ZERO GRACE/ZERO MALICE

Amazon's purchase of One Medical could speed up American healthcare

The U.S. healthcare industry is a 7-ton seal bleeding at sea. Predators are circling. Unearned margin: price increases relative to inflation without quality improvements. Amazon is the 11-foot megalodon with 7-inch teeth. Amazon is no longer circling... but attacking.

In 2020 dollars, per capita U.S. healthcare spending increased from $2,968 in 1980 to $12,531. The result is a massive industry with 13% of the nation's workers and a fifth of GDP.

Doctor No

In 40 years, healthcare has made progress. From 73.7 in 1980 to 78.8 in 2019, life expectancy rose (before Covid knocked it back down a bit). Pharmacological therapies have revolutionized, and genetic research is paying off. The financial return, improvement split by cost increases, is terrible. No country has expense rises like the U.S., and no one spends as much per capita as we do. Developed countries have longer life expectancies, healthier populations, and less economic hardship.

Two-thirds of U.S. personal bankruptcies are due to medical expenses and/or missed work. Mom or Dad getting cancer could bankrupt many middle-class American families. 40% of American adults delayed or skipped needed care due to cost. Every healthcare improvement seems to have a downside. Same pharmacological revolution that helped millions caused opioid epidemic. Our results are poor in many areas: The U.S. has a high infant mortality rate.

Healthcare is the second-worst retail industry in the country. Gas stations are #1. Imagine walking into a Best Buy to buy a TV and a Blue Shirt associate requests you fill out the same 14 pages of paperwork you filled out yesterday. Then you wait in a crowded room until they call you, 20 minutes after the scheduled appointment you were asked to arrive early for, to see the one person in the store who can talk to you about TVs, who has 10 minutes for you. The average emergency room wait time in New York is 6 hours and 10 minutes.

If it's bad for the customer, it's worse for the business. Physicians spend 27% of their time helping patients; 49% on EHRs. Documentation, order entry, billing, and inbox management. Spend a decade getting an M.D., then become a bureaucrat.

No industry better illustrates scale diseconomies. If we got the same return on healthcare spending as other countries, we'd all live to 100. We could spend less, live longer and healthier, and pay off the national debt in 15 years. U.S. healthcare is the worst ever.

What now? Competition is at the heart of capitalism, the worst system of its kind.

Priority Time

Amazon is buying One Medical for $3.9 billion. I think this deal will liberate society. Two years in, I think One Medical is great. When I got Covid, I pressed the One Medical symbol on my phone; a nurse practitioner prescribed Paxlovid and told me which pharmacies had it in stock.

Amazon enables the company's vision. One Medical's stock is down to $10 from $40 at the start of 2021. Last year, it lost $250 million and needs cash (Amazon has $60 billion). ONEM must grow. The service has 736,000 members. Half of U.S. households have Amazon Prime. Finally, delivery. One Medical is a digital health/physical office hybrid, but you must pick up medication at the pharmacy. Upgrade your Paxlovid delivery time after a remote consultation. Amazon's core competency means it'll happen. Healthcare speed and convenience will feel alien.

It's been a long, winding road to disruption. Amazon, JPMorgan, and Berkshire Hathaway formed Haven four years ago to provide better healthcare for their 1.5 million employees. It rocked healthcare stocks the morning of the press release, but folded in 2021.

Amazon Care is an employee-focused service. Home-delivered virtual health services and nurses. It's doing well, expanding nationwide, and providing healthcare for other companies. Hilton is Amazon Care's biggest customer. The acquisition of One Medical will bring 66 million Prime households capital, domain expertise, and billing infrastructure. Imagine:

"Alexa, I'm hot and my back hurts."

"Connecting you to a Prime doctor now."

Want to vs. Have to

I predicted Amazon entering healthcare years ago. Why? For the same reason Apple is getting into auto. Amazon's P/E is 56, double Walmart's. The corporation must add $250 billion in revenue over the next five years to retain its share price. White-label clothes or smart home products won't generate as much revenue. It must enter a huge market without scale, operational competence, and data skills.

Current Situation

Healthcare reform benefits both consumers and investors. In 2015, healthcare services had S&P 500-average multiples. The market is losing faith in public healthcare businesses' growth. Healthcare services have lower EV/EBITDA multiples than the S&P 500.

Amazon isn't the only prey-hunter. Walmart and Alibaba are starting pharmacies. Uber is developing medical transportation. Private markets invested $29 billion in telehealth last year, up 95% from 2020.

The pandemic accelerated telehealth, the immediate unlock. After the first positive Covid case in the U.S., services that had to be delivered in person shifted to Zoom... We lived. We grew. Video house calls continued after in-person visits were allowed. McKinsey estimates telehealth visits are 38 times pre-pandemic levels. Doctors adopted the technology, regulators loosened restrictions, and patients saved time. We're far from remote surgery, but many patient visits are unnecessary. A study of 40 million patients during lockdown found that for chronic disease patients, online visits didn't affect outcomes. This method of care will only improve.

Amazon's disruption will be significant and will inspire a flood of capital, startups, and consumer brands. Mark Cuban launched a pharmacy that eliminates middlemen in January. Outcome? A 90-day supply of acid-reflux medication costs $17. Medicare could have saved $3.6 billion by buying generic drugs from Cuban's pharmacy. Other apex predators will look at different limbs of the carcass for food. Nike could enter healthcare via orthopedics, acupuncture, and chiropractic. LVMH, L'Oréal, and Estée Lauder may launch global plastic surgery brands. Hilton and Four Seasons may open hospitals. Lennar and Pulte could build "Active Living" communities that Nana would leave feet first, avoiding the expense and tragedy of dying among strangers.

Risks

Privacy matters: HIV status is different from credit card and billing address. Most customers (60%) feel fine sharing personal health data via virtual technologies, though. Unavoidable. 85% of doctors believe data-sharing and interoperability will become the norm. Amazon is the most trusted tech company for handling personal data. Not Meta: Amazon.

What about antitrust, then?

Amazon should be required to spin off AWS and/or Amazon Fulfillment and banned from promoting its own products. It should be allowed to acquire hospitals. One Medical's $3.9 billion acquisition is a drop in the bucket compared to UnitedHealth's $498 billion market valuation.

Antitrust enforcement shouldn't assume some people/firms are good/bad. It should recognize that competition is good and focus on making markets more competitive in each deal. The FTC should force asset divestitures in e-commerce, digital marketing, and social media. These companies can also promote competition in a social ill.

U.S. healthcare makes us fat, depressed, and broke. Competition has produced massive value and prosperity across most of our economy.

Dear Amazon … bring it.

How a misplaced item may change your outlook

Losing your wallet means life stops. Money vanishes. No credit. Your identity is unverifiable. As you check your pockets for the missing object, you can't drive. You can't borrow a library book.

Last seen? intuitively. Every kid asks this, including yours. However, you know where you lost it: On the Providence River cycling trail. While pedaling vigorously, the wallet dropped out of your back pocket and onto the pavement.

A woman you know—your son's art teacher—says it will be returned. Faith.

You want that faith. Losing a wallet is all-consuming. You must presume it has been stolen and is being used to buy every diamond and non-fungible token on the market. Your identity may have been used to open bank accounts and fake passports. Because he used your license address, a ski mask-wearing man may be driving slowly past your house.

As you delete yourself by canceling cards, these images run through your head. You wait in limbo for replacements. Digital text on the DMV website promises your new license will come within 60 days and be approved by local and state law enforcement. In the following two months, your only defense is a screenshot.

Your wallet was ordinary. A worn, overstuffed leather rectangle. You understand how tenuous your existence has always been since you've never lost a wallet. You barely breathe without your documents.

Ironically, you wore a wallet-belt chain. You adored being a 1993 slacker for 15 years. Your wife just convinced you last year that your office job wasn't professional. You nodded and hid the chain.

Never lost your wallet. Until now.

Angry. Feeling stupid. How could you drop something vital? Why? Is the world cruel? No more dumb luck. You're always one pedal-stroke from death.

Then you get a call: We have your wallet.

Local post office, not cops.

The clerk said someone returned it. Due to trying to identify you, it's a chaos. It has your cards but no cash.

Your automobile screeches down the highway. You yell at the windshield, amazed. Submitted. Art teacher was right. Have some trust.

You thank the postmaster. You ramble through the story. The clerk doesn't know the customer, simply a neighborhood Good Samaritan. You wish you could thank that person for lifting your spirits.

You get home, beaming with gratitude. You thumb through your wallet, amazed that it’s all intact. Then you dig out your chain and reattach it.

Because even faith could use a little help.

Many of us have struggled for years to master a second language (in my case, English). Because (at least in my situation) we've always used an input-based system or method.

I'll explain in detail, but briefly: We can understand some conversations or sentences (since we've trained), but we can't give sophisticated answers or speak fluently (because we have NOT trained at all).

What exactly is input-based learning?

Reading, listening, writing, and speaking are key language abilities (if you look closely at that list, it seems that people tend to order them in this way: inadvertently giving more priority to the first ones than to the last ones).

These talents fall under two learning styles:

• Reading and listening are input-based activities (sometimes referred to as receptive skills or passive learning).

• Writing and speaking are output-based tasks (also known as the productive skills and/or active learning).

What's the best learning style? To learn a language, we must master four interconnected skills. The difficulty is how much time and effort we give each.

According to Shion Kabasawa's books The Power of Input: How to Maximize Learning and The Power of Output: How to Change Learning to Outcome (available only in Japanese), we spend 7:3 more time on Input Based skills than Output Based skills when we should be doing the opposite, leaning more towards Output (Input: Output->3:7).

I can't tell you how he got those numbers, but I think he's not far off because, for example, think of how many people say they're learning a second language and are satisfied bragging about it by only watching TV, series, or movies in VO (and/or reading a book or whatever) their Input is: 7:0 output!

You can't be good at a sport by watching TikTok videos about it; you must play.

“being pushed to produce language puts learners in a better position to notice the ‘gaps’ in their language knowledge”, encouraging them to ‘upgrade’ their existing interlanguage system. And, as they are pushed to produce language in real time and thereby forced to automate low-level operations by incorporating them into higher-level routines, it may also contribute to the development of fluency. — Scott Thornbury (P is for Push)

How may I practice output-based learning more?

I know that listening or reading is easy and convenient because we can do it on our own in a wide range of situations, even during another activity (although, as you know, it's not ideal), writing can be tedious/boring (it's funny that we almost always excuse ourselves in the lack of ideas), and speaking requires an interlocutor. But we must leave our comfort zone and modify our thinking to go from 3:7 to 7:3. (or at least balance it better to something closer). Gradually.

“You don’t have to do a lot every day, but you have to do something. Something. Every day.” — Callie Oettinger (Do this every day)

We can practice speaking like boxers shadow box.

Speaking out loud strengthens the mind-mouth link (otherwise, you will still speak fluently in your mind but you will choke when speaking out loud). This doesn't mean we should talk to ourselves on the way to work, while strolling, or on public transportation. We should try to do it without disturbing others, such as explaining what we've heard, read, or seen (the list is endless: you can TALK about what happened yesterday, your bedtime book, stories you heard at the office, that new kitten video you saw on Instagram, an experience you had, some new fact, that new boring episode you watched on Netflix, what you ate, what you're going to do next, your upcoming vacation, what’s trending, the news of the day)

Who will correct my grammar, vocabulary, or pronunciation with an imagined friend? We can't have everything, but tools and services can help [1].

Lack of bravery

Fear of speaking a language different than one's mother tongue in front of native speakers is global. It's easier said than done, because strangers, not your friends, will always make fun of your accent or faults. Accept it and try again. Karma will prevail.

Perfectionism is a trap. Stop self-sabotaging. Communication is key (and for that you have to practice the Output too ).

“Don’t forget to have fun and enjoy the process.” — Ruri Ohama

[1] Grammarly, Deepl, Google Translate, etc.

During the dot-com bust, I started my internet career. People used the internet intermittently to check email, plan travel, and do research. The average internet user spent 30 minutes online a day, compared to 7 today. To use the internet, you had to "log on" (most people still used dial-up), unlike today's always-on, high-speed mobile internet. In 2001, Amazon's market cap was $2.2B, 1/500th of what it is today. A study asked Americans if they'd adopt broadband, and most said no. They didn't see a need to speed up email, the most popular internet use. The National Academy of Sciences ranked the internet 13th among the 100 greatest inventions, below radio and phones. The internet was a cool invention, but it had limited uses and wasn't a good place to build a business. 

A small but growing movement of developers and founders believed the internet could be more than a read-only medium, allowing anyone to create and publish. This is web 2. The runner up name was read-write web. (These terms were used in prominent publications and conferences.) 

Web 2 concepts included letting users publish whatever they want ("user generated content" was a buzzword), social graphs, APIs and mashups (what we call composability today), and tagging over hierarchical navigation. Technical innovations occurred. A seemingly simple but important one was dynamically updating web pages without reloading. This is now how people expect web apps to work. Mobile devices that could access the web were niche (I was an avid Sidekick user). 

The contrast between what smart founders and engineers discussed over dinner and on weekends and what the mainstream tech world took seriously during the week was striking. Enterprise security appliances, essentially preloaded servers with security software, were a popular trend. Many of the same people would talk about "serious" products at work, then talk about consumer internet products and web 2. It was tech's biggest news. Web 2 products were seen as toys, not real businesses. They were hobbies, not work-related. 

There's a strong correlation between rich product design spaces and what smart people find interesting, which took me some time to learn and led to blog posts like "The next big thing will start out looking like a toy" Web 2's novel product design possibilities sparked dinner and weekend conversations. Imagine combining these features. What if you used this pattern elsewhere? What new product ideas are next? This excited people. "Serious stuff" like security appliances seemed more limited. 

The small and passionate web 2 community also stood out. I attended the first New York Tech meetup in 2004. Everyone fit in Meetup's small conference room. Late at night, people demoed their software and chatted. I have old friends. Sometimes I get asked how I first met old friends like Fred Wilson and Alexis Ohanian. These topics didn't interest many people, especially on the east coast. We were friends. Real community. Alex Rampell, who now works with me at a16z, is someone I met in 2003 when a friend said, "Hey, I met someone else interested in consumer internet." Rare. People were focused and enthusiastic. Revolution seemed imminent. We knew a secret nobody else did. 

My web 2 startup was called SiteAdvisor. When my co-founders and I started developing the idea in 2003, web security was out of control. Phishing and spyware were common on Internet Explorer PCs. SiteAdvisor was designed to warn users about security threats like phishing and spyware, and then, using web 2 concepts like user-generated reviews, add more subjective judgments (similar to what TrustPilot seems to do today). This staged approach was common at the time; I called it "Come for the tool, stay for the network." We built APIs, encouraged mashups, and did SEO marketing. 

Yahoo's 2005 acquisitions of Flickr and Delicious boosted web 2 in 2005. By today's standards, the amounts were small, around $30M each, but it was a signal. Web 2 was assumed to be a fun hobby, a way to build cool stuff, but not a business. Yahoo was a savvy company that said it would make web 2 a priority. 

As I recall, that's when web 2 started becoming mainstream tech. Early web 2 founders transitioned successfully. Other entrepreneurs built on the early enthusiasts' work. Competition shifted from ideation to execution. You had to decide if you wanted to be an idealistic indie bar band or a pragmatic stadium band. 

Web 2 was booming in 2007 Facebook passed 10M users, Twitter grew and got VC funding, and Google bought YouTube. The 2008 financial crisis tested entrepreneurs' resolve. Smart people predicted another great depression as tech funding dried up. 

Many people struggled during the recession. 2008-2011 was a golden age for startups. By 2009, talented founders were flooding Apple's iPhone app store. Mobile apps were booming. Uber, Venmo, Snap, and Instagram were all founded between 2009 and 2011. Social media (which had replaced web 2), cloud computing (which enabled apps to scale server side), and smartphones converged. Even if social, cloud, and mobile improve linearly, the combination could improve exponentially. 

This chart shows how I view product and financial cycles. Product and financial cycles evolve separately. The Nasdaq index is a proxy for the financial sentiment. Financial sentiment wildly fluctuates. 

Next row shows iconic startup or product years. Bottom-row product cycles dictate timing. Product cycles are more predictable than financial cycles because they follow internal logic. In the incubation phase, enthusiasts build products for other enthusiasts on nights and weekends. When the right mix of technology, talent, and community knowledge arrives, products go mainstream. (I show the biggest tech cycles in the chart, but smaller ones happen, like web 2 in the 2000s and fintech and SaaS in the 2010s.) 

Tech has changed since the 2000s. Few tech giants dominate the internet, exerting economic and cultural influence. In the 2000s, web 2 was ignored or dismissed as trivial. Entrenched interests respond aggressively to new movements that could threaten them. Creative patterns from the 2000s continue today, driven by enthusiasts who see possibilities where others don't. Know where to look. Crypto and web 3 are where I'd start. 

Today's negative financial sentiment reminds me of 2008. If we face a prolonged downturn, we can learn from 2008 by preserving capital and focusing on the long term. Keep an eye on the product cycle. Smart people are interested in things with product potential. This becomes true. Toys become necessities. Hobbies become mainstream. Optimists build the future, not cynics.

Full article is available here

I placed a link on HackerNews and got 300 signups in a week. This post explains what happened.

Product Concept

The product is DbSchemaLibrary. A library of Database Schema.

I'm not sure where this idea originated from. Very fast. Build fast, fail fast, test many ideas, and one will be a hit. I tried it. Let's try it anyway, even though it'll probably fail. I finished The Lean Startup book and wanted to use it.

Database job bores me. Important! I get drowsy working on it. Someone must do it. I remember this happening once. I needed examples at the time. Something similar to Recall (my other project) that I can copy — or at least use as a reference.

Frequently googled. Many tabs open. The results were useless. I raised my hand and agreed to construct the database myself.

It resurfaced. I decided to do something.

Due Diligence

Lean Startup emphasizes validated learning. Everything the startup does should result in learning. I may build something nobody wants otherwise. That's what happened to Recall.

So, I wrote a business plan document. This happens before I code. What am I solving? What is my proposed solution? What is the leap of faith between the problem and solution? Who would be my target audience?

My note:

In my previous project, I did the opposite!

I wrote my expectations after reading the book's advice.

“Failure is a prerequisite to learning. The problem with the notion of shipping a product and then seeing what happens is that you are guaranteed to succeed — at seeing what happens.” — The Lean Startup book

These are successful metrics. If I don't reach them, I'll drop the idea and try another. I didn't understand numbers then. Below are guesses. But it’s a start!

I then wrote the project's What and Why. I'll use this everywhere. Before, I wrote a different pitch each time. I thought certain words would be better. I felt the audience might want something unusual.

Occasionally, this works. I'm unsure if it's a good idea. No stats, just my writing-time opinion. Writing every time is time-consuming and sometimes hazardous. Having a copy saved me duplication.

I can measure and learn from performance.

Last, I identified communities that might demand the product. This became an exercise in creativity.

The MVP

So now it’s time to build.

A MVP can test my assumptions. Business may learn from it. Not low-quality. We should learn from the tiniest thing.

I like the example of how Dropbox did theirs. They assumed that if the product works, people will utilize it. How can this be tested without a quality product? They made a movie demonstrating the software's functionality. Who knows how much functionality existed?

So I tested my biggest assumption. Users want schema references. How can I test if users want to reference another schema? I'd love this. Recall taught me that wanting something doesn't mean others do.

I made an email-collection landing page. Describe it briefly. Reference library. Each email sender wants a reference. They're interested in the product. Few other reasons exist.

Header and footer were skipped. No name or logo. DbSchemaLibrary is a name I thought of after the fact. 5-minute logo. I expected a flop. Recall has no users after months of labor. What could happen to a 2-day project?

I didn't compromise learning validation. How many visitors sign up? To draw a conclusion, I must track these results.

Posting Time

Now that the job is done, gauge interest. The next morning, I posted on all my channels. I didn't want to be spammy, therefore it required more time.

I made sure each channel had at least one fan of this product. I also answer people's inquiries in the channel.

My list stinks. Several channels wouldn't work. The product's target market isn't there. Posting there would waste our time. This taught me to create marketing channels depending on my persona.

Statistics! What actually happened

My favorite part! 23 channels received the link.

I stopped posting to Discord despite its high conversion rate. I eliminated some channels because they didn't fit. According to the numbers, some users like it. Most users think it's spam.

I was skeptical. And 12 people viewed it.

I didn't expect much attention on a startup subreddit. I'll likely examine Reddit further in the future. As I have enough info, I didn't post much. Time for the next validated learning

No comment. The post had few views, therefore the numbers are low.

The targeted people come next.

I'm a Toptal freelancer. There's a member-only Slack channel. Most people can't use this marketing channel, but you should! It's not as spectacular as discord's 27% conversion rate. But I think the users here are better.

I don’t really have a following anywhere so this isn’t something I can leverage.

The best yet. 10% is converted. With more data, I expect to attain a 10% conversion rate from other channels. Stable number.

This number required some work. Did you know that people use many different clients to read HN?

Unknowns

Untrackable views and signups abound. 1136 views and 135 signups are untraceable. It's 11%. I bet much of that came from Hackernews.

Overall Statistics

The 7-day signup-to-visit ratio was 17%. (Hourly data points)

First-day percentages were lower, which is noteworthy. Initially, it was little above 10%. The HN post started getting views then.

When traffic drops, the number reaches just around 20%. More individuals are interested in the connection. hn.algolia.com sent 2 visitors. This means people are searching and finding my post.

Interesting discoveries

1. HN post struggled till the US woke up.

11am UTC. After an hour, it lost popularity. It seemed over. 7 signups converted 13%. Not amazing, but I would've thought ahead.

After 4pm UTC, traffic grew again. 4pm UTC is 9am PDT. US awakened. 10am PDT saw 512 views.

2. The product was highlighted in a newsletter.

I found Revue references when gathering data. Newsletter platform. Someone posted the newsletter link. 37 views and 3 registrations.

3. HN numbers are extremely reliable

I don't have a time-lapse graph (yet). The statistics were constant all day.

• 2717 views later 272 new users, or 10.1%

• With 293 signups at 2856 views, 10.25%

• At 306 signups at 2965 views, 10.32%

Learnings

1. My initial estimations were wildly inaccurate

I wrote 30% conversion. Reading some articles, looks like 10% is a good number to aim for.

2. Paying attention to what matters rather than vain metrics

The Lean Startup discourages vanity metrics. Feel-good metrics that don't measure growth or traction. Considering the proportion instead of the total visitors made me realize there was something here.

What’s next?

There are lots of work to do. Data aggregation, display, website development, marketing, legal issues. Fun! It's satisfying to solve an issue rather than investigate its cause.

In the meantime, I’ve already written the first project update in another post. Continue reading it if you’d like to know more about the project itself! Shifting from Quantity to Quality — DbSchemaLibrary