We all know the U.S. health care system is bad. But why hasn’t any business come in and fixed it? The market is massive, inefficient, and extremely wasteful. Some estimates suggest wasteful spending accounts for between $760 billion and $935 billion annually, from a combination of unnecessary administrative costs, fraud, over-treatment, poor care coordination, and other factors. It’s an industry ripe for disruption. The challenges created by Covid-19 have added new urgency around fixing the health care system, and will likely inspire a new wave of health tech entrepreneurs. But as someone who has extensively researched health care startups and worked with health care entrepreneurs over the last few years, I have noticed a pattern of challenges that entrepreneurs tend to face as they build health tech companies and try to take on the industry. Here are some of the key issues that make health care particularly tricky to disrupt:

我们都知道，美国的医疗体系是坏的。 但是，为什么没有任何业务进入并进行修复？ 市场巨大，效率低下，而且非常浪费。 一些估计表明，由于不必要的行政成本，欺诈，过度治疗，护理协调不善和其他因素的综合影响，每年浪费的支出约占7600亿美元至9350亿美元。 这是一个颠覆行业的成熟时机。 Covid-19提出的挑战增加了修复医疗保健系统的紧迫性，并可能激发新一波的医疗技术企业家。 但是，作为过去几年中对医疗保健初创公司进行了广泛研究并与医疗保健企业家合作的人，我注意到企业家在建立医疗技术公司并试图接管该行业时往往会面临的挑战。 以下是使医疗保健难以解决的一些关键问题：

修复医疗保健的最大障碍 (The big obstacles to fixing health care)

First, there’s the principal-agent problem, in which the buyer and the user of a good or service are not the same person. For example, most people are on a health insurance plan chosen by their employer. Even though you’re the user, the insurance carrier is selling to your employer, and employers tend to be most concerned about cost. User experience, product simplicity, and other features are a non-priority. Most buyers in health care would rather renew or buy the safest option — they don’t get bonus points for trying a new startup but will get fired if they go with a new startup that fails.

首先，存在委托代理问题 ，其中商品或服务的购买者与用户不是同一个人。 例如，大多数人都在其雇主选择的健康保险计划中。 即使您是用户，保险公司还是在向您的雇主出售产品，而雇主往往最担心成本。 用户体验，产品简便性和其他功能不是优先事项。 大多数医疗保健购买者宁愿续签或购买最安全的选择-他们尝试新成立的公司不会获得加分，但是如果他们选择失败的新公司会被解雇。

Second, our health care system has evolved to favor customized solutions instead of standardized ones. Each insurer negotiates a different rate for each service at each hospital. Health benefits consultants sell custom benefits packages to each employer. Each hospital uses its own kind of electronic medical record. This lack of standardization makes it extremely hard to scale a health care business because you now need to work around a custom process for each customer, and they expect that level of personalization from their service providers.

其次，我们的医疗保健系统已经发展为偏向于定制解决方案，而不是标准化解决方案。 每个保险公司针对每个医院的每种服务协商不同的费率。 健康福利顾问向每个雇主出售定制福利包。 每个医院都使用自己的电子病历。 由于缺乏标准化，因此很难扩展医疗保健业务，因为您现在需要围绕每个客户制定自定义流程，他们希望他们的服务提供商提供这种个性化水平。

Third, health care feedback loops are really long. This makes it difficult to know if your service is working as intended while you wait for feedback, or if in the end it was your service that made the difference. How do you really know it was your therapy solution that helped a patient recover, when it could have been any number of other factors?

第三， 医疗保健反馈循环确实很长。 这使得您很难在等待反馈时就知道您的服务是否按预期工作，或者最终是否是您的服务才有所作为。 当可能是其他许多因素影响时，您如何真正知道是您的治疗解决方案帮助患者康复了？

Fourth, there’s the employer-insurance entanglement. One of the uniquely terrible things about U.S. health care is that employers get tax-benefitted dollars to pay for health insurance that individuals don’t. This effectively means health insurance is tied to employment, and you switch health plans any time you move or change jobs. Because of that, your insurer has no incentive to keep you healthy long term or give you a great user experience to keep you on their plan, since they know you’re eventually going to switch anyway.

第四， 存在雇主与保险的纠缠。 关于美国医疗保健的唯一可怕的事情之一是，雇主获得了税收优惠的美元来支付个人没有的医疗保险。 这实际上意味着健康保险与就业相关，并且您在移动或更换工作时都可以更改健康计划。 因此，您的保险公司没有动力让您长期健康，也无法给您带来出色的用户体验以使您按计划行事，因为他们知道您最终还是会做出选择。

And finally, there’s a huge challenge of getting your first customer. How can you find customers to demonstrate your solution works when no one wants to be the first to try it? Most health care entities want to see some proof before buying. Some companies enter pilot initiatives with hospitals or insurers, but in many cases those are destined to fail as they lack real internal buy-in or resources. There’s a graveyard full of “death by pilot” startups like HomeHero or Healthrageous, where the first customer was used as a case study but didn’t convert into a longer-term relationship.

最后， 要获得第一个客户还面临着巨大的挑战。 当没人想成为第一个尝试该解决方案的人时，您如何找到客户来证明您的解决方案有效？ 大多数医疗保健实体都希望在购买前看到一些证据。 一些公司与医院或保险公司签订了试点计划，但在许多情况下，由于缺乏真正的内部支持或资源，这些计划注定会失败。 有一个墓地到处都是HomeHero或Healthrageous 这样的“飞行员死亡”初创公司，在那里，第一个客户被用作案例研究，但并没有转化为长期的关系。

People new to the business of health care tend to encounter these problems through what I call the “six stages of health tech grief” (my play on Gartner’s Hype Cycle, which illustrates the adoption of new technologies). These are the six stages that many new health startups hit as they try to take on the health care system.

P eople新的医疗保健业务往往遇到过我所说的(我玩“健康科技悲伤的六个阶段”这些问题Gartner的炒作周期 ，这说明了采用新技术)。 这是许多新的医疗保健初创公司在尝试采用医疗保健系统时遇到的六个阶段。

'我们应该付钱给人' (‘We should pay people’)

If you were to start disassembling the problems in the U.S. health care system, one of the first things you’ll discover is how much we spend on chronic disease (at least $1.1 trillion in direct costs alone). Many chronic diseases are a result of unhealthy behaviors upstream, so most new health tech entrepreneurs focus on fixing those upstream behaviors.

如果您要开始解决美国医疗保健系统中的问题，您会发现的第一件事就是我们在慢性病上花费了多少(仅直接费用就至少有 1.1万亿美元)。 许多慢性病是上游行为不健康的结果，因此，大多数新的医疗技术企业家都致力于解决上游行为。

In the current system, there’s unfortunately no business model to keep someone healthy for the long run.

不幸的是，在当前的系统中，没有一种商业模式可以使某人长期保持健康。

Poor eating and exercise habits, sleep deprivation, stress, and more lead to a raft of chronic health issues that would be cheaper to prevent than treat over the course of a patient’s lifetime. Wouldn’t it make sense to pay people small amounts today to make healthier choices so we spend less as a system in the long term?

不良的饮食和运动习惯，睡眠不足，压力大，等等会导致一系列慢性健康问题，与在患者一生中进行治疗相比，预防这些疾病要便宜得多。 今天向人们支付少量款项以做出更健康的选择，这样从长远来看，我们作为系统的支出会减少吗？

One problem with this approach is that the results of paying people to do different behaviors are pretty mixed depending on the behavior, length of time, and type of reward offered. But the bigger problem is that in the current system, there’s unfortunately no business model to keep someone healthy for the long run. Unless you can lower the cost of some very specific health issue and you can attribute that lowered cost to your specific solution, paying for healthy behaviors isn’t a very attractive proposition.

这种方法的一个问题是，根据行为，时间长短和所提供的报酬类型，支付人们去做不同行为的结果是很复杂的 。 但是更大的问题是，在当前系统中，没有一种商业模式可以使某人长期保持健康。 除非您可以降低某些非常特定的健康问题的成本， 并且可以将降低的成本归因于您的特定解决方案，否则为健康的行为付费并不是一个很有吸引力的主张。

Giving patients cash for healthy behaviors can work — but it has to be extremely targeted to a specific behavior, and most people who start at this proposition don’t do that. For example, insurance carriers will pay for getting preventive tests like a breast cancer screen, which will save them much more money down the line. It’s also much easier to incentivize a patient to take a one-time preventive test than to fundamentally change their habits.

为患者的健康行为提供现金是可以的，但必须针对特定行为，而且大多数从这一主张入手的人都不会这样做。 例如，保险公司将为获得预防性检查(如乳腺癌筛查) 付费 ，这将为他们节省更多的钱。 激励患者进行一次性预防性检查要比从根本上改变其习惯要容易得多。

“我们需要建立一个新的EMR” (‘We need to build a new EMR’)

Whether or not paying patients for healthy behaviors is a feasible part of your solution, you’ll quickly realize that if you want to build a patient-centric solution, you need patient data, and all the valuable patient data is locked in a disparate network of electronic medical records (EMRs), and it’s hard to get that data out. What we need, you decide, is a new, and better EMR.

无论是否向患者支付健康的行为是解决方案的可行部分，您都会很快意识到，如果您想构建以患者为中心的解决方案，则需要患者数据，并且所有有价值的患者数据都被锁定在一个完全不同的网络中电子病历(EMR)，很难将这些数据取出。 您决定， 我们需要的 是一种新的，更好的EMR。

Entrepreneurs who try to tackle the EMR problem take one of the following approaches and run into their corresponding challenges:

尝试解决EMR问题的企业家采用以下方法之一并遇到相应的挑战：

• Creating a personal health record for patients. The reality is that most patients don’t need to interact with their record very often since they aren’t frequent users of the health care system, so most patients’ willingness to pay for their own record is very low.

  为患者创建个人健康记录。 现实情况是，大多数患者由于不是医疗保健系统的频繁用户，因此不需要经常与记录互动，因此大多数患者支付自己记录的意愿很低。

• Making a better EMR for doctors. Hospitals and physicians are risk-averse purchasers, and rolling out and training staff on a new EMR can take months, sometimes years. Plus, the reason hospitals buy EMRs is to track the services they bill for, which existing EMRs actually do very well.

  为医生制定更好的EMR。 医院和医师是规避风险的购买者，推出新的EMR并对其进行培训可能需要数月甚至数年的时间。 另外，医院购买EMR的原因是为了跟踪他们为其付费的服务，而现有EMR实际上做得很好。

• Connecting data from all the existing EMRs. This is a reasonable approach, but it’s a slog and takes a long time. You have to approach each health care provider individually, get an agreement, integrate with them, and then standardize and structure the data. Apple’s Health app is integrated with just 474 health care institutions two to three years after announcing the feature that lets users pull their records in from different health systems. And they’re Apple, not a small startup.

  连接来自所有现有EMR的数据。 这是一种合理的方法，但它是一个标语，需要很长时间。 您必须分别与每个医疗保健提供者联系，达成协议，与他们集成，然后对数据进行标准化和结构化。 在宣布该功能允许用户从不同的卫生系统提取其记录后，苹果的Health应用程序仅与474家医疗机构集成了两到三年。 他们是苹果公司，而不是一家小型创业公司。

“让我们从自我保险的雇主开始” (‘Let’s start with self-insured employers’)

Employers are even more involved in health care than most people think. Once a company gets to a certain size, it’s likely self-insured. This means that instead of contracting with an insurance carrier, they pay employees’ medical bills themselves, putting them financially on the hook for their employees’ health (for as long as they’re employees of the company).

雇主比大多数人想象的更多地参与医疗保健。 一旦公司达到一定规模，就很可能是自保的 。 这意味着，他们无需与保险公司签约，而是自行支付员工的医疗费，从而在财务上为员工的健康着迷(只要他们是公司的员工)。

More than 70 million people in the U.S. are covered by a self-insured plan. Large companies like Walmart, Comcast, and Disney fall into this camp and spend a large chunk of change on their employees’ health care costs. Some entrepreneurs might see this and think, “I’ll bypass the insurance companies by selling directly to these self-insured employers to help them manage their employees’ health.”

自我保险计划为美国超过7,000万人提供了保险。 沃尔玛(Walmart)，康卡斯特(Comcast)和迪斯尼(Disney)等大公司都加入了这一阵营，并在员工的医疗保健费用上花费了很大的变化。 一些企业家可能会看到这种情况，并认为：“我将直接出售给这些自保雇主以帮助他们管理员工的健康，从而绕过保险公司。”

Congratulations, you have solved health care.

恭喜，您已经解决了医疗保健问题。

The problem here is that just 4% of employer plans cover 65% of people in this segment. Given this concentration, those few self-insured employers have heard every pitch already. No employer wants to hear one more pitch from a startup promising to “give your employees telemedicine so they avoid ER visits.” There are a lot of those companies already (98point6, FireFly Health, Teladoc, MDLIVE, to name a few).

这里的问题是，只有4％的雇主计划涵盖了该细分市场中65％的人 。 考虑到这种集中度，那些很少有自保能力的雇主已经听到了每个声音。 没有哪个雇主愿意再听到一个承诺“让您的员工进行远程医疗，从而避免急诊室拜访”的初创公司。 这些公司已经很多 (98point6，FireFly Health，Teladoc，MDLIVE等)。

Even if you do manage to get a contract with a self-insured employer, you actually have to get their employees to use your product, which is no easy feat. Livongo, a company that helps employees manage their diabetes, says in their investor documents that rolling their solution out takes about three months, and a total of 12 months to get just 34% of total recruitable individuals to use it. And if you don’t get employees to engage, guess who’s not getting a contract renewal?

即使您确实设法与自保雇主签订合同，您实际上也必须让其雇员使用您的产品，这绝非易事。 Livongo，一个公司，帮助员工管理自己的糖尿病， 说在他们的投资者文档滚动他们的解决方案出来大约需要三个月，共12个月的时间总recruitable个人只有34％使用它。 而且，如果您没有让员工参与，那么猜猜谁没有续签合同？

让我们将这一过程提高5％ (Let’s make this one process 5% better)

Many health tech entrepreneurs eventually decide that the way forward is to narrow their focus to a single pain point of one of their target customers, and make it a little bit better with software.

许多医疗技术企业家最终决定，解决方案是将关注点缩小到目标客户之一的单一痛点，并通过软件使其更好一点。

The idea is that there’s some task or process that’s currently handled with spreadsheets or calls or emails that could be better handled by software. In an ideal world, you would train users to use your software to perform the task, they would see their time spent on the task go down, then the parent company pays you to continue speeding up the task and making their employees’ lives easier. Outside the health care world, for example, a company might integrate Zendesk and Slack to make it easy to see and respond to customer support inquiries. It saves the company time and headache, so they’re willing to pay for these tools.

这个想法是，目前有一些任务或流程可以通过电子表格，电话或电子邮件来处理，而这些可以通过软件更好地处理。 在理想的环境中，您将培训用户使用软件来执行任务，他们会看到他们花在任务上的时间减少了，然后母公司向您付款以继续加快任务速度并简化员工的生活。 例如，在医疗保健领域之外，公司可能会整合Zendesk和Slack，以使其易于查看和响应客户支持查询。 它节省了公司的时间和麻烦，因此他们愿意为这些工具付费。

When you say “our tool can do this for you” the other side is hearing “here’s another thing you have to learn after you spent months trying to figure out the last tool.”

当您说“我们的工具可以为您做到这一点”时，另一边却听到“在花了几个月的时间弄清楚最后一个工具之后，您还必须学习另一件事。”

There are a few reasons I think this is way tougher in health care.

我认为这在医疗保健方面要困难得多，原因有几个。

What you think is a lightweight tool that can plug nicely into some process without integrating with too many systems is never as lightweight as you think. Most health care companies have dragged their feet on moving their IT infrastructure to the cloud and have rigorous compliance processes which they evaluate their vendors against. If you need to pass data between any two systems, this is going to take time from both you and your customer to get up and running.

您认为的轻量级工具可以很好地插入某些过程中，而无需与太多系统集成，因此它从来没有像您想象的那样轻量级。 大多数医疗保健公司在将其IT基础架构迁移到云上时都拖了脚，并制定了严格的合规流程，以评估其供应商。 如果您需要在任何两个系统之间传递数据，那么您和您的客户都需要花费一些时间才能启动并运行。

And then we’re back to the principal-agent problem. The person making the purchasing decision and the person using the product are totally different. At a hospital, the purchaser might be a chief information officer, but the user would be frontline physicians. The CIO cares way more about keeping price and workflow disruption to a minimum than making marginal improvements to usability or the speed of doing things.

然后我们回到委托代理问题。 做出购买决定的人和使用产品的人完全不同。 在医院，购买者可能是首席信息官，但用户将是一线医生。 CIO更关心的是将价格和工作流程的干扰降到最低，而不是对可用性或处理速度进行少量改进。

The other unfortunate reality is that no one in health care wants to learn a new tech tool or process. When you say “our tool can do this for you” the other side is hearing “here’s another thing you have to learn after you spent months trying to figure out the last tool.”

另一个不幸的现实是，医疗保健领域没人愿意学习一种新的技术工具或过程。 当您说“我们的工具可以为您做到这一点”时，另一边却听到“在花了几个月的时间弄清楚最后一个工具之后，您还必须学习另一件事。”

When you try to sell software tools for a specific use case, you’ll also discover that the companies you’re selling to actually can’t use the tools properly because they either don’t have the expertise in-house (for example, data/tech talent or health care knowledge), or because the efficiencies you created with your tool immediately get wiped out once you hit whatever the legacy system is.

当您尝试销售特定用例的软件工具时，还会发现您要出售给的公司实际上无法正确使用这些工具，因为它们要么没有内部专业知识(例如，数据/技术人才或医疗保健知识)，或者因为一旦您使用了任何旧系统，使用工具创建的效率就会立即消失。

Many entrepreneurs either end up having to loan people out to help their clients make the most of their tool — or realizing that it makes more sense to actually become a tech-enabled pharmacy, insurance carrier, or provider themselves.

许多企业家要么不得不借钱来帮助他们的客户充分利用他们的工具，要么意识到自己真正成为技术支持的药房，保险公司或提供者会更有意义。

“我猜我们是一家服务公司” (‘I guess we’re a services company’)

Trust is the most valuable currency in health care. To earn that trust, some companies will tie themselves to outcomes, that is, only get paid if the product works. But to ensure that the buyer uses the product effectively, many companies eventually realize that they need to move beyond just software and include services as part of their sale.

信任是医疗保健中最有价值的货币。 为了赢得这种信任，一些公司会将自己与成果联系在一起，也就是说，只有在产品有效的情况下才能获得报酬。 但是，为了确保购买者有效地使用产品，许多公司最终意识到他们需要超越仅仅软件的范畴，并将服务纳入销售范围。

Many tech companies discover that services are actually a great way to help scale their business. Digital health companies will use professional services to help onboard, train, and set up a company onto their platform. Companies like Veeva and Health Catalyst have done this well.

许多科技公司发现服务实际上是帮助扩展业务的好方法。 数字医疗公司将使用专业服务来帮助在其平台上进行公司注册，培训和成立公司。 Veeva和Health Catalyst等公司都做得很好。

Services can also be the core product, with tech living in the background to help it scale. Livongo is a good case of how delivering on outcomes for their customers let them expand into new areas. It started by helping employers manage their employees with diabetes via remote monitoring, coaching, texting, and emails. But their success in that area is what let them expand into other chronic disease areas (such as hypertension).

服务也可以是核心产品，而技术则可以在后台进行扩展。 Livongo是一个很好的例子，说明如何为客户带来成果，从而使他们扩展到新的领域。 首先，它通过远程监控，指导，短信和电子邮件帮助雇主管理患有糖尿病的员工。 但是他们在该领域的成功使他们得以扩展到其他慢性疾病领域(例如高血压)。

You can use tech to streamline your operations too. One Medical, a primary care company, is leaning heavily into digital visits, which would be way cheaper and more scalable for them operationally. Physicians can “see” more patients asynchronously via text, use lower-cost labor when possible, and fill unused capacity when the physicians have downtime in-office.

您也可以使用技术来简化操作。 基层医疗服务公司One Medical大量依赖数字访问，这对于他们的运营而言将更便宜且更具可扩展性。 医生可以通过文本异步“看到”更多的患者，在可能的情况下使用成本较低的人工，并在医生处于办公室停机时间时填补未使用的容量。

Do you need to be a services company to be successful in health care? No. Many companies build solid businesses by sticking to software, but many of them see their revenue growth slow quickly as they find it difficult to scale past their initial few customers. So there’s nothing wrong with having a higher headcount to support services — it potentially means bigger contracts, smoother operations, and more, if you do it right.

您需要成为服务公司才能在医疗保健方面取得成功吗？ 不会。许多公司通过坚持使用软件来建立稳固的业务，但是许多公司发现收入增长Swift放缓，因为他们发现很难扩展到最初的几个客户。 因此，拥有更高的人员支持服务并没有错–如果您做对的话，可能意味着更大的合同，更流畅的运营等等。

为什么今天仍然应该建立一家医疗保健公司 (Why you should still build a health care company today)

Even though I just explain all the mistakes and challenges a new health care-focused tech startup would face — I still think this is the best time ever to build a health care company.

即使我只是解释了一家专注于医疗保健的新技术初创公司将面临的所有错误和挑战，但我仍然认为这是建立医疗保健公司的最佳时机。

Thanks to the cloud, new plug-in services designed to help health tech companies, and better hardware, the infrastructure needed to build a new health care startup has never been better, and continues to improve. New regulations are making it easier to get paid, share data, and deliver care virtually. Meanwhile, incumbent companies are stuck in their old business models and processes.

多亏了云，旨在帮助医疗技术公司的新插件服务以及更好的硬件，构建新的医疗保健初创公司所需的基础架构从未如此完善，而且还在不断改善。 新法规使虚拟支付，共享数据和提供护理变得更加容易。 同时，老牌公司陷入了旧的商业模式和流程。

Health care is hard, and I can’t pretend like it isn’t. But if you can navigate through the challenges, you can build an extremely valuable business that tangibly improves the lives of people.

卫生保健很难，我不能假装不是。 但是，如果您能够应对挑战，那么您可以建立极其有价值的业务，从而切实改善人们的生活。