The Silence of the Sirens

The photo shows the side of an ambulance with a blue Star of Life.
File Photo

Dispatch from HLTH 2021 On the Viability of VC Investment in Medicaid Innovations

Mobile Medicine made an immediate appearance during the first few hours of the HLTH conference in Boston. At the conference, Health Tech 4 Medicaid (HT4M) organized lectures and panels featuring a cadre of luminaries focused specifically on “doing very well by doing very good” in service of a range of indigent, underserved and disadvantaged communities.

I do not use the word “luminaries” here as a cliché, but rather, in an admiring and almost literal sense: Some of these speakers are so passionate about their commitments that they appear to radiate as they speak about them. One can only hope that their commitment will be contagious.  

Among the presenters were an entrepreneur, civic leaders, advocates for the “unmentionables” in healthcare, including the personal plights of unpaid caregivers for both adults and children, and investors focused on healthcare technologies and services.  

More from Jonathon S. Feit

Because this session was about Medicaid, however—needs for starters, and innovations designed to address them—the entire Mobile Medicine industry was conspicuously absent. The silence of the sirens was deafening. After all, Mobile Medical professionals go toward the healthcare crisis, and across the United States, a substantial proportion of patients who utilize ambulances are on Medicaid.One emerged with a sense that all in attendance—while well-meaning and dedicated to safety net care—were unaware of the critical, inseparable role of Mobile Medicine in that very safety net.

After all, one presenter described her frustrations in trying to find a stable sites to care for patients who need health services, including for mental and substance abuse issues, after-hours—but this was on an everyday basis, not due to COVID-related hospital overcrowding. Ultimately, she would be told to get the patient to the emergency department. Who transports patients to the hospital when they have nowhere else to get care?  Mobile Medical Professionals, of course. Patients in crisis do not levitate or wish their way to the hospital. (They do, however, sometimes grab an Uber or Lyft, a reality represents a significant potential liability for those companies).

What if the Mobile Medical professional could offer comparable care without the transport? That would save hospitals money, which would save insurers money.But without a change to how ambulances are paid in the U.S. today (i.e., almost entirely mileage-based), it would saddle the ambulance service with an expense that does not correspond to revenue. How many of those who are advocating for non-transport services realize the impending doom that they are advocating for their safety net provider of necessity?

The reality is that ambulance-based services are not the care provider of first resort, nor of last resort. Ambulances are, in many millions of cases, the provider of only resort—especially for the indigent, the underserved and the disadvantaged. If these services are left out of conversations about innovations for Medicaid patients, then something has gone terribly missing.

Some points to consider:

  • Do public health administrators not understand how their ecosystem functions?
  • Do administrators of hospitals that have emergency departments not understand how their ecosystem functions?
  • Is it on the part of the public, which expects Mobile Medical services to be available any time but doesn’t want to duly compensate those professionals for their work?
  • Is it on the part of the federal government that still classifies Mobile Medicine as a “suppliers to” healthcare rather than a “provider of” it—and in so doing, has chopped the industry’s knees, hamstringing its advancement by excluding it from most programs designed to advance healthcare innovation while simultaneously expanding its scope of practice?
  • Could healthcare investors have defined “healthcare innovation” far too narrowly?

Maybe the answer is a bit of all of the above. To this author, the operative question came from an investor who said, with remarkable candor and clarify, that they were unaware of any company currently serving the Medicaid market that represented a significant growth opportunity.

But…

But…

The ambulance industry is enormous! Not only is its total addressable market in the billions annually (both in the U.S. and around the world), but its investments are commensurately large. Ambulances aren’t powered by coffee and smiles. Suppliers to these “suppliers to healthcare” are themselves now or previously public, like Stryker, Zoll, REV and Tyler Technologies.  Others have received hundreds of millions of private equity funding.

Private equity firms, after all, understand that Mobile Medicine represents “sticky money,” often powered by long-term reliable contracts, and that these care providers engage a range of payers from CMS to private insurance. Finally, they are one of the only industries—in the United States and globally—that is truly ubiquitous. Every jurisdiction has some kind of emergency response or medical transportation provider. Sometimes those jurisdictions are huge, like rural counties and even a whole state in America. Sometimes that function is served by a military or civil defense function in various countries, sometimes it’s operated by a trust in the UK or by private and public companies in various regions of America. But it exists.

Perhaps venture investors do not see Medicaid-focused companies “blowing up” because they are not funding them…a classic Catch-22. To meet their mission anyway, such companies are “going it alone,” raising community funding, customer-based funding, angel funding, or debt. These can be reliable financing methods even if they are slower—they also represent missed opportunities for venture investors to win from the earliest days. With enhanced awareness of the market’s size and need, the first VCs to stake the Mobile Medical market will enjoy outsized, long-unrealized gains. The opportunities are not hiding: they are often literally adorned by flashing lights and sirens.

*           *           *

Seventy-two hours after this conference session and utterance by a leading investor in healthcare IT and services, I was in upstate New York touring volunteer ambulance services that run an insufficient number of vehicles and served too large an area. The result is a necessary heroism by individual community members who volunteer their time and risking their safety and health, waking in the middle of the night, jumping on a rig to drive as much as 40 minutes one-way into the beautiful but desolate hills, because someone had a cardiac arrest, an overdose, or cut an appendage while mowing their breathtaking acreage. 

I could not help thinking about a lesson I learned early in my time studying at Carnegie Mellon’s Tepper School of Business. Namely, that one should approach entrepreneurship armed with the paranoid assumption that if a market is huge, the need is painful, and its solution is lucrative, then the niche his already being served. Yet I saw again firsthand how often the need is not being served. Folks find ways to “make do.” That may be the essence of humanness: we specialized in toolmaking.

When it comes to solving needs in Mobile Medicine and Medicaid, however, we are not just talking about widgets. We’re not even “just” talking about lives. There is an opportunity that is inconceivably big, yet it is unusual because it requires creative thinking about how value-based care can be measured among the otherwise helpless. It is compelling, urgent and immediate. It is driven—in disjointed pieces—by federal, state, even local legislation.

The needs are so compelling that agencies are forging creative collaborations with names like “Community Integrated Paramedicine” and “Street Team”—but oh!  What progress could be made, faster and at scale, to the betterment of all and in the interest of smart and healthy cities, if more investors, with more capital, who are seeking the greatest good in addition to profits, would see beyond the “reimbursement” misnomer (it should called “compensation” anyway) and engage the outsized opportunity in Mobile Medicine.

No posts to display