ZERO GRACE/ZERO MALICE

Amazon's purchase of One Medical could speed up American healthcare

The U.S. healthcare industry is a 7-ton seal bleeding at sea. Predators are circling. Unearned margin: price increases relative to inflation without quality improvements. Amazon is the 11-foot megalodon with 7-inch teeth. Amazon is no longer circling... but attacking.

In 2020 dollars, per capita U.S. healthcare spending increased from $2,968 in 1980 to $12,531. The result is a massive industry with 13% of the nation's workers and a fifth of GDP.

Doctor No

In 40 years, healthcare has made progress. From 73.7 in 1980 to 78.8 in 2019, life expectancy rose (before Covid knocked it back down a bit). Pharmacological therapies have revolutionized, and genetic research is paying off. The financial return, improvement split by cost increases, is terrible. No country has expense rises like the U.S., and no one spends as much per capita as we do. Developed countries have longer life expectancies, healthier populations, and less economic hardship.

Two-thirds of U.S. personal bankruptcies are due to medical expenses and/or missed work. Mom or Dad getting cancer could bankrupt many middle-class American families. 40% of American adults delayed or skipped needed care due to cost. Every healthcare improvement seems to have a downside. Same pharmacological revolution that helped millions caused opioid epidemic. Our results are poor in many areas: The U.S. has a high infant mortality rate.

Healthcare is the second-worst retail industry in the country. Gas stations are #1. Imagine walking into a Best Buy to buy a TV and a Blue Shirt associate requests you fill out the same 14 pages of paperwork you filled out yesterday. Then you wait in a crowded room until they call you, 20 minutes after the scheduled appointment you were asked to arrive early for, to see the one person in the store who can talk to you about TVs, who has 10 minutes for you. The average emergency room wait time in New York is 6 hours and 10 minutes.

If it's bad for the customer, it's worse for the business. Physicians spend 27% of their time helping patients; 49% on EHRs. Documentation, order entry, billing, and inbox management. Spend a decade getting an M.D., then become a bureaucrat.

No industry better illustrates scale diseconomies. If we got the same return on healthcare spending as other countries, we'd all live to 100. We could spend less, live longer and healthier, and pay off the national debt in 15 years. U.S. healthcare is the worst ever.

What now? Competition is at the heart of capitalism, the worst system of its kind.

Priority Time

Amazon is buying One Medical for $3.9 billion. I think this deal will liberate society. Two years in, I think One Medical is great. When I got Covid, I pressed the One Medical symbol on my phone; a nurse practitioner prescribed Paxlovid and told me which pharmacies had it in stock.

Amazon enables the company's vision. One Medical's stock is down to $10 from $40 at the start of 2021. Last year, it lost $250 million and needs cash (Amazon has $60 billion). ONEM must grow. The service has 736,000 members. Half of U.S. households have Amazon Prime. Finally, delivery. One Medical is a digital health/physical office hybrid, but you must pick up medication at the pharmacy. Upgrade your Paxlovid delivery time after a remote consultation. Amazon's core competency means it'll happen. Healthcare speed and convenience will feel alien.

It's been a long, winding road to disruption. Amazon, JPMorgan, and Berkshire Hathaway formed Haven four years ago to provide better healthcare for their 1.5 million employees. It rocked healthcare stocks the morning of the press release, but folded in 2021.

Amazon Care is an employee-focused service. Home-delivered virtual health services and nurses. It's doing well, expanding nationwide, and providing healthcare for other companies. Hilton is Amazon Care's biggest customer. The acquisition of One Medical will bring 66 million Prime households capital, domain expertise, and billing infrastructure. Imagine:

"Alexa, I'm hot and my back hurts."

"Connecting you to a Prime doctor now."

Want to vs. Have to

I predicted Amazon entering healthcare years ago. Why? For the same reason Apple is getting into auto. Amazon's P/E is 56, double Walmart's. The corporation must add $250 billion in revenue over the next five years to retain its share price. White-label clothes or smart home products won't generate as much revenue. It must enter a huge market without scale, operational competence, and data skills.

Current Situation

Healthcare reform benefits both consumers and investors. In 2015, healthcare services had S&P 500-average multiples. The market is losing faith in public healthcare businesses' growth. Healthcare services have lower EV/EBITDA multiples than the S&P 500.

Amazon isn't the only prey-hunter. Walmart and Alibaba are starting pharmacies. Uber is developing medical transportation. Private markets invested $29 billion in telehealth last year, up 95% from 2020.

The pandemic accelerated telehealth, the immediate unlock. After the first positive Covid case in the U.S., services that had to be delivered in person shifted to Zoom... We lived. We grew. Video house calls continued after in-person visits were allowed. McKinsey estimates telehealth visits are 38 times pre-pandemic levels. Doctors adopted the technology, regulators loosened restrictions, and patients saved time. We're far from remote surgery, but many patient visits are unnecessary. A study of 40 million patients during lockdown found that for chronic disease patients, online visits didn't affect outcomes. This method of care will only improve.

Amazon's disruption will be significant and will inspire a flood of capital, startups, and consumer brands. Mark Cuban launched a pharmacy that eliminates middlemen in January. Outcome? A 90-day supply of acid-reflux medication costs $17. Medicare could have saved $3.6 billion by buying generic drugs from Cuban's pharmacy. Other apex predators will look at different limbs of the carcass for food. Nike could enter healthcare via orthopedics, acupuncture, and chiropractic. LVMH, L'Oréal, and Estée Lauder may launch global plastic surgery brands. Hilton and Four Seasons may open hospitals. Lennar and Pulte could build "Active Living" communities that Nana would leave feet first, avoiding the expense and tragedy of dying among strangers.

Risks

Privacy matters: HIV status is different from credit card and billing address. Most customers (60%) feel fine sharing personal health data via virtual technologies, though. Unavoidable. 85% of doctors believe data-sharing and interoperability will become the norm. Amazon is the most trusted tech company for handling personal data. Not Meta: Amazon.

What about antitrust, then?

Amazon should be required to spin off AWS and/or Amazon Fulfillment and banned from promoting its own products. It should be allowed to acquire hospitals. One Medical's $3.9 billion acquisition is a drop in the bucket compared to UnitedHealth's $498 billion market valuation.

Antitrust enforcement shouldn't assume some people/firms are good/bad. It should recognize that competition is good and focus on making markets more competitive in each deal. The FTC should force asset divestitures in e-commerce, digital marketing, and social media. These companies can also promote competition in a social ill.

U.S. healthcare makes us fat, depressed, and broke. Competition has produced massive value and prosperity across most of our economy.

Dear Amazon … bring it.

Kim Kardashian created Skky Partners. Consumer products, internet & e-commerce, consumer media, hospitality, and luxury are company targets.

Some call this another Kardashian publicity gimmick.

This maneuver is brilliance upon closer inspection. Why?

1) Kim has amassed a sizable social media fan base:

Over 320 million Instagram and 70 million Twitter users follow Kim Kardashian.

Kim Kardashian's Instagram account ranks 8th. Three Kardashians in top 10 is ridiculous.

This gives her access to consumer data. She knows what people are discussing. Investment firms need this data.

Quality, not quantity, of her followers matters. Studies suggest that her following are more engaged than Selena Gomez and Beyonce's.

Kim's followers are worth roughly $500 million to her brand, according to a research. They trust her and buy what she recommends.

2) She has a special aptitude for identifying trends.

Kim Kardashian can sense trends.

She's always ahead of fashion and beauty trends. She's always trying new things, too. She doesn't mind making mistakes when trying anything new. Her desire to experiment makes her a good business prospector.

Kim has also created a lifestyle brand that followers love. Kim is an entrepreneur, mom, and role model, not just a reality TV star or model. She's established a brand around her appearance, so people want to buy her things.

Her fragrance collection has sold over $100 million since its 2009 introduction, and her Sears apparel line did over $200 million in its first year.

SKIMS is her latest $3.2bn brand. She can establish multibillion-dollar firms with her enormous distribution platform.

Early founders would kill for Kim Kardashian's network.

Making great products is hard, but distribution is more difficult. — David Sacks, All-in-Podcast

3) She can delegate the financial choices to Jay Sammons, one of the greatest in the industry.

Jay Sammons is well-suited to develop Kim Kardashian's new private equity fund.

Sammons has 16 years of consumer investing experience at Carlyle. This will help Kardashian invest in consumer-facing enterprises.

Sammons has invested in Supreme and Beats Electronics, both of which have grown significantly. Sammons' track record and competence make him the obvious choice.

Kim Kardashian and Jay Sammons have joined forces to create a new business endeavor. The agreement will increase Kardashian's commercial empire. Sammons can leverage one of the world's most famous celebrities.

“Together we hope to leverage our complementary expertise to build the next generation consumer and media private equity firm” — Kim Kardashian

Kim Kardashian is a successful businesswoman. She developed an empire by leveraging social media to connect with fans. By developing a global lifestyle brand, she has sold things and experiences that have made her one of the world's richest celebrities.

She's a shrewd entrepreneur who knows how to maximize on herself and her image.

Imagine how much interest Kim K will bring to private equity and venture capital.

I'm curious about the company's growth.

My colleague Ilana Ovental and I examined pandemic media coverage of education at the end of last year. That analysis examined coverage changes. We tracked K-12 topic attention over the previous two decades using Lexis Nexis. See the results here.

I was struck by how cleanly the past two decades can be divided up into three (or three and a half) eras of school reform—a framing that can help us comprehend where we are and how we got here. In a time when epidemic, political unrest, frenetic news cycles, and culture war can make six months seem like a lifetime, it's worth pausing for context.

If you look at the peaks in the above graph, the 21st century looks to be divided into periods. The decade-long rise and fall of No Child Left Behind began during the Bush administration. In a few years, NCLB became the dominant K-12 framework. Advocates and financiers discussed achievement gaps and measured success with AYP.

NCLB collapsed under the weight of rigorous testing, high-stakes accountability, and a race to the bottom by the Obama years. Obama's Race to the Top garnered attention, but its most controversial component, the Common Core State Standards, rose quickly.

Academic standards replaced assessment and accountability. New math, fiction, and standards were hotly debated. Reformers and funders chanted worldwide benchmarking and systems interoperability.

We went from federally driven testing and accountability to government encouraged/subsidized/mandated (pick your verb) reading and math standardization. Last year, Checker Finn and I wrote The End of School Reform? The 2010s populist wave thwarted these objectives. The Tea Party, Occupy Wall Street, Black Lives Matter, and Trump/MAGA all attacked established institutions.

Consequently, once the Common Core fell, no alternative program emerged. Instead, school choice—the policy most aligned with populist suspicion of institutional power—reached a half-peak. This was less a case of choice erupting to prominence than of continuous growth in a vacuum. Even with Betsy DeVos' determined, controversial efforts, school choice received only half the media attention that NCLB and Common Core did at their heights.

Recently, culture clash-fueled attention to race-based curriculum and pedagogy has exploded (all playing out under the banner of critical race theory). This third, culture war-driven wave may not last as long as the other waves.

Even though I don't understand it, the move from slow-building policy debate to fast cultural confrontation over two decades is notable. I don't know if it's cyclical or permanent, or if it's about schooling, media, public discourse, or all three.

One final thought: After doing this work for decades, I've noticed how smoothly advocacy groups, associations, and other activists adapt to the zeitgeist. In 2007, mission statements focused on accomplishment disparities. Five years later, they promoted standardization. Language has changed again.

Part of this is unavoidable and healthy. Chasing currents can also make companies look unprincipled, promote scepticism, and keep them spinning the wheel. Bearing in mind that these tides ebb and flow may give educators, leaders, and activists more confidence to hold onto their values and pause when they feel compelled to follow the crowd.

Are MVPs outdated and have no place in modern product culture?

Frank Robinson coined "MVP" in 2001. In the same year as the Agile Manifesto, the first Scrum experiment began. MVPs are old.

The concept was created to solve the waterfall problem at the time.

The market was still sour from the .com bubble. The tech industry needed a new approach. Product and Agile gained popularity because they weren't waterfall.

More than 20 years later, waterfall is dead as dead can be, but we are still talking about MVPs. Does that make sense?

What is an MVP?

Minimum viable product. You probably know that, so I'll be brief:

[…] The MVP fits your company and customer. It's big enough to cause adoption, satisfaction, and sales, but not bloated and risky. It's the product with the highest ROI/risk. […] — Frank Robinson, SyncDev

MVP is a complete product. It's not a prototype. It's your product's first iteration, which you'll improve. It must drive sales and be user-friendly.

At the MVP stage, you should know your product's core value, audience, and price. We are way deep into early adoption territory.

What about all the things that come before?

Modern product discovery

Eric Ries popularized the term with The Lean Startup in 2011. (Ries would work with the concept since 2008, but wide adoption came after the book was released).

Ries' definition of MVP was similar to Robinson's: "Test the market" before releasing anything. Ries never mentioned money, unlike Jobs. His MVP's goal was learning.

“Remove any feature, process, or effort that doesn't directly contribute to learning” — Eric Ries, The Lean Startup

Product has since become more about "what" to build than building it. What started as a learning tool is now a discovery discipline: fake doors, prototyping, lean inception, value proposition canvas, continuous interview, opportunity tree... These are cheap, effective learning tools.

Over time, companies realized that "maximum ROI divided by risk" started with discovery, not the MVP. MVPs are still considered discovery tools. What is the problem with that?

Time to Market vs Product Market Fit

Waterfall's Time to Market is its biggest flaw. Since projects are sliced horizontally rather than vertically, when there is nothing else to be done, it’s not because the product is ready, it’s because no one cares to buy it anymore.

MVPs were originally conceived as a way to cut corners and speed Time to Market by delivering more customer requests after they paid.

Original product development was waterfall-like.

Time to Market defines an optimal, specific window in which value should be delivered. It's impossible to predict how long or how often this window will be open.

Product Market Fit makes this window a "state." You don’t achieve Product Market Fit, you have it… and you may lose it.

Take, for example, Snapchat. They had a great time to market, but lost product-market fit later. They regained product-market fit in 2018 and have grown since.

An MVP couldn't handle this. What should Snapchat do? Launch Snapchat 2 and see what the market was expecting differently from the last time? MVPs are a snapshot in time that may be wrong in two weeks.

MVPs are mini-projects. Instead of spending a lot of time and money on waterfall, you spend less but are still unsure of the results.

MVPs aren't always wrong. When releasing your first product version, consider an MVP.

Minimum viable product became less of a thing on its own and more interchangeable with Alpha Release or V.1 release over time.

Modern discovery technics are more assertive and predictable than the MVP, but clarity comes only when you reach the market.

MVPs aren't the starting point, but they're the best way to validate your product concept.

A fascinating business conversation.

This week at Web Summit, I had mentor hour.

Mentor hour connects startups with experienced entrepreneurs.

The YC-selected founder who mentored me had grown his company to $100 million in 18 months.

I had 45 minutes to question him.

I've compiled this.

Context

Founder's name is Zack.

After working in private equity, Zack opted to acquire an MBA.

Surrounded by entrepreneurs at a prominent school, he decided to become one himself.

Unsure how to proceed, he bet on two horses.

On one side, he received an offer from folks who needed help running their startup owing to lack of time. On the other hand, he had an idea for a SaaS to start himself.

He just needed to validate it.

Validating

Since Zack's proposal helped companies, he contacted university entrepreneurs for comments.

He contacted university founders.

Once he knew he'd correctly identified the problem and that people were willing to pay to address it, he started developing.

He earned $100k in a university entrepreneurship competition.

His plan was evident by then.

The other startup's founders saw his potential and granted him $400k to launch his own SaaS.

Hiring

He started looking for a tech co-founder because he lacked IT skills.

He interviewed dozens and picked the finest.

As he didn't want to wait for his program to be ready, he contacted hundreds of potential clients and got 15 letters of intent promising they'd join up when it was available.

YC accepted him by then.

He had enough positive signals to raise.

Raising

He didn't say how many VCs he called, but he indicated 50 were interested.

He jammed meetings into two weeks to generate pressure and encourage them to invest.

Seed raise: $11 million.

Selling

His objective was to contact as many entrepreneurs as possible to promote his product.

He first contacted startups by scraping CrunchBase data.

Once he had more money, he started targeting companies with ZoomInfo.

His VC urged him not to hire salespeople until he closed 50 clients himself.

He closed 100 and hired a CRO through a headhunter.

Scaling

Three persons started the business.

1. He primarily works in sales.

2. Coding the product was done by his co-founder.

3. Another person performing operational duties.

He regretted recruiting the third co-founder, who was ineffective (could have hired an employee instead).

He wanted his company to be big, so he hired two young marketing people from a competing company.

After validating several marketing channels, he chose PR.

$100 Million and under

He developed a sales team and now employs 30 individuals.

He raised a $100 million Series A.

Additionally, he stated

• He’s been rejected a lot. Like, a lot.

• Two great books to read: Steve Jobs by Isaacson, and Why Startups Fail by Tom Eisenmann.

• The best skill to learn for non-tech founders is “telling stories”, which means sales. A founder’s main job is to convince: co-founders, employees, investors, and customers. Learn code, or learn sales.

Conclusion

I often read about these stories but hardly take them seriously.

Zack was amazing.

Three things about him stand out:

1. His vision. He possessed a certain amount of fire.

2. His vitality. The man had a lot of enthusiasm and spoke quickly and decisively. He takes no chances and pushes the envelope in all he does.

3. His Rolex.

He didn't do all this in 18 months.

Not really.

He couldn't launch his company without private equity experience.

These accounts disregard entrepreneurs' original knowledge.

Hormozi will tell you how he founded Gym Launch, but he won't tell you how he had a gym first, how he worked at uni to pay for his gym, or how he went to the gym and learnt about fitness, which gave him the idea to open his own.

Nobody knows nothing. If you scale quickly, it's probable because you gained information early.

Lincoln said, "Give me six hours to chop down a tree, and I'll spend four sharpening the axe."

Sharper axes cut trees faster.