https://www.ycombinator.com/companies/brave-care
https://www.bizjournals.com/portland/news/2021/10/07/brave-c... | https://archive.today/Qd8fQ
https://techcrunch.com/2019/09/09/yc-backed-brave-care-raise...
Healthcare insurance in the US is heavily subsidized, and no number of revolutionary care delivery models will put you on level terms with the behemoth of US govt insurance subsidies.
Your only hope as a non-provider is to come in with your own a-la-carte insurance that is able to take those subsidies, while you set your moat and innovate in the delivery front.
Health insurance is undisruptable, unless you’re ready to light billions of dollars on fire over several years, or take decades to do it by growing extremely slowly.
The provider side is equally difficult, but I think it’s at least doable. Though you’re still screwed having to deal with CMS or insurance carriers.
Or is it that the Healthcare industry has tilted the government into making rules that favor the status-quo?
It's not an easy market to jump into; you spend a huge amount upfront on site construction (particularly if you're building standalone clinics outside of existing medical buildings, which is not unusual for urgent care), labor cost and complexity is high, and reimbursement cycles are long and painful. Healthcare chains scale like retail, not like software, with all the attendant cash management problems.
It feels like they did offer a superior service with lots of effort put into getting into the community, but I question both their decision to try and build a custom EHR -- yes, EHRs suck, but once you start building your own, you're no longer a medical services company, you're now an EHR company -- and not to pursue a regional-centric expansion strategy aligned with local health systems via contract or JV, instead choosing to build a small number of clinics across the country, which goes against proven successful buildout strategies in healthcare.
It's a shame they've gone under -- again, superior service, obviously a lot of care for their patients -- but "we went under because of cash management problems and inappropriate growth strategy" is a pretty standard story in the healthcare world.
Thanks to decades of neo-liberalism (the idea of deregulation and "free market" economy). Americans have allowed corporations to form massive entities (in health insurance, UHC + optum bank + optima rx comes to mind) to the point of manipulating the price to their advantage. Then you have to deal with some companies that deny a majority of your claims in hopes that you (the patient and/or healthcare provider) give up (delay, deny, defend policies) or pay out of pocket for treatment.
American healthcare industry is a fucking mess.
This is more an anti-trust problem than deregulation. In the 80s Robert Bork and some others led a charge within the court system to rewrite federal anti-trust law without actually rewriting the laws. The result was that merger/acquisition guidelines were loosened, and the focus was on whether the result would cause the consumer to pay more money. And thanks to the way health care is paid for, it's a little complicated to make that case.
Or email me: chris@juniperplatform.com
(The health care industry is a mess, I agree!)
Healthcare is one of the most regulated industries in the United States.
Want to be a doctor? You've got the aptitude, the knowledge, the mindset, and the will, but a government-guaranteed cartel of medical schools won't let you in, so too damn bad. Learn to code.
Want to open a clinic? You really only need about a half-million in hardware to operate at the level of a 1980s hospital, but regulatory compliance will push your annual opex into the millions as a baseline, not to mention having to deal with the nightmare that is health insurance.
Those "massive entities" you mentioned are entirely protected from competition by force of law.
You know why healthcare used to be cheap? Nobody had insurance.
Anyone that had the aptitude and wanted to be a doctor basically could.
You went to the hospital, paid your bill, and that was that.
I'm not saying "zero regulation, caveat emptor!", but over the past hundred years, the precise opposite of "deregulation" has happened across every aspect of American life.
This isn’t unique to America. In countries with government healthcare, the government determines your rates. Typically government rates are lower than private insurance rates in the US, too.
For as much as Americans like to complain about insurance companies, we actually get a lot more care and pay higher rates to providers than other countries. There’s a reason doctor pay in the United States is so much higher, among other things.
One account is that the US has too many medical facilities in urban areas. In other words, there might be five hospitals each with its own radiology equipment. That equipment is idle some of the time, so you could close some of the imaging departments and leave just one or two for the metro area. That would obviously inconvenience some people, but the gist of the criticism is that the US duplicates medical capacity for the sake of convenience.
The other criticism is that there are too few clinics and such. That's why there was a big push to open health clinics in pharmacies and urgent care locations recently.
Now I know these aren't mutually exclusive; you can have too few clinics and too many hospitals. But I would like to know if anyone is more informed than I am what validity there is to each criticism.
I'm curious what the truth is regarding the number and character of brick-and-mortar healthcare facilities in the US: too many? too few? Because it looks like this company was opening physical clinics.
I'm curious what the truth is regarding the number and character
of brick-and-mortar healthcare facilities in the US: too many?
too few? Because it looks like this company was opening physical
clinics.
Even within urban areas care is uneven. Hospitals are concentrated in the more wealthy parts of San Francisco and the poorer (e.g. southeastern) parts see sparse coverage. One of the big points of contention when Sutter Health bought out St Luke's hospital in SF was that Sutter wanted to transition from primary care to more profitable specialties. This would've left the neighborhood bereft of primary care.
In more rural areas you'll find that funding is a political football. As that funding wanes so does the level of care. On top of that the post-Roe v Wade environment encourages some folks to migrate towards urban areas in more "permissive" states.
In terms of too much urban coverage. When I needed an ultrasound through UCSF I had to book it out months in advance. It's not clear to me that there is a ton of duplication there — more the point if I'd looked elsewhere I would've had to figure out what was/wasn't in network with my insurance provider. Last I looked Kaiser has a grand total of eight urgent care clinics in the Bay Area. There are nine counties in the Bay Area. That's efficient from a business standpoint but leaves plenty of customers out in the cold as Kaiser covers out-of-network services in very limited circumstances. Likewise, try to find a GP that accepts insurance and is taking new patience. When I checked eons ago UCSF had a nearly year long wait.
As far as convenience vs efficiency, the argument was that to achieve the efficiencies found in other countries, which often have longer wait times for services than the US, you do have to sacrifice convenience. The US, by treating healthcare like a consumer good rather than a rationed utility, has built out excess capacity for the sake of convenience. This is, according to the argument, part of the reason we spend more on healthcare than peers. (Healthcare must always be rationed; the US does so on price rather than wait times.)
Crucially, among those who leave are not just patients. There are also doctors leaving.
> The other criticism is that there are too few clinics and such. That's why there was a big push to open health clinics in pharmacies and urgent care locations recently.
Funny enough, germany has the exact same two problems.
* Too many small urban hospitals do too many things, but have no speciality, leading to high cost, underutilization and higher risk procedures.
* Too few specialist doctors for checkups leading to long waiting times.
Or outright kill them due to a delay in a critical finding. This is more than a convenience factor, and moving patients between facilities is non-trivial.
It's likely the other way around from what you are saying, with limits to market entry enabling the existing facilities to charge more than the efficient price for the service.
I work for a hospital chain that has done similar things. A lot of the failing hospitals in little towns across the US is because of this, and the consolidation that's happening is to remove similar inefficiencies. People that live in these little towns with failing hospitals see any move towards correcting these inefficiencies as evidence that our medical system is failing and use it to vote for right wing politicians who make empty promises.
If you have 2 hospitals and one takes your insurance and the other doesn't you still get service. If you consolidate to one and they don't take your insurance you may have to drive hours to get medical service.
A huge failure of the system is how health insurance works.
I visited their clinics for my daughter several times when she was a toddler for ear aches and other ailments— I found the experience refreshing: instant online booking, no BS registration and online communication with staff was seamless. Very sad to see them go so abruptly.
Up until this morning when I was told they were gone, I had no idea they were YC or otherwise VC funded. Just came here to pour one out for a genuinely helpful and pleasant medical company.
Currently, there’s a doctor shortage problem (supposedly, they can’t hire, or there aren’t enough positions, depending on who you ask), which has caused issues with the quality of care (according to the doctors that went on strike over this, and personal experience).
It’s unclear what the root cause or solution is.
Anyway, you can get the experience you described, and it’s great until you hit an understaffed corner case health problem.
Most taxpayers have to realize the loss to take a tax deduction against their gains, but some tax elections allow you to do the same without finding a buyer for the worthless shares, which narrows down the incentives
Mark to Market election
as well as non-profits
some non-profit investors have stricter scrutiny as their charitable distribution requirement is based on net assets. so there is an incentive to arbitrarily mark malperforming investments down to lower values, but being able to get the business to announce their failure supports it better
Just thinking out loud
[1] makes it sound like they were assuming a never-ending stream of venture funding and didn't make a sustainable business. It'd be interesting to see where the money went.
[1] https://www.oregonlive.com/business/2022/09/portland-pediatr...
Could you explain "indigent" here, please. It looks like a typo.
Effectively it is no cost care for those who are sufficiently poor.
My mom refuses to leave the US healthcare system despite the costs because
1. She pays for insurance, not surgery (in her mind)
2. regardless of the keening US healthcare system is the best in the world
The problem is not that pediatric urgent care is not a viable business.
The problem is that it's not a great VC-funded business.
VC investors are hoping for huge growth and eventually earning back multiples of their investment.
That's going to be really hard to do in this segment of the health-care market.
We've got a wonderful pediatric urgent-care place in our area, backed by the best children's hospital in our metro region, and it seems to be doing great. But does that mean it could ever grow at the rate needed to satisfy VC investors? Probably not.
With the decline in birth rates in the US, didn't seem like a sustainable model from the get go.