The $100B Paradox: Why the Largest Company in Healthcare Hasn’t Been Built Yet

Originally published in Second Opinion, a newsletter for healthcare founders, operators, and investors.

If the United States’ healthcare sector were its own country, it would be the third largest economy in the world. By any rule of capitalism, a market that size should have minted a titan. Software gave us multiple trillion dollar platforms. Retail, search, advertising, even payments each produced a generational tech giant. And yet healthcare has not produced a single $100 billion healthtech company. 

Why? The short answer is that technology, for the most part, hasn’t actually created value in healthcare. It shuffled it, bureaucratized it, and in many cases destroyed it. The longer answer is that might all be changing now.

Continue reading →

The Future of Substance Use Care Is AI-Native

Repost from LinkedIn.

A clinician finishes a 50-minute session. The member leaves. The clinician opens their laptop and begins the second session: 45 minutes of documentation. They reconstruct the conversation from memory, translate it into billing codes, fill templates designed for auditors, and hunt through tabs to cross-reference previous notes. Then they move to the next patient.

This happens six times a day. More time documenting than treating. It’s not an edge case. It’s the norm.

Show me the incentive and I’ll show you the outcome

Electronic Health Records (EHRs) were never built for care. They were built for billing. The systems designed in the 1990s now stand between clinicians and patients, optimized to capture every action, convert it into codes, and generate revenue. Clinical workflows became data-entry workflows – serving payers, not patients.

This design misalignment produces predictable distortions. Providers maximize billable sessions because income scales with time spent, not outcomes achieved. The financial incentive isn’t to solve the problem efficiently. It’s to extend the engagement. In that sense, the system isn’t broken, it’s working exactly as intended. The flaw lies in what it was designed to optimize.

The consequences are staggering. The U.S. spends roughly $50 billion each year on substance use disorder (SUD) treatment, yet reaches only about 10% of those in need. The remaining 90%, generate an estimated $135 billion in preventable downstream costs, from ER visits to comorbidity complications to inpatient care.

We’re spending more and helping fewer. The bottleneck isn’t money. It’s infrastructure built around the wrong objective function.

Continue reading →

(Auto)biographies: A Window Into Greatness

“If I have seen further, it is by standing on the shoulders of giants.”

Isaac Newton

I’ve just finished reading “Play Nice But Win” by Michael Dell, a thrilling tale of boldness, resilience and reinvention. I found myself reflecting on why I love reading about other people’s lives. 

A biography is the closest we get to peering into the lives of the people who shape our world. They give us a glimpse into their early memories, formative experiences, and decision-making processes. If history is a record of the activities of mankind, biographies, autobiographies, memoirs and diaries are perhaps the best explanation we have of the historical record.

Walter Isaacson once said, “When you write biographies, whether it’s about Ben Franklin or Einstein, you discover something amazing: They are human.” Society often reinforces the “Great Man Theory of Leadership”; that leaders are born, not made. I’ve found that biographies help to humanize the people we most admire by showing us that even the greatest people face fears, insecurities, and self-doubt.

Continue reading →

Lessons Learned Scaling A Mission-Driven Startup

Note: This post is based on a presentation I gave at Web Summit 2021 and was later compiled in an article published in Forbes on Aug 22, 2022.

At the age of 14, when I started my first business, the notion that it was a business didn’t compute. Sure, there were ads to sell to pay for server costs and hire programmers, but the label of “business” sounded like a betrayal of our mission-driven values. At age 30 and working on my third startup, being mission-driven and for-profit no longer seems paradoxical.

Over the years, I’ve learned three crucial lessons in scaling a mission-driven business:

1. Don’t make it about the short term.

Many people—even some investors—think that mission-driven means nonprofit. The reality couldn’t be further from the truth. The most profitable companies are mission-driven, but their purpose goes beyond Wall Street’s short-term quarterly expectations.

Continue reading →

In Defence of the Naïve Founder 

One of my most memorable moments from medical school was during my rotation in a psychiatric hospital. Unlike traditional medicine, you’re unlikely to figure out what is going on by sticking the patient with needles. Instead you learn to listen for inconsistencies that might indicate a delusion or hallucination.

On one occasion, I was taking a medical history from a well-kept man on a psychiatric ward who wouldn’t have looked out of place in a law firm or investment bank. That was until he started to describe, in all seriousness, that “agents” had been tailing him for weeks. Apparently, he had been assigned a top secret mission to penetrate a cult and was on the verge of uncovering a major conspiracy.

While delusions of this kind sound impressive, it wouldn’t be unusual to hear similarly grandiose stories from a startup founder.

Self-confidence to the point of delusional seems to be a common trait amongst successful founders. Later stage founders often admit to having no idea what they were getting themselves into when they first started their company. 

Continue reading →

Does Artificial General Intelligence Explain Fermi’s Paradox? A “Human Compatible” Book Review

“He who controls the algorithms controls the universe.”

Like many tech entrepreneurs, I am a definite optimist. Despite the many challenges we face, I believe that, as a species, we have the resilience and ingenuity to build a better future, overcoming obstacles from climate change to an aging population.

In a similar vein, it has become clear that artificial intelligence will be one of the defining technologies of the twenty-first century. The question is when rather than if machines will be smarter than humans. There’s general consensus that we’re talking decades, not centuries. This is something that many people alive today will probably see.

In spite of this, I have given the question of AI safety and a potential apocalypse the same relative importance in my mind as seat belts likely had in the 1800s. One that seems like a good idea to explore, but an order of magnitude less important than figuring out how to consistently drive at speeds greater than 10mph.

The book that changed all of that was Human Compatible: AI and the Problem of Control by Stuart J. Russell. Human Compatible, courtesy of Quit Genius’ book club, has become one of my favorites of the year. 

Continue reading →

The Art of Deciding

“To take away a man’s freedom of choice, even his freedom to make the wrong choice, is to manipulate him as though he were a puppet and not a person.”

Madeline L’Engle

The ability to decide is at the heart of what it means to be human. After all, history started with the hasty decision to take a bite of the forbidden fruit. And, like Adam most of us make consequential decisions with little to no thought. 

Decision-making is not taught in schools and rarely discussed in leadership circles. There are countless books on how to be more productive, yet relatively few on how to decide. In fact, it wasn’t until recently that academia moved away from the ludicrous idea that humans are rational beings and decision-making gained the fancy moniker, “behavioral economics”, signifying its elevation as a formal field of science, thanks to the work of prominent academics such as Daniel Kahneman and Richard Thaler.

Continue reading →

The Most Important Thing I Learned During Y Combinator

Tuesday “dinners” were a big part of the YC experience. An opportunity to take a break from the grind, share notes and compare progress with fellow batchmates. 

But the highlight of the evening was always an off-the-record talk by an experienced startup founder who was, more often than not, also YC alumnus. During my batch (Winter 2018), we had the opportunity to hear from no less than Drew Houston (Dropbox), Brian Chesky and Joe Gebbia (Airbnb), and Emmit Shear and Justin Kan (Twitch), to name a few. 

The talk that I’ve thought back to the most was Sam Altman, former President of YC’s, opening address on “How to Succeed”.

Continue reading →

Prescription Digital Therapeutics: Hope or Hype?

It’s been a wild year of innovation and growth in digital health. Necessity, after all, is the mother of invention. As the global pandemic arrived, digital health transformed from a convenience to a requirement. Yet contrary to popular belief, the spoils have not been evenly distributed.

The long-heralded class of “prescription digital therapeutics” has lagged in adoption, while the growth of “virtual care platforms” has been explosive. What differentiates each approach and what are the key takeaways for payers, providers, consumers, and investors? 

Continue reading →

My Antifragile Investment Portfolio

If you thought that 2020 was a rollercoaster, my hunch is that 2021 has something special in store for us.

Barely one month in, the (former) democratically elected President of the United States fumbled Order 66. The S&P 500 and Bitcoin hit their all-time highs. “Meme stocks” became accepted financial jargon. A bunch of anti-establishment retail investors brought Wall St hedge funds to their knees. And as I write this, the global supply of silver is in the midst of being controlled by a subreddit.

The point I’m trying to make is that the future is uncertain and as Nassim Taleb would say, I make no time for the “charlatans” who think they can map it.

As a twenty-something-year-old, I have found myself asking what this means for my own fledgling asset portfolio. The financial press swivels between warnings of unchecked hubris followed by explanations of why “this time is different”.

Meanwhile, there seems to be an endlessly tantalizing buffet (pun-intended) of growth stocks, IPOs, SPACs, Bitcoin, Altcoins and meme stocks to choose from. It’s difficult to decide whether to play it safe or go all-in on the latest trend.

Continue reading →