Dr. Ali Behbahani – Venture Capital in Medicine (Episode #20)

On the 20th episode of the Penn HealthX Podcast, I sat down with Dr. Ali Behbahani, who led a workshop on “Thinking Like a Venture Capitalist” at our 2017 Penn HealthX Conference.

Dr. Behbahani earned his undergraduate degree in Biomedical Engineering, Electrical Engineering, and Chemistry from Duke University. After graduation, he worked in healthcare investment banking at Lehman Brothers and venture capital at Morgan Stanley Venture Partners. He then attended the University of Pennsylvania, where he earned a dual MD/MBA degree from the University of Pennsylvania School of Medicine and the Wharton School. After graduation, he went to work for New Enterprise Associates, where he is now a partner on the healthcare team.

Here are some key takeaways from the discussion:

1. Don’t be afraid to take time to explore your interests

Dr. Behbahani took an unusual path to medical school. Throughout undergrad, his goal was to attend medical school. As graduation approached, he stumbled across the world of investment banking, where he ended up working. After two years of investment banking, he was accepted to medical school and planned to attend. However, an opportunity to work in venture capital arose, so he deferred his medical school acceptance to take the job. Had he simply taken the straightforward path and gone directly to medical school, Dr. Behbahani might never have known about venture investing. He stressed that it is okay to take a year or two to explore something you love doing, especially early in a career, and that taking such a break set him on his ultimate career path. However, he eventually had to make a decision that did close some doors. While it is possible to balance certain fields like medicine and research, it is challenging to be really good at both clinical medicine and investing. This reality further highlights the value of taking time early in a career to explore various interests – it is much easier than trying to change careers later in life.

2. Venture investing lets him make an impact on a societal level

Working as a physician is an amazing way to impact lives one at a time. However, research and venture capital work together to change the way medicine is practiced, creating change on a societal level. Bringing a novel therapeutic to market requires a large amount of capital, which venture capital can provide. A large part of Dr. Behbahani’s work involves attending conferences and meeting with thought leaders in various fields of medicine. He stays abreast of changes in medical practice, and with each investment into a new field, Dr. Behbahani learns about new diseases and treatment that were not covered in medical school. Thus, his career in venture investing is one of lifelong learning.

3. Venture investing gives insight into the “bleeding edge” of scientific innovation

Dr. Behbahani spends his days evaluating cutting edge medical technology. He splits his work between seeking new investment opportunities, performing due diligence on investments he is considering, and managing companies in which he has made investments. When approaching an investment, he gets much more excited about companies that could change the way medicine is practiced than those that make incremental improvements on what already exists. We are living in an era with a proliferation of nontraditional therapeutics which are changing medicine and helping patients like never before. It is an exciting time to work in venture capital, where he sees therapeutics when they are still in the lab and works to bring them to the clinic.

 

You can learn more about NEA and Dr. Behbahani at NEA’s website, http://www.nea.com/.

– Logan is a second-year medical student at the Perelman School of Medicine. He was the co-VP of curriculum for Penn Health-X in 2017, and is an occasional co-host of the Penn HealthX podcast, and a contributor to the Penn HealthX blog. You can contact him at  john.brock@uphs.upenn.edu –

Alastair Blake – Learning From the U.K Health System (Episode #19)

For our 19th episode of the podcast, Logan and I sat down with Alastair Blake to discuss the U.K health system, and why Alastair is interested in health policy and consulting. Alastair is a British-trained physician who went to Cambridge. He performed his residency in London, and has worked in health policy for the NHS. He is currently a Wharton MBA student, and plans on working full time after graduation with the consulting firm, McKinsey.

Here are a few takeaways from the discussion.

1. There Are Very Few Clinical Voices Representing Physicians and Patients in Government and Industry

One thing Alastair was surprised to find when he was a fellow working with Professor Steven Field was just how few clinical voices there are the higher up you get in government and industry. Even when there were executives and high-ups in government with medical training, they had usually been out of practice for many years, and thus were likely out of touch with the issues of the modern day.

This reminded me of when a cardiology professor told us that he was learning about the Frank-Starling mechanism of the heart in the 60’s when the Beatles came to America. Think about just how long ago many of the current leaders in medicine studied and trained. Many did so before most of the major advancements we’ve seen in terms of drugs and technologies in the last number of decades. It’s important for junior physicians, and students even, to speak up and be a part of the discussion. We are uniquely poised to understand the challenges that come along with modern technologies and how they are impacting medicine and patient care.

2. Contrary to Popular Tropes, the U.K Healthcare System is Neither Perfect, Nor a Disaster

The NHS and the single-payer system in the U.K is often pointed to on both ends of the U.S political spectrum as either an ideal to aspire towards, or a socialistic disaster to avoid at all costs. Obviously, the truth is somewhere in the middle. Alastair believes that the systems of each respective country reflects their values, their history, and politics. There is no one-size-fits all system. Interestingly, the U.K system is actually starting to become more like the U.S system in some respects, and over time the U.S has been creeping towards a more U.K-like system, with the expansion of Medicare and Medicaid.

3. Every System Rations – We Just Do So in Different Ways

The U.K pays way less per-capita on healthcare than the U.S, but there is some rationing that takes place, and often times physicians and hospital systems feel financial pressures, and aren’t able to deliver care exactly as they see fit. There will be tradeoffs in every system – while the U.K rations based on effectiveness of treatments through NICE, we ration in the U.S based on an individual’s ability to pay for their insurance, or their care. Again, it reflects the values of the country, and what we are and aren’t comfortable with as a population.

4. “If you can find money to kill people, you can find money to help people” – Tony Benn

One thing that is notable about how the U.K got to single-payer, is that it was almost entirely based on historical happenstance. Large sweeping changes to something as big as healthcare come very infrequently, and require both a lot of political tact, as well as proper timing when the country is poised for change. For the U.K, this moment was after World War II, when England and London was left in ruins. Many came together and realized, if they could find money during the war to kill other people, why couldn’t they also find money while not at war to help their own people? This video from the movie Sicko features Tony Benn, who used to be a member of Parliament in the U.K. This simple idea has led to a lot of my own personal beliefs on the types of health policies that we should strive to.

A single payer system like in the U.K will not work in the U.S – at least not at the present moment. However, I do believe that in the coming years we will need to asses our values, and what we are an aren’t okay with as a population – the money is there, it’s how we choose to align our values and decide how to spend it. It will take future leadership to help steer the country toward such changes when the opportunities arise, and I hope to be one of those leaders. The only way to be ready to act is to learn now, and – like Alastair – study health systems, and get numerous experiences under our belts. I’m excited to see what happens in the coming years.

– Ryan is a second year medical student at the Perelman School of Medicine. He was the co-VP of curriculum for Penn HealthX in 2017, is the co-host of the Penn HealthX podcast, and founder/editor-in-chief of the Penn HealthX blog. You can contact him at ryan.o’keefe@uphs.upenn.edu –

The Co-Founders of Neuroflow on Start-Ups and Mental Health (Episode #16)

On our 16th episode of the Penn HealthX Podcast, Ryan sat down with Chris Moralo and Adam Pardes, the co-founders of NeuroFlow, a medical device company recently launched out of the University of Pennsylvania.

Chris is a US army veteran who holds an undergraduate degree from the United States Military Academy and an MBA from the Wharton School at the University of Pennsylvania, where he was a student when he co-founded NeuroFlow with Adam. Adam is a bioengineer by training, who is currently on a leave of absence from a PhD program at Penn while he works on NeuroFlow. The two met through the InSITE program at UPenn, where they were brought together by their shared interest in entrepreneurship. To hear more about the NeuroFlow story, check out their website at http://www.neuroflowsolution.com/

In the podcast, Chris and Adam spoke about what they have learned through the process of starting Neuroflow. Here are some key takeaways from the discussion:

1. Think years ahead but act in the moment

One of the biggest challenges of running a startup is balancing the long-term vision with taking the steps necessary to succeed today. Chris and Adam learned through their fundraising that investors that investors cared much more about the problem, the market, and the team than the exact solution. The solution itself is likely to change as the company grows – initially, the goal of NeuroFlow was to create a device to help treat PTSD, but the company has since pivoted and the first product is now a clinical tool to help measure stress levels using validated biochemical markers. While the product itself changed, there was no change in the problem that they were trying to address – the long-term vision remaining the same, but the team changed the specific actions they were taking day-to-day to align with their new game plan.

ptsd_brain1

2. Define a set of values and live by them

In the course of a couple short years, NeuroFlow has grown from an idea shared by Adam and Chris into a team with 15 members working toward a common goal. As the company grew, Adam and Chris had to think carefully about how to align the goals and values of the team. They drew on their past experience, particularly Chris’ time as an officer in the US Army, to establish a set of values for the company. Importantly, they stressed that having a set of values only matters if you truly espouse and live them. Having these values gives the team a shared set of principles to guide their work and to keep pushing hard even when the hours are long.

3. They’ve had a lot of proud moments along the way

Chris, Adam, and the team are hard at work taking Neuroflow from an intriguing idea to a working product. They shared some of their most challenging and their proudest experiences from working on the company. One moment that was simultaneously challenging and proud was when they first hired team members. As Adam and Chris stressed, once they hired a team, that team was relying on them to continue to exist and to succeed. Their team members left comfortable, stable jobs at established companies to work on NeuroFlow, and Adam and Chris feel a sense of responsibility to their employees. Another proud moment that they shared came from seeing the fruits of their labor. Chris described the emotion of the first time a doctor went live with NeuroFlow on a real patient, and the pride that followed from seeing their work in action.

We are excited to follow NeuroFlow as they continue to grow and launch their product. Check them out at www.neuroflowsolution.com.

– Logan is a second-year medical student at the Perelman School of Medicine. He was the co-VP of curriculum for Penn Health-X in 2017, is an occasional co-host of the Penn HealthX podcast, and a contributor to the Penn HealtphX blog. You can contact him at  john.brock@uphs.upenn.edu –

Aaron Bholé – Drug Pricing and Orphan Drugs (Episode #14)

On the 14th episode of the Penn HealthX Podcast, Ryan sat down with Aaron Bholé, a first-year medical student at the Sidney Kimmel Medical College (SKMC) in Philadelphia.

Aaron graduated from a 3+2 program at Cornell, where he earned an undergraduate degree in neuroscience and an MBA. While at Cornell, he interned with FileVision USA and Northwestern Medicine. At the SKMC, Aaron is a part of an organization called the Physician Executive Leadership program, which is similar to HealthX at Penn. He is also combining his business and medical knowledge through an internship with Militia Hill Ventures in Philadelphia. Aaron holds a specific interest in drug pricing, and Ryan and Aaron delved into the topic during their discussion.

Some key takeaways from the discussion:

1. Prescription drugs cost hundreds of billions of dollars per year

Given the heightened visibility of drug pricing in the media spotlight over the past year, it is not a surprise that drug spending accounts for a substantial portion of healthcare spending. Currently, prescription drugs make up nearly 10% of all healthcare spending in the US, according to the Kaiser Family Foundation. Given that healthcare now costs the United States $3.3 trillion dollars per year, prescription drugs cost Americans over $300BB annually.

2. Specialty drugs receive more news coverage, but generics can also be expensive

Much of the news coverage around drug pricing focuses on extremely expensive specialty drugs, such as Biogen’s Spinraza for spinal muscular atrophy, which will cost $750,000 per patient, generics can also be extremely expensive. While the cost of generics has been declining overall, many drugs have only a single generic manufacturer. As a result, that manufacturer can have significant pricing power. This leads to situations where drugs that have been off patent for decades can see price increases of hundreds or even thousands of percent, as was the case when Martin Shkreli raised the price of Daraprim in 2015, which made him infamous overnight .

3. It takes more than the sticker price to know if a drug price is “fair”

Drug pricing is complicated. One of the biggest challenges in determining a reasonable price for a drug is that the cost must be weighed against the effectiveness of the drug. Two common methods of valuing drugs are to compare the drug to the current standard of care and increase the price in accordance with the benefits (safety, efficacy, adherence) it provides or to place a value on the complications that it can avoid. Thus, an expensive but very efficacious drug could be relatively more cost-effective than a drug with a much lower price tag but less efficacy. As an example, consider Harvoni, a hepatitis C drug that was developed by Gilead pharmaceuticals. The drug was initially priced at $95,000, although with discounts the average cost is about $40,000 for a course of treatment. While the sticker price is high, it cures hepatitis C in over 90% of patients – so even though the price of the drug is massive, it is considered a “high value” treatment.

 

To hear more about drug pricing, orphan drugs, patents law surrounding drugs, and some legal history of drug pricing in the United States, check out this episode of the HealthX podcast.

– Logan is a second-year medical student at the Perelman School of Medicine. He was the co-VP of curriculum for Penn Health-X in 2017, is an occasional co-host of the Penn HealthX podcast, and a contributor to the Penn HealthX blog. You can contact him at  john.brock@uphs.upenn.edu –

Crash Course in Health System Quality Improvement with Dr. Neha Patel

– Logan Brock, MS2 –

For our most recent HealthX Crash Course, we hosted Dr. Neha Patel, MD, MS, who gave a Crash Course on healthcare quality and patient safety. Dr. Patel earned her medical degree at the University of Pennsylvania School of Medicine and completed her residency in internal medicine at the Hospital of the University of Pennsylvania. She has been a practicing hospitalist in the Section of Hospital Medicine since 2009. During her time as faculty at Penn, she completed a Master of Science in Healthcare Quality and Patient Safety at Northwestern University in 2013. In 2016, she transitioned from Interim Chief of the Hospitalist group to become Associate CMIO at Penn, in a role that was specifically created for her to develop Penn’s mHealth strategy. Additionally, she serves as the Director of the Healthcare Leadership in Quality Residency Track, which prepares physicians for leadership roles in health system by providing hands on experience improving healthcare quality. To top it off, she serves as Director of Mobile Strategy and Applications at Penn Medicine. Here are some key takeaways from her talk:

Work Within a Framework – It Doesn’t Matter Which

The key to successfully implementing quality improvement projects in a hospital system is to use a framework that allows problems to be approach systematically. While this is crucial to ensure effective quality programs, it is less important which specific framework is followed. There are a number of different change management systems that are used in healthcare, including Six Sigma and the Model for Improvement. While these models differ slightly in their approach, each provides a method to rapidly design, test, improve, and implement changes to hospital systems, allowing the hospital to continually improve.

Measuring Healthcare Quality is Extremely Complicated

While it certainly isn’t surprising to hear that measuring quality in healthcare can be a challenge, Dr. Patel illuminated just how challenging it really is. In the current healthcare climate, terms like “bundled payments” and “value-based purchasing” are frequently tossed around – however, it can be rather complicated to understand what they really mean. As an example, Dr. Patel brought the current year’s value-based purchasing “domain weighting” chart – essentially, the metrics to which 2% of all Medicare payments are tied in 2018 (here’s an overview of value-based purchasing). The metrics include four categories that contribute to the overall “value” the hospital provides and multiple subcategories within each category. As an example, one sub-category is “pain management,” as reported by patients. The score used for this metric is compiled from surveys randomly given to patients, in which they rate the quality of their hospital stay. Thus, improving the score would likely require massive overhauls in hospital operations, and this is just one of many metrics to which hospital reimbursement is tied. This crash course conveyed the immense challenge of measuring healthcare quality.

Improvement Requires Openness to Evaluation

Dr. Patel highlighted one of the most significant challenges to implementing quality improvement initiatives in the hospital – in order to make changes to improve a process, it is first necessary to admit that the process might be flawed. In a healthcare system where doctors are working as hard as they possibly can to provide the best care they can, it is a difficult shift to admit that there could be room for improvement. Thus, one of the key challenges in improving healthcare quality is allowing the measurement and reporting of areas where care could be enhanced. This is naturally difficult for a profession in which mistakes can have life-or-death consequences, but it is crucial for continual improvement.

 

It was a pleasure to host Dr. Patel and learn more about quality improvement in healthcare and the significant challenges that physician-leaders grapple with every day in their quest to provide better healthcare.

– Logan is a second-year medical student at the Perelman School of Medicine. He is the co-VP of curriculum for Penn Health-X, an occasional co-host of the Penn HealthX podcast, and a contributor to the Penn HealthX blog. You can contact him at  john.brock@uphs.upenn.edu –

Crash Course on Medical Device Start-Ups with Dr. Jeffrey Solomon

jeffreysolomon

– Logan Brock, MS2 –

For our first HealthX Crash Course, we hosted Dr. Jeff Solomon, MD, MBA who gave a Crash Course on the medical device industry. Dr. Solomon earned his medical degree at the University of Pennsylvania School of Medicine, completed a residency in diagnostic radiology and a fellowship in interventional radiology at Penn, then stayed on as an attending in the IR department. During his fellowship, he also earned an MBA at the Wharton School at the University of Pennsylvania. After working as an attending for several years, Dr. Solomon chose to leave clinical practice to become President of Infiniti Medical, a medical device company focused on the veterinary market. With this perspective, Dr. Solomon shared some lessons he wished he knew when he made the transition to the startup world. Here are some key takeaways from the talk:

The One Constant in Startups is Risk

We constantly hear about the excitement and the fast pace of startups, but Dr. Solomon focused the crash course on what he believes is an equally pervasive aspect of life at a startup: risk. Throughout his talk, Dr. Solomon reminded us that while we hear stories of the startups that succeed, there are many more companies we never hear about because they failed. Rather than trying to discourage us from pursuing a startup career, he encouraged the audience to inform themselves of the risks and to consider them carefully when weighing the decision whether to pursue a startup career. He emphasized the importance of balancing the risk and the potential rewards and only pursuing an option when the rewards outweighed the risks by enough to justify the risk.

Startups Must Succeed or Fail Quickly

Dr. Solomon explained that building and operating a private company is not an option for a startup that has taken on venture funding. While this might seem like a possible route, venture funds have defined periods of time after which they must return capital to the limited partners. As a result, a venture fund is forced to pursue an exit at that point. Therefore, companies must always operate with the goal of a liquidity event – an IPO, a strategic acquisition, acquisition by a PE firm, or failure. From the founder’s perspective, this actually has a benefit – Dr. Solomon stressed that failing (or, of course, succeeding) quickly is better than failing over many years.

Understand Equity Dilution

With very rare exceptions, startups cannot succeed without raising capital. Thus, founders must partner with sources of capital to make their ideas into realities. Dr. Solomon spoke at length about the different types of capital available to entrepreneurs and the associated benefits and drawbacks. These sources include personal funds, friends and family, angel investors, and venture capital (which are usually received in that order). As a rule, as a founder moves from personal funds toward venture capital, each subsequent investment requires dilution of equity and loss of control over the company.

It is crucial for the founder of a company to understand how taking on funding affects both company control and the distribution of equity. Dr. Solomon illustrated how dividends, liquidation preference, stock options, creation of new stock classes, and the fees associated with selling a company could substantially decrease the founder’s share of an exit. From the outset, an entrepreneur should take careful stock of the amount of funding they will need to raise to bring the company to an exit and ensure that there will be a sufficient stake remaining after that dilution to justify the risks of starting a company.

It’s Easier to Ask for $100 Million than $1 Million

Building a company is a huge challenge, whatever the market. Since it’s going to be difficult either way, pick a market that is worth working long and hard to capture. This benefits the company in multiple ways. First and foremost, if the company succeeds in a large market, that success will be all the more significant and exciting than if it occurred in a smaller market. Beyond that, Dr. Solomon stressed that it is significantly easier to raise capital to go after a big idea than a small one. Venture firms make multiple investments and expect that some will fail – therefore, they have a strong incentive to place large bets that can lead to significant gains. A venture fund will often not be interested in a company with a $10 million market – even if the company succeeds, that success wouldn’t move the needle for the fund. A startup that targets a $1 billion market, on the other hand, could provide exactly the success the venture firm needs.

 

It was a privilege to host Dr. Solomon for our first HealthX Crash Course, we learned a great deal about the medical device startup world, the risks involved, and what it takes to succeed.

– Logan is a second-year medical student at the Perelman School of Medicine. He is the co-VP of curriculum for Penn Health-X, an occasional co-host of the Penn HealthX podcast, and a contributor to the Penn HealthX blog. You can contact him at  john.brock@uphs.upenn.edu –

Spectrum Scores, LGBTQ+ Health Disparities, and HealthX Labs (Episode #11)

 Ryan O’Keefe, MS2 –

In the most recent episode of The Penn HealthX Podcast, I was able to sit down with Phil Williams, Naveen Jain, and Jun Jeon, the three co-founders of Spectrum Scores. Spectrum Scores looks to address health disparities in the LGBTQ+ population by connecting patients with providers who are able to address any unique healthcare needs they have. The project was launched out of the 2017 HealthX Labs accelerator program, and has continued to grow since.

Some takeaways from our conversation:

1. If you don’t care about the problem, you will quit

The team repeatedly mentioned the importance of identifying a problem, rather than trying to force a solution you’ve come up with down people’s throats. This is important advice to remember when starting a company – the idea needs to be born out of an identifiable need. Otherwise, when push comes to shove, no one will use your product. More importantly, if you aren’t drawn to the problem you are looking to solve, in all likelihood, you will lose motivation, and give up. You may be able to push through for a while, but if your heart isn’t in it, you won’t last.

2. If your idea is truly innovative, most people won’t understand it

History tells us that inventors and innovators who are well ahead of their time are met with severe skepticism, and even ridicule. Not everyone will have the same vision as you, which can be rather troublesome in the modern world, considering meaningful innovation in healthcare often requires substantial investment and buy-in from larger players in the system. In the case of Spectrum Scores, it wasn’t that people didn’t understand the idea. Rather, many who are not members of the LGBTQ+ community simply can’t appreciate how crucial the problem is. Further, the same people won’t understand that tight-night communities are able to help a project like Spectrum Scores gain traction. The usual concerns companies need to address when pitching their ideas – what is the market, how will you make money, how soon can you exit and see a meaningful return on investment – are simply not the main focus of Spectrum Scores, at least for now. Those who want to work at the intersection of advocacy, medicine, and business will likely deal with these very objections. It doesn’t mean your idea is unattainable, but it does mean you face a steeper incline.

3. If you worry too much about perfection, you’ll wind up with nothing

I appreciated when the team shared their initial discomfort with releasing their product to the masses. Many in medicine are Type-A personalities, who want to do things right and have their work be flawless. However, if you spend all of your time fussing about how your product is imperfect and not ready to be judged, you will wind up with nothing. Being vulnerable is part of the process – feedback from others is what drives improvements in your products, and will bring up things you never even thought about. Compromise can be difficult, but if you put yourself out there, and have a truly innovative and meaningful idea, the details will work themselves out over time.

4. Publicity can build on itself, so be ready!

Though you may have to sacrifice perfection when starting a company, you do need to have a polished, presentable pitch ready to go. As the team shared, you never know when NBC will want to interview you. Publicity in the modern age can be confusing and surprising, but if you are lucky, it will build on itself, and others will begin to take notice of your company. This can be nerve-wracking, but it also keeps you on your toes, ensuring you are putting out the best product you can. Nothing lights a fire under you as much as built up expectations and hype. You may not always be able to control your messaging, but you can do your very best to deliver what you promise.

– Ryan is a second year medical student at the Perelman School of Medicine. He is the co-VP of curriculum for Penn HealthX, the co-host of the Penn HealthX podcast, and founder/editor-in-chief of the Penn HealthX blog. You can contact him at ryan.o’keefe@uphs.upenn.edu –