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.

His story will inspire you.

“Google search went down for a few hours in 2002; Jeff Dean handled all the queries by hand and checked quality doubled.”- Jeff Dean Facts.

One of many Jeff Dean jokes, but you get the idea.

Google's top six engineers met in a war room in mid-2000. Google's crawling system, which indexed the Web, stopped working. Users could still enter queries, but results were five months old.

Google just signed a deal with Yahoo to power a ten-times-larger search engine. Tension rose. It was crucial. If they failed, the Yahoo agreement would likely fall through, risking bankruptcy for the firm. Their efforts could be lost.

A rangy, tall, energetic thirty-one-year-old man named Jeff dean was among those six brilliant engineers in the makeshift room. He had just left D. E. C. a couple of months ago and started his career in a relatively new firm Google, which was about to change the world. He rolled his chair over his colleague Sanjay and sat right next to him, cajoling his code like a movie director. The history started from there.

When you think of people who shaped the World Wide Web, you probably picture founders and CEOs like Larry Page and Sergey Brin, Marc Andreesen, Tim Berners-Lee, Bill Gates, and Mark Zuckerberg. They’re undoubtedly the brightest people on earth.

Under these giants, legions of anonymous coders work at keyboards to create the systems and products we use. These computer workers are irreplaceable.

Let's get to know him better.

It's possible you've never heard of Jeff Dean. He's American. Dean created many behind-the-scenes Google products. Jeff, co-founder and head of Google's deep learning research engineering team, is a popular technology, innovation, and AI keynote speaker.

While earning an MS and Ph.D. in computer science at the University of Washington, he was a teaching assistant, instructor, and research assistant. Dean joined the Compaq Computer Corporation Western Research Laboratory research team after graduating.

Jeff co-created ProfileMe and the Continuous Profiling Infrastructure for Digital at Compaq. He co-designed and implemented Swift, one of the fastest Java implementations. He was a senior technical staff member at mySimon Inc., retrieving and caching electronic commerce content.

Dean, a top young computer scientist, joined Google in mid-1999. He was always trying to maximize a computer's potential as a child.

An expert

His high school program for processing massive epidemiological data was 26 times faster than professionals'. Epi Info, in 13 languages, is used by the CDC. He worked on compilers as a computer science Ph.D. These apps make source code computer-readable.

Dean never wanted to work on compilers forever. He left Academia for Google, which had less than 20 employees. Dean helped found Google News and AdSense, which transformed the internet economy. He then addressed Google's biggest issue, scaling.

Growing Google faced a huge computing challenge. They developed PageRank in the late 1990s to return the most relevant search results. Google's popularity slowed machine deployment.

Dean solved problems, his specialty. He and fellow great programmer Sanjay Ghemawat created the Google File System, which distributed large data over thousands of cheap machines.

These two also created MapReduce, which let programmers handle massive data quantities on parallel machines. They could also add calculations to the search algorithm. A 2004 research article explained MapReduce, which became an industry sensation.

Several revolutionary inventions

Dean's other initiatives were also game-changers. BigTable, a petabyte-capable distributed data storage system, was based on Google File. The first global database, Spanner, stores data on millions of servers in dozens of data centers worldwide.

It underpins Gmail and AdWords. Google Translate co-founder Jeff Dean is surprising. He contributes heavily to Google News. Dean is Senior Fellow of Google Research and Health and leads Google AI.

Recognitions

The National Academy of Engineering elected Dean in 2009. He received the 2009 Association for Computing Machinery fellowship and the 2016 American Academy of Arts and Science fellowship. He received the 2007 ACM-SIGOPS Mark Weiser Award and the 2012 ACM-Infosys Foundation Award. Lists could continue.

A sneaky question may arrive in your mind: How much does this big brain earn? Well, most believe he is one of the highest-paid employees at Google. According to a survey, he is paid $3 million a year.

He makes espresso and chats with a small group of Googlers most mornings. Dean steams milk, another grinds, and another brews espresso. They discuss families and technology while making coffee. He thinks this little collaboration and idea-sharing keeps Google going.

“Some of us have been working together for more than 15 years,” Dean said. “We estimate that we’ve collectively made more than 20,000 cappuccinos together.”

We all know great developers and software engineers. It may inspire many.

A worldwide energy crisis might have hampered renewable energy and clean tech investment. Nope.

BNEF's 2023 Energy Transition Investment Trends study surprised and encouraged. Global energy transition investment reached $1 trillion for the first time ($1.11t), up 31% from 2021. From 2013, the clean energy transition has come and cannot be reversed.

BNEF Head of Global Analysis Albert Cheung said our findings ended the energy crisis's influence on renewable energy deployment. Energy transition investment has reached a record as countries and corporations implement transition strategies. Clean energy investments will soon surpass fossil fuel investments.

The table below indicates the tripping point, which means the energy shift is occuring today.

BNEF calls money invested on clean technology including electric vehicles, heat pumps, hydrogen, and carbon capture energy transition investment. In 2022, electrified heat received $64b and energy storage $15.7b.

Nonetheless, $495b in renewables (up 17%) and $466b in electrified transport (up 54%) account for most of the investment. Hydrogen and carbon capture are tiny despite the fanfare. Hydrogen received the least funding in 2022 at $1.1 billion (0.1%).

China dominates investment. China spends $546 billion on energy transition, half the global amount. Second, the US total of $141 billion in 2022 was up 11% from 2021. With $180 billion, the EU is unofficially second. China invested 91% in battery technologies.

The 2022 transition tipping point is encouraging, but the BNEF research shows how far we must go to get Net Zero. Energy transition investment must average $4.55 trillion between 2023 and 2030—three times the amount spent in 2022—to reach global Net Zero. Investment must be seven times today's record to reach Net Zero by 2050.

BNEF 2023 Energy Transition Investment Trends.

As shown in the graph above, BNEF experts have been using their crystal balls to determine where that investment should go. CCS and hydrogen are still modest components of the picture. Interestingly, they see nuclear almost fading. Active transport advocates like me may have something to say about the massive $4b in electrified transport. If we focus on walkable 15-minute cities, we may need fewer electric automobiles. Though we need more electric trains and buses.

Albert Cheung of BNEF emphasizes the challenge. This week's figures promise short-term job creation and medium-term energy security, but more investment is needed to reach net zero in the long run.

I expect the BNEF Energy Transition Investment Trends report to show clean tech investment outpacing fossil fuels investment every year. Finally saying that is amazing. It's insufficient. The planet must maintain its electric (not gas) pedal. In response to the research, Christina Karapataki, VC at Breakthrough Energy Ventures, a clean tech investment firm, tweeted: Clean energy investment needs to average more than 3x this level, for the remainder of this decade, to get on track for BNEFs Net Zero Scenario. Go!

Are you an idiot at fundraising?

Humans undervalue what they don't grasp. Consider NASCAR. How is that a sport? ask uneducated observers. Circular traffic. Driving near a car's physical limits is different from daily driving. When driving at 200 mph, seemingly simple things like changing gas weight or asphalt temperature might be life-or-death.

Venture investors do something similar in entrepreneurship. Most entrepreneurs don't realize how complex venture finance is.

In my early startup days, I didn't comprehend venture capital's intricacy. I thought VCs were rich folks looking for the next Mark Zuckerberg. I was meant to be a sleek, enthusiastic young entrepreneur who could razzle-dazzle investors.

Finally, one of the VCs I was trying to woo set me straight. He insulted me.

How I learned that I was approaching the wrong investor

I was constructing a consumer-facing, pre-revenue marketplace firm. I looked for investors in my old university's alumni database. My city had one. After some research, I learned he was a partner at a growth-stage, energy-focused VC company with billions under management.

Billions? I thought. Surely he can write a million-dollar cheque. He'd hardly notice.

I emailed the VC about our shared alumni status, explaining that I was building a startup in the area and wanted advice. When he agreed to meet the next week, I prepared my pitch deck.

First error.

The meeting seemed like a funding request. Imagine the awkwardness.

His assistant walked me to the firm's conference room and told me her boss was running late. While waiting, I prepared my pitch. I connected my computer to the projector, queued up my PowerPoint slides, and waited for the VC.

He didn't say hello or apologize when he entered a few minutes later. What are you doing?

Hi! I said, Confused but confident. Dinin Aaron. My startup's pitch.

Who? Suspicious, he replied. Your email says otherwise. You wanted help.

I said, "Isn't that a euphemism for contacting investors?" Fundraising I figured I should pitch you.

As he sat down, he smiled and said, "Put away your computer." You need to study venture capital.

Recognizing the business aspects of venture capital

The VC taught me venture capital in an hour. Young entrepreneur me needed this lesson. I assume you need it, so I'm sharing it.

Most people view venture money from an entrepreneur's perspective, he said. They envision a world where venture capital serves entrepreneurs and startups.

As my VC indicated, VCs perceive their work differently. Venture investors don't serve entrepreneurs. Instead, they run businesses. Their product doesn't look like most products. Instead, the VCs you're proposing have recognized an undervalued market segment. By investing in undervalued companies, they hope to profit. It's their investment thesis.

Your company doesn't fit my investment thesis, the venture capitalist told me. Your pitch won't beat my investing theory. I invest in multimillion-dollar clean energy companies. Asking me to invest in you is like ordering a breakfast burrito at a fancy steakhouse. They could, but why? They don't do that.

Yeah, I’m not a fine steak yet, I laughed, feeling like a fool for pitching a growth-stage VC used to looking at energy businesses with millions in revenues on my pre-revenue, consumer startup.

He stressed that it's not necessary. There are investors targeting your company. Not me. Find investors and pitch them.

Remember this when fundraising. Your investors aren't philanthropists who want to help entrepreneurs realize their company goals. Venture capital is a sophisticated investment strategy, and VC firm managers are industry experts. They're looking for companies that meet their investment criteria. As a young entrepreneur, I didn't grasp this, which is why I struggled to raise money. In retrospect, I probably seemed like an idiot. Hopefully, you won't after reading this.

I've spent over 50 hours researching one-person firms, which interest me. I've found countless one-person enterprises that made millions on the founder's determination and perseverance.

Throughout my investigation, I found three of the most outstanding one-person enterprises. These enterprises show that people who work hard and dedicate themselves to their ideas may succeed.

Eric Barone (@ConcernedApe) created Stardew Valley in 2011 to better his job prospects. Eric loved making the game, in which players inherit a farm, grow crops, raise livestock, make friends with the villagers, and form a family.

Eric handled complete game production, including 3D graphics, animations, and music, to maintain creative control. He stopped job hunting and worked 8-15 hours a day on the game.

Eric developed a Stardew Valley website and subreddit to engage with gamers and get feedback. Eric's devoted community helped him meet Steam's minimum vote requirement for single creators.

Stardew Valley sold 1 million copies in two months after Eric launched it for $15 in 2016. The game has sold 20 million copies and made $300 million.

The game's inexpensive price, outsourcing of PR, marketing, and publication, and loyal player base helped it succeed. Eric has turned down million-dollar proposals from Sony and Nintendo to sell the game and instead updates and improves it. Haunted Chocolatier is Eric's new game.

Is farming not profitable? Ask Stardew Valley creator Eric Barone.

Gary Brewer established BuiltWith to assist users find website technologies and services. BuiltWith boasts 3000 paying customers and $14 million in yearly revenue, making it a significant resource for businesses wishing to generate leads, do customer analytics, obtain business insight, compare websites, or search websites by keyword.

BuiltWith has one full-time employee, Gary, and one or two part-time contractors that help with the blog. Gary handles sales, customer service, and other company functions alone.

BuiltWith acquired popularity through blog promotions and a top Digg ranking. About Us, a domain directory, connected to BuiltWith on every domain page, boosting it. Gary introduced $295–$995 monthly subscriptions to search technology, keywords, and potential consumers in response to customer demand.

Gary uses numerous methods to manage a firm without staff. He spends one to two hours every day answering user queries, most of which are handled quickly by linking to BuiltWiths knowledge store. Gary creates step-by-step essays or videos for complex problems. Gary can focus on providing new features based on customer comments and requests since he makes it easy to unsubscribe.

BuiltWith is entirely automated and successful due to its unique approach and useful offerings. It works for Google, Meta, Amazon, and Twitter.

Digital Inspiration develops Google Documents, Sheets, and Slides plugins. Digital Inspiration, founded by Amit Agarwal, receives 5 million monthly visits and earns $10 million. 40 million individuals have downloaded Digital Inspirations plugins.

Amit started Digital Inspiration by advertising his blog at tech events and getting Indian filter blogs and other newspapers to promote his articles. Amit built plugins and promoted them on the blog once the blog acquired popularity, using ideas from comments, friends, and Reddit. Digital Inspiration has over 20 free and premium plugins.

Mail Merge, Notifications for Google Forms, YouTube Uploader, and Document Studio are some of Digital Inspiration's most popular plugins. Mail Merge allows users to send personalized emails in bulk and track email opens and clicks.

Since Amits manages Digital Inspiration alone, his success is astounding. Amit developed a successful company via hard work and creativity, despite platform dependence. His tale inspires entrepreneurs.