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!

It's kids' digital crack

TikTok is a destructive social media platform.

• The interface shortens attention spans and dopamine receptors.

• TikTok shares more data than other apps.

• Seeing an endless stream of dancing teens on my glowing box makes me feel like a Blade Runner extra.

TikTok did in one year what MTV, Hollywood, and Warner Music tried to do in 20 years. TikTok has psychotized the two-thirds of society Aldous Huxley said were hypnotizable.

Millions of people, mostly kids, are addicted to learning a new dance, lip-sync, or prank, and those who best dramatize this collective improvisation get likes, comments, and shares.

TikTok is a great app. So what?

The Commercial Magnifying Glass TikTok made me realize my generation's time was up and the teenage Zoomers were the target.

I told my 14-year-old sister, "Enjoy your time under the commercial magnifying glass."

TikTok sells your every move, gesture, and thought. Data is the new oil. If you tell someone, they'll say, "Yeah, they collect data, but who cares? I have nothing to hide."

It's a George Orwell novel's beginning. Look up Big Brother Award winners to see if TikTok won.

TikTok shares your data more than any other social media app, and where it goes is unclear. TikTok uses third-party trackers to monitor your activity after you leave the app.

Consumers can't see what data is shared or how it will be used. — Genius URL

32.5 percent of Tiktok's users are 10 to 19 and 29.5% are 20 to 29.

TikTok is the greatest digital marketing opportunity in history, and they'll use it to sell you things, track you, and control your thoughts. Any of its users will tell you, "I don't care, I just want to be famous."

TikTok manufactures mental illness

TikTok's effect on dopamine and the brain is absurd. Dopamine controls the brain's pleasure and reward centers. It's like a switch that tells your brain "this feels good, repeat."

Dr. Julie Albright, a digital culture and communication sociologist, said TikTok users are "carried away by dopamine." It's hypnotic, you'll keep watching."

TikTok constantly releases dopamine. A guy on TikTok recently said he didn't like books because they were slow and boring.

The US didn't ban Tiktok.

Biden and Trump agree on bad things. Both agree that TikTok threatens national security and children's mental health.

The Chinese Communist Party owns and operates TikTok, but that's not its only problem.

• There’s borderline child porn on TikTok

• It's unsafe for children and violated COPPA.

• It's also Chinese spyware. I'm not a Trump supporter, but I was glad he wanted TikTok regulated and disappointed when he failed.

Full-on internet censorship is rare outside of China, so banning it may be excessive. US should regulate TikTok more.

We must reject a low-quality present for a high-quality future.

TikTok vs YouTube

People got mad when I wrote about YouTube's death.

They didn't like when I said TikTok was YouTube's first real challenger.

Indeed. TikTok is the fastest-growing social network. In three years, the Chinese social media app TikTok has gained over 1 billion active users. In the first quarter of 2020, it had the most downloads of any app in a single quarter.

TikTok is the perfect social media app in many ways. It's brief and direct.

Can you believe they had a YouTube vs TikTok boxing match? We are doomed as a species.

YouTube hosts my favorite videos. That’s why I use it. That’s why you use it. New users expect more. They want something quicker, more addictive.

TikTok's impact on other social media platforms frustrates me. YouTube copied TikTok to compete.

It's all about short, addictive content.

I'll admit I'm probably wrong about TikTok. My friend says his feed is full of videos about food, cute animals, book recommendations, and hot lesbians.

Whatever.

TikTok makes us bad

TikTok is the opposite of what the Ancient Greeks believed about wisdom.

It encourages people to be fake. It's like a never-ending costume party where everyone competes.

It does not mean that Gen Z is doomed.

They could be the saviors of the world for all I know.

TikTok feels like a step towards Mike Judge's "Idiocracy," where the average person is a pleasure-seeking moron.

No Paid Ads Required

I had an online store. After a year of running the company alongside my 9-to-5, I made enough to resign.

That day was amazing.

This Instagram marketing plan helped the store succeed.

How did I increase my sales to five figures a month without using any paid advertising?

I used customer event marketing.

I'm not sure this term exists. I invented it to describe what I was doing.

Instagram word-of-mouth, fan engagement, and interaction drove sales.

If a customer liked or disliked a product, the buzz would drive attention to the store.

I used customer-based events to increase engagement and store sales.

Success!

Here are the weekly Instagram customer events I coordinated while running my business:

• Be the Buyer Days

• Flash sales

• Mystery boxes

Be the Buyer Days: How do they work?

Be the Buyer Days are exactly that.

You choose a day to share stock selections with social media followers.

This is an easy approach to engaging customers and getting fans enthusiastic about new releases.

First, pick a handful of items you’re considering ordering. I’d usually pick around 3 for Be the Buyer Day.

Then I'd poll the crowd on Instagram to vote on their favorites.

This was before Instagram stories, polls, and all the other cool features Instagram offers today. I think using these tools now would make this event even better.

I'd ask customers their favorite back then.

The growing comments excited customers.

Then I'd declare the winner, acquire the products, and start selling it.

How do flash sales work?

I mostly ran flash sales.

You choose a limited number of itemsdd for a few-hour sale.

We wanted most sales to result in sold-out items.

When an item sells out, it contributes to the sensation of scarcity and can inspire customers to visit your store to buy a comparable product, join your email list, become a fan, etc.

We hoped they'd act quickly.

I'd hold flash deals twice a week, which generated scarcity and boosted sales.

The store had a few thousand Instagram followers when I started flash deals.

Each flash sale item would make $400 to $600.

$400 x 3= $1,200

That's $1,200 on social media!

Twice a week, you'll make roughly $10K a month from Instagram.

$1,200/day x 8 events/month=$9,600

Flash sales did great.

We held weekly flash deals and sent social media and email reminders. That’s about it!

How are mystery boxes put together?

All you do is package a box of store products and sell it as a mystery box on TikTok or retail websites.

A $100 mystery box would cost $30.

You're discounting high-value boxes.

This is a clever approach to get rid of excess inventory and makes customers happy.

It worked!

Be the Buyer Days, flash deals, and mystery boxes helped build my company without paid advertisements.

All companies can use customer event marketing. Involving customers and providing an engaging environment can boost sales.

Try it!

What they'll do is scarier.

My acquaintance recently joined a VC-funded startup. Money, equity, and upside possibilities were nice, but he had a nagging dread.

They just secured a $40M round and are hiring like crazy to prepare for their IPO in two years. All signals pointed to this startup's (a B2B IT business in a stable industry) success, and its equity-holding workers wouldn't pass that up.

Five months after starting the work, my friend struggled with leaving. We might overlook the awful culture and long hours at the proper price. This price plus the company's fate and survival abilities sent my friend departing in an unpleasant unplanned resignation before jumping on yet another sinking ship.

This affects founders. This affects VC-backed companies (and all businesses). This affects anyone starting, buying, or running a business.

Here's the under-the-table approach that's draining VC capital, leaving staff terrified (or jobless), founders rattled, and investors upset. How to recognize, solve, and avoid it

The unsettling reality behind door #1

You can't raise money off just your looks, right? If "looks" means your founding team's expertise, then maybe. In my friend's case, the founding team's strong qualifications and track records won over investors before talking figures.

They're hardly the only startup to raise money without a profitable customer acquisition strategy. Another firm raised money for an expensive sleep product because it's eco-friendly. They were off to the races with a few keywords and key players.

Both companies, along with numerous others, elected to invest on product development first. Company A employed all the tech, then courted half their market (they’re a tech marketplace that connects two parties). Company B spent millions on R&D to create a palatable product, then flooded the world with marketing.

My friend is on Company B's financial team, and he's seen where they've gone wrong. It's terrible.

Company A (tech market): Growing? Not quite. To achieve the ambitious expansion they (and their investors) demand, they've poured much of their little capital into salespeople: Cold-calling commission and salary salesmen. Is it working? Considering attrition and companies' dwindling capital, I don't think so.

Company B (green sleep) has been hiring, digital marketing, and opening new stores like crazy. Growing expenses should result in growing revenues and a favorable return on investment; if you grow too rapidly, you may neglect to check that ROI.

Once Company A cut headcount and Company B declared “going concerned”, my friend realized both startups had the same ailment and didn't recognize it.

I shouldn't have to ask a friend to verify a company's cash reserves and profitability to spot a financial problem. It happened anyhow.

The frightening part isn't that investors were willing to invest millions without product-market fit, CAC, or LTV estimates. That's alarming, but not as scary as the fact that startups aren't understanding the problem until VC rounds have dried up.

When they question consultants if their company will be around in 6 months. It’s a red flag. How will they stretch $20M through a 2-year recession with a $3M/month burn rate and no profitability? Alarms go off.

Who's in danger?

In a word, everyone who raised money without a profitable client acquisition strategy or enough resources to ride out dry spells.

Money mismanagement and poor priorities affect every industry (like sinking all your capital into your product, team, or tech, at the expense of probing what customer acquisition really takes and looks like).

This isn't about tech, real estate, or recession-proof luxury products. Fast, cheap, easy money flows into flashy-looking teams with buzzwords, trending industries, and attractive credentials.

If these companies can't show progress or get a profitable CAC, they can't raise more money. They die if they can't raise more money (or slash headcount and find shoestring budget solutions until they solve the real problem).

The kiss of death (and how to avoid it)

If you're running a startup and think raising VC is the answer, pause and evaluate. Do you need the money now?

I'm not saying VC is terrible or has no role. Founders have used it as a Band-Aid for larger, pervasive problems. Venture cash isn't a crutch for recruiting consumers profitably; it's rocket fuel to get you what and who you need.

Pay-to-play isn't a way to throw money at the wall and hope for a return. Pay-to-play works until you run out of money, and if you haven't mastered client acquisition, your cash will diminish quickly.

How can you avoid this bottomless pit? Tips:

• Understand your burn rate

• Keep an eye on your growth or profitability.

• Analyze each and every marketing channel and initiative.

• Make lucrative customer acquisition strategies and satisfied customers your top two priorities. not brand-new products. not stellar hires. avoid the fundraising rollercoaster to save time. If you succeed in these two tasks, investors will approach you with their thirsty offers rather than the other way around, and your cash reserves won't diminish as a result.

Not as much as your grandfather

My family friend always justified expensive, impractical expenditures by saying it was only monopoly money. In business, startups, and especially with money from investors expecting a return, that's not true.

More founders could understand that there isn't always another round if they viewed VC money as their own limited pool. When the well runs dry, you must refill it or save the day.

Venture financing isn't your grandpa's money. A discerning investor has entrusted you with dry powder in the hope that you'll use it wisely, strategically, and thoughtfully. Use it well.