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.

A worldwide energy crisis might have hampered renewable energy and clean tech investment. Nope.

BNEF's 2023 Energy Transition Investment Trends study surprised and encouraged. Global energy transition investment reached $1 trillion for the first time ($1.11t), up 31% from 2021. From 2013, the clean energy transition has come and cannot be reversed.

BNEF Head of Global Analysis Albert Cheung said our findings ended the energy crisis's influence on renewable energy deployment. Energy transition investment has reached a record as countries and corporations implement transition strategies. Clean energy investments will soon surpass fossil fuel investments.

The table below indicates the tripping point, which means the energy shift is occuring today.

BNEF calls money invested on clean technology including electric vehicles, heat pumps, hydrogen, and carbon capture energy transition investment. In 2022, electrified heat received $64b and energy storage $15.7b.

Nonetheless, $495b in renewables (up 17%) and $466b in electrified transport (up 54%) account for most of the investment. Hydrogen and carbon capture are tiny despite the fanfare. Hydrogen received the least funding in 2022 at $1.1 billion (0.1%).

China dominates investment. China spends $546 billion on energy transition, half the global amount. Second, the US total of $141 billion in 2022 was up 11% from 2021. With $180 billion, the EU is unofficially second. China invested 91% in battery technologies.

The 2022 transition tipping point is encouraging, but the BNEF research shows how far we must go to get Net Zero. Energy transition investment must average $4.55 trillion between 2023 and 2030—three times the amount spent in 2022—to reach global Net Zero. Investment must be seven times today's record to reach Net Zero by 2050.

BNEF 2023 Energy Transition Investment Trends.

As shown in the graph above, BNEF experts have been using their crystal balls to determine where that investment should go. CCS and hydrogen are still modest components of the picture. Interestingly, they see nuclear almost fading. Active transport advocates like me may have something to say about the massive $4b in electrified transport. If we focus on walkable 15-minute cities, we may need fewer electric automobiles. Though we need more electric trains and buses.

Albert Cheung of BNEF emphasizes the challenge. This week's figures promise short-term job creation and medium-term energy security, but more investment is needed to reach net zero in the long run.

I expect the BNEF Energy Transition Investment Trends report to show clean tech investment outpacing fossil fuels investment every year. Finally saying that is amazing. It's insufficient. The planet must maintain its electric (not gas) pedal. In response to the research, Christina Karapataki, VC at Breakthrough Energy Ventures, a clean tech investment firm, tweeted: Clean energy investment needs to average more than 3x this level, for the remainder of this decade, to get on track for BNEFs Net Zero Scenario. Go!

From oil to attention.

Oil has been the most important commodity for a century. It's sparked wars. Pearl Harbor was a preemptive strike to guarantee Japanese access to Indonesian oil, and it made desert tribes rich. Oil's heyday is over. From oil to attention.

We talked about an information economy. In an age of abundant information, what's scarce? Attention. Scale of the world's largest enterprises, wealth of its richest people, and power of governments all stem from attention extraction, monetization, and custody.

Attention-grabbing isn't new. Humans have competed for attention and turned content into wealth since Aeschylus' Oresteia. The internal combustion engine, industrial revolutions in mechanization and plastics, and the emergence of a mobile Western lifestyle boosted oil. Digitization has put wells in pockets, on automobile dashboards, and on kitchen counters, drilling for attention.

The most valuable firms are attention-seeking enterprises, not oil companies. Big Tech dominates the top 4. Tech and media firms are the sheikhs and wildcatters who capture our attention. Blood will flow as the oil economy rises.

Attention to Detail

More than IT and media companies compete for attention. Podcasting is a high-growth, low-barrier-to-entry chance for newbies to gain attention and (for around 1%) make money. Conferences are good for capturing in-person attention. Salesforce paid $30 billion for Slack's dominance of workplace attention, while Spotify is transforming music listening attention into a media platform.

Conferences, newsletters, and even music streaming are artisan projects. Even 130,000-person Comic Con barely registers on the attention economy's Richter scale. Big players have hundreds of millions of monthly users.

Supermajors

Even titans can be disrupted in the attention economy. TikTok is fracking king Chesapeake Energy, a rule-breaking insurgent with revolutionary extraction technologies. Attention must be extracted, processed, and monetized. Innovators disrupt the attention economy value chain.

Attention pre-digital Entrepreneurs commercialized intriguing or amusing stuff like a newspaper or TV show through subscriptions and ads. Digital storage and distribution's limitless capacity drove the initial wave of innovation. Netflix became dominant by releasing old sitcoms and movies. More ad-free content gained attention. By 2016, Netflix was greater than cable TV. Linear scale, few network effects.

Social media introduced two breakthroughs. First, users produced and paid for content. Netflix's economics are dwarfed by TikTok and YouTube, where customers create the content drill rigs that the platforms monetize.

Next, social media businesses expanded content possibilities. Twitter, Facebook, and Reddit offer traditional content, but they transform user comments into more valuable (addictive) emotional content. By emotional resonance, I mean they satisfy a craving for acceptance or anger us. Attention and emotion are mined from comments/replies, piss-fights, and fast-brigaded craziness. Exxon has turned exhaust into heroin. Should we be so linked without a commensurate presence? You wouldn't say this in person. Anonymity allows fraudulent accounts and undesirable actors, which platforms accept to profit from more pollution.

FrackTok

A new entrepreneur emerged as ad-driven social media anger contaminated the water table. TikTok is remaking the attention economy. Short-form video platform relies on user-generated content, although delivery is narrower and less social.

Netflix grew on endless options. Choice requires cognitive effort. TikTok is the least demanding platform since TV. App video plays when opened. Every video can be skipped with a swipe. An algorithm watches how long you watch, what you finish, and whether you like or follow to create a unique streaming network. You can follow creators and respond, but the app is passive. TikTok's attention economy recombination makes it apex predator. The app has more users than Facebook and Instagram combined. Among teens, it's overtaking the passive king, TV.

Externalities

Now we understand fossil fuel externalities. A carbon-based economy has harmed the world. Fracking brought large riches and rebalanced the oil economy, but at a cost: flammable water, earthquakes, and chemical leaks.

TikTok has various concerns associated with algorithmically generated content and platforms. A Wall Street Journal analysis discovered new accounts listed as belonging to 13- to 15-year-olds would swerve into rabbitholes of sex- and drug-related films in mere days. TikTok has a unique externality: Chinese Communist Party ties. Our last two presidents realized the relationship's perils. Concerned about platform's propaganda potential.

No evidence suggests the CCP manipulated information to harm American interests. A headjack implanted on America's youth, who spend more time on TikTok than any other network, connects them to a neural network that may be modified by the CCP. If the product and ownership can't be separated, the app should be banned. Putting restrictions near media increases problems. We should have a reciprocal approach with China regarding media firms. Ban TikTok

It was a conference theme. I anticipated Axel Springer CEO Mathias Döpfner to say, "We're watching them." (That's CEO protocol.) TikTok should be outlawed in every democracy as an espionage tool. Rumored regulations could lead to a ban, and FCC Commissioner Brendan Carr pushes for app store prohibitions. Why not restrict Chinese propaganda? Some disagree: Several renowned tech writers argued my TikTok diatribe last week distracted us from privacy and data reform. The situation isn't zero-sum. I've warned about Facebook and other tech platforms for years. Chewing gum while walking is possible.

The Future

Is TikTok the attention-economy titans' final evolution? The attention economy acts like it. No original content. CNN+ was unplugged, Netflix is losing members and has lost 70% of its market cap, and households are canceling cable and streaming subscriptions in historic numbers. Snap Originals closed in August after YouTube Originals in January.

Everyone is outTik-ing the Tok. Netflix debuted Fast Laughs, Instagram Reels, YouTube Shorts, Snap Spotlight, Roku The Buzz, Pinterest Watch, and Twitter is developing a TikTok-like product. I think they should call it Vine. Just a thought.

Meta's internal documents show that users spend less time on Instagram Reels than TikTok. Reels engagement is dropping, possibly because a third of the videos were generated elsewhere (usually TikTok, complete with watermark). Meta has tried to downrank these videos, but they persist. Users reject product modifications. Kim Kardashian and Kylie Jenner posted a meme urging Meta to Make Instagram Instagram Again, resulting in 312,000 signatures. Mark won't hear the petition. Meta is the fastest follower in social (see Oculus and legless hellscape fever nightmares). Meta's stock is at a five-year low, giving those who opposed my demands to break it up a compelling argument.

Blue Pill

TikTok's short-term dominance in attention extraction won't be stopped by anyone who doesn't hear Hail to the Chief every time they come in. Will TikTok still be a supermajor in five years? If not, YouTube will likely rule and protect Kings Landing.

56% of Americans regularly watch YouTube. Compared to Facebook and TikTok, 95% of teens use Instagram. YouTube users upload more than 500 hours of video per minute, a number that's likely higher today. Last year, the platform garnered $29 billion in advertising income, equivalent to Netflix's total.

Business and biology both value diversity. Oil can be found in the desert, under the sea, or in the Arctic. Each area requires a specific ability. Refiners turn crude into gas, lubricants, and aspirin. YouTube's variety is unmatched. One-second videos to 12-hour movies. Others are studio-produced. (My Bill Maher appearance was edited for YouTube.)

You can dispute in the comment section or just stream videos. YouTube is used for home improvement, makeup advice, music videos, product reviews, etc. You can load endless videos on a topic or creator, subscribe to your favorites, or let the suggestion algo take over. YouTube relies on user content, but it doesn't wait passively. Strategic partners advise 12,000 creators. According to a senior director, if a YouTube star doesn’t post once week, their manager is “likely to know why.”

YouTube's kevlar is its middle, especially for creators. Like TikTok, users can start with low-production vlogs and selfie videos. As your following expands, so does the scope of your production, bringing longer videos, broadcast-quality camera teams and performers, and increasing prices. MrBeast, a YouTuber, is an example. MrBeast made gaming videos and YouTube drama comments.

Donaldson's YouTube subscriber base rose. MrBeast invests earnings to develop impressive productions. His most popular video was a $3.5 million Squid Game reenactment (the cost of an episode of Mad Men). 300 million people watched. TikTok's attention-grabbing tech is too limiting for this type of material. Now, Donaldson is focusing on offline energy with a burger restaurant and cloud kitchen enterprise.

Steps to Take

Rapid wealth growth has externalities. There is no free lunch. OK, maybe caffeine. The externalities are opaque, and the parties best suited to handle them early are incentivized to construct weapons of mass distraction to postpone and obfuscate while achieving economic security for themselves and their families. The longer an externality runs unchecked, the more damage it causes and the more it costs to fix. Vanessa Pappas, TikTok's COO, didn't shine before congressional hearings. Her comms team over-consulted her and said ByteDance had no headquarters because it's scattered. Being full of garbage simply promotes further anger against the company and the awkward bond it's built between the CCP and a rising generation of American citizens.

This shouldn't distract us from the (still existent) harm American platforms pose to our privacy, teenagers' mental health, and civic dialogue. Leaders of American media outlets don't suffer from immorality but amorality, indifference, and dissonance. Money rain blurs eyesight.

Autocratic governments that undermine America's standing and way of life are immoral. The CCP has and will continue to use all its assets to harm U.S. interests domestically and abroad. TikTok should be spun to Western investors or treated the way China treats American platforms: kicked out.

So rich,

Note-taking is a vital skill. But it's mostly learned.

Recently, innovative note-taking apps have flooded the market.

In the next few years, Evernote and Craft will be important digital note-taking companies.

Evernote is a 2008 note-taking program. It can capture ideas, track tasks, and organize information on numerous platforms.

It's one of the only note-taking app that lets users input text, audio, photos, and videos. It's great for collecting research notes, brainstorming, and remaining organized.

Craft is a popular note-taking app.

Craft is a more concentrated note-taking application than Evernote. It organizes notes into subjects, tags, and relationships, making it ideal for technical or research notes.

Craft's search engine makes it easy to find what you need.

Both Evernote and Craft are likely to be the major players in digital note-taking in the years to come.

Their concentration on gathering and organizing information lets users generate notes quickly and simply. Multimedia elements and a strong search engine make them the note-taking apps of the future.

Evernote and Craft are great note-taking tools for staying organized and tracking ideas and projects.

With their focus on acquiring and organizing information, they'll dominate digital note-taking in 2023.

Pros

• Concentrate on gathering and compiling information

• special features including a strong search engine and multimedia components

• Possibility of subject, tag, and relationship structuring

• enables users to incorporate multimedia elements

• Excellent tool for maintaining organization, arranging research notes, and brainstorming

Cons

• Software may be difficult for folks who are not tech-savvy to utilize.

• Limited assistance for hardware running an outdated operating system

• Subscriptions could be pricey.

• Data loss risk because of security issues

Evernote and Craft both have downsides.

1. The risk of data loss as a result of security flaws and software defects comes first.

2. Additionally, their subscription fees could be high, and they might restrict support for hardware that isn't running the newest operating systems.

3. Finally, folks who need to be tech-savvy may find the software difficult.

Evernote versus. Productivity Titans Evernote will make Notion more useful. medium.com