Disclaimer: Flare Capital Companions is an investor in Aetion, Cohere Well being, HealthVerity, Inbound Well being, Iora Well being and VivorCare. See the broader Flare presentation right here.
That is half certainly one of a two-part collection on innovation in most cancers care supply. Partly one, we’ll talk about the complexity of end-to-end most cancers care administration, the unmet wants and the way some rising digital well being gamers deal with these issues. Partly two, we’ll spotlight the “subsequent wave” and rising developments of digital health-enabled most cancers care supply.
It is no secret: Most cancers is patently advanced.
Sufferers usually battle to know the complexities of the U.S. well being system, and this confusion is usually amplified after a affected person receives a most cancers prognosis. The Worldwide Company for Analysis on Most cancers forecasts the variety of new most cancers circumstances worldwide will attain greater than 29 million by 2040 in contrast with simply over 18 million in 2018. As remedy protocols advance and other people stay longer, generally conquering a number of cancers of their lifetime, the right storm of power illness will rise and problem our healthcare system in quite a lot of methods.
With this improve within the variety of most cancers survivors, organizations should be ready to deal with the following impacts of long-term toxicities, recurrence of most cancers, infertility points, cardiovascular side-effects and psychological aftereffects.
Whereas analysis reveals most cancers has surpassed coronary heart illness because the primary reason behind loss of life in some high-income counties within the U.S., we now have not seen the identical development and adoption of digital platforms for most cancers within the ways in which we have seen for different power illnesses corresponding to diabetes, musculoskeletal illness and power kidney illness. So why is not extra innovation occurring for most cancers care supply?
We search to reply this query by understanding the important thing challenges opposing value-based most cancers care, and unbundling a very powerful features of care supply, to determine the important thing developments that may affect innovation for most cancers care within the subsequent decade.
Whereas tailwinds from COVID-19 and healthcare consumerism have pushed record-setting quantities of fundraising for early-stage digital well being startups over the past three years, main challenges exist for most cancers care supply that makes this space a very troublesome area to disrupt.
One purpose progressive care fashions corresponding to value-based and home-based care haven’t seen faster adoption lies within the problem related to integrating, and sometimes reintegrating, companies across the care crew. As we proceed to innovate for most cancers care supply, organizations should be considerate in regards to the reintegration of care (e.g., level options). As well as, new options should empower the care groups to carry the very best high quality instruments whereas additionally elevating affected person and supplier satisfaction — a troublesome stability to strike.
In talking with Aaron Gerber, CEO and cofounder of Reimagine Care, he famous the combination of correct instruments is not the one problem.
“When taking a look at specialty medicine, we have to think about each complexity [to administer the drug] and margin it generates for the healthcare system. We are able to then take a phased method that begins with the decrease complexity, decrease margin medicine and increase over time, however solely after demonstrating success and elevated consolation with the affected person’s main oncology crew,” he stated. “Executed nicely, this will increase affected person and supplier expertise whereas offering the chance to ship very high-quality house and digital care to sufferers.”
Level-solution fatigue for payers and suppliers, specialty drug buying and the chance of the perceived adjustments’ influence on profitability for current enterprise fashions usually stifle collaboration throughout stakeholders. Capital depth related to growing these strong options, usually tied to platform growth and the hiring prices for expert clinicians and care suppliers, stays a priority for early buyers as platforms scale. Different challenges embrace the necessity to tightly combine surgical care into the answer to deal with greater acuity affected person populations. Add to that the widening disparity of take care of underserved and rural populations, historically served by neighborhood suppliers, and also you shortly end up in a discipline of competing incentives and lagging enterprise fashions.
Key parts of the most cancers care continuum have been highlighted beneath to section an in any other case dastardly set of companies rendered throughout the affected person journey. Features of the journey span the earliest stage of a affected person’s journey (corresponding to discount in solar publicity and tobacco use), to superior care and end-of-life care planning.
Whereas the best alternative to disrupt conventional enterprise fashions stays to be seen for most cancers care, startups have more and more tried to enter totally different components of the care continuum solely to run right into a slew of regulatory, incentive and integration hurdles imposed by incumbents within the area. As well as, the service-based features corresponding to prognosis, remedy, survivorship and end-of-life care require robust coordination round different features corresponding to funds, training and household/caregiver assist planning.
Innovation is starting to take form in numerous methods. Startups proceed to deal with unmet wants by filling care gaps and supplementing current remedy types. Nevertheless, companies which have historically been non-revenue-generating appear to be a typical theme the place suppliers do not traditionally have the means to fund these initiatives, and payers are nonetheless too early in contracting for risk-based most cancers fashions. Whether or not startups can generate sustainable income within the short-term and display worth to stakeholders corresponding to well being techniques and payers stays an open query.
Regardless of maintaining features of the biopharma and therapeutics area separate (we acknowledge there’s a a lot broader biotechnology and therapeutics marketplace for oncology, and quite a few firms are driving innovation ahead), probably the most outstanding startup exercise for care supply has been in diagnostic companies, remedy coordination and danger enablement.
On the sooner aspect of the affected person continuum, prevention and danger discount options proceed to face a robust headwind as organizations attempt to combine preventative and screening-based companies with their acute care counterparts. Balancing the fee-for-service nature of acute care supply with value-based preventative companies shall be troublesome; aligning incentives shall be essential. We anticipate survivorship companies (most notably, neighborhood and vitamin companies) will proceed to combine extra tightly upstream with features of acute care supply and recurrence prevention (e.g., screening, prognosis).
On this market map, we spotlight a number of startups innovating throughout key classes. (See the broader Flare presentation right here.)
Remedy: Leveraging knowledge, care coordination and affected person assist instruments to enhance determination making
Remedy is on the core of most cancers care supply, and we see numerous options being constructed throughout the class. A lot of the current most cancers remedy plans encompass three core companies: surgical intervention, systemic remedy and radiation remedy. Relying on the stage and presenting most cancers, surgical intervention is usually the primal type of remedy for early-stage diagnoses, and it is usually complemented or augmented with each systemic (chemo, hormone and immunotherapy) and radiation remedy.
Startups, nevertheless, are addressing challenges round remedy pathways in numerous methods, specializing in issues corresponding to navigation, coordination, remedy suggestions (for an knowledgeable shopper) and affected person assist. We’ve additionally referred to as out house care, given the rise of at-home remedy choices (corresponding to house infusion remedy and lab exams), though we acknowledge many features of house care in oncology fall underneath different classes corresponding to screening and prognosis.
The trade has additionally seen a drastic improve within the availability of information (e.g., claims, EMR, diagnostics, imaging) over the past 20 years to raised handle most cancers sufferers. Along with Flatiron Well being, there have been numerous knowledge platforms, marketplaces (HealthVerity, Graphite Well being) and analytics-ready knowledge enablers (Mendel, Aetion) rising to make knowledge extra accessible to researchers and clinicians. Nevertheless, many challenges nonetheless exist for clinicians managing their sufferers by an evidence-based method.
“Well being techniques at the moment are sometimes not set as much as make selections based mostly on real-world knowledge. Medical trial knowledge and different revealed knowledge is available, however organizations are starting to make the shift from the established order of revealed proof (expertise-driven) to real-world proof (data-driven method) in medical follow,” stated Matt Bettonville, who leads Oncology Enterprise Investing at Emerson Collective.
Instruments that use real-world proof (RWE) to assist suppliers reply questions and supply clinical-decision assist in a well timed method, each standalone firms (e.g, Atropos Well being) or these internally developed by well being techniques and educational medical facilities, are anticipated to emerge within the coming years to drive extra personalised remedy protocols.
The primary space we unbundle inside the remedy class is navigation.
As know-how continues to embed itself throughout the most cancers care continuum, extra alternatives have arisen for know-how to bridge the hole between current remedy regimes and finally present extra holistic and personalised ranges of most cancers care. Even when core therapies aren’t basically altering (e.g., surgical intervention), sufferers and physicians can fine-tune features of care to the affected person utilizing knowledge and automation to assist the administration of signs, uncomfortable side effects, weight-reduction plan monitoring, appointments, affected person funds and general coordination of in any other case disparate features of care.
Navigation companies are in some ways the bedrock for sufferers navigating the complexities of care, and these companies play a essential position to deal with affected person’s largely unmet wants. Gamers corresponding to Jasper Well being provide digital care administration instruments and a library of sources to help sufferers with all the things from dealing with uncomfortable side effects to monetary planning.
Care coordination is a sizeable sub-category inside remedy that features determination assist instruments to help physicians with managing affected person wants and, in idea, cut back administrative burden. One instance, Preveta, is a care coordination platform that takes illness protocols and interprets them into personalised care navigation workflows. By way of automated dashboards and refined knowledge seize, techniques purpose to allow the clinician to seize further affected person knowledge between visits. In flip, the software program can assist assess the information and get it again into the fingers of the docs shortly to enhance remedy.
One other aspect of care coordination contains digital symptom administration, which sits on the intersection of distant monitoring instruments for patient-reported outcomes (e.g., Vinehealth, Reprosent) and proactive administration of signs by companion apps. As these startups scale, it turns into more and more essential to display improved affected person outcomes and ROI for purchasers (payers, suppliers) adopting the software program. Participating payers early additionally turns into an essential issue for organizations searching for to allow danger and handle bundled companies.
Alternatively, the route of accumulating and aggregating affected person knowledge by digital affected person assist instruments can grow to be a horny alternative for pharmaceutical firms that search to faucet into distinctive affected person datapoints (corresponding to social determinants of well being), which can assist inform drug adoption and adherence, medical trial enablement and a number of features of drug growth.
Remedy Suggestions and Affected person Help
As affected person knowledge turns into extra commoditized, and clinicians are inundated with the sheer quantity of information and analysis publications that aren’t humanly attainable to course of, medical determination assist (CDS) instruments and next-generation analytics firms that may present the “so-what” will play a central position in remedy advice and affected person administration.
Whereas Merative (previously IBM Watson Well being) and different CDS distributors primarily depend on publicly accessible tips and analysis publications, a brand new class of digital well being startups augments current tips with real-world knowledge (RWD) and real-world proof (RWE) to supply a extra data-driven approach of treating most cancers sufferers.
“You want RWE and analytics and determination assist that oncologists can get behind,” stated Dan McCarthy, CEO of New Century Well being and president of Evolent Well being.
Gamers corresponding to Atropos Well being present options that assist physicians reply beforehand unanswered medical questions utilizing real-world medical and administrative knowledge in a well timed method. Digital well being firms corresponding to Outcomes4Me and Ciitizen emerge and attempt to assist most cancers sufferers of their journey to discovering the correct remedy choices, and applicable medical trials, by training and affected person assist.
Traces proceed to blur as supplier organizations search to create touchpoints earlier and earlier in a affected person’s journey by establishing digital entrance doorways, and alternatively, pharmaceutical firms search to realize entry to extra longitudinal knowledge to assist decision-making.
Dwelling-Based mostly Most cancers Care
The shift to home-based take care of most cancers has been in growth for over a decade, however the latest adjustments within the regulatory atmosphere have enabled sure types of remedy to be administered within the consolation of a affected person’s house. Key adjustments, spawned partly by COVID-19, embrace the elevated adoption and wish for care administered within the house, and rising pressures on the system on account of rising prices in key areas of spend (together with musculoskeletal, most cancers and renal).
Gamers like Reimagine Care and Karkonos are tackling house infusions, lab attracts and digital visits with the aim of creating care extra inexpensive and extra accessible. Whereas others corresponding to Inbound Well being and Medically Dwelling are enabling well being techniques to manage hospital-at-home for medium- and high-acuity sufferers, though the prime focus could not all the time be solely on most cancers sufferers.
Questions stay across the stage of involvement that well being techniques and payers could have within the growth of house well being on the whole. Whereas it’s nonetheless unclear precisely how and the place well being techniques and AMCs will combine into the broader ecosystem, startups are starting to display (and justify) a key understanding of price when growing these home-based capabilities for most cancers.
As startups proceed to make progress in sure areas of the remedy pathway, we count on to see increasingly well being techniques and payers searching for partnerships with outdoors organizations as they increase their hospital-at-home and home-based companies.
Enablement and Threat-Bearing Entities: An effort to basically shift the enterprise mannequin of most cancers care to worth
Prior to now, oncologists have been fairly nervous about taking dangers, even professionally, on account of anxiousness round specialty drug prices. For many medical teams, the know-how wants are additionally too daunting as too many level options are sometimes wanted to correctly handle populations. Payers are additionally nonetheless within the state of transitioning, as disagreement across the stage of inclusion for specialty drug prices usually ends in a rate-limiting step for contracting.
Whereas challenges persist, latest developments have enabled increasingly oncology teams to start shifting towards danger. As Shawn Morris, CEO of Privia Well being, stated, “When requested in regards to the risk by buyers and analysts, there are just a few specialties which are excessive quantity and might underwrite the chance from an actuarial standpoint in Medicare —orthopedics, GI, urology, ophthalmology and oncology. The success of shifting into value-based preparations and danger is predicated on correct alignment with physicians and payers and having the mandatory instruments, expertise and know-how (knowledge) to handle danger.”
Alternatives are increasing for startups and oncology teams to begin with skilled capitation and finally transfer upstream. These preparations are largely seen within the Medicare Benefit area, and as organizations proceed to display improved outcomes, business alternatives could quickly be on the horizon.
“Success in bearing danger is feasible in case you design the correct methodology,” Robin Shah, CEO and cofounder of Thyme Care, stated. “This requires a deep understanding of the affected person past their medical components, and to construct that understanding you want to develop trusted relationships with members. With out these relationships in place, you gained’t have the ability to affect habits change.”
Completely different Approaches
We see innovation in danger enablement taking many types. Whether or not it’s firms corresponding to Transcarent (e.g., lately introduced Transcarent Oncology Care) searching for to overtake the employer self-insured enterprise or firms taking a data-driven method to enhancing broader affected person care pathways, specializing in features corresponding to tumor boards, many enablement platforms are rising that drive collaboration throughout sufferers, suppliers and payers. Different gamers, corresponding to Azra AI, are utilizing synthetic intelligence to interpret knowledge in real-time to tell prognosis by care administration. Thyme Care presents a nursing-led platform that’s geared up with knowledge and analytics to proactively assist most cancers sufferers’ determination making and coordination all through the method. Cohere Well being seems to align medical and monetary selections holistically throughout an oncology affected person’s care journey, enabling higher collaboration and decision-making in the direction of high-value care.
If arrange appropriately, enablement platforms have the potential to supply a brand new method to navigate members to high-quality, low-cost care, even when which means shifting them to the most effective and least costly facility in a patient-friendly approach. Current enterprise fashions have an essential cost-focused distinction that’s basically totally different in some ways in contrast with the standard, revenue-focused actions launched by giant most cancers facilities within the early 2010s (e.g., CTCA collaborates to supply free air transportation for most cancers sufferers) that had been usually established to develop an current supplier’s footprint.
In abstract, a elementary shift from historic most cancers care enterprise fashions should happen so digital well being innovation might be adopted extra shortly. With the emergence of re-bundling applied sciences and tech-enabled companies, we count on the progress of risk-bearing and risk-enablement platforms to be a key facet for accelerating the evolution of the most cancers enterprise mannequin.
Screening and Analysis: Tech developments and home-enabled companies producing distinctive entry factors
Early most cancers screening and prognosis can usually be the distinction between life and loss of life for most cancers sufferers. In line with the American Most cancers Society, the 5-year relative survival price between two colon most cancers sufferers, one on the “localized” SEER stage (91%) and one on the “distant” SEER stage (14%), is staggering. The significance of early screening and detection of most cancers is well-established and well-known to clinicians and sufferers alike.
Over the previous 20 years, exceptional enhancements in applied sciences have allowed physicians to search out most cancers at an early stage, lengthy earlier than signs seem. From higher imaging procedures to numerous breakthrough diagnostic exams (e.g., liquid biopsy, single-cell genomic testing, multi-OMICs), the flexibility to display screen and diagnose cancers has taken a large leap ahead.
Vital enhancements in sequencing know-how and value led to the rise of firms like GRAIL, which pitches a multi-cancer early detection check that may display screen over 50 varieties of most cancers by a single blood draw for roughly $1,000. Along with enhancing novel screening and diagnostic exams, private and non-private sectors have additionally carried out their fair proportion of elevating most cancers screening consciousness and enhancing entry. From numerous most cancers screening campaigns from the non-public sector and non-profits to CMS making a number of most cancers screening (e.g., breast most cancers, colorectal most cancers) a part of the Medicare Half C Star Scores measurement, screening and detection play a entrance and heart position on this evolution of most cancers care.
Whereas important technological and coverage enhancements have been made, many unmet wants nonetheless exist. Limitations embrace transportation to diagnostic websites, lengthy wait instances for specialists and entry to genetic counselors. Digital well being innovators can play a vital position in addressing these unmet wants. From a affected person entry to screening standpoint, we now have seen non-invasive, home-based diagnostic exams, corresponding to Cologuard, which are getting used and promoted by payers over the previous decade (e.g., Humana to cowl Cologuard for colorectal most cancers screening).
Progressive digital well being and home-based diagnostics firms (e.g., EverlyWell) have emerged over the previous decade to enhance entry to diagnostic exams that may be carried out at point-of-care or with samples collected at house. It isn’t inconceivable that platforms like EverlyWell will transfer past well being and wellness exams and use their consumer base to enhance most cancers screening and detection. Different rising gamers that may dramatically cut back entry obstacles embrace house phlebotomy firms (e.g., GetLabs, Sprinter Well being) that would make the blood draw extra accessible. They will additionally help in ongoing affected person administration for these sufferers who’re finally recognized with most cancers and may very well be enrolled in home-based most cancers administration and medical trials.
Educating sufferers on the influence of medical remedy and life-style change stays a largely unmet want, no matter affected person acuity or circumstance. Most cancers facilities have taken a proactive step over the past 20 years to supply training instruments and companies to equip the sufferers with extra info (together with the rise of tech-enabled directories e.g., Mayo Clinic’s on-line sources and library), however outcomes can usually be described as “info overload,” inflicting sufferers to really feel overwhelmed.
Systematic opinions for superior most cancers sufferers and casual caregivers (e.g., partner, relations) have three frequent areas of unmet want: psychological, bodily and healthcare companies info.
A number of the greatest instructional gaps for sufferers lie in the advantages and uncomfortable side effects of remedy in addition to life-style adjustments, each after the preliminary prognosis and when transitioning from energetic remedy to survivorship. Training and care coordination startups are beginning to emerge that empower their sufferers with instruments corresponding to automated aspect impact assist (e.g., Ankr) that may help in ongoing, asynchronous affected person administration to supply essential power administration and inhabitants well being knowledge.
Survivorship: An emergence of digital-hybrid communities and vitamin assist to assist with a affected person’s altering life-style
Sufferers will want extra individualized assist as remedy and affected person administration turn into extra focused and personalised. In at the moment’s social media-connected world, most cancers sufferers search to narrate to sufferers like them. First-generation, patient-focused social networking websites like PatientsLikeMe emerged within the 2000s, whereas new affected person communities corresponding to Encourage and That is Dwelling With Most cancers have emerged to supply neighborhood assist and steerage on remedy choices in more moderen years.
Along with peer assist networks, expert-guided digital clinics, corresponding to VivorCare, have emerged to supply custom-made assist and tailor-made packages that assist most cancers survivors handle their care outdoors the hospital setting, beginning with packages designed for psychological well being. Vitamin-as-medicine continues to take off, and whereas many startups are specializing in gastrointestinal care (in lots of circumstances, beginning with IBD and IBS sufferers), startups are rising (Savor Vitamin, Season Well being) which are nicely positioned to fill the hole for oncology sufferers with food-as-medicine, just like how these gamers are managing sufferers with power illnesses corresponding to diabetes.
In regards to the Authors: Ian Chiang is a companion at Flare Capital Companions, a healthcare know-how and services-focused enterprise capital agency. Previous to becoming a member of Flare, he was the SVP of product and innovation and a founding member of CareAllies, Cigna’s household of multi-payer supplier companies, inhabitants well being administration, value-based care enablement and home-based care companies. Beforehand, he was a digital well being entrepreneur and a former administration guide at McKinsey & Firm.
Jonathon George is an MBA candidate at Kellogg College of Administration and a Flare Capital Scholar. Whereas at Kellogg, he interned on the Mayo Clinic of their Oncology Division and at OCA Ventures as an investor. Beforehand, he was a administration guide at Chartis targeted on well being techniques and companies.
A particular because of Aaron Gerber, Dan McCarthy, Matt Bettonville, Ryan Langdale, Robin Shah, Shawn Morris and numerous others for offering their time and insights by a number of interviews. The crew at Flare interviewed 20+ executives, founders, buyers, sufferers and leaders from throughout the nation on subjects associated to oncology, innovation and tech-enabled companies for most cancers care supply. This text wouldn’t be attainable with out their assist.