Potential Next Steps – Where to Invest…

Emerging healthcare technology themes quickly reveal themselves at this time of year with the frenetic JP Morgan conference and the industry chatter leading up to the HIMMS (Healthcare Information and Management Systems Society) conference, which is in full swing in Orlando this week. It is also a time to reflect on some of the industry milestones from the prior year. All of this is made more complicated this year by the priorities of the new administration, which have yet to be clearly articulated.

It certainly appears that on the heels of the investor euphoria in 2014-2015, that the healthcare technology sector went through an appropriate period of assessment and consolidation in 2016. Now with the broader public equity markets setting new highs on a regular basis, the momentum from the movement to value-based care should endure with an even greater emphasis on de-regulation, price transparency and increased patient responsibility. Arguably, if V1.0 of the healthcare technology sector was triggered by the HITECH Act of 2009 (Health Information Technology for Economic and Clinical Health Act) which mandated the implementation of EMR infrastructure touching off the explosion of consumer digital health apps, the sector is now entering the V2.0 phase. Much of the commentary today is focused on “AI” (artificial intelligence) and “VR” (virtual reality) solutions to make the healthcare system “capital light” to drive meaningful operating efficiencies from the significant investment of the past three years.

A cottage industry has been created since November 9, 2016 to predict the future regulatory framework for healthcare. If there is an emerging consensus, it tends to center around a handful of core themes. It certainly appears that burdensome federal ACA mandates are under fire which will lessen the role of the federal government while moving more power to the states (likely via block grants). Individual mandates and age band requirements that increase cost of coverage for the young and healthy are likely to end. Much of the Republican commentary seeks to correct what is not working such as leveling subsidies to avoid significant price increases, create greater consumer choice and to move away from narrow networks. And it is quite clear that there are several third-rail features which will not go away such as allowing for pre-existing conditions, allowing children until the age of 26 to stay on their parent’s plans, and retaining a set of consumer protections such as prohibition on annual and lifetime coverage limits.

By implication then, there are several exciting market opportunities that should develop over the next few years. Quite clearly value-based payment models will endure, such as MACRA (Medicare Access and CHIP Reauthorization Act) and MIPS (Merit-based Incentive Payment System) which were implemented in 2016 by CMS (Centers for Medicare & Medicaid Services) to reward providers for efficiency and quality. Products and service to assist the healthcare consumer will be important with wider adoption of HSAs, greater price transparency and other reward systems all underscore the industry embrace of “personalized” healthcare. Expect to see greater innovation in the Medicare Advantage marketplace with the increased convergence of health and wealth management. According to Fidelity Investments, the average 65-year old couple on Medicare will still spend approximately $260,000 during their remaining lives. Below summarizes certain in- and out-of-favor healthcare technology opportunities.

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In 2015 total healthcare costs per capita in the United States exceeded $10,000, a notable milestone. In aggregate, the cost of private health insurance, hospital care, physician and clinical services, and prescription drugs in 2015 increased 5.8% over 2014 levels to total $3.2 trillion. Across all sectors of healthcare, there was $12.5 billion of venture capital investment in 2016 according to Dow Jones VentureSource which was a decline of 25% from 2015, largely due to significant decline in biotech investments.

The healthcare technology sector continued to see robust investment activity. According to Rock Health, there were 296 venture financings although the amount of capital invested declined slightly to $4.2 billion from $4.6 billion in 2015. Interestingly, the average round size declined 8.0% in 2016 to $13.8 million. The stage of financing activity revealed another important dynamic in 2016 as just over 50% of all transactions were considered to be Seed or Series A financings. There was a marked increase in the percentage of Series B financings and importantly, nearly 15% of investments were bridge financings. Arguably, 2016 was the period of rationalization given the tremendous amount of investment activity in 2014 and 2015; companies in 2016 either hit their initial milestones and were able to raise a Series B round in 2016 or were less fortunate and were bridged to a more narrow set of endpoints, most likely to a sale. Monthly data provided by Fairmount Partners showed a notable and consistent deceleration in financing activity in 2H16 as well, perhaps tied to uncertainties stemming from the presidential election.

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Just three categories accounted more than $1 billion of overall financing activity in 2016: genomics and sequencing ($410 million), analytics and big data ($341 million), and wearables and bio-sensing ($312 million). The next three most activity categories included telemedicine, digital medical devices, and population health management, which underscores the diversity of products and services in the healthcare technology sector. This activity also highlights the V2.0 phenomenon the industry is now entering as more sophisticated solutions are being developed to drive actionable insights that will improve clinical care at lower costs.

This past year continued to see robust M&A activity in the healthcare technology sector as well. According to Fairmount Partners, there were 160 M&A transactions, which while slightly down from the 183 in 2015, was markedly greater in terms of disclosed transaction value – $16.0 billion versus $8.2 billion, respectively. The average revenue and EBITDA multiples paid in the disclosed transactions were 4.4x and 13.1x, respectively. A majority of these M&A transactions included companies selling solutions into the provider space.

The public markets were less forgiving in 4Q16, in large measure due to the regulatory uncertainty. After a very strong 3Q16, the Leerink Healthcare Technology/Services public stock index declined 9.3% this past quarter, ending the full year only slightly positive (up 1.7%), effectively surrendering the gains for the first nine months of 2016. The 4Q16 pain was limited to two specific categories in the index: PBMs/Distributors (down 18.7%) and Providers (down 17.2%). The Healthcare Technology and Brokers categories were both ahead more than 20% for the year, possibly indicating who the net winners and losers might be under TrumpCare.

As we head into healthcare technology V2.0 phase what might be expected over the course of 2017? With some fanfare, late in 2016 Rock Health shared the results of their recent consumer health survey that digital health had reached a “tipping point” as approximately half of all respondents had adopted at least three types of digital health products (which was up dramatically from the 19% in 2015). A majority of respondents wanted a copy of their medical records, 87% wanted to control who has access to their healthcare data, and 39% expressed strong willingness to pay health expenses out of pocket.

Recognizing that there are still another 28 million Americans uninsured, and the new regulatory framework is still a long way from being promulgated, the following are just a few possible developments that drive a number of our investment themes. Exciting start-ups are being launched to address these opportunities.

  • Transparency of provider networks will underscore the move to more consumer-centric purchasing behavior. New tools and services will be developed to facilitate the consumer assuming more financial ownership as to assessing both outcomes and quality (value)
  • More distributed healthcare delivery models will emerge to take advantage of new telehealth and multi-channel interactions. Provision and access to care will be made more affordable and convenient through the usage of passive and “always on” monitoring platforms and support systems. Traditional “bricks and mortar” providers will manage significantly more patients per square foot of real estate
  • Brands will become even more important
  • Advent of specialized clustered service offerings around certain chronic diseases (mental health, diabetes, end-of-life, fertility) will be bundled and branded
  • Personalized and precision medicines will continue to be developed along with better diagnostic tools (and regulators will struggle to catch up). This will transform everything from drug discovery processes to clinical decision support.
  • Continued convergence of the management of both health and wealth will bring financial institutions closer to the healthcare industry, with potentially some fascinating partnerships emerging
  • Technology companies will continue to develop broadly horizontal management platforms for consumers to manage health and wellness needs

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Engineering Mosquitos…

Perhaps it was the title of the panel (“Engineering Mosquitos to Fight Malaria”) right before I was to speak that caused me to feel that I was at the wrong event. Or maybe it was because I had just met several senior health ministers from across the developing world. The “Rethinking Malaria Leadership Forum” hosted last week at Harvard Business School brought together delegates from many different disciplines to explore emerging strategies to combat this awful disease.

Malaria wasn’t a disease that I had ever particularly focused on, even though as a child I had lived and traveled in parts of the world confronting this scourge, so I was passingly familiar with it. What little I knew about malaria suggested that some of the healthcare technologies proliferating today (telehealth, connected devices, analytics) might actually have an impact. But what a complicated situation.

Per World Health Organization estimates, there were 212 million malaria cases in 2015 which tragically resulted in 429k deaths – and some believe there may be another 60 million cases which go unreported. Staggering. Furthermore, it is believed that 3.2 billion people are susceptible to the disease – nearly half the world’s population. In 1955, the World Health Assembly launched the first coordinated global effort to eradicate the disease, and while there has been marked improvement over the ensuing decades, malaria is proving to be one of the most complex biological disease systems.

In 2000, there were 262 million cases and 839k fatalities, which had been nearly cut in half 15 years later. As is evident by the map below, there are now 91 countries battling malaria. Thirteen countries, mostly in sub-Saharan Africa, accounted for 75% of all cases. Quite clearly the regions most afflicted are arguably the least equipped to battle this disease. For instance, given the political instability and the failure of government, Venezuela now has more cases than all the other South American countries combined.

 

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In 2000, funding globally for prevention and treatment was estimated to be $200 million and is now running approximately $2.5 billion annually. It is estimated that the United States accounts for 35% of this amount. For many of last week’s participants at Harvard, the U.S. presidential election has now introduced yet another very disturbing risk to the global response to malaria – where does the U.S. stand going forward? Foreign aid the past few years has declined as attention was redirected to disease outbreaks such as Ebola and Zika.

Notably, while there are a handful of therapeutic treatments and effective antimalarial drugs, adequate diagnostic tools in the field are limited, leaving prevention as the approach that has had the most significant impact on lowering incidence levels. Insecticide-treated mosquito nets (known as “ITNs”) have a dramatic impact on transmission rates. Efficient distribution of ITNs require basic in-country logistic capabilities, which is often times the most challenging issue. This “last mile” of care delivery in territories ravaged by war and poverty are often non-existent. The heterogeneity of country responses demand a more coordinated strategy while respecting trans-boundary issues.

Vector control. What a fascinating framework to manage a disease, which in this case is to eradicate all mosquitos in an affected region. As was pointed out repeatedly, mosquitos have been around for 200 million years and are marvelously adaptive. There are more than 400 different species of mosquitos. The average life span for a male mosquito is between 1- 2 weeks and 6 – 8 weeks for females. In fact, in many countries mosquitos are exhibiting high levels of insecticide resistance, which is obviously very troublesome. Going after mosquitos does not even address the underlying cause of the disease which is the parasitic protozoa that are carried by mosquitos (so disease eradication is premised on wiping out the “messenger”).

For such a disease, healthcare technologies potentially serve as a great democratizing force for access to quality care delivery. Most of the health ministers and foundations who participated at this forum had significant experience with sophisticated predictive models. Of course, such tools, while potentially very powerful, are dependent on credible and timely data from the field. In addition to better data capture and reporting, the promise of greater penetration of cellular infrastructure, low-cost sensors and connected devices like digital thermometers offer potentially more effective management of distributed populations and “care-at-a-distance” models. For example, the Malaria Elimination Initiative at the University of California, San Francisco has developed evidence-based solutions by country and in so doing has built a very sophisticated malaria map.

Another interesting map was created by NASA using “gridded population data” which slices the globe into 28 million cells (each cell is approximately 3 x 3 miles). The yellow regions below are comprised of cells with more than 8,000 people each which equates to nearly 900 people per square mile (or about what we see in the Commonwealth of Massachusetts – which to be clear is a blue state, not a yellow state). When superimposing the two maps, one initial reaction is that malaria does not necessarily correlate to areas of high population densities.

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As the health ministers from Namibia and Kenya pointed out several times to me, public health is often viewed as an unattractive career for many of their brightest minds, and yet initiatives around increasing awareness through robust community activities, delivering ITNs, and indoor spraying programs have shown outsized impact. Many of the forum participants were looking to pharma to discover and make available break through therapeutics and/or sophisticated genetic tools to modify mosquitos – undoubtedly essential and promising advances. Others seemed to be searching for low cost surveillance technologies. Others struggled with how to architect appropriate funding schemes to support public health initiatives and build local innovation ecosystems.

Harder to satisfy was the desire for competent and effective government in many of these countries that would marshal the resources to eradicate such a devastating disease.

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Whoa Nelly – A Pullback on the Reins…

Maybe you thought that the investment pace was going to slow even faster than it did in this past quarter, which dropped nearly 20% when compared to 3Q16? Per the National Venture Capital Association, in partnership with PitchBook, 4Q16 marked the sixth consecutive quarterly decline in deal volume. What is perhaps more surprising was that the $12.7 billion invested last quarter was the lowest quarterly amount since the end of 2013.

Arguably this retrenchment reflects concerns about valuation levels and the lack of “unicorn liquidity” as many later stage companies stayed private and/or struggled, and crossover investors backed away from new commitments. In 2016, of the 111 IPOs, only 37 were venture-backed companies. The average offering size was only $71 million. Notwithstanding unprecedented public consternation surrounding the election, the public markets experienced rather modest volatility; in fact, the VIX (the CBOE Volatility Index) languished in the mid-teens for much of this past quarter while hovering in the mid-20’s over the summer, post-Brexit.

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With near historic low levels of unemployment and quite compelling GDP growth, the tightening monetary policy positions of the new administration suggest that bond yields will increase in the face of modestly higher inflation. GDP growth for 3Q16 was just revised upward again to 3.5% and the whisper estimates for 4Q16 suggest growth this past quarter was around 3.0%. All of this makes the marked slowdown in venture investing at the end of 2016 even more confounding, which was quite pronounced in some important sectors such as consumer service (40% decline in dollars invested) and e-commerce (62% decline). Alongside a handful of notable company struggles, the trouble with some high profile late stage companies seems to have rippled back to the early stage marketplace.

But by no means is it all doom and gloom on the investment front. For the entire year $69.1 billion was invested in over 8,100 deals and venture firms raised $42 billion. The median round size for early stage financings was $5.3 million last year versus $4.5 million in 2015, while later stage rounds stayed essentially flat at $10 million in size. It does appear, though, that much of the end of year pull-back in deal activity was seen in the sub-$5 million round size; in 2014 there were over 3,500 such deals while last year there were only 2,350 deals. Other highlights include:

  • For 2016, $33 billion was invested in 3,100 software companies, which continued to be the largest industry category and is nearly 4x in dollars invested as the next largest category, pharma and biotech ($7.8 billion and 515 deals, respectively)
  • Healthcare services and systems attracted $3.3 billion across 488 deals
  • The top ten financings in 4Q16 totaled $1.4 billion or in other words, 11% of invested capital went to 0.6% of the 1,744 companies which raised capital
  • Of the 8,136 deals in 2016, 29% were first round financings totaling $6.6 billion, which implies that nearly 90% of the total venture capital invested last year ($69 billion) was for follow-on rounds
  • Over $30 billion (or 44%) of the total investments in 2016 involved a strategic investor in the syndicate which underscored the important role corporates play in the venture capital industry (both as direct investors and LPs in venture funds). Notably in just 4Q16, corporate participation was just under 30%, perhaps signaling a “corporate pull-back”
  • Not surprisingly, corporate investors tend to invest later; 69% of their participation was in deals greater than $5 million in size
  • Just over 40% of last year’s investment activity was considered growth equity which is down from 46% in 2015
  • As point of reference, overall private equity investors closed on 3,538 transactions with a total value of $649 billion – VCs were just less than 10% of all private equity activity last year
  • 14 states had three or fewer venture financings in 4Q16, signaling that the VC model remains concentrated in a limited number of geographies

At its essence, investor confidence to make new commitments stems from perspectives about the exit environment and prospects for meaningful liquidity; the news here is less compelling – and getting worse. The weakness in IPO activity has been well chronicled (although, according to Renaissance Capital, if one had purchased a basket of all the 2016 tech IPOs, the return would have been 39.8% which is 5x better than the NASDAQ’s performance). In total, the 111 IPOs in 2016 raised $24.2 billion which was the lowest amount since 2003 and 33% below 2015 levels. Of the $46.8 billion in M&A activity for the 726 venture-backed companies sold in 2016, the median transaction value was $90 million which compares quite unfavorably to the median pre-money valuation of the growth equity rounds in 2016 of $141 million – that kind of stings. As a point of comparison, there were 1,040 M&A venture-backed exits in 2014 for a total value of $82 billion.

According to PitchBook, there were 3,538 private equity transactions in 2016 with a total value of $649 billion. This was a modest decline of 12% and 14% from 2015, respectively. Interestingly, the technology sector was nearly 25% of the total value and a high-water mark over the last 15 years.

There is another important emerging theme at play here, which is the increasing privatization of equity ownership. At the mid-point of 2016 there were 5,734 public companies in the US, which was approximately the same number as 1982 when the economy was roughly half the size. In 1997 there were 9,113 public companies. Clearly the stepped-up roles of private equity firms and sovereign wealth funds are contributing to this development. As shown below, the amount of capital held by those investors has increased nearly 5x over the last dozen years.

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One of the implications of this increase in the number and size of the private pools of capital is the amount of the “capital overhang” sitting on the sidelines, waiting to be invested. Cambridge Associates has calculated that there is approximately $450 billion of capital which has been raised but has yet to be invested.

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Globally, fund managers raised $602 billion of private capital across 1,228 funds according to Preqin Ltd, which are both modestly down from the 2015 levels of $637 billion and 1,486 funds, respectively. More specifically, venture capitalists for the year raised $41.6 billion over 253 funds; 50 funds closed on $7.3 billion in 4Q16 – the lowest quarterly total since 3Q15. Recent fundraising softness may, in part, be attributed to short-term VC benchmark performance. According to Cambridge Associates, the VC Index recently has trailed the Dow Jones US Small Cap Index – 3.3% vs 6.7%, 1.1% vs 10.7% and 3.4% vs 12.4% for 3Q16, year-to-date and prior one year, respectively. Other interesting elements that emerged in the 4Q16 fundraising data include

  • The top ten funds in 4Q16 totaled $4.7 billion or 64% of total capital yet were just 20% of the number of funds
  • Across all of 2016 there were seven funds raised which were larger than $1 billion in size
  • Per PitchBook the median fund size in 2016 was $75 million versus $40 million for 2015, reflecting the prevalence of $1.0+ billion funds
  • There were 22 “first time” funds launched in 2016 which raised $2.2 billion which was 9% and 5% of the totals, respectively, further highlighting the bifurcation of the venture industry between large and small focused firms

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And in other parts of the world, the venture model continues to scale in important markets. For instance, in China there was $31 billion invested domestically in 2016, even though the number of deals declined by 42% according to KPMG. China was approximately 25% of global venture activity. Ominously, though, China’s debt to GDP which was 131% in 2008 and spiked to 235% in 2015, is projected by many analysts to increase to nearly 350% by 2020. In Israel, VC’s raised $1.4 billion in 23 new funds, which was 7% ahead of 2015 levels and is estimated to be $1.6 billion in 2017.

 

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Israel – Such a Complicated Corner of the World…

As I reflect on a head-spinning five days in Israel last week, it struck me that for all that is going on around that country, people seem remarkably poised and operate with such grace. Next to the lead article in The Jerusalem Post about the delivery of two F-35 jet fighters (which was very big news, maybe in part because they were six hours delayed due to fog – really?) was an article discussing the Health Minister’s announcement imploring the public to refrain from eating donuts during Hanukkah because “there is no need for us to fatten our children.”

The phenomenon of the “Start-up Nation” is well-chronicled now, which does not make it any less impressive whenever witnessed firsthand. Since 2012, it is estimated that there are approximately 1,100 start-ups created each year; on average, over the last four years nearly $4.4 billion of venture capital was invested in Israel. In 2015 there was $148 billion venture capital invested globally which means that Israeli entrepreneurs captured 3.0% of the total dollars; this for a country of 8.6 million people which is only 0.12% of the world’s total population of 7.4 billion. Civilian R&D is 4.3% of Israeli GDP. According to the Mr. Avi Hasson, the Chief Scientist of Israel, he has closed more than 70 bilateral R&D agreements worldwide. He also shared that 21% of the population is Israeli Arab and that he is committed to improving upon the fact that they only account for 3% of all Israeli IT jobs.

There were two other announcements last week that were striking and frankly quite unexpected, and underscored how impressive the progress is despite profoundly challenging structural issues. More than 2.4 million (or 29%) Israelis live below the poverty line per the 2016 Alternative Poverty Report. Separately, but arguably related, the Organization for Economic Cooperation and Development (OECD) announced the same day that Israel has a poor record fostering non-tech small and medium-sized enterprises (SMEs), which account for a surprisingly 99.8% of all companies in Israel. The OECD noted that Israel has the largest share of early-stage venture capital funds as a percent of GDP of any country, and other than Korea, invests at one of the highest R&D rates globally. Importantly, the OECD also observed that the lack of government financial incentives and training programs account for the disappointing labor productivity in the non-tech sector.

The Israeli tech sector is unrivalled. Specific areas of expertise include healthcare technology and cybersecurity, and both reflect the needs and challenges of this part of the world. Two healthcare announcements last week were notable. Tel Aviv University’s School of Psychological Sciences published fascinating research supporting important advances with virtual reality technologies in the field of physical rehabilitation. A few days before that, the University of Haifa released two studies that supported the calming power of work and sticking to a routine. Given the painful geopolitical issues surrounding Israel, the phrase “necessity is the mother of invention” never seemed more appropriate.

Notably, The Jerusalem Post also ran an editorial last week bemoaning the fact that Israeli school children chronically rank quite low on standardized testing when compared to other OECD countries (ranking 16th and 19th in mathematics and sciences, respectively). The piece goes on to attribute this phenomenon to two fundamental issues, both of which are controversial: low quality of teachers and number of disadvantaged Israeli Arabs. Like many other parts of the world, issues of societal bifurcation play out in painful and unfortunate ways.

A week later, I am most struck though by the overwhelming geopolitical complexities. Tel Aviv is only 132 miles from Damascus (Boston is the same distance to New Haven, well before you even get to New York City). Aleppo is 314 miles away. This is a very tough neighborhood, arguably made even more complicated by the recent naming of the US Envoy to Israel who has publicly disavowed the two-state solution. Every day the newspapers ran heart-wrenching stories about the devastation unfolding on every one of its borders. Good thing that the extraordinary work being done in the Israeli tech sector can be calming.

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Life Expectancy Gradient…Role of Healthcare Technology

It is readily accepted that social determinants and education levels directly influence life expectancy gradients; that is, the central issue to well-being is not simply poverty but more fundamentally an issue of inequality. The profound promise of technology in healthcare is its role as the great democratizing force across all strata of society by improving access, engagement, care coordination and outcomes at lower costs. The journal Health Affairs published an important study this summer which showed that more healthcare dollars are spent in affluent neighborhoods even though the medical needs tend to be greatest in poorer communities. Evidence suggests that members of these communities forgo healthcare at higher rates due to issues of access and economic consequences associated with the “consumerization” of healthcare (i.e., high deductible plans, cost shifting, etc.).

Worldwide life expectancy improved from 26 years in 1820 to 31 years in 1900 to 49 years in 1950 to 79 years by 2010. Obviously, the accelerated rate of change over the last fifty years was largely due to advances in our understanding of biological pathways and innovative new medical technologies. Arguably, we are now on the threshold of another step function of improvements with innovative new care delivery models coupled with precision, more tailored medicines, which are supported by “value-based” payment models. Healthcare technology’s promise today is to both extend the curve below to the right as well as meaningfully increase the “area under the curve” with dramatically improved health status.

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 A worrying societal development is the “senior boom” which can only be addressed by advances in healthcare technology. When Medicare was established in 1965, there were 5.4 Americans between the ages of 20 – 64 years for every American over 65. This year that ratio has decreased to 4-to-1, and now the Congressional Budget Office is warning that in 30 years that relationship will be 2.6-to-1. Compounding this situation is the burden of U.S. Treasury debt on society. In 1999, it was 38% of U.S. GDP and analysts estimate that level today to be 76% of GDP and an unimaginable 141% in 30 years from now. As a result, investments in healthcare technology have become an absolute imperative.

Just over the last five years, healthcare technology spend on a per physician basis increased nearly 50% from approximately $23k in 2010 to $33k in 2015, according to the Medical Group Management Association, underscoring data’s role in optimizing outcomes. The promise of better matching patient to provider, or patient to therapy, is real and Artificial Intelligence (AI) will play a powerful role as computer neural networks develop to optimize the human-to-data interface. This last observation is fundamental to many of our portfolio companies as entrepreneurs seek to utilize rigid clinical data captured in patient-based systems made actionable with more informed, appropriate and predictive decisions.

As the complexity of the “business of healthcare” accelerated over the past 30 years, new technologies were developed to manage the escalating administrative burdens. In 1980 over $27 billion was incurred in administrative and insurance-related costs; that number in 2012 was $413 billion. An explosion of innovative tools and services have been developed to manage those expenses. Compounding this situation is regulatory reform which has introduced new financial and operating risks into the delivery system that must be assessed, underwritten and then managed.

According to StartUp Health, in 3Q16 global digital health investment activity (including partnership and joint venture activity) totaled $2.4 billion and year-to-date nearly $6.5 billion has been invested in 394 companies. This level of activity continues the pace set during 2014 and 2015. The three most significant sub-categories in the healthcare technology sector this year are Patient/Consumer Experience ($2.5 billion invested year-to-date), Wellness ($918 million) and Personalized Health/Quantified Self ($634 million).

Public investor enthusiasm was equally robust this past quarter. The Leerink Healthcare Technology and Services index of 33 publicly traded stocks increased 7.9% in 3Q16 and 11% year-to-date. Leerink estimates that aggregate revenue growth for these companies will be 19.6% in 2016 and 14.7% in 2017, which accounts for average valuation multiples of 13.7x and 13.0x for 2016 and 2017 EBITDA estimates, respectively. In a period where broader publicly stock indices have advanced modestly (S&P 500 is up 4.8% year-to-date), the healthcare technology sector has been embraced. Having said that, it is worth noting that this is the final year for Meaningful Use payments which likely introduces some uncertainty for some healthcare technology vendors.

While still in excess of $200 billion, global healthcare M&A activity is off more than 50% year-to-date when compared to 2015 volumes, much of this due to Department of Justice delayed reviews of the large pending insurance mergers. Overall M&A activity across all sectors is down more than 20% to put that in some perspective. Specific healthcare technology M&A consolidation themes that emerged this past quarter generally centered on consumerism/patient engagement, telemedicine/remote monitoring, data-driven devices and strengthened infrastructure offerings.

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Pins and Needles…3Q VC Data

Given the obvious anxiety and frustration that surrounds us all, the US venture industry is also exhibiting some fatigue as we finish the 88th month since the last recession. This is the fourth-longest period of economic growth in US history (admittedly, at 2.1%, the growth over this period of time is the slowest since World War II). According to the National Venture Capital Association, this past quarter $15 billion was invested in 1,810 deals which compares unfavorably to both the prior quarter ($22.1 billion, 2,034) and 3Q15 ($21.1 billion, 2,559), signaling perhaps a period of digestion given how much had been invested during 2014 – 2015 window. Notably, this was the lowest quarterly deal volume since 4Q11, a period spanning 19 quarters.

What is most interesting is the activity beneath the headline data. Year-to-date annualized investment activity suggests that 2016 will see approximately $74 billion invested in just under 8,000 companies, which would still make it the second most active year in the past decade, although with a marked deceleration. The amount invested is consistent with what was deployed in each of the last few years, but the median round size across each stage of financing has increased significantly as the level of deal activity has declined. For instance, early stage round sizes are tracking to be nearly $5.5 million this year versus $3.0 million in 2013. Just in the past six quarters, seed stage investing activity has declined dramatically: in 2Q15, there were 1,547 seed deals as compared to 898 this past quarter. As a percent of overall activity, seed investing dropped from 55% in 3Q15 to 50% in 3Q16.

The direct implication of larger round sizes is to provide companies with greater runway but this flies in the face of the capital efficiency mantra, something venture capitalists shouted from mountain tops when we were in a more challenging fundraising environment. In the early stage category, nearly 54% of deals in 2016 were greater than $5 million in size, which compares to 32% of investments right on the heels of the Great Recession in 2010. Have investors drifted, becoming less dogmatic about hitting interim milestones with as little capital as possible?

One of the emerging story lines in the back half of 2016 is the pullback of late stage “unicorn” financings – only eight new “unicorns” were created this past quarter. In 3Q16 the top ten largest venture financings in aggregate raised $2.1 billion which represented 14% of overall activity. In the prior quarter that number was 40%. The largest round in 3Q16 was $474 million, raised by a Boston-based biotech company called Moderna. Notably only three of the top ten companies were software companies, which over the past few years has been the category that represented so many of the “unicorns.”

The data also risk masking a number of other important emerging themes when considered in the aggregate, so here are a couple of other nuggets to consider:

  • The broader software category captured $27 billion to date in 2016 or nearly 50% of all dollars invested; biotech was second with $6.3 billion invested or 11% of capital
  • Through 3Q16 the 357 healthcare technology sector deals raised $2.6 billion which was 6% of the overall activity
  • Average round size for healthcare technology is $7.4 million which is meaningfully below the $9.3 million for all categories
  • The number of late stage deals (355) in 3Q16 has dropped materially from 3Q15 (429) and is down 36% from the high water mark set in 2Q14 (555), reflecting a steady decline in large mezzanine rounds
  • Just over 13% of all financings to date in 2016 included a corporate venture investor; the corporates greatest impact in 3Q16 was felt in the late stage rounds where those investors participated in 23% of those financings versus only 5% of all seed rounds
  • A dozen states had less than 3 companies venture-financed in 3Q16, underscoring the continued concentration of capital in a handful of markets

In general, investment activity is bolstered by investor confidence that a predictable exit environment will continue. In 3Q16 there were 162 venture-backed exits which generated $14.6 billion of value, coincidentally an amount just below how much was invested that quarter. The top five M&A transactions accounted for just about 50% of that value. Notwithstanding the underwhelming IPO market – year-to-date there have only been 32 IPOs with average proceeds of $67 million – the annualized exit activity suggests that there will be in excess of $50 billion of exit value created. The greatest level of exit activity over the past decade was in 2014 with nearly $82 billion of activity; the annual average for the last ten years is $39 billion.

Liquidity feeds right into the fundraising conditions for venture fund managers. This past quarter there were 56 new funds which raised $9.0 billion for an average fund size of $161 million. This is significantly greater than the $77 million average fund size in 3Q15. This fundraising pace is somewhat less than the prior three quarters but meaningfully ahead of 3Q15 which saw only $4.1 billion raised by venture capitalists. Interestingly, the top ten funds closed on $6.1 billion or 68% of all capital raised, indicating a further concentration of investment managers; in the prior quarter 62% was raised by the top ten funds. Just over 40% of funds raised this past quarter were less than $50 million in size.

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The projected $43.2 billion raised in 2016 is on pace to be the strongest year since the early 2000’s. Notwithstanding this robust pace, the “funding gap” persists, strongly suggesting that non-VC’s are continuing to invest aggressively in start-ups. According to the recent Preqin Quarterly Update (3Q16), in a survey of active institutional investors in private equity, 71% expressed a “positive” perception of the asset class while 56% expected to increase their allocations to private equity (and of those, 59% planned to do so before year-end).

The other closely watched quarterly report is produced by Cambridge Associates, which recently released its Venture Capital Index and Benchmark Statistics with data as of June 30, 2016. While year-to-date 2016 performance has trailed other public indices, the Venture Capital Index consistently and meaningfully outperforms over longer periods of time. The 3-Year, 5-Year and 10-Year venture returns were 19.2%, 13.6% and 10.4%, accordingly, while the S&P 500 Index was 11.7%, 12.1% and 7.4%, respectively.

So where does that leave us as we enter the final quarter of 2016? The elephant (and donkey) in the room is the US elections, clearly. Interestingly, this past quarter the European venture capital investment pace fell by 32% in the wake of Brexit and was 39% lower than the same period in 2015, according to Dow Jones VentureSource. Isolating just the United Kingdom, the news is even more disturbing: U.K. venture firms invested only $58 million in 3Q16 versus $282 million in 2Q16 and $656 million in 3Q15 – that is what running into a wall looks like, a huuuge wall.

Here are a couple of other noteworthy developments that add to the economic commentary for 3Q16:

  • There is another group of “unicorns” out there – the human ones – the billionaires. Total wealth held globally by all 1,397 billionaires fell by $300 billion to $5.1 trillion since 2014, mostly as a result of commodity price deflation and drop in the value of technology and finance holdings, according to a report jointly published by UBS and PricewaterhouseCoopers. Family Offices are an important class of Limited Partners.
  • In the midst of unprecedented global turmoil, Saudi Arabia just raised $17.5 billion in the largest sovereign bond issuance ever; there was $67 billion of demand, making it nearly 4x over-subscribed. Why is this important? Let me count the ways: institutional investors seeking greater returns, the transition of an oil economy to a more diversified one (recall Saudi Arabia also announced the goal to create a $100 billion (with a “b”) tech fund with Softbank), strength of global capital flows, investor rotation to emerging markets.
  • Slowing growth in China compounded by extraordinary levels of debt and inflated real estate values have set off flashing yellow lights in many corners of the global capital markets. It is quite clear that credit growth is still faster than nominal GDP growth in China, and that often does not end well. Analysts estimate that the local housing sector is singularly responsible for nearly half of all investment in China today.

As complicated as the world now appears, the financing of innovation remains attractive and compelling, drawing in both investors and great entrepreneurs, hopefully making many of these issues background noise.

 

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Our Newest Seed Has the Coolest Name…

Venture investors have the great honor of backing some of the most talented, passionate people in the world, all trying to solve really big problems. And sometimes, their companies also have really cool names. Last week we hit the trifecta – we backed a brilliant team going after a big problem with a cool company name – Circulation.

This is my third time working with Robin Heffernan, a twice successful entrepreneur with a PhD in Chemical Engineering from Harvard. Robin worked with me as a venture capitalist at my prior firm years ago and then was one of the first employees of an exciting portfolio company of ours (which she was instrumental in sourcing). Third time is a charm – it is a great privilege to work with her again as she scales Circulation with John Brownstein, her co-founder, who is the Chief Innovation Officer at Boston Children’s Hospital and Professor at Harvard Medical School; notably, he is also the Uber Healthcare Advisor – very relevant to the Circulation story. Additionally, I happen to serve on John’s advisory board at the Hospital. Together, those two successfully bootstrapped and sold their last company, Epidemico. Circulation is also very fortunate to have as a founding partner, Klick Health, the leading digital health agency.

Turns out non-emergency medical transport (“NEMT”) services is a significant industry, with nearly $6 billion spent annually on rides to and from hospitals and for clinical trials. Utilizing its preferred partnership with Uber to access its API’s, Circulation has built a transportation exchange whereby providers, payers and companies running clinical trials can provide comprehensive transportation offerings for patients through a central care coordination platform, which basically doesn’t exist today. As providers and payers embrace “value-based” business models, there is growing demand for lower cost, more reliable NEMT services to reduce “no show” rates and to improve patient discharge processes. There are more than 3.6 million patients who miss appointments each year, much of that is due to inadequate access to reliable or appropriate transportation.

Consistent with our fund’s focus on the “business of healthcare,” seemingly mundane issues around transportation have outsized impact on care delivery models. Analysts estimate that for every missed appointment, the provider has lost nearly $150 in revenue. The ability to get patients at the time of discharge out of the hospital quickly frees up beds that can be used for new patients, say nothing of the improved satisfaction scores recorded by those patients.

And the beauty of having Uber as a strategic partner, most everyone is now comfortable with consumer ride-hailing services, with no hesitation about getting in the back seat of a stranger’s car. Obviously there is considerable sophistication in the Circulation platform (HIPAA-compliant, checks rider eligibility, driver training, ride authorization, etc.) versus simply hailing a taxi, using paper vouchers. And care coordinators embrace the level of insights from now being able to manage holistically all transportation costs while creating a detailed audit trail.

Also consistent with our investment strategy is our seed program. We expect that a number of the core holdings in this fund will be derived through our aggressive seed investment program, affectionately called “Flare Ignite” (branding cred goes to my partner’s wife, Kristi Geary) As we did with our Executive Partner, Bob Sheehy in our Bright Health investment last year, Flare is excited to seed exceptional founders addressing enormous market needs. We set a relatively high bar for our seeds as we treat each of them as core holdings, committing all of the firm’s resources even though we may have initially invested only a modest amount of capital.

And not all of the Flare Ignite seeds need to have really cool names…

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