developer or mall owner. Family offices may be anywhere in the range of $50 million to $5 Billion AUM. They are different from private endowments or foundations primarily in their internal structure. They answer to a small board of family members or an individual rather than a larger group of more conservative executors who themselves normally hire an external consultant for plausible deniability if an investment goes south.

Why early and small investment rounds are difficult to raise

The Funds Gap

Consider the structure of an institutional asset manager. They charge 2% on Assets Under Management (AUM). So a $250 million fund generates $5 million/year in fees. Operational and fundraising expenses take away ~ 40% of that leaving $3 million for compensation. An institutional PM doesn’t get out of bed for less than $1 million/year and they need a research and support team that costs ~half of their pay. So with $3 million of net fees available for compensation expenses, we have two teams at $1.5 million each that we can support. How many companies can each team cover? It depends on their philosophy. Some funds have adopted a scattershot approach: Let’s say they can cover 100 mostly hands-off investments. Liken them to the Skinny Syndicate from my earlier posts. A hands-on team might focus on a more manageable number like 25.

OK skinny syndicate fund: $250 million AUM, 2 teams, 100 companies each = $250 million/200 yields an average check size of $1.25 million. Investors do not like that format. The scattershot approach means very little direct support or management interaction with the portfolio companies. Add in the 2% per year management fee to sit and watch,

and that is a big performance drag. Exits are ~ 5 years for many early stage companies and could be as long as 10 years. That’s 10–20% off the top for a hands-off strategy. No thanks, I’ll take the monkey and the dart board again. As a result, while these structures do exist, they are primarily family office operations that have launched a coinvestment fund to try and cover a share of their sunk costs.

What about that more closely watched and held managed fund? It has $250 million in AUM, 2 teams, 25 companies each = $250 million/50 or an average check of $5 million. You see where I’m going with this. Even the skinny fire-and-forget fund writes checks between $1 to $2 million. The managed fund won’t get involved until $5 million. The biggest reason that checks do not get easily written in the $250,000 to $2,500,000 range isn’t the companies’ fault. It is because there is little or no institutional appetite for that size of investment. There are also style and ego components, but we’ll save that for another day (asset managers are people too).

But shouldn’t high net worth and family offices fill in that gap? Unfortunately these groups still obey the same economics as the funds. Generally speaking, they do not have the internal resources to fully research

AngelMD loves Seed through Early A. In healthcare, we see the most companies and products, we are best situated to filter the wheat from the chaff, and we have the greatest resources to support these early stage companies. Because of the Funding Gap, we also are investing at a time when capital is most dear. When investment dollars are desperately needed, investors get the best entry point as measured in a risk-return metric. Further, if you can eliminate 50% of the poor investments, your portfolio returns become much much better than average.

and understand specialty fields. There is a reason they are not particularly active in life sciences. Healthcare is hard. To get around it they often invest in packs to share the burden of analysis and support. Theranos didn’t get funded in a vacuum. It took a village to mess that decision up so completely.

The bottom line is this: The funding gap exists for a structural reason, and you as an entrepreneur will not change that. Instead you will need to learn how to build on your personal networks. But that is a class for another day. n

Michael Schmanske is a 24-year Wall Street veteran with experience on trading desks and asset managers. He is the managing director for AngelMD Capital and is the chief investment officer at AngelMD.

Healthcare and a Divided Government

What can and cannot get done and what it

With the November elections behind us, Washington and investors are now looking at a divided government for the next two years. The familiar refrain is that nothing will get done between a Republican House and the Biden Administration, but there are several areas where progress can be expected and would be impactful across the healthcare ecosystem.

What can get done in Congress

2022 Year-End Legislation: After the November elections, Congress must return to DC for a lame-duck session to fund the government past December 16. This must-pass vehicle creates an opportunity for healthcare

legislative action including providing FDA additional authority to regulate Laboratory Developed Tests (LDTs), changes to FDA’s Accelerated Approval Pathway (in focus post-Aduhelm/ Makena), incentives for antibiotic resistant therapies and delays in a number of scheduled Medicare cuts.

2023 Agenda—focus on the must do’s and the can do’s

1. Pandemic Preparedness Act

Reauthorization: Next year, authorization for the Pandemic and All-Hazards Preparedness Act (PAHPA) expires, creating uncertainty for myriad programs focused on developing, funding and acquiring medical

By Jones Point

means for VCs

countermeasures (eg BARDA/ASPR grants which early stage companies can access). While there may be significant posturing on both funding and vaccine mandates, the pandemic is still fresh in the minds of voters. This legislation will be top of mind in Congress and creates opportunities for innovators in the space to influence policy and secure funding opportunities.

2. Farm Bill: This is also up for reauthorization and given the bipartisan popularity associated with the program and money for large swaths of the country, it’s likely to be one of the few pieces of legislation that can move forward in 2023. Impacted sectors include food tech, cannabis and potentially digital assets since the bill covers the CFTC. Many in the digital asset/DeFi industry would prefer CFTC regulation, as opposed to the SEC.

Executive administrative actions

Facing a divided government and uncertain electoral prospects in 2024, the Biden Administration is likely to move forward aggressively with its

policy agenda via regulatory procedures and executive action.

1. Women’s Health: Women’s health became a nationwide focus after the Supreme Court’s decision in the Dobbs v Jackson case. Expect administrative policies designed to ensure continued access to women’s health and contraception services, both of which have been a large focus for private equity and venture capital.

2. Health Equity/Food as Medicine: One the Biden Administration’s main health care priorities is health equity and they believe that nutrition / food as medicine is one way to address the disparity in health care outcomes. Will governments rely on new innovators (start-ups like Season) to solve problems they cannot address?

3. AI in Healthcare: HHS will continue to develop policies around the use of AI in health care, both from a reimbursement perspective and data privacy. We expect more clarity from HHS and FDA on reimbursement and regulatory

pathways in the coming year, which will be key for this growing field.

What Black Swan events could be on the radar?

1. Debt Limit: DC has to raise the debt limit in 2023 and Republicans are already making noises about using it as leverage for spending cuts. The black swan would be if they fail to lift it causing market disruption - which could obviously impact higher risk asset classes like VC.

2. NIH Funding: GOP may leverage their pursuit of anti-Fauci hearings into defunding or lowering NIH funding, which is key for academic medical centers. With key NIH champions retiring from the Senate, there is a risk here and the impact on academic medical centers and funding are important for early stage companies. n

Jones Point consults with companies seeking to navigate the regulatory landscape and the Washington lobbying community. Their mission is to serve as a trusted guide for companies and investors navigating political and market currents.

Policy Innovation

The physician’s important role in driving healthcare policy

With a divided Congress, the focus now turns to the outlook for 2023. It is important to focus on how the Biden Administration plans on spending the time before the 2024 election and how they can leverage the various executive branch levers to impact the healthcare system.

The Center for Medicare and Medicare Innovation (CMMI) is the most powerful tool in the Biden Administration’s tool kit. It possesses the authority to move forward with large-scale and potentially mandatory payment models. CMMI has been largely quiet during the pandemic—out

of logical concerns about disrupting a fragile health care system. But as the public health emergency comes to a close, recent developments from CMMI suggest a more active period to come. In November, CMMI announced the next steps in its strategic refresh and shed some light on where they may look to focus in the years ahead.

What role can physicians play in influencing the direction of CMMI’s future payment models? More broadly, how can they shape innovation in both payments and health technology that improves outcomes?

By Tommy Barletta

The physician perspective is crucial because of the direct role they play in the patient’s care.

WHAT DO YOU THINK?

CMMI lessons learned— physicians need to play a greater role

CMMI’s stated goal is the development and implementation of payment models that “achieve better care for patients, smarter spending and healthier communities (CMMI Website).” However during their 2021 Strategic Refresh, they found that “only six out of more than 50 models launched generated statistically significant savings to Medicare and to taxpayers.” (CMMI Strategic Refresh).

While reducing spending is not the only metric worth considering, the limited success here when combined

with the Administration’s broader health care goals suggests that CMMI is at a crossroads of how to design reimbursement models to improve quality, outcomes and savings for the taxpayers.

I spoke with AngelMD Chief Medical Officer Mark Froimson to get his perspective on how best to move forward with innovative payment models. According to Dr. Froimson, CMMI models like CJR and BPCI produced savings only on the margins because “[CMMI] was hospital centric in their way of thinking due to the strength of the hospital lobby.” They were unwilling to put the responsibility

in the hands of physicians. In his view, if CMMI had given that bundled payment to physicians, “they could deliver value because they know where the bodies are buried and where the waste is in the system.”

In the near future, CMMI is likely to consider future and potentially mandatory models that build upon CJR, BPCI and BPCI Advanced.

According to Froimson, physicians need to be at the center of driving these innovations. “If you incentivize physicians to be in charge of every dollar prospectively, they will be much better as a general contractor to determine what innovations they need to improve results.”

Oncology and cancer care models—the near term opportunity

A concrete example of the role that physicians—specifically oncologists— have played in both leading innovation, improving care and lowering costs can be seen via the success of CMMI’s Oncology Care Model. This model included roughly one-quarter of Medicare FFS-related-chemotherapy related care and had more than 200 practices participating. The ongoing analysis of the demonstration—which ended in 2022—demonstrated a reduction in overall costs, high quality of care and encouraging levels of patient satisfaction.

In their November report, CMMI called out the successes from the OCM and highlighted the 2023 launch of the Enhanced Oncology Care model. This new model will introduce the concept of downside risk for participants, which provides a powerful opportunity for oncologists to demonstrate how physician-led models can truly be transformative for the health care system.

Technologies leading innovation in payment reform

The conversation about innovative payment models

“We keep trying to solve this problem by adding complexity, but the complexity is making it worse”

Mark Froimson, AngelMD CMO

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about the innovative technologies that accelerate those shifts and achieve the performance benchmarks.

With respect to these future models, Froimson believes “it’s not just innovation in payment, [the goal] is to foster innovation throughout medicine, utilizing the levers the a as government…to drive not just innovation in payment design, but to encourage innovation in care delivery.”

Once again, the physician perspective is crucial because of the direct role they play in the patient’s care. “If policy allowed physicians to drive these things, the technology to better manage the financial aspect and [patient care] via remote patient monitoring (for example)—they would be incentivized to purchase innovations that actually improve care,” said Froimson.

Considering that CMMI is in process of planning future models and given the expertise of AngelMD’s 35,000 members, we return to the question of what role should physicians play in developing an Innovation Agenda that helps guide the future of health care delivery. With that in mind, we are interested in developing principles for an AngelMD Innovation Agenda that can be shared across industry, policymakers and the broader health ecosystem. n

Tommy Barletta is the founder of Jones Point firm, which provides strategic advisory services to companies and investors impacted by an ever-changing regulatory and legislative environment. The firm leverages its 20+ years of experience in Washington, D.C., and deep Wall Street relationships to advise companies on effective advocacy strategies and guide their execution.

BE A THOUGHT LEADER

Email MDNext@AngelMD.co to join the conversation.

• What should the pillars of an AngelMD innovation agenda include?

• As Washington considers other models to improve care delivery, what specialties should be at the top of the list, that offer the greatest opportunity for innovation in the standard of care and create opportunity for innovating companies to partner with physicians and hospital systems

• How do these payment models impact your decision to invest in services or products to help improve care and lower costs

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Q. Tell us a little about growing up in India.

A. I grew up in Kayalpatnam, a small village in the southern state of Tamil Nadu. It’s on the east coast, not far from Sri Lanka, with a laid-back lifestyle where the shops and business establishments still close for an afternoon siesta. We would gather in the evenings, play beach soccer and eat snacks.

Q. Sounds like a wonderful place to grow up. What was your childhood like?

A: Though most Indian families have many children, I was the only child. But I had lots of aunts, uncles and cousins who all lived next to us and next to each other. So, I never felt like an only child. We didn’t have a TV or any electronics when we were growing up. We spent all our time outdoors, playing football (soccer) and cricket or many traditional games, like marbles, gilli danda, and kabaddi. One of my favorite things was to picnic at the local groves. We’d climb the trees and pick our choice of fruit; my favorites were (and still are) the coconuts and the mangoes. So many joyful memories.

Q. You shared in our previous podcast that medicine was not actually your initial choice of vocation. How did you come to medicine?

A. Being from a business family, I always thought that I would also enter business. My dad was the first person from my hometown to graduate with a BSc in Agriculture. But it seems he had always wanted to be a doctor. I was a high-achieving student and was accepted to both medical school and engineering college. It was my dad’s decision that I become a doctor and I am grateful for his guidance as it has been an immensely rewarding path.

Jaffar Raza, MD, FACC

Cardiology, Interventional Cardiology, Vascular Medicine

Q. You have worked under some real leaders in your field. How important was mentorship for you?

A. Many people have had positive influences on me through my career.

One of the earliest was my great grandfather, a naturopathic doctor in India. He knew all about Siddha, Unani and Ayurvedic medicines. My memories of him are plucking locally growing plants and making medicine from them. It was fascinating. We used to call him Hakim (the Arabic and Urdu word for a physician).

Another was Dr. M.K. Mani, the Chief Nephrologist at Apollo Hospital, Chennai and founder of Kidney Help Trust, Chennai, India, which works to prevent kidney disease in rural Tamil Nadu. He was one of the most meticulous physicians I have ever known. When I worked with him he had practiced medicine for more than 40 years; yet he still had the “Physician’s Desk Reference” (PDR) and referred to it prior to prescribing any medications. He taught me how to pay attention to every detail in patient care, and that no detail is too small.

I have been very fortunate in my career to work with several pioneers and luminaries in Interventional Cardiology from whom I have learned the art and skills of coronary and peripheral interventions. Dr. Joseph

Babb, Dr. Gary Roubin, Dr. Sri Iyer, Dr. Howard Cohen, Dr. Kirk Garratt, to name a few, who have played a tremendous role in guiding me. I still hear Dr. Babb’s voice in my head, “Just because you have a hammer, you should not treat everything like a nail.” Yes I have skills to do an intervention, but it may not be the best clinical decision for the patient.

Q. What are the areas of innovation in your field you are most excited about? How do you see your field changing over the next five+ years?

A. It’s an exciting time to be in the cardiovascular field. There are a lot of new and groundbreaking developments happening on the medical, procedural and technology fronts.

Medically, there are new pharmacological advancements to treat heart failure whereby they decrease mortality and hospitalization. The future management of lipids may involve mRNA technology.

Procedurally, many new devices are available and continue to be developed for heart failure. Up until now, this has been predominantly medically managed. Advancement in mechanical circulatory support has allowed us to treat patients who previously were considered very high risk for revascularization and therefore not treated. Valvular disease patients

are now able to get percutaneous treatment rather than open heart surgical procedures.

Technologically, CV disease prevention with AI and machine learning is going to change the way we practice medicine. With all the various data being collected and studied, and increased adoption of smart wearables/sensors, clinicians will be able to monitor their patients closely in real time and develop actionable insights. Machine learning will also help with CV risk assessments and enhanced CV imaging.

I continue to experience humbling lessons in patient care, like when we see patients that follow the established guidelines for a healthy lifestyle still developing coronary artery disease and other patients who don’t follow the guidelines having no disease. That puzzle is fascinating and continues to push me daily.

Physician burnout is real and self care is important. Often, we are so focused on caring for others that we forget to care for ourselves. Having a supportive family is a blessing that allows you to focus on taking care of your patients and also brings emotional and personal joy.

a profound experience for me each time as the routine frustrations of the business of medicine like insurances, pre-authorizations, etc. are absent. When we volunteer our time and knowledge for the sole purpose of serving and healing, we reconnect with the mission-driven spirit that drove me and many [other] physicians into medicine as our career. n

A. I believe medicine is a noble profession. Serving people with the goal of helping them have a better quality of life gives me immense satisfaction.

Finally, giving back to the community goes a long way toward professional satisfaction. I volunteer with One World Surgery in the Dominican Republic every year. It’s

Jaffar Raza, MD, is a cardiology specialist in New York, NY, with more than 29 years in medicine. Dr. Raza has extensive experience in interventional cardiac procedures including complex coronary interventions, radial access, peripheral interventions, nuclear cardiology, and echocardiography. Dr. Raza has published numerous articles in well-known medical journals and is active in teaching residents and fellows.

When a medical startup has an association with Formula 1® Racing, it gets our attention. When it has data to show incredible efficacy, it really gets our attention. Alyve Medical is one such startup and they are firing on all cylinders. What follows is a Q&A with Alyve CEO Yvonne Bokelman, a seasoned medical device industry executive brought in to lead this fast-moving startup.

Q. Alyve was born out of Formula 1 Racing in Italy. Can you give us the backstory on that?

A. Yes, this is a great story. Our founder and current chief research officer started his career working for Formula 1 and MotoSport: Ferrari, Lamborghini

* See Startup Profiles on p. 14 for more details on Alyve Medical Inc.

Yvonne Bokelman

and Ducati. He became very familiar working with high-tech/highperformance equipment and sensors. He was able to take that knowledge when he pivoted to orthopedics, facilitating the development of our devices.

a soccer player and saw and suffered one too many injuries. Then early in his career he worked in a consulting capacity for an orthopedic company. He has a number of patents in this and other orthopedic technologies, so he was well acquainted with working with orthopedic surgeons. Our technology was the result of collaboration between him and one of those notable orthopedic experts.

A. There was always an interest in healthcare. When he was young, he was

Q. What are a few key lessons you have learned over the years as a doctor?

Q. What made the engineering founder decide to apply the initial technology to healthcare applications?

Q. You were previously in executive medical device roles. Give us some

CEO, Alyve Medical Inc.*

more context on your background and how you came to Alyve.

A. I feel very fortunate with the path that led me to Alyve. Early in my career, I was a hospital administrator, and after 13 years made the choice to branch out into consulting and the healthcare IT space. After an executive VP stint in that arena, I pivoted to medical devices—initially working for Medtronic, and then for the last eleven years with Zimmer Biomet. I left a president/GM role there, with plans to pursue a startup. Through my network, I came to know what is now Alyve Medical. I was very impressed with the technology and knew it was something special with big potential. Combine that with the regulatory approvals, growing body of evidence, and orthopedic and PT support, I knew we could make a difference for patients and have a very successful company.

Q. Alyve technology has initially focused on the shoulder. But you are headed to knee and spine applications as resources allow. Give us some of the thinking on this.

A. It became clear very quickly that this is a platform technology—thus some of the need for the rebranding from what had been Shoulder Pacemaker to Neuralign System™ S. As we started gaining traction, orthopedic surgeons were quick to tell us that we needed to create a similar technology for other joints and areas of the body. The unmet need for a Neuralign Knee product is huge. That work has begun and we could not be more excited with where it is going.

Q. You currently have two products. Give us more detail on both products and how they work together. A. The original product development

started with ShowMotion™, our diagnostic sensor kit, which objectively determines normal and/or abnormal movement in the joint function. It provides results very quickly—in five to seven minutes—and with instant graphic results. Neuralign System S is our therapeutic technology: a substantially differentiated NMES wearable device, providing patented motion-activated stimulation and trimodal biofeedback. While the two solutions can obviously be utilized independently, tremendous value is unlocked when they are combined in a coordinated therapy.

Being able to objectively identify exactly what is going on in the shoulder and with the scapular-humeral rhythm—and then target any clinical impairment with the use of Neuralign S—is really the comprehensive approach. Confirming the electrode

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placement or any adjustment needed, and objectively validating the progress and success of Neuralign S, are benefits as well. I have put this all in context of the medical application, which is our focus today. There is also big potential in the sports arena, utilizing the two technologies for performance and potentially injury prevention.

Q. There are lots of products in the market based on hype, but Alyve has increasing data to demonstrate the efficacy of the products. Walk us through the results to date. A. We do have a growing body of evidence for both products and a publication cadence that we are quite proud of as a startup. Most significantly, and the publication is forthcoming, were the recently released results from an independent randomized control trial. It essentially compared six weeks of the gold standard of physical therapy to six weeks of physical therapy utilizing Neuralign S. The results demonstrated statistically significant improvement in WOSI scores using Neuralign S over physicial therapy alone. The results were sustained over the 12 months of the study. A cross-over population, permitted by the study protocol, also confirmed the positive results. I am eager for the publication, as the results are so validating for the use of the technology. n

Yvonne Bokelman is a results-driven life sciences executive with a unique leadership background and executive experience in medical device, hospital, consulting and healthcare information technology. Before joining Alyve Medical, Yvonne spent more than a decade with Zimmer Biomet in a variety of leadership positions, and was with Medtronic Spine & Biologics for six years prior to that. Earlier in her career, she was in hospital administration, spent several years as executive vice president at QuadraMed, and held other executive positions. Yvonne holds an MBA and is a fellow in the American College of Healthcare Executives.

SENDERS WINE:

BY MICHAEL SCHMANSKE | PHOTOS COURTESTY OF SENDERS WINE

How a surgeon cultivates a blend of science and art while giving back globally

As careers mature, children leave to lead their own lives, our hair turns gray and thoughts turn towards what to do with our newfound time and freedom. If you have the talent you might take up painting or golf. Those with means might choose to invest in travel, boating or other extravagant hobbies. But the ultimate passion project has to be owning your own vineyard. It’s expensive, risky, requires great patience and embraces difficult physical labor. Scores of variables go into making a passable wine and dozens or hundreds more contribute to running a winery as a profitable business.

Doctors certainly fit the mold of potential vintners. Intelligence,

education, competitiveness, quality control and a mastery of delayed gratification (hello, med school and residency) are all qualities that define the medical profession and contribute to a successful production vineyard. But there is one clinical specialty which may have a significant leg up on the competition.

If you explore wine tasting, you quickly learn that it largely engages the olfactory sense. To the layman, this means the sense of smell. Further, it turns out that most of the senses used to enjoy wine are the senses on which otolaryngologiests (ear, nose and throat specialists, or ENTs) focus. Craig Senders, MD, is one such ENT and he merged his love of wine with his skill

and passion as a physician to become a winemaker.

The wine enthusiast becomes vintner

About forty years ago, Senders was a young pediatric surgeon on a muchneeded break from work on a river rafting trip with his colleagues— enjoying some Napa wine. The brief respite from his rigorous practice had a lasting impression on him, and he launched a new journey into winemaking. He began by making wine casually at home while continuing to advance his medical career. The challenge, he discovered, was balancing his life as a medical humanitarian and artisanal winemaker.

Owning your own vineyard may seem to be an ultimate affirmation of the hobby lifestyle.

Craig Senders handles all aspects of winemaking the brand’s small-batch vintages

A pre-surgical screening of a patient on one of his many global outreach trips

As time passed, his medical career advanced and his winemaking improved. His list of medical publications grew while his small-batch wine was attracting critical acclaim and numerous accolades. He struggled to reconcile his passions: Frequent surgical outreach projects around the world and limited resources restricted his ability to make wine.

Yearning to make better wine and further their humanitarian goals, Craig and Karen founded Senders Wines in 2005. This small, family-owned boutique winery specializes in small lots of Cabernet Sauvignon and Pinot Noir from grapes harvested in Napa and Sonoma. The Pinot Noir grapes are sourced from the Russian River Valley and Carneros appellations. Craig crafts the wines at a custom crush facility in Napa while his wife Karen handles marketing and sales.

But focusing on the wine alone

would miss one of the most important characteristics of the Davis/Napa/ Sonoma-centered winery: The Senders have turned their passion for wine into a humanitarian cause that transcends the accolades given to their Pinots, Cabernets and Sauv Blancs. One hundred percent of profits from Senders Wines go to funding cleft lip and palate repair around the world. These are much-needed procedures that end suffering and promote health in communities without sufficient medical resources.

Today, Craig leverages his sophisticated knowledge of human sensory as a distinguished ENT surgeon to help engineer delicate Pinots and sophisticated Cabernets with scintillating aromas and enduring flavor.

Dr. Senders’ medical practice is based in Davis, California, where he is the director of pediatric otolaryngology

and director of the Cleft and Craniofacial program at University of California, Davis, Children’s Hospital. Serendipitously, UC Davis also happens to be a vortex of wine talent including some of the top educational programming in the wine industry.

As for Karen, she was flight attendant for Continental airlines followed by a director for March of Dimes. She loves everything about wine. “I love the history, art, food-pairings,

One hundred percent of profits from Senders Wines go to funding cleft lip and palate repair around the world.

friendships and mood enhancement!” said Karen.

Karen attributes the worldrenowned UC Davis Viticulture and Enology program, living one hour from Napa, and a Napa-fueled social circle of wine connoisseurs, cooks and foodies for driving Craig’s passion. “We started turning the best fruit in the valley into wine,” said Karen. “After a few years of winning awards for our home winemaking, increasing demand for the wine and encouragement from friends, Senders Wines went commercial in 2005.”

Over the years, Karen and Craig developed relationships with celebrated growers in Carneros, Oakville, and other Northern California regions vital to the cultivation of a library of wines. These local supporters are integral to the goal of making both art and a difference in the world. According to Craig, “They recognize our need for amazing fruit

and often invite us to hand pick the best rows that year for our small-batch harvest.”

The Cabernet Sauvignon is made of vines from Oakville Station Vineyard,

which is surrounded by other famous vineyards including Opus One, Martha’s and To Kalon. This hallowed soil produces small, slow-to-ripen grapes which create intense and balanced

The spirit and smile of a patient

Alora: before and after surgery

wines. As a result, Senders Wines are intended to drink very well upon release but still age gracefully.

Craig’s greatest passion is their Pinot Noir. “Cabernet is like wine in a sweatshirt—the intensity of the grape covers up many nuanced flavors. Pinot Noir is like wine in a negligee—all the nuanced flavors show through,” says the winemaker. The Pinot comes from grower Frances Mahoney in Carneros.

Karen shares, “Craig loves the challenge that the Pinot Noir grape gives him.” He agrees with the movie “Sideways” that states “the Pinot Noir grape is the most finicky, complicated, needing constant care and nurturing to be coaxed to its fullest expression.”

Creating smiles around the world

A cleft palate occurs when the roof of the mouth contains an opening into the nose. The disorder can result in feeding problems, speech problems, hearing problems and frequent ear infections. Untreated, children often experience speech and/or developmental delays,

social exclusion and other life-defining difficulties. This feels particularly wasteful since a cleft palate can be quickly repaired with a surgery called palatoplasty when the baby is 10–12 months old. The goals are to close the opening between the nose and mouth, create a palate that works well for speech and to prevent food and liquid from leaking out of the nose.

With proper medical care patients with cleft lip and palate conditions can be treated successfully with no lasting problems. A team experienced in treating children with cleft lip and palate can perform the surgery in about two to three hours, and most babies can go home after one or two days in the hospital.

To further his humanitarian goals and reach patients in need, Dr. Senders is also a board member of Faces of Tomorrow, a non-profit organization delivering medical care to an underserved population of children, youth and adults who might otherwise not receive the benefit of surgical

treatments for their cleft lip or palate. He personally trained most of the surgeons involved in the organization and the impact he is having on patients around the world is inspiring others to do the same.

Senders “Wines with a Cause” is the framework for blending Senders Wines with the humanitarian goals of Karen and Craig—and they integrated the tag line “Take a Sip and Save a Lip” to promote their fundraising efforts. As a result, more than 3,000 children have received new smiles and have had their lives changed by the teams of surgeons, dentists and nurses from these missions. Their award-winning vintages literally have the added flavor of generosity.

“Senders Wines followers love both the wines and the cause,” said Karen. “Many customers gift our wines because to them it’s fulfilling, like giving and receiving to the recipient.”

Nothing pairs better with a beautiful wine than a beautiful cause that helps children to smile again. And in the end, Sender’s Wine doesn’t have to choose between developing memorable wine and making an impact on the world. The Senders have done a masterful job of combining both passions. n

WHERE TO PURCHASE?

Senders Wines: senders-wines. obtainwine.com/collection/wines

Sign up for the wine club and the winery donates an additional $100 to Faces of Tomorrow.

Doctors are increasingly interested in medical innovation. They are intellectually curious and it meets their need to stay abreast of the most modern treatment options to help their patients. Increasingly, we encounter professionals looking for an outlet. Unfortunately, many physicians face burnout due to COVID-19 and professional frustrations. Unique outlets and opportunities like entrepreneurship, consulting work and investing can offer a lifeline and help physicians regain an internal locus of control.

If you are one of those clinicians looking to take the next steps and get serious about entrepreneurship as a way to generate additional income or engineer a career transition, then you are well served by creating a defined framework for evaluating startups.

I like to call mine the 7 P’s. I use them to identify a company’s strengths and areas of improvement, describe opportunities for improvement, and influence future company goals. This framework informs investment decisions. It can also be paired with your unique professional background to offer relevant insights as a company advisor or chief medical officer (CMO).

Each of these topics deserves its own individual treatment. And I will be presenting them as an ongoing blog series with company case studies and other personal examples from my own experience. You can find the first two, ‘Product’ and ‘Physician Feedback,’ at angelmd.com.

The 7 P’s

1. Product

Does the proposed solution address a medical practice pain point? The company may be in the idea phase, may have a minimum viable product (MVP),

Seven P’s to Evaluate Healthcare Companies

A framework for physicians to determine the strengths and weaknesses of startups

By John R. Dayton, MD, FACEP, FAAEM

or have a functioning prototype.

We certainly want to know if their solution is better and cheaper than the available alternatives. But while improvement over the standard of care is necessary, it is not sufficient. We also need to know how big is the pain point they are addressing? Is it a known problem supported by and constructed with the experts in their space? What does that mean about the size of the capturable market?

And that, my friends, is the beginning and end of “Product” (Don’t get me wrong we have A LOT to unpack there). But it is also why so many startups can fail even with a viable product and why it is so important that we travel much further. The other 6 P’s are where we find dragons.

2. Physician and patient feedback

Successful startups are often led by physicians or have physician advisors. Getting feedback from medical experts helps a company at every stage of company growth: from ideation to product development to running a successful pilot. Two crucial questions

to ask a startup team are when they spoke with physicians about their idea and what kind of feedback they received.

3. (Intellectual) Property (IP)

Patents can be obtained for medical devices, pharmaceutical compounds and digital health assets. These provide protection from knockoff products and also provide companies with a valuable asset that is the core of many healthcare acquisitions. Without strong IP, a company may succeed in the short term yet fail to monetize in the long run.

4. Process for product clearance

What kind of medical device needs a 501(k) clearance? How does the FDA’s Software as a Medical Device (SaMD) work for machine learning? When does an innovation need a De Novo request? The FDA has different approval processes for medical devices, digital health tools, pharmaceuticals and AI applications. Understanding how the product you’re evaluating is regulated is essential for assuring patient safety and

helps you budget for future regulatory needs.

5. Payment

This includes the company cost of production and revenue models. How much does it cost a company to build or implement their solution and how much does it cost them to acquire a new customer? You’ll want to know how much the company charges patients, offices or hospitals to use their product and whether that is covered by a Current Procedure Terminology (CPT) billing code. Although patients benefit from innovation, are they the purchaser or will the company sell to healthcare organizations or physician offices?

6. Pilots

Healthcare startups improve their product and achieve traction by obtaining early customers. The first physician office to use that innovation is able to provide invaluable feedback that will help the startup improve their solution before scaling their business. When evaluating a company, ask about current pilot programs, how well they are going and how the company has responded to feedback from physicians and patients.

7. Publications

In addition to obtaining physician feedback, startups also need to document how well their product performs in those pilots. Is it effective? Is it more effective than the current gold standard? In addition to using this data to improve early versions of the product, companies should also publish reports on their product’s performance. You should ask how startups are tracking data and their current goals for improvement. Even if they don’t have peer-reviewed journal publication, they will have materials you can review and assess.

As a clinician, you are a healthcare expert. You are acutely aware of your practice pain points, whether a product could be incorporated into your workflow and the current market

competition. You are able to offer valuable insight into the viability of an idea, potential use cases, and how to bring it to market. Companies are increasingly aware of both the value of that insight and the need to integrate it into their business strategy. With a proper repeatable framework you will find yourself much more comfortable navigating between multiple startups to identify the most likely to succeed. n

John Dayton, MD, is an emergency physician and the first Medical Innovation Fellow with Stanford’s Department of Emergency Medicine. He is a physician consultant for Zus Health, a Venture Partner for SpringTide, and he writes about healthcare innovation for several publications, including Emergency Physicians Monthly. He also founded MedForums, a ‘yelp’ for physician feedback that focuses on social proof and research related to education resources and healthcare innovations. You can reach out to him via LinkedIn.

Grow to Thrive

Strengthen your practice’s core with this four-step methodology to scale growth

By Pariksith Singh, MD

Athletes know their core conditioning governs many aspects of their training and competitive success. While the exercise can be uncomfortable, without a strong core much of your other efforts will be wasted. Your clinician practice has a core also: the combination of processes, actions and systems that allow you to deliver your medical services as a business.

Access Health Care was founded in 2001 as a single clinic, primary care practice in Florida. Today we have 83 offices serving more than 66,000 patients. We achieved this by keeping our core strong as we scaled the practice.

Step One: Procedure planning— create your treatment flowchart

What would it look like if you followed a patient walking around your office, mapping out their every sequential step as you welcomed, examined, treated and checked them out? Map these steps

into a simple flowchart—box to box to box—of all the steps they went through and experienced in the course of their interaction with your practice. This will help you understand how to improve efficiency and productivity as well as patient satisfaction and quality of care.

Once you’ve laid that process out visually, do the same thing from the perspective of your most expensive providers: your physicians. Follow them through the flow of what they do and where they go, step by step, as they treat patients and perform procedures. With this raw information in hand, it’s time to move on to step two.

Step Two: Peer review—audit the process

Gather together a small team of your key people in a conference room for ninety minutes to take a fresh look at the way you produce your core medical services. This is important! By teaching others what you’ve learned, you will

gain valuable insight and feedback that we can miss by being too close to a problem. Make it a breakout session: Buy some pizzas and beer, get a whiteboard, put your two flowcharts up on the wall and discuss them as a team. Start with the patient-view flowchart, and ask the following questions:

• What jumps out at you as not making sense about this process?

Is the waiting room dead time or a place where patients receive valuable education? Do your doctors move in a chaotic flow back and forth to both ends of your facility? Small moments of chaos can easily eat up extra minutes of every day each week. Are physicians handling parts of the process that medical assistants could do instead?

• How could you reduce the number of steps in your overall process?

Could you show educational videos in the waiting room so that nurses are not tasked with conveying the same educational material to every patient? Could you reduce wait times?

• Where could you make a small investment to get an exponential increase in production efficiency? Concentrate on your pain points. Could you hire a medical tech to team with each physician and speed up charting and note recording in your EMR system? What about installing better Wi-Fi or upgrading your computers to speed up access to the EMR system itself?

• What frictions are there in the process that are bottlenecks?

How could you streamline your process to minimize or remove these factors? For instance, could you employ a scribe who accompanies a provider, so that provider can give full attention to the patient without typing into the EMR?

• What steps are missing that, if you added them to the process, would improve the efficiency, consistency, and/or quality of care for your patients?

Create an enrichment center next to the waiting room so that patients can be educated, entertained, and/ or engaged. Could you have medical assistants do preliminary screenings and leave a note to bring the physician’s attention to the reason for the visit?

• What are your most expensive constraints to seeing more patients or performing more procedures? Is it your physical space? Or a lack of key providers? Or perhaps a lack of certain systems or automation? Identifying your most expensive constraints will give you clues about how to refine your core workflow to maximize around these constraints.

Now take a second pass at these questions, and this time invert the focus specifically on the physician’s flow diagram.

Step Three: Triage—pick your “sweet spot(s)” to address Based on my experience coaching practices through this process, at this

point you’ve got an overwhelming mass of ideas that you know you “should” do to improve your core practice flow. But let’s get real: There is simply no way you and your team can implement all these ideas at one time. In fact, doing so would be so disruptive to your current activities that your practice would actually suffer.

Instead, go back over your list of possible practice enhancements and flow fixes, and pick the one or two ideas to implement that are easiest for you to apply and will have the biggest impact. These are your “sweet spot” ideas.

Take your few sweet spot ideas and turn them into a mini game plan to execute. Who needs to do what by when? We encourage you to download the Sweet Spot Analysis Tool, which you can get for free at www.GrowMyMedicalPractice.com.

Step Four: Winning—formalize

your winners

After you’ve implemented your first few core process-improvement sweet spot ideas, observe which of the ideas you’ve tried have worked well. We call these your “winners.” The strategic principle is to “feed your winners; starve your losers.” When you find a core process improvement that clearly works, formalize it. This means building a formal system for it and adding it to your UBS. It also means training all of your team on its use.

Essentially what this does is help your practice institutionalize the best of your workflow refinements. Now the key knowledge to run your practice isn’t in the hands (or heads) of only one or two experienced team members, but, rather, it has been absorbed by the practice itself. Next quarter, repeat this process of picking your next round of Sweet Spot enhancements and formalize the ideas that have been proven to work. n

Pariksith Singh, MD, is the founder of Access Health Care Physicians, an IPA in Spring Hill, Florida. He also owns Healthcare IT firm Mirra Healthcare and is the author of several books in the American healthcare domain.

Are you a physician looking to start a profitable side hustle this year?

You’re not alone! Many physicians are searching for ways to diversify their income and take advantage of new opportunities to leverage their wisdom and expertise

Some obvious benefits of a side hustle include:

• With the changing economic landscape and the uncertainty of the future, having a side-hustle can provide a financial buffer for physicians.

• Starting a side-hustle can also provide a sense of fulfillment and give physicians more flexibility in their schedules.

• Ability to diversity your income

Make your new year resolution to explore how you might richen your life with stimulating side gigs. With the right know-how and resources, you can make this year the year you start your own side hustle and reap the rewards.

You probably didn’t succeed in your medical profession without doing the work. Starting any new venture can be intimidating but it doesn’t have to be. The key to a successful beginning is to do research and create a plan, understand the industry and what it takes to succeed, and definitely get

Hustle and Bustle

The financial rewards of a side hustle can be just the beginning

a mentor that has “been there, done that.” Take the time to network with professionals in the industry and learn as much as you can. Once you have a better understanding of what you are doing, create a plan that includes our goals, timeline and budget. Finally, take action and follow your plan.

Remember to be patient and consistent. It may not happen overnight but with dedication, you can reach the goals you have set. Having both active and passive income streams from side hustles can provide much-needed financial stability and open up new avenues for income. Active income from side hustles can provide short-term income, while passive income can give long-term financial stability.

If you seek out these opportunities

with a plan and purpose you will likely discover the second big benefit to side hustles—a new joy in your chosen career. Let’s be realistic: Clinicians generally love their careers but hate their jobs. Everyone got into medicine for a reason. It might be the satisfaction of helping patients and positively impacting society. It could be the intellectual pleasure of working with skilled peers and maintaining a lifetime of education. Or it might be the satisfaction of accomplishment from building things and overcoming obstacles.

With some research and a bit of creativity, anyone can get started on their side hustle journey. Looking forward to seeing you on the road. n

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That’s One Way to Deal with a Noisy

Roommate

A 72-year-old woman was arrested on Nov. 29 in Berlin after she allegedly turned off her hospital roommate’s ventilator—twice—because the sound of it was annoying her, The Washington Post reported. After the first incident, police said, the woman was told the machine was necessary to keep the roommate alive, but she switched it off again later in the evening. The other patient had to be revived, although she is expected to recover. The suspect was charged with suspicion of attempted manslaughter.

The Last Laugh

That’s Not How You Become the Energizer Bunny

Doctors in Ireland discovered 55 batteries (AA and AAA) in a woman’s body when she presented to the emergency department with abdominal pain; apparently this was the ‘highest reported number’ of ingested batteries—ever. Initially physicians “milked” four of the cylinders from her colon to her anus, but after reviewing x-rays it was determined she needed to have the rest surgically removed from her colon and stomach. The terms “emergency” and “AAA” typically connote a roadside incident. Certain doctors in Dublin, however, are unlikely to ever associate those terms with anything but the 66-year-old woman’s surgery.

No, Sir, We are High on Life

Apparently spiritual Zen wasn’t enough for Buddhist monks at two small temples in northern Thailand, The Washington Post reported. As part of an investigation into drug abuse in the Phetchabun province, officials visited the monasteries on Nov. 25 and discovered that all of the monks—even the abbot—tested positive for methamphetamine. “I was frightened because I never thought the monks would be addicted to drugs,” said Sungyut Namburi, the village headman. But the monks’ behavior gave them away. “When I inspected the abbot’s shelter, I was stunned because it was a mess,” Sungyut said. The monks were forced to leave the monkhood and enter rehab. For now, “the temple is empty,” Sungyut said.

In a Related Matter: We Found Their Dealers

Police in Mathura, India, reported to the Narcotic Drugs and Psychotropic Substances Act court that more than 500kg of marijuana—confiscated and stored in two police stations—had been “eaten” by rats, Gulf News reported. Officers told the judge that mice and rats, although small, do not fear police. A district judge ordered police to eradicate the “mice menace” and provide proof that the critters actually consumed the weed.

Science’s Weirdest Discoveries

The sex lives of constipated scorpions, cute ducklings with an innate sense of physics, and a life-size rubber moose may not appear to have much in common, but they all inspired the winners of this year’s Ig Nobels: prizes awarded for comical scientific achievement. Winners included two scientists who studied that scorpions that have lost their tails become seriously constipated— effecting their ability to mate; a person who made a life-size crash test dummy of a moose—resulting in its application in auto-safety tests in Sweden; and an art history prize based on a study of ritual enema scenes on ancient Maya pottery.

Doctor, Your 3 o-Clock Has Arrived

A pair of Virginia cow wranglers responded to a doctor’s office in December, where it was reported that a 650-pound bull had supposedly jumped from the back of a trailer and ran down the road towards Orange Family Physicians in Orange, Virginia, before smashing through the glass doors and entering the medical practice. At one point the bull ran to a back room where one of the wranglers tried to grab him; the bull took off, dragging the cowboy down the hall. Eventually the bull was put into a headlock and they were able to secure him and bring him back home safely. May be a good time to take another look at the bovine coverage on your medical practice policy.

Hope They Brought Enough Sunscreen

This past November a mass nude photo shoot was staged on Sydney’s Bondi Beach as part of National Skin Cancer Action Week and to raise awareness about skin cancer. In order to pull off the event, local laws were changed temporarily, declaring the location a nude beach for a day. The sea of swimsuit-less individuals was directed via megaphone by U.S. photographer Spencer Tunick, standing on top of a large ladder. Australia has one of the highest rates of skin cancer in the world.

Add that to Your Trophy Case

A hospice nurse in Durand, Wisconsin, was charged with physical abuse of an elder person after she performed surgery on a man under her care. The woman was working at Spring Valley Health and Rehab Center, where she cared for a patient suffering from severe frostbite on his feet. In May, she took it upon herself to remove the victim’s right foot—without a doctor’s order or permission. Another nurse, who held the victim’s hand during the procedure, said he was moaning and squeezing her hand, and he told yet another nurse that “he felt everything, and it hurt very bad.” The nurse’s rationale was that her family has a taxidermy shop and she intended to preserve the foot and put it on display with a sign warning kids to “wear your boots.” She is due in court this month.

She Wants a Pearl Necklace

Designer Amanda Booth, of Toronto, Canada, has a jewelry business aptly named Trinkets by Amanda. This past fall, Oddee reported that her first pieces were of clay, but then a friend contacted her and asked if she could make a jewelry set from her son’s ashes. She did just that. Booth has “never said no” to a friend, and the set inspired other customers— including one who asked if she could use breast milk to make jewelry. She posted about the jewelry on TikTok and business took off, including orders for items made with umbilical cords, placenta and hair. But the real crème de la crème came when people started requesting jewelry made from semen. Booth transforms the liquids to powder via dehydration, mixes the powder with clay, then sculpts the jewelry piece. “I am an openminded artist,” Booth said. n

NIKITA KHANDELWAL

TIFFANY ANTHONY