Rebecca Mitchell, MD
@RebeccaCoelius
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Investor and Product Doc | Managing Partner at Scrub Capital, EVP @ViveCollective | Modern Brady Bunch family of 7 | Former Livongo, UCSF, HHS
San Francisco
Joined January 2009
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@nickmmark
Reason 10,000 it’s terrifying sometimes to be a patient. “Do I have a Bruce today, or is this physician speaking with their actual specialized training and recent practice experience.”
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@halletecco
@AIHealthUncut
Just this year through VC backed digital health:
1. Saved $300 on a prescription with GoodRx
2. Was FINALLY properly diagnosed with early menopause and experienced life altering symptom improvement on low dose estrogen through Midi
3. Using DTC lab ordering and a lipidoligist I
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I continue to be flabbergasted by how well virtual clinics are growing via referrals from clinicians in the larger health ecosystem if it’s in an area with an access / waitlist problem.
We all screwed up spending years trying to sell to clinicians instead of doing this. And A
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Are you bootstrapping in healthcare? I would love to talk to you.
Bootstrapping early stage until you are ready for a growth round is a current darling concept in mainstream tech, but I admittedly don’t see many examples in healthcare (outside clinicians starting private
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@jeremyphoward
Genuine question - what would a non cringe dev day look like? As half the things you are making fun of in the screenshot do materially move humanity forward if adopted en masse, while the other half sparks forward thinking about applications of the technology in daily life.
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I am 40 years old and by far the most popular event I’ve ever helped put together is a panel for clinicians interested in product work as a way to reshape health care at scale.
We hit the max event size in < 24 hours, even after we filtered for clinicians with serious sounding
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@TaraViswanathan
VC here- I am delighted when I receive a memo vs deck, and hear similar from other former operators. I can see the thinking and hear your story much more clearly in concise writing than a deck.
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@nikillinit
It’s a mind F.
You are super proud, and maybe a little too proud for your level of constribution and how much was luck.
You are rich on paper well before any of it is liquid. And then you can’t leave and are paranoid of getting fired bc you can’t afford to exercise.
And
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@chiglinsky
@chrissyfarr
Ok but as counterpoint - this except they were so sure it was my cat, we actively getting rid of cat and I demanded broader testing. Guess who isn’t allergic to cats?
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I am suddenly flooded with requests to help recruit great mid/senior IC and Head of Product/CPO candidates with significant experience building in digital health. Not sure what’s changed, but send me a DM if you are open to hearing about these opps!
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Just hugely impressed a Founder bc I know what a FQHC is.
This is not a humble brag. This is despair over the bar being SO LOW.
Come on people.
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A year into VC, I still often feel more like the Founders than other investors when navigating this industry. I’m going to start saying what insiders think is super obvious out loud (but is not) in hopes it helps other people. Here goes.
The “use of funds” plan in a pitch is
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Kaiser isn’t perfect, but they are nailing hybrid care. In less than 10 minutes:
- E-Visit for simple complaint, basically a brief questionnaire
- Within 5 minutes, an asynch message confirming diagnosis and prescription
- I order 24 hour home delivery, set up med reminders
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After 3 great days at
#HLTH2023
I can’t shake the feeling that we have two event horizons in front of us in AI and GLP-1 like drugs. Everyone sorta knows we are about to play a very different game, but doesn’t yet understand the rules.
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@chrissyfarr
My experience is that as soon as I flood them with toys and clothing for a given obsession, they find a new one…
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@rikrenard
I call bs on this being the reason. Most (not all) health systems treat their engineers like “IT and tech support”. Not people empowered to get close to problems and collaboratively define and ship solutions. Same reason they seldom recruit the best PMs, designers.
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Headed to
#ViVE2024
with a full heart and very dusty shoes after a week with all 5 kids in Arizona. Little is logistically easy in our blended family, but we are lucky to never be short on love or adventure.
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@anothercohen
It struck me the other day that I feel much physically and mentally healthier at 39 than at any earlier point in my life.
Our societal and internal framing that 50+ years of average lifespan = “old” is pathological.
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I just heard Epic shut Particle off from the HIEs. Widespread impact to Particle customers. Can anybody confirm or explain what’s going on?
@healthapiguy
?
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It’s trendy to knock on point solutions, but I’ve had some of my best healthcare experiences ever recently with condition focused virtual clinics.
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While true that ambient note taking will become a commodity capability, it is equally true that the companies currently winning on distribution are VASTLY better positioned to take on the next set of Gen AI in healthcare use cases. If you think they will own scribing and then sit
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I met a physician last night who started an AI CoPilot company that he’s been using during ED shifts, and now it’s quickly spreading to his colleagues in the same facility and others in the region. While he built it using best practice for security/privacy etc, it was not
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Insiders who never stop questioning the system paired with humble outsiders with complementary skills are unbeatable teams in healthcare.
(They are also vastly less annoying than insiders who think they know everything, or outsiders who think everyone who built the system must
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There is a lot of scary news lately about clinicians leaving medicine.
But its not the whole story - many are building the healthcare system of tomorrow they are eager to practice in and receive care from.
Great article from
@chrissyfarr
out today
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The Clinicians who VC group has launched! Co-instigators
@chrissyfarr
@slotkinjr
and I want to see more clinicians on cap tables and influencing funding decisions. Interest has been off the charts, plz use this form to nominate yourself or others
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Inspired by the
@OscarHealth
alumni -> founder list, our team is creating a public list of OG digital health Operators turned Founders to celebrate the journeys and our digital health mafias. We will interview many for an upcoming article. Please help!
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The first good acquisition or IPO of an at scale, decent growth + *profitable* tech enabled services co is going to be a huge unlock for the industry.
It is hard to overstate how much comps to the ZIRP cos hemorrhaging cash and traditional brick and mortar is hurting new
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Recently
@chrissyfarr
@slotkinjr
and I started a group for clinicians who already participate in or want to dive into the startup and venture ecosystem- Clinicians who VC
I recently posted a search for 2 interns at the Vive Collective. The response was overwhelming from early
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The naïveté of people who have never managed a P+L more complex than the family budget consistently astounds me.
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I beat my forehead against the wall of clinician referrals into digital health + virtual care products for ten years.
This week I met several virtual clinic cos w/ a primary patient acquisition channel via brick and mortar clinics over capacity. And hear there are many more.
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Every place I’ve worked with clinicians on staff had a giant text message thread where we exchanged pics of our family’s throats, rashes, asks for referral reccs, etc amidst the work banter. Hard to relate to the furor around this concept, other than ensuring it’s compensated.
SMS-based care should be a first line of defense. Here’s a reason why:
Often the treatment is no treatment. But going to a clinic, patients feel they should walk out with something (a script). SMS care allows us to feel we got checked in on, without needing that something extra.
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I’m not shaking my product roots as an investor, and spend a lot of time with users and customers
Countless times this year I’ve heard that people want a whole lifestyle program for daily support, that hooks into medical models if needed. Huge opp here - this is not wellness.
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One of the wildest things to me at conferences and in the press is how much air time is given to official sanctioned speakers going on about the hot theme of the moment in digital health and how their company is investing in it, while everyone who works there knows it’s bs.
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I don’t pretend to be a good investor yet.
But every time I see another article on “current benchmarks for good V bad healthcare companies” I remind myself that 0 top tier investors talk about making money by chasing what has historically worked and what the herd is thinking
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Imagine what would be possible if we didn’t need to justify most new spend in healthcare on a one year returns timeline.
Real investment in childhood obesity? Caring about heart health in your 20s and 30s instead of once you hit a ten year risk threshold?
This is the deep
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Digital health pays less than other tech verticals and gets good people on mission. Are your engineers brought in early to collaboratively understand interesting problems, and define/test solutions? Or tossed “engineer work” way downstream? A good R+D person can smell those 🚩🚩
Just spoke with a CIO at a major health system. They're offering $170K base salaries and just can't snag go engineering talent.
Why? Startups are outbidding them like crazy.
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I struggle with conversations around physician shortages that ignore the BILLIONS of people without access to decent healthcare around the world.
If you aren’t designing for that level of care expansion, you aren’t solving the real problem.
YES we should pay certain
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Anybody have a great recruiter for clinicians transitioning into partial or full time roles in digital health? I do tons of these calls myself and love supporting others early in the journey, but the volume is getting challenging and there must be people specializing in this.
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@mjc565
@DrLeanaWen
I don’t understand replies like this. Nobody is arguing COVID has a 100% mortality rate. So… good for you, but what point are you making?
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RIP Cormac McCarthy, whose final paragraph of The Road is both writing perfection and made me understand in my bones what we have to lose.
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The number of people popping up to say the product was terrible in this thread and others makes me think we should not attach any sweeping takeaways about the value of telehealth to it…
You have to get to the nuance of what problems it was being used for, how it was marketed,
What are people's smart takes on Optum getting out of the telehealth biz? Confirmed yesterday.
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@nikillinit
How you feel after you eventually leave whether you got rich or not is another worthwhile question.
It’s shocking to realize how much of your identity and life was wrapped up in the rocket ship. And then that’s gone and it’s just money in the bank and the industry quickly moves
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After multiple refill cycles trying to make a big brand pharmacy pickup and mail order work, then transferring between multiple startup pharmacies that were too slow or annoying or expensive (including the father of all coupon aggregators) I finally tried Amazon pharmacy.
Holy
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current CGM furor:
Medicine: we need people engaging with their health to prevent disease!
Person: my CGM is teaching me so much!
Medicine: not like that outside the system!
Person: ok so my questions about cardiometabolic health are..
Medicine: NO DEFINITELY NOT LIKE THAT
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@jkvedar
Tripping over whether to say user / consumer / member / patient / person depending on the audience
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I was lucky to be referred the same coach by Chrissy. Could not agree more that she is individually exceptional, and that this kind of work is an enormous unlock especially for women.
For the first time about six months ago, I started working with an executive coach. I am sure there are a lot of not great ones out there, but this coach has utterly changed my way of thinking. Probably also shortcut a few years of therapy. Essential work.
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@Bob_Wachter
@ashishkjha
@AshishKJha46
@CDCgov
I was with you until the “it’s unreasonable to ask people to mask to protect a few babies (I assume you mean under 5, not only babies) on the plane”. Seriously?
You also gloss over the ventilation issues during onboarding and deplaning. We sit in a CO2 cesspool.
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Can anybody explain who IS allowed to invest in or own at scale care delivery if this passes? ACA already said no more physician owned hospitals.
Only risk adverse banks and existing corp medicine structures that aren’t PE backed?
To be clear I take serious issue with
I spoke with three legal experts to dig into a California bill that could kill the friendly PC model in digital health. This is a very big deal. If you are in digital health, you should know about it.
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Super fun to meet and walk with a bunch of the Clinicians who VC in person! Best way to kick off
#HLTH2023
@chrissyfarr
@slotkinjr
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I truly love all the emphasis on women’s health right now, but why are the plays currently so divorced from the caregiver needs we have with kids? There is a big spike around fertility and having the baby, then nothing other than Telehealth for the next 18 years.
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Here is my only contribution to the career actualization hacking community:
Including a pic of your new puppy in life update / let’s reconnect emails = 100% response rate.
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A red flag on a team is someone insisting they “speak for the users/patients because they know them best”. Clinicians and designers are the biggest culprits.
Don’t do this. Spend the money and time on research to let people speak for themselves, and ensure the whole team can
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I’m convinced price transparency hasn’t worked yet because it has to be paired with a fintech product that smooths out the inevitable unexpected costs and the bullshit wrangling of all the different payment sources.
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@caleb_bank
What to learn if you are building:
- CAC is going through the roof on much of DTC care
- most valuations from last 12 mths are 🤡
- hybrid care is what users, buyers want. Those paying attention know Teladoc strategically pivoted > 2 years ago, but takes time to build, sell.
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@B_Madden4
PCPs absolutely are saints and the problems primary care exists to solve in the industry are profoundly important.
But there are options here beyond everyone doing mostly the exact same model but just changing the inputs to be less capital intensive, or the business model so
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@EWeinzap
@chiglinsky
@chrissyfarr
Oh happily it was caught in time!
An assumption we for sure knew the cause without testing for other possibilities. New cat arrival was correlated with allergies.
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As I struggle to submit FSA and HSA expenses I’m reminded again that all of our datapoints about “consumers making cost conscious healthcare decisions” are trash when it’s this impossible to shop or pay for even routine services.
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Lots of hustle talk over thanksgiving, celebrating hanging out in Discord instead of with family.
There is definitely a time for this and the quiet quitting culture the last few years sucked.
But burnout is real and it can take years to recover. Respect your nervous system.
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I have no insider insight on whether they can come back. But damn is it refreshing to hear a leader address this so publicly, so unflinchingly, and with the energy and conviction to pull it off shining through.
I still think that to be a real company, you have to be a public company. But I can confirm that losing 94% of your value is as soul-crushing as it seems (not to mention for our investors). I always felt confident that we had all the bones to get the company on track, but when
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THIS is why I’m so bullish on partnering with clinician innovators to scale better clinical models with tech and virtual care teams.
The biggest product opportunities are when you can find a market where a small number of people have figured out how to solve an important problem, and you can design a simpler, more cost effective, and more scalable solution to that problem.
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Yes people have preferences for how their healthcare problems are solved, but they care a whole lot more that their problems GET SOLVED. Right now we are failing a lot of people. Do not underestimate how fast things can change if a viable alternative emerges.
healthcare is having its top deck of the titanic moment
what happens in the next year will define the next century of american healthcare, and basically everyone is ignoring it.
here's the real story:
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I worked with Jess as a fed when she was at the FDA and I was at ONC. Her brilliance and humor got me through many tough days
#unicornjess
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If you have a bias towards action, and married someone who shares a bias towards action… best of luck around cute puppies. She arrives tomorrow.
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Full room at the M+A breakfast hosted by
@vivecollective
@Rock_Health
and True Search. So much interest here in 2024.
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Great breakdown from Dhruv and IMO this also maps to what is and is not a venture backable TES company…
If the care model is not novel, and does not require or meaningfully benefit from novel enabling tech, I struggle to find the high risk/high reward angle.
Unless you are
A very common conversation im having with founders of tech enabled series biz right now is how much to invest or not invest in product / tech.
Topics like how many PMs to hire, who they should report to, etc.
I think it really comes to how unique your care model is.
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I wager half the people complaining at
@chrissyfarr
would not hesitate to go to the pharmacist for their GI distress or pink eye if they were the ones traveling
Got pink eye on vacation. I went to the pharmacist, instead of the doctor, and got prescription eye drops in 5m. If we want to save costs, how about letting pharmacists do their jobs? They’re more than capable of taking care of basic medical needs.
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@AshleyGWinter
I got all of my vaccines and labwork done to matriculate at UCSF when I was in India and thought the bill was missing several 0s when I received it.
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@caleb_bank
As someone part of that team, I assure you it was a lot more complicated. Financially excellent to be liquid at the frothiest point of COVID valuation in an already frothy industry. But most of us were true believers in the mission, and knew the growth bar was now absurd.
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Fantastic example. And there are SO MANY supply/demand curves that could look different in healthcare. Every month+ wait, everything deferred or avoided because of cost and inconvenience.
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@AshleyGWinter
I ask bc I grew up there, so was in my 20s when I realized most adults do NOT drink milk with dinner 🐮
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@Bob_Wachter
When we vacc < 5 I will be totally with you. Until then we still have an unvacc’d vector and long COVID risk in our house who I love more than anything, and it bums me out when people declare we have reached a steady state.
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@clairevo
Demo call just yesterday. Two laptops because two jobs both with everything locked down. 😼 slunk over moments later.
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All the people jumping in excited sharing their examples underlines something I’ve believed for awhile.
Almost no entrepreneurs WANT to build something uncoordinated with the rest of healthcare. There was just no clear way to click together the puzzle pieces.
Possible reasons
I continue to be flabbergasted by how well virtual clinics are growing via referrals from clinicians in the larger health ecosystem if it’s in an area with an access / waitlist problem.
We all screwed up spending years trying to sell to clinicians instead of doing this. And A
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The best way to understand healthcare right now is knowing every actor is in the early throes of an ass kicking innovators dilemma while most people continue to rely on them for life or death situations.
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I just unboxed my Oura ring. ffs can we get some industrial designers over in medical DME and logistics companies? Reflecting on past experience as a caregiver to someone at end of life w/ cancer, I predict 100x ROI on both clinical outcomes and reduced family and patient rage.
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Attributed lives at risk is going the way of contracted revenue.
Its an undeniable opportunity - but showing engagement and outcomes in the population, and conversion to realized revenue, is where the valuation should come from.
This is a good thing. Otherwise VCs are just
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@chrissyfarr
I hesitate to reveal this given your following- but the Alameda Beach is pretty great when the fog and wind are light in the east bay. Have The Star (2nd Little Star location) deliver a pizza, bring shade, and chill all day.
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@healthcareandy
this is so interesting - people rag on digital health all the time about companies not being quality/outcomes oriented (which a few sensational cases aside- I have not seen), but my hypotheses is this buyer dynamic will make the whole industry leapfrog the prior standard
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@chrissyfarr
Equally a fantasy is the bioethicist talking about these sophisticated interviews Physicians are supposedly doing to pick up on all of the lifestyle and stressor events going on patients don’t want to talk about. Maybe in concierge medicine.
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@nikillinit
You think there are enough VC dollars to hire all the clinicians away into tech companies and worsen the provider shortage? 😝
More seriously - this absolutely is care delivery. You design something better and ensure it gets built and measure it and make it even better and
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@RossFelix
@halletecco
@AIHealthUncut
I find nothing more pointless than debating the definition of digital health.
It was something new built by a startup that materially helps people. I didn’t even include the example of my dying from appendix cancer mother in law able to afford Zofran after her PBM idiotically
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@chrissyfarr
How do we get payers to care beyond 12-18 month ROI because there are SO MANY THINGS critical to human health that have a longer timeline to bend cost curves (childhood obesity…)
How can we invest high upfront for long term returns when Medicare budgets are fixed
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Stuart’s posts are both hilarious and a freebie masterclass for all founders, investors, and operators new to digital health.
Signed, someone who made most of these mistakes the expensive way
When I talk to another health tech founder that assumes they’ll get full, national reimbursement contracts with payors in 90 days
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An under appreciated part of the good newco care model companies - BM, virtual, or hybrid- is acceleration and iterative perfection of true team based care models
It’s not tech enabled services alone that creates scale and better margin. It’s tech and team enabled services.
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My parents planted this willow tree when I left home for good at 19. It thrilled me to watch the young tree grow and thrive as I embarked on early adulthood adventures.
The willow is now entering the final years of its natural life span. A very midlife memento mori to meditate
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@healthcareandy
Also pretending most brick and mortar care is all gold standard with perfect patient access when comparing outcomes to hybrid or virtual care companies is an infuriating, common practice. Like recent pretense that pill mills for mental health aren’t found in brick + mortar too.
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“How might we spend less time on bullshit” seems to be the unifying product job to be done across digital health right now. I’m so here for it.
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There is one of these people in every health tech startup too
If you want to get into Hard Tech, but you don't have "Hard Tech" skills, do this:
DM a bunch of hard tech founders, & tell them you will be their "just figure it out" person.
Every hard tech co needs people who will take the weirdest/hardest problems and "just figure it out".
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Really fun helping to write about something so near and dear with fantastic fellow investors!
🚨New Second Opinion is out!🚨
It's a deep dive into "tech enabled services" with
@IanEChiang
@AlyssaJoyJaffee
&
@RebeccaCoelius
. As the digital health world has moved to favor software only, we argue services shouldn't be neglected.
Here's why!
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Our cat caught on fire today. How was your MLK day?
(Cat is fine)
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People creating a following for themselves by flaming the “us vs them, insiders vs outsiders” dialogue are lame.
Stop wasting your time reading their divisive drivel. Go find humble talented partners and build something.
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A team with a unique wedge from which you build the proof points and traction with a core set of users/clients that sets you up to attack the next set of gates VS trying to build everything all at once to not be a “point solution” is my investor love language in 2024.
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Who is doing great work in preventive cardiometabolic health for kids? I’m looking for the
@PeterAttiaMD
equivalent thinkers for this population.
If this sounds wacky- do a quick search on cardiometabolic chronic disease in kids. We have a public health disaster brewing.
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Hey PM and Eng leads!
CEO bumming you out asking for a high commitment 2 year roadmap and 100% productivity and accounting over every minute of engineering time?
Ask them about the last 3 year pro forma and staffing plan they put together for the fundraise. How much did
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@chrissyfarr
Need to diversify across at least ten deals at early stage even if it means checks are small. Go be an advisor if you want to get super close to one and you don’t have the wallet to buy that access.
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