Escape to Singapore…

Having been chased out of Hong Kong by Super Typhoon Mangkhut on Friday, a few days in Singapore with investors and entrepreneurs offered a modest respite. Actually, no…it was the Singapore Formula One Grand Prix weekend at the sovereign city-state, which coincided with the Singapore Summit that convened global leaders (quite different from the notorious June 2018 summit with other leaders, Trump and Kim). Not surprisingly, Lewis Hamilton below in the silver “car” (more like a rocket with wheels) won the race.

Singapore 2018

This island country of less than 280 square miles, sitting on the southern tip of Malaysia balanced on the equator, has become a global powerhouse in commerce, finance, education and healthcare since securing independence in 1965 from said Malaysia. Home to 5.6 million people, 74% of whom are ethnic Chinese, Singapore ranks third in the world in GDP per capita and fourth in quality of healthcare.

Unfortunately, like many countries in Southeast Asia, the current economic climate is being battered by bellicose trade rhetoric between the U.S. and China. The Singapore Straits Time Index is trading at its lowest level in the last 18 months. The Singapore Commercial Credit Bureau just significantly moderated its 4Q18 Business Optimism Index, which tracks the top 200 companies in country. This theme seems to be playing out across the region.

Singapore spends 4.6% of its GDP on healthcare, which is less than the 4.9% it spends on its military (the U.S. is approximately 19% and 3%, respectively). The healthcare system struggles with many of the same structural issues experienced in the U.S. – how to provide care in non-traditional settings, drive down cost of care, and how best to utilize many of the innovative healthcare technology solutions coming to market. While there over just a few days, there were several interesting healthcare announcements:

  • The Ministry of Health established a “regulatory sandbox” for telemedicine providers, announcing the creation of four telehealth start-ups
  • Formation of several community health centers to address chronic conditions for the elderly, with an objective to dramatically increase the number of health assessments across the population
  • Installation of automated external defibrillators across the city

And given Flare Capital’s investment in Circulation (more to come on that later), it was particularly notable that Singapore-based Grab, the leading regional provider of ride-hailing services (Grab acquired Uber’s Southeast Asian operations in 1Q18), announced this week that transportation volume to / from medical centers increased by 500% since 2015, making those facilities the third most popular destinations. A leading medical tourism survey recently ranked Singapore as the most attractive of all Asian countries.

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Calm Before the Storm…in Hong Kong

While in Hong Kong this past week, it appeared that there were only three stories that the newspapers wanted to cover. Quite clearly, the first and by far the most important was Super Typhoon Mangkhut which made landfall the day after I headed out. It was forecasted to be the worst storm to hit the colony in recorded history, graded a level T10 which is the highest possible level. And it did not disappoint.

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Growing up in Hong Kong, I had become somewhat accustom to significant tropical storms battering the island. In fact, Hong Kong has become quite resilient to these storms, and as devastating as Mangkhut was, there was very modest loss of life (initial counts point to less than five fatalities in Hong Kong, although there was significant carnage in the Philippines). All the focus on the typhoon underscored how impressive the Hong Kong healthcare system is but also was a jarring metaphor for its current economic condition as it is further absorbed into China.

The quality of healthcare in Hong Kong is surprisingly exceptional. There are 11 private and 42 public hospitals for a population of 7.3 million people. There are 1.7 doctors for every 1,000 residents so relatively rapid access to care is assured. Fortunately, there are also 6,000 practitioners of traditional Chinese medicine. This week there was great fanfare around the “Tap the Hidden, Tap Your Talent” collaboration by many of the public hospitals to provide more aggressive outreach programs to address mental illness in the community.

In fact, Hong Kong is considered one of the healthiest places in the world, with average life expectancies of 85.9 years (women) and 80.0 years (men) putting it third in the world according to the World Health Organization. Interestingly, greater China has average life expectancy of 76.4 years. Infant mortality in Hong Kong ranks ninth in the world with 2.73 deaths per 1,000 births. Perhaps more ominous is that 18% of the population is now over 65 years old. And these results have been achieved quite efficiently; total healthcare expenditures are approximately $17.5 billion or 6.0% of GDP.

Unfortunately, this past week also witnessed the Hang Seng stock index entering “bear market” territory as it is now more than 20% off trading levels at the beginning of this year. The Hang Seng has a total market capitalization of $2.1 trillion and is comprised of 50 large cap stocks, just over half of which are Mainland Chinese companies. Tencent alone has lost $200 billion of market value since its January 2018 highs. Trade tensions with the U.S. have a direct impact on local business sentiment as does the strong U.S. dollar. Notwithstanding the numerous full-page financing tombstones in the business press, Hong Kong is tragically on a path to be further marginalized on the global stage as China aggressively develops other economic centers.

One of the other stories which captured a number of headlines was the disappearance of China’s most famous and wealthy actress, Fan Bingbing. She has not been seen for three months now, right after she was accused of tax evasion. The release this week of a state-sponsored study on social responsibility for the top 100 performers in China, Hong Kong and Taiwan did not help as it had her last with a total score of zero out of a possible 100. Evidently, not being socially responsible can be bad for one’s health. Undoubtedly, not paying one’s taxes is also unhealthy.

The other story that fascinated many this week in Hong Kong was the murder trial of Professor Khaw Kim Sun who stands accused of filling something called a yoga ball with carbon monoxide and placing it in his estranged, now dead wife’s car. The good professor was an anesthesiologist at the Prince of Wales Hospital and claimed that he was stockpiling the poisonous gas to eradicate rats in his home. Quite clearly, he would have benefitted immensely from tapping his hidden talents in that community outreach program.

 

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Twilight Zone…

What a remarkable week, and not just because of the political “twilight zone” we are now dialed into, but the current S&P 500 bull run officially became the longest one over the past 70 years. Since this run started in March 2009, the index has increased 323% over the past 3,452 days. Unfortunately, over the past 20 years, U.S. public equity markets have returned only 6.5% per annum, which is well below longer term equity returns of 10%, per DataTrek Research. Inevitably this has caused many institutional investors to seek greater returns elsewhere. Against this backdrop, seemingly unrelated occurrences such as the crash of cryptocurrencies, performance of emerging market equities, repatriation of overseas cash, and the level of household debt start to make more sense. Mostly due to levels of unprecedented innovation, these fund flows have also contributed to what has been yet again another very strong quarter in the venture capital industry.

Bull Run

Quite clearly, 2018 is on pace to exceed 2017 in overall venture capital activity, which would make it the most active year in nearly two decades. Per the National Venture Capital Association and Pitchbook, this past quarter $27.3 billion was invested in 1,859 deals, for an average of $14.7 million, which given the diversity of activity is a relatively meaningless number. For instance, more than 60% of all deals included non-traditional venture investors and 20% of all capital was invested in “unicorns” which suggest very large round sizes. As a point of comparison, Chinese venture capital firms have invested $2.4 billion in U.S. companies through May 2018 per the Rhodium Group. In 2Q18, $11.5 billion was invested in 592 early stage deals but this includes 24 financings that were larger than $100 million (recall these are “early stage” companies); more than half of these 592 financings were larger than $25 million. The median Series A and Series B round sizes were $11.3 million and $29.3 million, respectively. Keep those numbers in mind when we look at the exit environment.

Additional color is provided when looking at either end of the investment spectrum. There were 792 angel and seed stage deals which accounted for $1.8 billion (average of $2.3 million per deal). It is quite clear that there is now a relatively large amount of “pre-seed” investment activity given the significant inflation in the size of seed rounds. Furthermore, this is the fewest number of seed investments since 4Q13, quite notably given quarterly seed activity has been consistently greater than 1,000 deals per quarter. Conversely, the late stage activity has remained quite strong with $14.9 billion invested in 475 deals. This is the third greatest quarterly investment pace in a dozen years. Investors seem to be eagerly looking for “de-risked” venture investment opportunities, possibly at the expense of the most nascent emerging ideas.

2Q18

Exit activity has improved, without debate. Year-to-date there have been 419 venture-backed exits for $28.7 billion in (disclosed) value. This year has seen a marked step-up in exit valuations. The median acquisition exit was $95 million (see below) while the average was $225 million, suggesting that there were some very significant liquidity events this year. Year-to-date there were 43 venture-backed IPOs for $6.3 billion of exit values with 29 of them in 2Q18 alone. Interestingly, there are only 3,671 public companies in the U.S. today as compared to over 7,300 in 1996, to underscore that going public is hard and quite a rare feat.

What is less obvious is how much capital was required to achieve these outcomes. Recall above that the median Series A and B rounds raised $40 million of capital in aggregate, which is tricky when exits are only $100 million. This dynamic really underscores the requirement to be capital efficient and for investors to own a lot of each company. Appreciate how over-used this phrase is but the math starts to breakdown much above these investment levels.

Exit no data

The most recent venture performance data reported by Cambridge Associates (1Q18) for one-year net returns was 15.0%, which should only improve with greater liquidity in subsequent quarters. The three, five and ten-year marks are 9.4%, 16.8% and 10.1%, respectively; the longer durations consistently outperform comparable public benchmarks, underscoring why venture funds are ten-year commitments. And these are NET return data after fees and expenses, which makes comparisons even more favorable.

Venture Capital - Fund Index Summary - Horizon Pooled Return

Interestingly, a survey conducted by Wilshire Trust of over 1,300 pension plans highlights this chase for returns. Over 59% of all pension assets are in stocks, an increase from 57% in 2Q17. More specifically, pension funds greater than $5 billion in assets allocated 20% to alternatives (including venture capital) which is significantly above the 17% in 2Q17.

This improved exit environment supports a robust fundraising environment for venture firms. In 2Q18 72 funds raised $10.8 billion, slightly exceeding 1Q18’s strong pace. While the median fund was $65 million, notably firms raising successor funds do so at 1.4x increase in fund size. Interestingly, 26 first-time funds raised $1.9 billion through the first six months of 2018 which, notwithstanding the continued concentration of capital around a few dozen firms, the venture industry does accommodate new venture managers with novel investment strategies. In fact, there have been 15 “micro-venture” firms created which have raised in total $308 million year-to-date.

This gap between invested and raised persists and is getting more accentuated. Venture-backed companies have become quite reliant on non-venture sources of capital such as sovereign wealth funds, private equity funds, corporates and family offices. Preqin tallies that there is $1.1 trillion of “dry powder” just with private equity funds. And then there is SoftBank’s Vision Fund which has created somewhat of an arm’s race amongst the larger venture franchises to raise ever larger funds.

Raised vs invested

Arguably the collapse of cryptocurrencies captured the greatest number of financial headlines this quarter. From the January 2018 highs, the total market capitalization of all cryptocurrencies plummeted from $800 billion to below $200 billion now. Bitcoin is trading around $6,000 per token, which seems inconceivable given it was at $19,000 in December 2017. Perhaps this is all due to the lack of regulatory clarity or maybe it actually was a speculative bubble after all, one that took six months to deflate, littered with numerous fraudulent ICOs. And recall that the total crypto market capitalization was a mere $18 billion at the end of 2016 – so perhaps we have not yet touched bottom. Those seeking greater returns need to step carefully through the token minefield.

The collapse of many foreign currencies also may reflect some of the desire to find greater returns in other seemingly attractive asset classes. Putting aside the self-inflicted wounds in Turkey, Venezuela, Argentina, etc, these issues have the risk of being more systemic than the bursting of the cryptocurrency bubble. These difficulties overseas will have investors seeking safety and returns in U.S. alternatives, suggesting supportive fund flows for venture managers, at least in the short to medium term.

GDP growth in 2Q18 was a robust 4.1% and with 91% of all the S&P 500 companies now having reported second quarter results, it is not surprising that 79% of them have exceeded analyst forecasts. It is somewhat surprising though, that of the $2 trillion of cash held overseas by U.S. companies, only $218 billion (through 1Q18) has been repatriated. Perhaps executives are struggling to find productive uses for all that cash. Coincidentally, there were $189 billion of stock buy-backs in 1Q18, which was a dramatic increase from the $50 billion in 4Q17. And was done with public equity markets flirting with near-record highs.

The Federal Reserve Bank of New York recently announced that at the end of 2Q18 U.S. household debt had reached a record level of $13.293 trillion, which was an increase of $82 billion from 1Q18. This level is now 65% of aggregate GDP, which is somewhat confounding given the rising interest rate environment, yet likely reflects consumer confidence given the robust public equity markets and low unemployment levels. Living in the shadow of the longest bull market can induce anxiety in some. In the midst of the Great Recession of 2009, debt was 87% of GDP, which was not that long ago.

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Art of Healthcare in Basel…

What a remarkable time to have traveled to Switzerland and the United Kingdom. After a series of meetings with healthcare industry leaders in Switzerland and England last week, the trip put some of the raging healthcare policy debates into better context. Unfortunately, the current U.S. political situation was at times quite distracting with revelation upon revelation unfolding throughout the trip; but no less so than the debates raging around Brexit, bickering over tariffs, Europe’s own version of Russian meddling, and the “baby Trump balloon.” What a surprise to learn that the State Department had issued a travel advisory warning for Americans traveling in London of all places.

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Often U.S. politicians opposed to the Affordable Care Act point to the “single payor system” in Europe which unfortunately ignores the fact that there is not one system in Europe and that while countries like Switzerland achieve universal coverage, they do so through a mosaic of private, non-profit and for-profit organizations. There are three principle health insurance models across Europe: (i) the government manages both the insurance and provider sectors; (ii) government provides insurance but leaves the provider sector private; or, (iii) both sectors are private yet the government mandates that all citizens must have coverage. Switzerland falls into this last category.

According to the Euro Health Consumer Index (2017), Switzerland is consistently ranked second (behind The Netherlands) for quality and cost effectiveness of its healthcare system. The study concluded that there is little correlation to quality of healthcare and money spent to deliver it, but that in fact, healthcare is a “process” industry that excels with well-managed systems. Think of Swiss watches. In 2015, Switzerland spent 11.7% of G.D.P. on healthcare, notably less than the U.S. healthcare system. Switzerland has the highest percentage of nurses per thousand citizens at 17.4 (in 2013) and has 313 hospitals, underscoring the depth of commitment to a distributed care delivery system. General life expectancy is 82.6 years, which places Switzerland near the top of all countries.

Basel is an extraordinary city with a population of only 175,000, and yet, it is home to some of the largest pharmaceutical companies in the world (Novartis, Hoffman-La Roche, Ciba Geigy, Syngenta, Actelion). Much like the Kendall Square phenomenon in Boston with Harvard and Massachusetts Institute of Technology, this cluster of leading drug development companies is anchored by the first university in Switzerland which was founded in 1460 and is particularly expert in the medical and chemical sciences. Conversations with a number of these executives revealed that talent is quite mobile from company to company, and yet there is a fierce pride associated with the role these companies play in the global pharma industry.

Despite the myriad of reasons to be troubled by the situation in the U.S., my Swiss hosts were incredibly respectful (at one company I was provided a set of guidelines with the first point being “Avoid contact with chemicals.”) Notwithstanding the current rhetoric in the U.S. concerning drug pricing, one leaves with a sense that executives view this to be temporal and will not unduly impact their core programs.

In addition to the pricing concessions offered by Novartis concurrent with my trip to Europe, there were two other “medical discoveries” announced while I was there. To screaming tabloid headlines in the U.K., researchers with the Cochrane Library on behalf of the National Health Service (NHS) announced that Omega-3 and fish oil supplements are useless. Apparently, the English spend 420 million pounds on supplements annually and the NHS is worried that much of it is wasted.

Perhaps more timely, given the proclivity of the U.S. President to tweet, the Journal of the American Medical Association released a study that confirmed heavy social media use may make one twice as likely to develop attention deficit hyperactivity disorders. I better tweet that right away.

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Step on Through: Healthcare’s “Digital Doorway”

Much of the significant recent merger activity in the healthcare sector is focusing renewed attention on the role of the pharmacy and the continued “retailization” of healthcare. Last month Flare Capital announced an investment in Aspen Health which will enable pharmacists to practice to their fullest potential. Now we are excited to announce Flare’s newest portfolio company higi, a company which will further position the pharmacy and other retail settings as the “front door” to one’s healthcare journey.

Higi has built a robust national network of over 11,000 smart health stations (as well as a host of robust mobile applications), which are within five miles of nearly 80% of all Americans, and capture a wide array of biometric data including blood pressure, pulse, weight as well as survey and demographic data. They are located across 14 retail partners (pharmacies, supermarkets covering more than 50 banners) as well as on corporate campuses and in community centers. Each week there are more than one million sessions across the network or 1.7 sessions per second. Since 2012, there have been more than 271 million tests completed on the network. In 2017, there were nearly 42 million blood pressure readings. Capturing these data outside of the hospital goes a long way to closing critical gaps in care. As the Chief Medical Officer of a leading academic medical center recently observed, such a network will meaningfully reduce the nearly 40% missed readings in his hospitals which directly impact coding.

Two weeks ago, Amazon announced the acquisition of PillPack for the rumored price of $1 billion, which directly led to the cumulative loss of $15 billion of market value for the stocks of drug chains and distributors. This transaction also renewed speculation about the evolution of the healthcare retail setting, and what other services could be provided in those environments. Clearly as novel care models emerge in non-traditional settings, the role of the retailer will be a particularly powerful one.

Underlying many of these M&A transactions is the desire to own the consumers healthcare journey while capturing timely and actionable clinical data which will make the ability to manage that individual more relevant and impactful. Higi clearly addresses both of these dimensions (as do many of the other Flare Capital portfolio companies such as Iora Health, Somatus, Bright Health to name a few of our value-based portfolio companies). Higi will “meet you where you are” as the platform is integrated with over 80 devices and mobile application platforms including leading EMR and pharmacy systems.

As with the PillPack acquisition, a similar phenomenon played out last year when Amazon acquired Whole Foods for $13.7 billion and the supermarket index traded off significantly, only to recover within a few months. Interestingly, Amazon has recently introduced 10% discounts to all Amazon Prime members who shop at the 460 Whole Foods stores coupled with aggressive two-hour delivery services in certain cities. This is in addition to new stocking fees Amazon is charging suppliers holding out the promise to them to access a much deeper pool of online Amazon customers. Expect to see aggressive cross-promotional activities and more sophisticated customer segmentation of the PillPack membership base as well.

There were several other considerations which made the higi investment particularly attractive. Sessions are free to the consumer, easy to use, available 24 hours a day, and as a senior executive at a major retailer shared with me, the “stations don’t judge.” All of higi’s strategic partners benefit. Providers can extend their reach into the communities they serve and the higi network is integrated seamlessly into their clinical workflows. Payors enjoy a level of unrivaled member engagement and activation, while capturing precious clinical data, often for members who have significant chronic conditions with dynamic dosing requirements. Healthcare brands also can engage members at critical “point-of-decision” moments and can utilize the network for end-to-end communication strategies. Ultimately, higi becomes a powerful virtual primary care network, and one that has the potential to also move share of the healthcare wallet.

higi.pdf

Additionally, the higi network has the potential to better inform and manage many of the social determinants confronting consumers. Robust survey capabilities and associated incentive programs are managed on the network. The ability to connect patients to relevant social and clinical providers is very compelling.

Consumer-centric approaches tend to win out as people simply vote with their feet. The higi network is meant to meet the consumers “wherever they are” and quite often they are at their local pharmacy or supermarket. This “digital doorway” has the great potential to influence many of the subsequent healthcare steps taken for what has been a historically challenging population to consistently engage and manage.

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Plus One – Flare Team Expands…

Investment partnerships make many decisions together – many are small and relatively inconsequently decisions while others are more profound and impactful. Together we will make dozens of investment decisions over the course of any given fund, but we will only make a few personnel decisions. So, with great anticipation, we are excited to announce that Sarah Sossong has joined Flare Capital Partners as a Principal.

For nearly two decades, Sarah has been in the middle of the transformation of healthcare, most recently as the Senior Director for the Center of Telehealth at Massachusetts General Hospital for the past six years, where she was in middle of launching several novel care delivery solutions. Previously, Sarah was managing a wide range of innovative healthcare technology projects at Kaiser Permanente for seven years. But it does not stop there: she is also super smart having graduated from Princeton University magna cum laude and then earning a master’s degree in health policy and management at the University of California at Berkeley. An amazing combination of practical work experience and academic research.

The privileged position in the venture capital industry is one of thought leadership. We want great entrepreneurs to look for us as hard as we are looking for them. Great investors provide important insights for entrepreneurs about product development roadmaps and where markets are heading, in addition to all the other roles – help recruit great executives, identify important early customers, engage other investors. Sarah’s industry breadth will push our thinking on where these markets are heading. Her depth of understanding of the emerging new business models and novel technologies that are coming to market is exceptional. She will be a lightning rod for great people and great ideas.

Please welcome Sarah to the team…

And a quick update on our Flare Scholar program which has continued to expand in exciting ways. To date, we have 65 current and former Scholars who are young healthcare technology executives and academics from across the country, all passionate about the transformation of the business of healthcare. Many of our Scholars are from our strategic investors while others are studying at leading graduate schools around the country and overseas. Serving as our “ambassadors” back on their home turfs, the Scholars assist with diligence but also identify emerging talent who may want to work in many of our portfolio companies or launch the next great start-up. Notably, five of our Scholars have joined portfolio companies in important roles and our Senior Associate, Vic Lanio, was in the great Flare Scholar Class of 2016.

Stay tuned as we continue to expand the Flare posse…

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A Pharmacist Working His Magic…

A staggering $453 billion will be spent on pharmaceutical products in 2018 in the United States per Statista analyst estimates. Ten years ago, that amount was $291 billion. With 326 million Americans, that is nearly $1,400 per capita. Into this marketplace enters Aspen Health, our most recent “semi-stealth” investment which is focused on enabling pharmacists to practice to their fullest potential.

Much has been made about the devastating opioid crisis, and appropriately so. What has come to light in this current raging debate has been greater scrutiny of the various pharmaceutical distribution channels and whether the role of the pharmacist can be expanded to play a more meaningful patient-centric role. The increased complexity of the mix of therapeutics as increasingly more of them move to biologics and specialty drugs (now 42% of pharma revenues) necessitates the need for competent clinical pharmacy practices.

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Aspen Health is founded by David Medvedeff, who has an unrivaled background in the pharmacy field, having received numerous industry awards and led many of the relevant trade associations, in addition to having started multiple successful companies. David exemplifies the profile so many of the Flare Capital CEOs embody which is a profound industry depth, giving them a set of product / market insights that allow them to see around corners. Success in the healthcare technology sector is absolutely driven by CEOs who understand the “voice-of-the-customer” better than anyone else.

Another critical element of this investment, and a common occurrence in the Flare Capital portfolio, is that our co-investor is one of our strategic LPs in the fund. In the healthcare technology sector, having strategics as early stage investors can be very powerful and drive important early product revenue.

According to the Bureau of Labor Statistics and the Occupational Outlook Handbook, there are 312,500 pharmacists in the United States. This is expected to grow by more than 6% per year through 2026, driven in large measure by the rapid opening of pharmacist schools in the last decade. There are over 130 accredited pharmacist colleges in the country, graduating nearly 15,000 each year. Arguably there are now too many pharmacists entering the field. In 2017, annual compensation was $124,000 and anecdotally, new graduates are being offered starting salaries less than $100,000, causing many of them to look for other platforms to practice. The road to becoming a pharmacist is hard: four years of college, followed by four years to earn a doctorate, and then at least one to two years of residency (not counting another one to three years to receive a fellowship). And all of that just to walk into a haymaker as salaries are dropping precipitously.

Over 65% of pharmacists operate in the retail setting, while 22% are in hospitals and the balance in supply chain or on-line organizations. The acceleration into value-based contracting and supply agreements, increasingly dependent on a depth of robust data sets, underscores the complexity now in the field. The aging population and more treatments being sent directly to the home exacerbate the need for high quality, consistent pharmacy practices. Complex therapies are at risk of overwhelming the community retail pharmacist. A more dynamic and coordinated pharmacist network will help bridge gaps in care. David’s insights revolve around how best to leverage the pharmacist in this rapidly changing marketplace.

 

pharmacy

 

The goals to improve patient compliance, reduce medication errors and improve chronic care management are only more pressing now. Improved interoperability and more coordinated care networks allows the pharmacist to better “plug in” and serve as a cornerstone of the patient’s extended care team. And as is well-understood by all, the pharmacist continues to be the first line of contact with patients. Making that capability “always on” and of high quality is essential.

Over 130 years ago, two other pharmacists changed the world. In 1885, the young pharmacist Charles Alderton brewed Dr. Pepper in Waco, TX to drive foot traffic to his counter. One year later, John Pemberton, who was wounded in the Civil War, concocted Coca Cola in Columbus, GA as a substitute for his morphine habit. Flare Capital is excited to partner with David and the Aspen Health team as they work their magic to build an equally important (and healthier) company.

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