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 one in every of a two-part sequence on innovation in most cancers care supply. Partly one, we’ll focus on 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 traits of digital health-enabled most cancers care supply.
It is no secret: Most cancers is patently advanced.
Sufferers typically wrestle to understand the complexities of the U.S. well being system, and this confusion is commonly amplified after a affected person receives a most cancers analysis. 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 therapy protocols advance and other people stay longer, typically conquering a number of cancers of their lifetime, the right storm of continual illness will rise and problem our healthcare system in a wide range of methods.
With this enhance 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 exhibits most cancers has surpassed coronary heart illness because the primary explanation for dying in some high-income counties within the U.S., we’ve not seen the identical development and adoption of digital platforms for most cancers within the ways in which we have seen for different continual ailments akin to diabetes, musculoskeletal illness and continual 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 an important points of care supply, to determine the important thing traits 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 during the last 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 akin 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 concerning the reintegration of care (e.g., level options). As well as, new options should empower the care groups to convey the very best high quality instruments whereas additionally elevating affected person and supplier satisfaction — a tricky steadiness to strike.
In talking with Aaron Gerber, CEO and cofounder of Reimagine Care, he famous the mixing of correct instruments is not the one problem.
“When specialty medicine, we have to think about each complexity [to administer the drug] and margin it generates for the healthcare system. We will 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 major oncology crew,” he mentioned. “Performed properly, 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 danger of the perceived adjustments’ influence on profitability for current enterprise fashions typically stifle collaboration throughout stakeholders. Capital depth related to creating these strong options, typically tied to platform improvement 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 larger acuity affected person populations. Add to that the widening disparity of look after underserved and rural populations, historically served by group suppliers, and also you rapidly end up in a subject of competing incentives and lagging enterprise fashions.
Key parts of the most cancers care continuum have been highlighted under to phase 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 (akin 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 elements 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 points akin to analysis, therapy, survivorship and end-of-life care require robust coordination round different points akin to funds, training and household/caregiver assist planning.
Innovation is starting to take form in numerous methods. Startups proceed to handle unmet wants by filling care gaps and supplementing current therapy types. Nevertheless, companies which have historically been non-revenue-generating appear to be a standard 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 earnings within the short-term and display worth to stakeholders akin to well being techniques and payers stays an open query.
Regardless of preserving points 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 corporations are driving innovation ahead), essentially the most distinguished startup exercise for care supply has been in diagnostic companies, therapy coordination and threat enablement.
On the sooner facet of the affected person continuum, prevention and threat 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 will likely be troublesome; aligning incentives will likely be important. We anticipate survivorship companies (most notably, group and diet companies) will proceed to combine extra tightly upstream with points of acute care supply and recurrence prevention (e.g., screening, analysis).
On this market map, we spotlight a number of startups innovating throughout key classes. (See the broader Flare presentation right here.)
Therapy: Leveraging information, care coordination and affected person assist instruments to enhance determination making
Therapy is on the core of most cancers care supply, and we see varied options being constructed throughout the class. A lot of the current most cancers therapy plans include three core companies: surgical intervention, systemic remedy and radiation therapy. Relying on the stage and presenting most cancers, surgical intervention is commonly the primal type of therapy for early-stage diagnoses, and it is typically complemented or augmented with each systemic (chemo, hormone and immunotherapy) and radiation remedy.
Startups, nonetheless, are addressing challenges round therapy pathways in numerous methods, specializing in issues akin to navigation, coordination, therapy suggestions (for an knowledgeable shopper) and affected person assist. We’ve additionally referred to as out house care, given the rise of at-home therapy choices (akin to house infusion remedy and lab assessments), though we acknowledge many points of house care in oncology fall below different classes akin to screening and analysis.
The trade has additionally seen a drastic enhance within the availability of information (e.g., claims, EMR, diagnostics, imaging) during the last 20 years to higher handle most cancers sufferers. Along with Flatiron Well being, there have been varied information platforms, marketplaces (HealthVerity, Graphite Well being) and analytics-ready information enablers (Mendel, Aetion) rising to make information extra accessible to researchers and clinicians. Nevertheless, many challenges nonetheless exist for clinicians managing their sufferers by means of an evidence-based method.
“Well being techniques at present are sometimes not set as much as make choices based mostly on real-world information. Medical trial information and different printed information is available, however organizations are starting to make the shift from the established order of printed proof (expertise-driven) to real-world proof (data-driven method) in scientific follow,” mentioned 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 corporations (e.g, Atropos Well being) or these internally developed by well being techniques and tutorial medical facilities, are anticipated to emerge within the coming years to drive extra customized therapy protocols.
The primary space we unbundle throughout the therapy class is navigation.
Navigation
As expertise continues to embed itself throughout the most cancers care continuum, extra alternatives have arisen for expertise to bridge the hole between current therapy regimes and finally present extra holistic and customized ranges of most cancers care. Even when core therapies aren’t essentially altering (e.g., surgical intervention), sufferers and physicians can fine-tune points of care to the affected person utilizing information and automation to assist the administration of signs, unwanted effects, eating regimen monitoring, appointments, affected person funds and general coordination of in any other case disparate points of care.
Navigation companies are in some ways the bedrock for sufferers navigating the complexities of care, and these companies play a important function to handle affected person’s largely unmet wants. Gamers akin to Jasper Well being supply digital care administration instruments and a library of sources to help sufferers with every part from dealing with unwanted effects to monetary planning.
Care Coordination
Care coordination is a sizeable sub-category inside therapy that features determination assist instruments to help physicians with managing affected person wants and, in concept, scale back administrative burden. One instance, Preveta, is a care coordination platform that takes illness protocols and interprets them into customized care navigation workflows. By means of automated dashboards and refined information seize, techniques intention to allow the clinician to seize further affected person information between visits. In flip, the software program may also help assess the information and get it again into the fingers of the medical doctors rapidly to enhance therapy.
One other facet of care coordination consists of 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 means of 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. Partaking payers early additionally turns into an essential issue for organizations looking for to allow threat and handle bundled companies.
Alternatively, the route of amassing and aggregating affected person information by means of digital affected person assist instruments can turn into a gorgeous alternative for pharmaceutical corporations that search to faucet into distinctive affected person datapoints (akin to social determinants of well being), which may also help inform drug adoption and adherence, scientific trial enablement and a number of points of drug improvement.
Therapy Suggestions and Affected person Assist
As affected person information 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, scientific determination assist (CDS) instruments and next-generation analytics corporations that may present the “so-what” will play a central function in therapy suggestion and affected person administration.
Whereas Merative (previously IBM Watson Well being) and different CDS distributors primarily depend on publicly obtainable pointers and analysis publications, a brand new class of digital well being startups augments current pointers with real-world information (RWD) and real-world proof (RWE) to supply a extra data-driven method of treating most cancers sufferers.
“You want RWE and analytics and determination assist that oncologists can get behind,” mentioned Dan McCarthy, CEO of New Century Well being and president of Evolent Well being.
Gamers akin to Atropos Well being present options that assist physicians reply beforehand unanswered scientific questions utilizing real-world scientific and administrative information in a well timed method. Digital well being corporations akin to Outcomes4Me and Ciitizen emerge and attempt to assist most cancers sufferers of their journey to discovering the precise therapy choices, and applicable scientific trials, by means of 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 corporations search to achieve entry to extra longitudinal information to assist decision-making.
Residence-Primarily based Most cancers Care
The shift to home-based look after most cancers has been in improvement for over a decade, however the current adjustments within the regulatory setting 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 want for care administered within the house, and growing pressures on the system as a consequence 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 reasonably priced and extra accessible. Whereas others akin to Inbound Well being and Medically Residence 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 completely on most cancers sufferers.
Questions stay across the stage of involvement that well being techniques and payers may have within the enlargement 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 value when creating these home-based capabilities for most cancers.
As startups proceed to make progress in sure areas of the therapy pathway, we count on to see increasingly well being techniques and payers looking for partnerships with outdoors organizations as they increase their hospital-at-home and home-based companies.
Enablement and Danger-Bearing Entities: An effort to essentially shift the enterprise mannequin of most cancers care to worth
Previously, oncologists have been fairly nervous about taking dangers, even professionally, as a consequence of nervousness round specialty drug prices. For many medical teams, the expertise 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 typically ends in a rate-limiting step for contracting.
Whereas challenges persist, current traits have enabled increasingly oncology teams to start shifting towards threat. As Shawn Morris, CEO of Privia Well being, mentioned, “When requested concerning the chance by buyers and analysts, there are a couple of specialties which might be excessive quantity and might underwrite the danger from an actuarial standpoint in Medicare —orthopedics, GI, urology, ophthalmology and oncology. The success of shifting into value-based preparations and threat relies on correct alignment with physicians and payers and having the mandatory instruments, expertise and expertise (information) to handle threat.”
Alternatives are increasing for startups and oncology teams to start out with skilled capitation and finally transfer upstream. These preparations are principally 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 threat is feasible in case you design the precise methodology,” Robin Shah, CEO and cofounder of Thyme Care, mentioned. “This requires a deep understanding of the affected person past their scientific components, and to construct that understanding you should develop trusted relationships with members. With out these relationships in place, you gained’t have the ability to affect conduct change.”
Totally different Approaches
We see innovation in threat enablement taking many types. Whether or not it’s corporations akin to Transcarent (e.g., lately introduced Transcarent Oncology Care) looking for to overtake the employer self-insured enterprise or corporations taking a data-driven method to enhancing broader affected person care pathways, specializing in points akin to tumor boards, many enablement platforms are rising that drive collaboration throughout sufferers, suppliers and payers. Different gamers, akin to Azra AI, are utilizing synthetic intelligence to interpret information in real-time to tell analysis by means of care administration. Thyme Care gives a nursing-led platform that’s geared up with information and analytics to proactively assist most cancers sufferers’ determination making and coordination all through the method. Cohere Well being seems to be to align scientific and monetary choices 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 strategy to navigate members to high-quality, low-cost care, even when which means shifting them to the perfect and least costly facility in a patient-friendly method. Current enterprise fashions have an essential cost-focused distinction that’s essentially totally different in some ways in contrast with the normal, 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 typically 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 may be adopted extra rapidly. 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 side for accelerating the evolution of the most cancers enterprise mannequin.
Screening and Prognosis: Tech developments and home-enabled companies producing distinctive entry factors
Early most cancers screening and analysis can typically be the distinction between life and dying for most cancers sufferers. In accordance with the American Most cancers Society, the 5-year relative survival fee 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, outstanding enhancements in applied sciences have allowed physicians to seek out most cancers at an early stage, lengthy earlier than signs seem. From higher imaging procedures to numerous breakthrough diagnostic assessments (e.g., liquid biopsy, single-cell genomic testing, multi-OMICs), the flexibility to display and diagnose cancers has taken a large leap ahead.
Diagnostics
Important enhancements in sequencing expertise and price led to the rise of corporations like GRAIL, which pitches a multi-cancer early detection check that may display over 50 sorts of most cancers by means of a single blood draw for roughly $1,000. Along with enhancing novel screening and diagnostic assessments, private and non-private sectors have additionally achieved their fair proportion of elevating most cancers screening consciousness and enhancing entry. From varied 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 Rankings measurement, screening and detection play a entrance and heart function 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 function in addressing these unmet wants. From a affected person entry to screening standpoint, we’ve seen non-invasive, home-based diagnostic assessments, akin to Cologuard, which might be getting used and promoted by payers over the previous decade (e.g., Humana to cowl Cologuard for colorectal most cancers screening).
Modern digital well being and home-based diagnostics corporations (e.g., EverlyWell) have emerged over the previous decade to enhance entry to diagnostic assessments that may be achieved at point-of-care or with samples collected at house. It’s not inconceivable that platforms like EverlyWell will transfer past well being and wellness assessments and use their person base to enhance most cancers screening and detection. Different rising gamers that may dramatically scale back entry limitations embrace house phlebotomy corporations (e.g., GetLabs, Sprinter Well being) that would make the blood draw extra accessible. They’ll additionally help in ongoing affected person administration for these sufferers who’re finally identified with most cancers and may very well be enrolled in home-based most cancers administration and scientific trials.
Schooling
Educating sufferers on the influence of scientific therapy and way of life change stays a largely unmet want, no matter affected person acuity or circumstance. Most cancers facilities have taken a proactive step during the last 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 typically 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 widespread areas of unmet want: psychological, bodily and healthcare companies info.
A number of the largest academic gaps for sufferers lie in the advantages and unwanted effects of therapy in addition to way of life adjustments, each after the preliminary analysis and when transitioning from energetic therapy to survivorship. Schooling and care coordination startups are beginning to emerge that empower their sufferers with instruments akin to automated facet impact assist (e.g., Ankr) that may help in ongoing, asynchronous affected person administration to supply essential continual administration and inhabitants well being information.
Survivorship: An emergence of digital-hybrid communities and diet assist to assist with a affected person’s altering way of life
Sufferers will want extra individualized assist as therapy and affected person administration turn into extra focused and customized. In at present’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 akin to Encourage and That is Dwelling With Most cancers have emerged to supply group assist and steerage on therapy choices in more moderen years.
Along with peer assist networks, expert-guided digital clinics, akin to VivorCare, have emerged to supply personalized assist and tailor-made applications that assist most cancers survivors handle their care outdoors the hospital setting, beginning with applications designed for psychological well being. Diet-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 Diet, Season Well being) which might be properly positioned to fill the hole for oncology sufferers with food-as-medicine, much like how these gamers are managing sufferers with continual ailments akin to diabetes.
Concerning the Authors: Ian Chiang is a accomplice at Flare Capital Companions, a healthcare expertise 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 marketing consultant 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 marketing consultant at Chartis centered on well being techniques and companies.
A particular due to Aaron Gerber, Dan McCarthy, Matt Bettonville, Ryan Langdale, Robin Shah, Shawn Morris and numerous others for offering their time and insights by means of 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.
