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 completely operating application requires many processes and technical challenges. Implementing coding standards can make apps right, work, and faster.

With years of experience working in software houses. Many client apps are scarcely maintained.

Why are these programs "barely maintainable"? If we're used to coding concepts, we can probably tell if an app is awful or good from its codebase.

This is how I coded much of my app.

Make It Work

Before adopting any concept, make sure the apps are completely functional. Why have a fully maintained codebase if the app can't be used?

The user doesn't care if the app is created on a super server or uses the greatest coding practices. The user just cares if the program helps them.

After the application is working, we may implement coding principles.

You Aren’t Gonna Need It

As a junior software engineer, I kept unneeded code, components, comments, etc., thinking I'd need them later.

In reality, I never use that code for weeks or months.

First, we must remove useless code from our primary codebase. If you insist on keeping it because "you'll need it later," employ version control.

If we remove code from our codebase, we can quickly roll back or copy-paste the previous code without preserving it permanently.

The larger the codebase, the more maintenance required.

Keep It Simple Stupid

Indeed. Keep things simple.

Why complicate something if we can make it simpler?

Our code improvements should lessen the server load and be manageable by others.

If our code didn't pass those benchmarks, it's too convoluted and needs restructuring. Using an open-source code critic or code smell library, we can quickly rewrite the code.

Simpler codebases and processes utilize fewer server resources.

Don't Repeat Yourself

Have you ever needed an action or process before every action, such as ensuring the user is logged in before accessing user pages?

As you can see from the above code, I try to call is user login? in every controller action, and it should be optimized, because if we need to rename the method or change the logic, etc. We can improve this method's efficiency.

We can write a constructor/middleware/before action that calls is_user_login?

The code is more maintainable and readable after refactoring.

Each programming language or framework handles this issue differently, so be adaptable.

Clean Code

Clean code is a broad notion that you've probably heard of before.

When creating a function, method, module, or variable name, the first rule of clean code is to be precise and simple.

The name should express its value or logic as a whole, and follow code rules because every programming language is distinct.

If you want to learn more about this topic, I recommend reading https://www.amazon.com/Clean-Code-Handbook-Software-Craftsmanship/dp/0132350882.

Standing On The Shoulder of Giants

Use industry standards and mature technologies, not your own(s).

There are several resources that explain how to build boilerplate code with tools, how to code with best practices, etc.

I propose following current conventions, best practices, and standardization since we shouldn't innovate on top of them until it gives us a competitive edge.

Boy Scout Rule

What reduces programmers' productivity?

When we have to maintain or build a project with messy code, our productivity decreases.

Having to cope with sloppy code will slow us down (shame of us).

How to cope? Uncle Bob's book says, "Always leave the campground cleaner than you found it."

When developing new features or maintaining current ones, we must improve our codebase. We can fix minor issues too. Renaming variables, deleting whitespace, standardizing indentation, etc.

Make It Fast

After making our code more maintainable, efficient, and understandable, we can speed up our app.

Whether it's database indexing, architecture, caching, etc.

A smart craftsman understands that refactoring takes time and it's preferable to balance all the principles simultaneously. Don't YAGNI phase 1.

Using these ideas in each iteration/milestone, while giving the bottom items less time/care.

You can check one of my articles for further information. https://medium.com/life-at-mekari/why-does-my-website-run-very-slowly-and-how-do-i-optimize-it-for-free-b21f8a2f0162

https://medium.com/life-at-mekari/what-you-need-to-make-your-app-a-high-availability-system-tackling-the-technical-challenges-8896abec363f

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