0:00:04 The content here is for informational purposes only should not be taken as legal business 0:00:10 tax or investment advice or be used to evaluate any investment or security and is not directed 0:00:14 at any investors or potential investors in any A16Z fund. 0:00:17 For more details, please see a16z.com/disclosures. 0:00:20 Hi, and welcome to the A16Z podcast. 0:00:22 I’m Lauren Murrow. 0:00:26 Since social distancing measures were first put in place, time spent gaming has gone up 0:00:28 75% during peak hours. 0:00:34 In this hallway-style conversation, A16Z partner John Lai joins me to talk about how the stay-at-home 0:00:39 movement is fueling gaming, what we’re playing, and why live streaming is having its moment. 0:00:44 Playtime in general is up massively across every category of gaming. 0:00:49 PC games erupt, steam, the world’s largest marketplace for digital PC games. 0:00:54 Steam has been around for 20 years and it’s never seen this level of user activity. 0:00:59 Average concurrent users online typically hover around 15 million. 0:01:04 It hit an all-time record high this past Saturday, around 22 million concurrent users online. 0:01:07 So that’s a spike of almost 50%. 0:01:09 Console games are up massively as well. 0:01:10 What is driving this spike? 0:01:15 Obviously, we’re all at home more, but what other factors are coming into play? 0:01:20 So I think what’s special about games versus other types of media is that gaming is a 0:01:24 massive activity that a set of friends can engage in at the same time. 0:01:30 There are moments of levity, competition, there are emotional highs and lows over the 0:01:32 course of a typical gaming session. 0:01:36 These are bonding moments for people and they create really deep social relationships. 0:01:40 It seems like smart game studios are also putting measures into place to encourage more 0:01:41 at-home play. 0:01:46 I know Pokemon Go changed its mechanics a bit to make it easier for people to play 0:01:47 from home. 0:01:50 It changed its events to make it easier for people to play alone. 0:01:51 Absolutely. 0:01:54 Blizzard of World of Warcraft, which is one of the largest and longest-running MMOs of 0:01:59 all time, launched a whole series of benefits during quarantine so that if you’re playing 0:02:05 right now, you actually get double experience as a way of incentivizing people to continue 0:02:06 playing the game. 0:02:09 What kinds of games are popular amid this crisis? 0:02:10 Are there particular titles? 0:02:15 One game that I’ll highlight as an example is a fairly recent one, Call of Duty Warzone, 0:02:19 which is a new battle royale game from Activision that just launched March 10th. 0:02:24 It ended up being one of the most successful and fastest growing PC console game launches 0:02:25 in history. 0:02:30 Over the course of three days, it reached 15 million players, and I think it reached 0:02:32 30 million players after two weeks. 0:02:37 I saw Infinity Ward had 6 million players in its first 24 hours. 0:02:41 I think a lot of games that are launching this month are seeing major spikes. 0:02:48 So Xbox Live, which is the multiplayer service for Xbox consoles, has had several outages 0:02:52 twice over the last week as more users logged on than the infrastructure can handle. 0:02:56 And Microsoft has some of the world’s best cloud infrastructure, so if they’re having 0:02:58 trouble with it, it’s got to be a lot of people logging on. 0:03:03 I’ve read of developers experimenting with ways to include a higher player count and 0:03:08 larger squads with all these new users, but that’s also potentially risky. 0:03:12 As you mentioned, Nintendo, Xbox Live, and Discord have all experienced outages within 0:03:13 the last month. 0:03:17 How are game developers responding to this massive influx of players? 0:03:19 Yeah, it’s a double-wed sword. 0:03:24 On one hand, you have unprecedented numbers of users coming to your servers, and you want 0:03:26 to be able to support them. 0:03:31 Increasing the number of users currently in a session is one way to try to minimize the 0:03:37 sheer number of servers or shards that you need to spin up for a game, but at the same 0:03:39 time that comes with its own technical challenges. 0:03:42 And so I think everyone’s just struggling to keep the lights on. 0:03:47 Discord announced that they had increased server capacity by 20% to keep up with demand, 0:03:52 and promptly, right after making that announcement, they had server outages themselves as well. 0:03:55 This isn’t something that’s just specific to games. 0:04:00 Netflix, for example, just cap bit rates over in Europe, so in an effort to sort of keep 0:04:06 bandwidth down, they’re no longer streaming in 4K or HDTV, and it’s clearly an attempt 0:04:10 to contain costs and continue maintaining the quality of the service in the face of 0:04:11 a lot of demand. 0:04:15 Is there anything surprising that you’ve noticed in the types of games you’re seeing played 0:04:18 more amid the coronavirus quarantine? 0:04:25 Online multiplayer games are the ones that are seen the most obvious and largest growth, 0:04:29 which makes sense because they’re fundamentally social games that you play with other people. 0:04:35 I actually think that VR, virtual reality, might be seen as surge in popularity. 0:04:36 How so? 0:04:41 Well, the whole notion of VR is predicated on enabling people to escape the real world 0:04:44 to a virtual reality, right? 0:04:48 And even prior to COVID, there were early indicators that in-home consumer VR may be 0:04:53 turning the corner, so the Oculus Quest was estimated to have sold well over a million 0:04:56 units before it went in backorder. 0:05:01 The Valve Index, which is perhaps the most powerful headset to date, sold out in minutes 0:05:03 upon initial release. 0:05:07 So VR headsets seem to have finally reached a price point and a hardware quality that 0:05:08 has mass market appeal. 0:05:13 And at the same time, you have exclusive AAA games coming to VR for the first time, titles 0:05:21 like Half-Life Alyx, and Half-Life is arguably Valve’s biggest and most exciting IP, a sci-fi 0:05:24 franchise that put them on a map, initially. 0:05:29 It’s famous for ending the franchise essentially on a cliffhanger, and the resolution for the 0:05:35 story is this Half-Life Alyx game, and it’s a VR exclusive, so you can only find out what 0:05:39 happens if you buy a VR headset and you play in VR. 0:05:44 Educational games are actually seeing tremendous growth as well these days. 0:05:47 Teachers in schools are also holding online classes through Discord. 0:05:49 I think that’s an interesting use case. 0:05:55 So rather than platforms like Zoom, some are turning to apps that were traditionally gaming 0:05:57 platforms like Discord or Twitch. 0:06:02 Yeah, I think they’re picking the platform that their audience is already on. 0:06:07 So if you’re an instructor and you’re trying to get kids to come online in order to listen 0:06:13 to AP buyer or whatever subject matter you’re teaching, it’s going to be easier to convince 0:06:17 them to come online if you pick Discord, because chances are they already use Discord to play 0:06:18 their favorite games. 0:06:23 So Discord actually just made a number of moves specifically to help educators come on 0:06:24 the platform. 0:06:29 It’s the user limit on screen change from 10 to 50 users, so you can accommodate larger 0:06:30 class sizes. 0:06:35 And in this case, the actual friction is on teaching the instructors, the teachers themselves 0:06:36 how to use Discord. 0:06:42 One thing in these gaming platforms is that as we’ve seen with video conferencing, the 0:06:45 natural rhythm of the conversation is off. 0:06:49 It’s difficult to respond without interrupting, sometimes it’s difficult to interject. 0:06:57 So when it comes to learning how to have a live interactive conversation online, ironically 0:07:03 I think gamers have received way more training in that area than almost any other demographic. 0:07:09 Because the very nature of playing a game and chatting with someone over Discord or 0:07:14 interacting with a livestream, it’s basically a constant act of juggling foreground versus 0:07:15 background activity. 0:07:19 And so being able to contact switch from okay, I’m listening to the lecture, to now I have 0:07:22 a question and we’re going to talk about this question. 0:07:26 This is something that gamers and then livestreamers in particular have a lot of experience with. 0:07:31 And I think it’s interesting to think about how this might become an increasingly more 0:07:38 critical skill in society as more teams and general folks start working and learning remotely 0:07:40 versus in person traditionally. 0:07:46 So you’re saying gamers may actually be prepared for this future whereas perhaps most of us 0:07:49 who are not gamers may have a steeper learning curve? 0:07:50 That’s right. 0:07:53 John, I want to talk about who is playing. 0:07:57 I think a lot of people have the conception that because schools are canceled in many 0:08:03 places, a lot of it is teens and kids playing more video games. 0:08:09 The average age of a gamer on League of Legends, for example, actually skews fairly old. 0:08:14 I think it’s something in the 20s or the 30s, over time it’s crept up. 0:08:19 And so you have a mix of adults, you have a lot of kids that are definitely playing since 0:08:20 they’re out of school. 0:08:24 And I think one of the neat things is that you have families that are coming together 0:08:28 and playing games potentially for the first time as a sort of quarantine. 0:08:35 Dungeons and Dragons, which is a tabletop fantasy RPG, has actually seen massive growth 0:08:37 as well over the course of quarantine. 0:08:42 In these turbulent times you end up having a lot of folks that are playing D&D together 0:08:44 over Zoom and House Party. 0:08:49 Those broadcast in the live streaming site Twitch is up 34% just in the last week, if 0:08:50 you’re not familiar. 0:08:55 It’s a tabletop game where a group of people role play a story and that story is often 0:08:58 created just by another player of the game. 0:08:59 It’s a giant improv party, essentially. 0:09:04 Yeah, I think it’s important to remember that there’s this whole new audience that is rediscovering 0:09:06 gaming as adults. 0:09:07 Absolutely. 0:09:11 A lot of people are coming back to games as a result of being housebound and they’re 0:09:16 discovering that even though they may not have a console or a gaming PC, they actually 0:09:18 already have an awesome gaming device on them. 0:09:23 PUBG Mobile, which is the mobile version of a player unknown battlegrounds reported increased 0:09:28 revenue of over 50% just in the last week compared to the prior week. 0:09:33 One of the largest mobile games in the world, Tencent’s Honor of Kings grew from an average 0:09:39 baseline of 60 million daily active users to over 100 million plus in February at the 0:09:44 height of quarantine in China, and that’s 60% plus growth, which is pretty amazing given 0:09:46 how large that game was to begin with. 0:09:50 Essentially, you have a lot of new gamers rediscovering that they have a gaming device 0:09:52 and perform at their smartphone. 0:09:55 And some of these newcomers may be traditional sports fans. 0:09:59 As in real life games and sporting events have been canceled, some of these leagues and 0:10:02 teams have been moving online to a digital format. 0:10:07 So about a week ago, the NBA turned one of their canceled games, I think it was Phoenix 0:10:09 versus the Dallas Mavericks. 0:10:14 They took that game and they actually turned it into an NBA 2K game, which is the video 0:10:20 game equivalent of the real NBA, and it was livestreamed on Twitch for everyone to watch. 0:10:26 It’s very trippy for me when I see an NBA star play their virtual persona in a video 0:10:27 game. 0:10:32 Well, and as NBA players have been put in isolation, I think many of them have been 0:10:33 turning to gaming. 0:10:37 There was a Call of Duty tournament for Miami Heat players that was also broadcast on Twitch. 0:10:44 And NASCAR just replaced the canceled races with the first ever eNASCAR series where you 0:10:47 were essentially piloting virtual race cars. 0:10:51 And they brought back a lot of recent legends like Dale Earnhardt Jr. to drive those race 0:10:52 cars. 0:10:57 So professional race car drivers are competing against each other in racing simulation software. 0:10:58 That’s right. 0:11:03 So could eSports be a gateway to turn non-gamers into gamers? 0:11:09 It’s a bit of a hybrid between traditional video games and that live, crowd-driven competitive 0:11:10 event. 0:11:11 It remains to be seen. 0:11:17 I think, yes, from the perspective that you’re having an audience that may have never actually 0:11:24 watched NBA 2K or FIFA, for example, any of these sports video games that are now exposed 0:11:27 to that and might actually think it’s pretty cool. 0:11:32 And it’ll be interesting how many of these NBA players, one, how many of them can build 0:11:38 large eSports followings and then, two, if their eSports followings actually end up being 0:11:42 larger than their real-life following, I think that would be a real success story. 0:11:44 It’s a brave new world. 0:11:46 Let’s turn to live streaming. 0:11:47 Absolutely. 0:11:52 So the analytics site, Sully Nome, actually just released a couple of data insights. 0:11:56 The high-level headline is that Twitch is essentially having the biggest month of its 0:11:57 history. 0:12:02 Livecast hours also grew by 35% over the last week compared to the average of the prior 0:12:03 three weeks. 0:12:10 And Sunday ended up being an all-time record breaker, where 47.7 million hours watched. 0:12:13 Why this rise in live streaming? 0:12:17 Part of that could be due to the fact that you have people that are checking out live 0:12:19 streaming for the first time. 0:12:26 Another interesting nugget was that downloads of the Twitch app increased by about 30% just 0:12:32 in the US alone between the weeks of March 8th and March 15th, so you have a lot of 0:12:34 people that are checking it out for the first time. 0:12:40 I think a second thing is that live streaming is unique as a media format and that it combines 0:12:45 the reach of a public broadcast with the intimacy of a small group community. 0:12:51 And what I mean by that is essentially, as a live streamer, you can reach hundreds of 0:12:53 millions of people with a single live stream. 0:12:59 So it is a public broadcast media just like TV or the radio. 0:13:03 But because of the fact that it’s interactive, your viewers can type at you and you can have 0:13:07 a conversation with them and you can adapt what you’re doing in real time to what your 0:13:09 viewers demand. 0:13:11 It feels like a smaller group conversation. 0:13:14 And you can monetize in real time, right? 0:13:15 That’s right. 0:13:18 People tip in real time if you’re doing something that’s very popular, that if you’ve answered 0:13:24 a request, people can subscribe to your channel and the subscriptions cost money anywhere from 0:13:26 a couple of dollars that way more. 0:13:31 So it’s interesting as both an engagement and a monetization model for influencers these 0:13:32 days. 0:13:39 So it’s kind of a hybrid of YouTube and TikTok in that you can amass this online following, 0:13:42 you can be streaming live, but you can also be monetizing instantly. 0:13:43 That’s right. 0:13:48 On YouTube and TikTok, for example, you produce content and then you upload it in any 0:13:51 way that you have to wait and see what happens and you’re not actually getting that much 0:13:53 in terms of real time feedback. 0:13:59 TikTok is slightly more real time than YouTube, simply because the videos are shorter and 0:14:03 people can like and comment very quickly after you upload something. 0:14:07 But live streaming platforms are unique in the sense that you are literally performing 0:14:12 in real time for a live audience and you’re getting the feedback just as if you’re a stage 0:14:17 performer in real life in real time, given either clapping or throwing tomatoes at you, 0:14:19 or digital tomatoes. 0:14:20 That’s right. 0:14:24 And I think that’s one of the things that makes live streaming work so well right now 0:14:26 in COVID times. 0:14:31 It’s because people are actually able to get a sense of community online through live 0:14:35 streaming that may otherwise be hard to find in the real world because we can’t get together 0:14:37 in large groups anymore, right? 0:14:41 Like you can’t go to church, you can’t go to school, you’re not at work. 0:14:45 So a lot of the communities that people are ordinarily members of I think have sort of 0:14:50 fallen by the wayside and Twitch has been able to provide that sense of community for 0:14:51 a lot of its viewers. 0:14:58 As opposed to passively binging Netflix, people want this more interactive way of being social 0:15:00 with their friends and family. 0:15:04 I mean, speaking of relationships, it’s a bit of a personal story, but video games actually 0:15:08 saved my marriage and totally not getting here. 0:15:10 How so? 0:15:15 So when my wife Jen and I first started dating, we were actually long distance for the first 0:15:16 year of our relationship. 0:15:21 I was in San Francisco, she was in New York, so we actually met at a New York City to get 0:15:27 together and then I had to fly out literally two days from afterwards and it was really 0:15:28 tough. 0:15:31 We didn’t know each other that well, but we started playing an online game called League 0:15:35 of Legends together and that completely saved the relationship. 0:15:39 When we didn’t feel like talking about serious things, we could just play the game and there 0:15:45 were enough sort of highs and lows and moments of tension and drama that we also got to know 0:15:47 each other better as we played together. 0:15:48 I love that story. 0:15:51 Yeah, so who says you can’t find love in video games, right? 0:15:53 So you’ve been married 10 years now. 0:15:56 Are you still playing League of Legends together? 0:15:57 We still are. 0:16:02 It’s one of the mainstays of our relationship actually, so a light-hearted way to spend time 0:16:06 and I imagine that’s what a lot of people these days are doing in quarantine as well. 0:16:11 You know, if you’re in a small apartment or a house with members of a larger extended 0:16:16 family, there’s only some sort of conversation you can have before fights start breaking 0:16:22 out, so maybe you break out the Xbox, play some mobile games, play some party games and 0:16:26 it helps generally improve the quality of life in the house. 0:16:29 I think there’s definitely a social dynamic at play. 0:16:35 A lot of people aren’t necessarily comfortable FaceTiming or video chatting and seeing their 0:16:38 own face reflected as they talk to family members. 0:16:41 So I think gaming provides this distraction. 0:16:45 You’re doing something else while you’re connecting with your family or friends. 0:16:50 Yeah, I think one of the best ways I’ve heard it described by a live streamer is actually 0:16:57 that games can switch back and forth between foreground and background activity, so you’re 0:17:01 not really thinking too hard about the game, but you’re actively conversing and you might 0:17:06 actually be talking about something that’s like very serious, but then you can just switch 0:17:09 the game back into the foreground and you both concentrate on the activity. 0:17:15 And so it provides activity to fill in the gaps that are very natural in conversations 0:17:19 and it doesn’t feel like just long periods of silence if you don’t have anything to say 0:17:20 to each other. 0:17:23 Yeah, I think that’s something we’re all familiar with. 0:17:28 The point is social distancing, quarantine, it’s lonely and I think a lot of people are 0:17:31 rediscovering gaming as a way to connect with others. 0:17:36 So after we weather this crisis, what will this mean for the games industry? 0:17:37 What is the bigger picture? 0:17:43 The bigger picture here is that gaming is unique as a media type and that it’s real 0:17:45 time and it’s fundamentally social. 0:17:50 When you’re playing a game, you’re partaking in an immersive activity with someone else. 0:17:54 And so I think that’s one of the reasons why gaming has seen such explosive growth since 0:17:56 the start of coronavirus. 0:18:01 And so I think games and live streaming are offering a lot of the social connections that 0:18:05 people are missing as they’re staying at home these days and I think that will only 0:18:06 continue over time. 0:18:12 So once this crisis is over, do you expect these new gamers to stick around? 0:18:13 I hope so. 0:18:17 It’s easier than ever to get into games today with just so many different platforms that 0:18:18 you can play on. 0:18:22 If you have a console or a gaming PC, that’s great but you don’t need one. 0:18:27 You can also play phenomenal, triple-way quality games in your mobile phones these days. 0:18:32 And so the barrier is the entry for people coming back in the game to discovering games 0:18:34 for the first time is lower than ever. 0:18:35 Great. 0:18:37 Well, John, thank you so much for joining us on the A16Z podcast. 0:18:38 It’s been a pleasure. 0:18:39 Thanks for taking the time.
Since social distancing measures were first put in place, time spent gaming has gone up—way up. According to a recent report by Verizon, video game usage in the U.S. has risen 75 percent during peak hours. The “stay at home” movement has given way to an upswell of new and returning gamers—as well as new challenges, as online platforms struggle to keep up with the surge.
In this episode, a16z partner Jon Lai joins host Lauren Murrow to talk about how game developers are grappling with skyrocketing numbers, why this may be an inflection point for VR, the surprising transition of professional sports into esports, and why live-streaming is having its moment.
0:00:02 (upbeat music) 0:00:14 – Welcome to this episode of “Hustling Tech.” 0:00:16 I’m Ben Horowitz, and with me today, 0:00:19 I have Josh Browder, who is the founder, 0:00:22 CEO of DoNotPay.com. 0:00:25 We have Makiri Omar, 0:00:29 who’s been hustling that platform to great effect. 0:00:30 And then with me, as always, 0:00:34 I have my co-host, Shaka Senghor, 0:00:36 who hustled his way out of the joint 0:00:40 and is now a leader in the community and my co-host. 0:00:41 So welcome. 0:00:42 – Yeah, welcome. 0:00:45 So I love, first of all, I just love the name DoNotPay. 0:00:48 I wanna stamp that on every bill that comes through 0:00:49 and just send it out to everybody. 0:00:52 – So tell us, what is DoNotPay? 0:00:53 How did it start? 0:00:55 – So DoNotPay today is a platform 0:00:58 that helps ordinary people fight for their consumer rights. 0:01:01 So getting back money from corporations and governments. 0:01:04 And it started out four years ago 0:01:05 when I got a bunch of parking tickets. 0:01:07 I was admittedly a terrible driver 0:01:09 and I was writing all of these appeal letters 0:01:11 to get out of my tickets. 0:01:13 And I learned that you can go to a lawyer 0:01:14 and the lawyer will say, 0:01:16 I’ll get you out of your parking ticket, 0:01:18 but I’ll take 50% of the cost of the ticket, 0:01:20 or you have to pay the ticket. 0:01:22 And there must be a better way than that. 0:01:25 And so I’ve researched all of these obscure government 0:01:27 documents to find out the top reasons 0:01:28 why people get out of their parking tickets. 0:01:30 The biggest one is signage. 0:01:32 They make the signage deliberately confusing. 0:01:34 For example, having a tree cover the sign, 0:01:37 having two signs say the opposite thing. 0:01:39 And then the second biggest reason is parking bays 0:01:41 that are physically impossible to park in. 0:01:45 And below 180 centimeters, you can’t get any car in. 0:01:47 And this is mainly because the lines aren’t painted. 0:01:49 Beyond that, they make mistakes on the ticket. 0:01:51 Then you can’t trust them with anything. 0:01:53 And I decided to automate that for my friends. 0:01:54 And then it turned out it was very popular. 0:01:57 So expanded it to the general public. 0:01:59 – And that’s actually kind of cool also, 0:02:00 ’cause coming from where you’re from, 0:02:03 Shaka, you know, a lot of guys with cases 0:02:05 get taken down by parking tickets. 0:02:06 – Yeah, absolutely. 0:02:09 Clear that right on up and not have to run into the courts 0:02:11 when they already got a warrant for other things. 0:02:14 – And McCary, so how did you come across the platform 0:02:15 and what were you doing with it? 0:02:18 – So I have a delivery service, 24/7 delivery service. 0:02:20 When you’re a delivery service and you live in LA, 0:02:22 we have a thing that we like to call parking ninches. 0:02:24 Those are the right. 0:02:25 So when you’re delivering things, 0:02:29 we deliver things at all times of day and hour and night. 0:02:32 So it’s one of those things where I literally needed 0:02:34 to find a way where I can either help some of my drivers, 0:02:37 get out of their tickets, because places like LA, 0:02:40 they literally like to stick you a ticket on your window 0:02:43 that says $70, $77, all the way up to $177. 0:02:45 And the violation can be like, 0:02:47 oh, you didn’t put your will to the left. 0:02:48 Just something really ridiculous. 0:02:50 So I was just trying to find the answer to that. 0:02:52 And then I just remember it was just 0:02:55 so half of the TV was on and next thing you know, 0:02:57 they said, oh, there’s an app, there’s a robot 0:02:59 that can literally take care of your parking tickets 0:03:01 and that could really go to bat for you 0:03:02 and get your money back. 0:03:05 I’m like, huh, yeah, let me try to put it to the test. 0:03:08 And it literally helped me with one or two of my parking 0:03:11 tickets that was a real big problem. 0:03:13 So basically you start using their service 0:03:16 and then later on, they start adding more features. 0:03:18 – When were the other features that you started using? 0:03:20 – So it’s one of those things where you’d have people 0:03:23 who would actually try to buy a product from you 0:03:25 and then they’ll try to say, oh, we never received 0:03:27 that product or they’ll do a charge back 0:03:29 or they’ll try to say whatever the case would be. 0:03:31 And then what would happen is, is that it would go 0:03:33 into my account, it would take money out of my account, 0:03:36 my merchant processor would take money out of my account. 0:03:38 And then it would charge, it would actually come back 0:03:41 to be where like I would have now a negative fund 0:03:44 in my account or they would charge me another like NSF fee. 0:03:46 It’s money that basically is in your account 0:03:47 or they take from you. 0:03:49 It’s just a fee that they charge you for an overdraft. 0:03:52 – So they robbed you facilitated 0:03:53 by the credit card company. 0:03:54 – The product’s gone, the money’s gone 0:03:56 and now you’re taking more money because of everything else. 0:03:59 So they now have something that basically like, 0:04:00 get your bank fees back. 0:04:03 Just like last week, I got like $62 back in fees. 0:04:04 So you can’t knock it. 0:04:07 – You know, the banking system is so, 0:04:10 I mean, for a small business or kind of a person 0:04:13 who doesn’t have a lot of money is the most broken thing. 0:04:16 It’s something we track a lot here and that if you’re me, 0:04:19 you pay nothing for banking services. 0:04:21 If you’re kind of a regular person 0:04:23 trying to go paycheck to paycheck, 0:04:28 it’s like $15 a month in ATM fees and this fee 0:04:29 and that fee and the other things. 0:04:32 It’s all hidden and under the covers. 0:04:33 – Yeah, I was actually thinking about, 0:04:36 if you have a small business like that can be just devastating 0:04:39 be those, ’cause those fees rack up relatively quickly. 0:04:41 So did you have just small businesses mine 0:04:45 or was it just in general, like this is something 0:04:47 that we just need to attack either way it goes. 0:04:48 – So when I launched Do Not Pay, 0:04:50 it was just from my small dorm room 0:04:52 and I put up this website for parking tickets. 0:04:54 I had a contact form on the website 0:04:56 and people didn’t know that there was a 17 year old 0:04:58 behind this website and they thought I was some big law firm. 0:05:01 So they actually say, I don’t have a parking ticket 0:05:06 but I’m getting like this small business like charge back, 0:05:07 things like that. 0:05:09 And so that’s where I got all the ideas to expand 0:05:11 and it’s a bigger problem than just parking tickets. 0:05:14 People are being exploited across the system. 0:05:15 – I’m like a power user. 0:05:18 I mean, it’s one of those things where they even have 0:05:19 something where if you’re going to court, 0:05:21 if you need to get money, 0:05:24 I have a situation now where I had to deal with a landlord 0:05:26 who basically was withholding money 0:05:28 because he went and told me 0:05:31 that the place I was moving into was the certain size. 0:05:32 And he wouldn’t let me see it because he was like, 0:05:35 well, you’ve seen the pictures, you’ve seen this, whatever. 0:05:36 I’m not gonna lie to you, you know, 0:05:37 I guarantee this, I guarantee that. 0:05:39 And it was supposed to be a certain square footage. 0:05:41 Well, it wasn’t, it was like, 0:05:43 it was supposed to be 12, 172 square feet, 0:05:44 but I walked in and I said, 0:05:46 this is 615 square feet. 0:05:48 And he was like, well, you know, you signed the lease. 0:05:51 He took $5,700 of my money. 0:05:54 And so like, I was just like, okay, where do I go? 0:05:55 What do I do for this point on? 0:05:58 So of course I went the legal shield route 0:05:59 because at first that’s the first thing you think of 0:06:00 is attorney base. 0:06:02 Let me see if I can get somebody to write a letter 0:06:03 like real quick. 0:06:04 That didn’t work. 0:06:06 And then finally I was like, okay, well, 0:06:07 small claims here I come. 0:06:08 So I did that. 0:06:11 But then also when I did the do not pay at the same time, 0:06:14 do not pay actually came up with a script 0:06:14 that literally was like, 0:06:16 they researched the whole situation 0:06:17 because you’re typing your situation. 0:06:21 And literally they now have a thing called that says, 0:06:22 what’s your problem? 0:06:25 And it’s like a customer service space problem area. 0:06:27 And it actually goes and it researches similar cases 0:06:30 or similar ideas or something that somebody else has done 0:06:32 or that have been through the same thing. 0:06:33 And it compiles your situation together 0:06:34 and it gives you the structure 0:06:36 of what you need to say and present in court. 0:06:39 So you know exactly what to say to the judge or not. 0:06:41 That’s one of the things that I’m super curious about. 0:06:43 I’ve done a lot of work in criminal justice space 0:06:46 nationally and when talking to people 0:06:48 about the legal structure in the U.S. 0:06:50 where they think it’s just one thing, 0:06:52 it’s one kind of legal structure. 0:06:54 But in reality, every state has its own thing. 0:06:57 How does do not pay work across all these laws 0:07:01 and different rules in each city and county and state? 0:07:02 Like how does that work? 0:07:04 – So it’s four years in the making 0:07:07 and we only focus mainly on consumer rights. 0:07:09 There’s a lot of national laws around consumer rights 0:07:10 that we rely on. 0:07:13 And then we’ve also adapted it for 50 states. 0:07:16 But you’re completely right and the justice system 0:07:17 in general is like pay to play. 0:07:20 The more money you have, the more successful you are. 0:07:22 And so that’s what we’re trying to stop. 0:07:24 – Wow, and how does the system work? 0:07:27 Because my landlord stole my money. 0:07:28 I need to get it back. 0:07:29 I’m taking them to a small claims court. 0:07:30 This is my case. 0:07:34 And then do not pay says, well, this is your argument. 0:07:36 How did you do that? 0:07:39 – So do not pay will talk to you like a real lawyer. 0:07:41 We call it a robot lawyer and ask you questions 0:07:42 about your issue. 0:07:44 And then it goes down through a decision tree 0:07:47 to classify it against like a legally sound way 0:07:49 to sue this person. 0:07:51 And in this case, it’s breach of contract. 0:07:55 So applied his breach of contract law to his case 0:07:58 and then generated a demand letter and small claims script. 0:08:01 And no lawyers are involved in small claims processes. 0:08:05 And so you can have the same power as like a top law firm. 0:08:06 – Right, right. 0:08:07 ‘Cause you’ve done the legal research. 0:08:09 So when you go in court, 0:08:11 you’re just basically going off the script. 0:08:12 Is that what you’re saying? 0:08:13 – That’s right. 0:08:16 And it even tells you responses 0:08:17 to what the other side could say. 0:08:21 So if the other side says, actually I did post it, 0:08:23 you say, well, not in the legally correct place. 0:08:26 So it gives you even back and forth discussion points. 0:08:28 – I mean, I’ve been small claims more than once. 0:08:31 Many people don’t know that when you go to small claims, 0:08:34 you are not allowed to be represented by an attorney. 0:08:36 You literally have to talk your case out 0:08:39 in front of a judge or a sit in judge. 0:08:42 And basically, you know, go back and forth 0:08:44 between the plaintiff and the defendant. 0:08:47 You can consult an attorney before you go 0:08:48 to make sure that what you’re saying is valid 0:08:50 and what you’re going against 0:08:52 is what you are really going to win. 0:08:54 And so like you can do that, 0:08:56 but you just can’t have one present with you. 0:09:00 So what do not pay does is that basically 0:09:01 it takes all that information. 0:09:04 You, I literally wrote out the whole script 0:09:07 and it just gave me the definitions of what point 0:09:09 I needed to basically cover. 0:09:11 And I need to make sure that, 0:09:13 and it even tells you in the whole little paragraph 0:09:15 that they give you, 0:09:18 you have to make sure that each point is clearly defined 0:09:20 and it clearly stated of why this happened 0:09:23 and this happened here or how does this define this? 0:09:24 So it gives you an understanding 0:09:27 of what you have to tell the judge. 0:09:30 I got, you know, I was actually robbed of my money 0:09:32 because this man told me that it was one size 0:09:34 and in actuality it was not. 0:09:35 Here are pictures, 0:09:36 here are everything, 0:09:37 give my evidence to back it up 0:09:39 and here’s what I need to present in order to do so. 0:09:41 So once you get that, 0:09:43 then you kind of feel comfortable going, 0:09:44 like you’re ready to go. 0:09:47 And then also if the person doesn’t show up, 0:09:49 for those who don’t know that, you know, 0:09:50 that you can win by default, 0:09:51 if that person doesn’t show up, 0:09:53 it tells you at the bottom like, okay, 0:09:54 if that person doesn’t show up, 0:09:55 then you tell the judge this 0:09:57 and it tells you a script to read. 0:09:59 So the judge will automatically know, okay, 0:10:01 well this person clearly knows what he’s talking about 0:10:03 because that’s what you have to do in the court of law. 0:10:04 – So how does that work for somebody 0:10:07 who has challenges with literacy? 0:10:10 ‘Cause I mean, like doing this work in criminal justice, 0:10:12 like one of the big issues 0:10:15 is that people take very poor deals largely 0:10:17 because they don’t understand or comprehend a law. 0:10:18 So how does this work? 0:10:20 Is there a way that, you know, 0:10:23 people can just verbally express their argument 0:10:24 or is it all written? 0:10:26 – So it’s all verbal, 0:10:28 but we’re launching voice input. 0:10:30 So you can open-ended say, 0:10:32 my landlord won’t give me my security deposit back 0:10:34 and it will figure it out for you. 0:10:36 We really think about this, making it accessible. 0:10:39 Do not pay a scripture in the simplest English possible. 0:10:42 You don’t have to have an iPhone to use, do not pay. 0:10:45 You can go onto donotpay.com and get access to everything. 0:10:49 And even if you’re blind, we have alt text 0:10:52 and we’re fully compatible with like screen readers 0:10:55 and stuff and soon we’re going to have voice input. 0:10:57 So it’s something we really think about. 0:10:58 Obviously we could be a lot better, 0:11:01 but we’re moving in that direction. 0:11:02 Unfortunately at the moment, 0:11:04 robots can’t represent people in court. 0:11:06 At one day the law will hopefully change. 0:11:09 – So Josh, you say that, you know, 0:11:12 you’re adding features based on your customer input 0:11:13 and all the things that they want to do. 0:11:14 What are some of the things? 0:11:17 – The biggest one is Robocall compensation. 0:11:18 So there are lots of apps that block Robocalls, 0:11:20 but none that get you some cash. 0:11:23 And we’re really excited about this one 0:11:25 because we actually give you a fake credit card 0:11:26 that you can give to the Robocaller 0:11:28 and it will get all of their details 0:11:29 to make it easier to sue them 0:11:32 when they try and run a fake transaction. 0:11:33 But in the longer term, 0:11:36 once you have five million people using Do Not Pay, 0:11:39 it almost gives like group leverage like a consumer union 0:11:41 to go to one of these big corporations 0:11:44 and say we have five million of your customers, 0:11:45 you better start treating them better 0:11:48 or we’ll switch them all to your competitor overnight 0:11:50 and at the same time flood you with legal requests. 0:11:52 So I think right now the leverage is in the law 0:11:56 and the individual, but soon it can be in like collective. 0:11:58 – And is there a fee associated with that? 0:12:01 – So right now Do Not Pay costs $3 a month 0:12:03 and the subscription only starts if you win. 0:12:05 So you can check it out for free. 0:12:07 And the most important aspect of that 0:12:09 is users keep 100% of what they save. 0:12:10 And we’re really looking to make it 0:12:12 as fair pricing as possible. 0:12:15 – And you’re getting something back in return. 0:12:17 Everybody has some type of issue with something or other 0:12:19 that wasn’t even fair 0:12:21 and seems like corporations are taking more advantage of you. 0:12:23 – McCarey, tell us a little bit 0:12:25 about your entrepreneurial journey. 0:12:28 Like how did you, you know, like what’s your background? 0:12:29 – I’ve always been an entrepreneur. 0:12:31 I basically learned to just work for myself 0:12:33 because I’ve already started working for somebody. 0:12:34 Like when I graduated from high school, 0:12:36 I worked for the weather channel. 0:12:38 Then I went and branched off to IBM. 0:12:40 And then after that, I then worked for my mom. 0:12:42 And then after that I did a development company 0:12:45 and then I decided to come out here from Atlanta, Georgia 0:12:48 to great California to actually go to Los Angeles film school 0:12:50 to pursue my dream in film. 0:12:51 – Oh, wow. 0:12:52 – Yeah, but that didn’t work out too well. 0:12:54 So I did a company for business branding. 0:12:56 Then that one kind of just went out on the wayside. 0:12:59 And then finally I was just, it just hit me, 0:12:59 it struck me one time, 0:13:02 but I guess I was in an adult situation. 0:13:05 And the thing was is that basically I literally tried 0:13:07 like all the different type of delivery services. 0:13:10 And none of them would deliver the essential products 0:13:13 that most people need when they are in situations like that. 0:13:14 And then when I tried to postmates, 0:13:16 I then tried to direct them like, okay, 0:13:18 I’ve already called the store. 0:13:19 The product is already on the counter. 0:13:20 You don’t have to worry about it. 0:13:21 It’s already ready to go. 0:13:23 Just pick it up and bring it in. 0:13:26 So I created like a 24/7 delivery service 0:13:29 for Los Angeles and it’s called Luber. 0:13:31 And it was like basically a on-demand delivery service 0:13:34 that do adult retail is what you need. 0:13:35 When you need it, we’ll bring it to you. 0:13:37 I mean, our slogan is basically, 0:13:39 we come even if no one else can. 0:13:42 So it’s just being, like I said, being a small business 0:13:43 is like you’re trying to find every little niche 0:13:46 to try to find something that will help you along the way. 0:13:49 I’ve had platform problems with like my websites, 0:13:51 with just a customer service or with like, 0:13:53 and these are huge companies that literally, 0:13:55 they do not care if they shut your business down 0:13:57 or if they put you on a hold or a freeze 0:13:59 because of something wrong with their system. 0:14:01 And I literally just went through a whole nightmare 0:14:03 during like the Christmas season and the New Year season 0:14:06 where all of a sudden the platform I was with 0:14:07 literally froze my account 0:14:09 because they went with a third party of developers 0:14:10 saying that, you know, 0:14:11 I didn’t want to renew my service with them 0:14:13 because they were actually ripping me off. 0:14:16 And I literally had a problem with trying to, you know, 0:14:18 give me my money back or at least open my site. 0:14:20 I was not late on my bill. 0:14:22 I literally did not want to renew my service. 0:14:24 So what they did was they held me hostage 0:14:26 or help my company hostage by shutting me down 0:14:29 on the most like busiest days of my company, 0:14:31 which is of course the holiday season. 0:14:34 So literally, like I had like inventory ready to go, 0:14:37 everything set to go and they froze it on Christmas day, 0:14:39 then they froze it on New Year’s day and then, and so on. 0:14:41 And I was like, okay, I can’t deal with this. 0:14:43 I even signed up for the big like, you know, 0:14:45 LinkedIn, like the premium service. 0:14:47 So I could literally write the head of the company 0:14:49 ’cause that’s the only way you never get to them. 0:14:50 Never got a response. 0:14:52 And so I finally did it through do not pay. 0:14:53 That’s at least fighting for me. 0:14:55 And I know that if they can’t get it solved, 0:14:57 it’ll at least keep my problem in front of their face 0:14:59 long enough that something’s gonna come of it. 0:15:02 And that’s what it actually did just recently. 0:15:04 I finally got access to like my old website. 0:15:06 So I could get at least my financials 0:15:08 and everything off of it so I can put on my new website. 0:15:10 Do not pay, I guess went and did something 0:15:12 with either the Better Business Bureau 0:15:15 or they did something where they actually got a route to them. 0:15:18 So it’s literally helped my company out tremendously. 0:15:19 – How do you think about that problem 0:15:21 that because you started with parking tickets 0:15:26 that people may not know that you’re their lawyer of choice 0:15:28 for every kind of dispute 0:15:31 that an individual might get into or a small business? 0:15:32 – It’s a tough problem. 0:15:35 People come to do not pay with this very episodic issue. 0:15:37 What we try and do is use the design of the app 0:15:41 to nudge them towards saving money in other areas. 0:15:44 So maybe in this case, someone comes for a parking ticket, 0:15:45 they finish their parking ticket appeal 0:15:48 and then a pop-up comes up as saying, 0:15:50 do you wanna appeal $50 a bank fees? 0:15:52 And then they can just one click press that 0:15:53 and move on to their next issue. 0:15:56 You can cancel any subscription with do not pay, 0:15:59 even one where you have to even mail in like a legal letter 0:16:01 just to cancel your subscription. 0:16:03 The most popular product is something we call 0:16:05 the free trial credit card, 0:16:08 which is a virtual credit card we give you through the app 0:16:09 and you can sign up for any free trial 0:16:11 and it automatically cancels it for you. 0:16:13 So you don’t have to worry about giving away 0:16:15 your financial information just to sign up 0:16:16 for a free trial for something. 0:16:18 What we’ve seen is a lot of power users 0:16:21 likes what’s being discussed as people come for one thing 0:16:23 and then all of a sudden try like 20 different things 0:16:24 and go crazy. 0:16:25 – Yeah, so in your estimation, 0:16:29 like what type of lawyer fees are we seeing save? 0:16:30 You know what I mean? 0:16:33 Like any litigation in America is very expensive. 0:16:35 – So on an aggregate level, 0:16:38 we’ve saved over $20 million in unfair fees 0:16:41 and lawyers typically charge 50% of what they save. 0:16:44 So maybe $10 million of legal fees. 0:16:45 And on an individual level, 0:16:50 we win cases from a $10 in-flight Wi-Fi refund 0:16:53 to $10,000 small claims dispute 0:16:55 against Equifax for the data breach. 0:16:56 Anything more than that, 0:16:58 we’re not sophisticated enough to argue yet, 0:17:01 but below $10,000, we’ve got you. 0:17:05 – So when you get into this customer service dispute 0:17:06 that McCurry had, 0:17:08 ’cause that sounds complicated, okay? 0:17:11 It’s a website, you know, they’re hosting service, 0:17:14 they take, they have his data, 0:17:16 they’re withholding it from him. 0:17:20 How did Do Not Pay figure out how to deal with that? 0:17:22 – So maybe the consumer wants a refund, 0:17:24 maybe they want access to their information. 0:17:26 In this case, it sounds like it’s both. 0:17:30 So it first finds out the goals 0:17:33 and then uses, like tries to match you 0:17:35 with legal justifications for those goals 0:17:37 and then sends it to the exact right place 0:17:39 for the people who can get it done. 0:17:42 In this case, the customer service is so bad 0:17:44 that the only way to actually get their attention 0:17:45 is to send them a legal notice 0:17:47 to their legal processing department. 0:17:49 And those people are actually efficient 0:17:53 at processing their claims and getting the right resolution. 0:17:56 – One of the things we talk a lot about in crypto world 0:17:58 is, you know, code as law. 0:18:01 And it seems like you’re ahead of the game on that. 0:18:05 You’ve got software that’s interprets the law. 0:18:06 So how does that all work? 0:18:07 – I completely agree. 0:18:09 I think law is society’s operating system. 0:18:12 And like it is just code. 0:18:14 Why is it so complicated to understand it? 0:18:16 Technology is based on rules 0:18:20 and it’s very good at understanding the different nuances. 0:18:23 The best processes are ones that can be submitted online. 0:18:26 And I think the most interesting technical angle 0:18:28 is everything comes from the user 0:18:31 and there’s nothing related to do not pay on the appeal. 0:18:34 So when we started appealing parking tickets, 0:18:36 all of a sudden we started sending thousands of appeals 0:18:38 to the local government and they just like shrugged 0:18:41 and said, we’re going to start ignoring these do not pay appeals. 0:18:43 So in response to that, 0:18:45 we decided to randomize all of the letters. 0:18:48 So every letter you get from do not pay is different. 0:18:49 (laughing) 0:18:52 – It’s like a denial of service attack on parking tickets. 0:18:53 – And then beyond that, 0:18:56 we use something called device side automation. 0:18:58 So lots of the automation and submitting the appeals 0:19:00 actually comes from the device, 0:19:02 which means that all of the technical fingerprints 0:19:05 like IP address and stuff like that 0:19:07 makes it seem like an organic user submission. 0:19:09 So when someone submits a claim from do not pay, 0:19:12 it just seems like they’re very knowledgeable about the law. 0:19:15 – All right, this is my want to be. 0:19:18 So how does one utilize it? 0:19:20 – So we have 150 different features 0:19:22 and I would say they fall into two categories. 0:19:24 Either you come to do not pay with a problem 0:19:27 or you’re just browsing and want free money back. 0:19:28 If it’s the latter category, 0:19:30 you can maybe connect to data source, 0:19:32 maybe link your transactions 0:19:33 and it will go through them 0:19:35 and figure out where the money lies. 0:19:37 So I think in the case of the bank of fear appeal, 0:19:40 lots of people don’t even know that they have these bank fees. 0:19:43 They’re just being silently collected from their account 0:19:44 and you can connect your bank account 0:19:47 and it will identify all of these opportunities for you. 0:19:49 – So okay, so you sign up like all, 0:19:50 just all your different bank accounts 0:19:53 and in the banks aren’t disputing 0:19:54 that you signed up for these fees? 0:19:57 Like how is it circumvent that process? 0:20:00 – So either the bank is making a legal promise to you. 0:20:01 So lots of credit cards. 0:20:03 If you see an ad for a credit card, 0:20:05 it’ll say no ATM fees. 0:20:07 But all of a sudden you go to an out-of-network ATM 0:20:09 that’s not owned by the bank 0:20:11 and you start getting the fees on your account 0:20:13 and the bank actually has to reimburse you for that 0:20:14 but you have to let them know. 0:20:17 So do not pay, identifies that and lets them know. 0:20:20 Separately maybe with overdraft fees. 0:20:23 Sometimes it’s the law, sometimes it’s customer service 0:20:26 where using all of this data that do not pay can compile. 0:20:27 It will make the best case 0:20:29 for why these fees should be appealed. 0:20:32 So like say, I’ve been a customer for X years, 0:20:34 I’ve held X minimum balance. 0:20:35 You should refund the fees. 0:20:39 – I literally the day before got an email saying, 0:20:44 congratulations, you just got $61.62 worth of like fees 0:20:46 from your bank back into your account. 0:20:47 I’m like, oh my God, this is great. 0:20:49 – So it works in the background. 0:20:50 – Oh wait, wait, wait. 0:20:52 So you start off with a parking ticket 0:20:53 and it’s like, well, by the way, 0:20:54 let me save you some cash. 0:20:58 – Originally what happened was, as he said before, 0:21:00 it starts to bill you when you win your case or whatever. 0:21:02 So if you win a case with them, then it starts, 0:21:03 and I’m like $3 a month, 0:21:06 like you just literally gave me my money back. 0:21:10 – So when you link your bank account to get reimbursed, 0:21:12 then it just starts working like, 0:21:14 oh, by the way, you got some money over here. 0:21:15 – That’s what it did. 0:21:16 It went through my transaction. 0:21:18 – No other law firm is proactive like that. 0:21:19 – It does ask you somewhere, 0:21:22 but once it’s on, it will get you the money back. 0:21:24 And because you’re keeping a hundred percent, 0:21:25 you don’t even have to worry. 0:21:26 – I cannot be the only one in this world 0:21:29 who like literally has like so many issues sometimes 0:21:32 where it’s like, can I not like, you know, lose to win? 0:21:33 Can I not like get something done? 0:21:35 – Well, you know, it’s so interesting 0:21:37 ’cause the financial services are like 0:21:40 low-key criminal organization 0:21:43 in that they sell you something, 0:21:46 they hit you with print, you can’t read things 0:21:49 that nobody would ever look at, all this kind of thing. 0:21:53 And then they work around all these laws. 0:21:54 So like, you know, they’re a usury law, 0:21:56 so nobody’s gonna charge you over that percentage, 0:22:00 but the overdraft fee, you know, 0:22:03 is way bigger than the interest would ever be 0:22:05 on a user’s requirements. 0:22:07 So they’re doing all this stuff 0:22:08 and there’s no way to fight it, 0:22:10 which is why nobody ever does. 0:22:13 – I had a small loan, I actually took the money out, 0:22:14 I paid it back. 0:22:16 There was one point where we kind of fell behind 0:22:17 a month or so. 0:22:20 And like literally the next thing you know, 0:22:21 all of a sudden they just start taking, 0:22:23 they decided what amounts they want to start 0:22:25 taking out of your account without letting you know. 0:22:27 So I literally, I’ve had to use do not pay 0:22:29 to actually try to get those fees back or whatever. 0:22:30 And I worked for that. 0:22:31 – So it worked and getting your fees back? 0:22:34 – Yeah, it definitely did because I was able to 0:22:37 at least express myself or show to the app itself, 0:22:39 like this money was taken for this 0:22:42 and here where they already took money out. 0:22:43 Like you can’t charge me an SFV 0:22:45 and then already take the money out. 0:22:46 It doesn’t work that way. 0:22:48 And so like, I’ve been able to show my bank like, 0:22:49 okay, you’re double dipping. 0:22:51 People, somebody’s double dipping here. 0:22:54 So it actually went through and actually found like two or three. 0:22:55 – Wow. 0:22:56 – So Jess, how do you go from like, 0:22:57 what was that moment where you was like, 0:23:00 okay, this is more than just helping my friends 0:23:02 beat dumb tickets to like, 0:23:04 oh, this is actually a business model 0:23:08 that can help people, but also that I can monetize. 0:23:10 – I think the reason it can be a business 0:23:13 is because you’re creating a huge amount of value for people. 0:23:14 And it’s a universal need. 0:23:16 We have homeless people use our product. 0:23:18 We have top VCs who use the product 0:23:20 to cancel their expensive equinox gym 0:23:22 and everyone in between. 0:23:24 We have a whole range of people 0:23:26 based on socioeconomic factors. 0:23:29 So it’s really everyone from a socioeconomic standpoint 0:23:32 and it skews older, about 80% on iPhone 0:23:34 and then the rest on web. 0:23:35 We don’t spend any money on marketing. 0:23:38 It’s all word of mouth and people talking about us 0:23:40 in the media and things like that. 0:23:43 Also, we post a lot of content on our website 0:23:46 and that ranks very highly organically on search engines. 0:23:49 So for example, if you search Sue United Airlines 0:23:50 with the number one result, 0:23:52 it’s more like they cancel a flight 0:23:55 or you cancel a flight and the refund just never went through. 0:23:57 So you never get your money back. 0:23:59 And so it’s a lot of this stuff. 0:24:01 – It’s not like they won’t give you your money 0:24:04 but they’ll make you jump through 30 flaming hoops. 0:24:05 – It’s really common. 0:24:06 I think it’s a business practice. 0:24:09 There’s this very famous Comcast calls 0:24:11 where someone phoned up Comcast 0:24:12 and they recorded it on YouTube 0:24:14 and they said, “I want to cancel my Comcast.” 0:24:17 And the Comcast representative held them up for an hour 0:24:20 rather than just canceling their service. 0:24:22 Do Not Pay actually has a product called Skip Weighting On Hold 0:24:24 that allows you to, a bot weights on hold 0:24:26 that transfers it to you. 0:24:28 – So I literally just got through moving. 0:24:29 You have to change your license, 0:24:31 you have to change everything else about everything. 0:24:33 And they actually have a thing where it says, 0:24:35 I think it’s like fill out government papers. 0:24:37 So like you click on that and then it says, 0:24:41 it gives you like CSA, DMV and like two other like items 0:24:41 or whatever. 0:24:42 Well, of course I need the DMV. 0:24:44 I also need to, you know, get my plates 0:24:45 and everything changed over. 0:24:47 Cause Los Angeles is very isonomous 0:24:49 for basically like pulling you over and saying, 0:24:51 “Oh, I’m sorry that this doesn’t fit the car. 0:24:52 This doesn’t feel whatever.” 0:24:54 Or they’ll try to find something on you. 0:24:56 And so basically I just like to try to stay on the up and up 0:24:57 when it comes to that, 0:24:58 especially being a delivery service. 0:25:00 So I was able to actually do that. 0:25:03 They actually made the appointment for me to actually go in 0:25:05 and actually do the thing for my plates 0:25:07 to change address or whatever. 0:25:08 – But what’s the difference between you just calling 0:25:10 and making an appointment yourself? 0:25:12 – I don’t know if you’ve ever called the DMV before 0:25:14 to even get to a person on the phone. 0:25:16 You have to wait the longest time ever. 0:25:18 So like literally it actually will sit up there 0:25:20 and do everything for you. 0:25:22 It’ll wait on hold the whole time for you. 0:25:25 And then it’ll ring you and let you know, like, hey, 0:25:26 you know, you pick up the phone and they’re like, 0:25:28 “Hi, you’ve been on hold for such and such. 0:25:29 How can I help you?” or whatever. 0:25:31 And it’s like, it took your place. 0:25:33 So it doesn’t work for you. 0:25:36 – Yeah, I mean, you’re clearly ahead of the bureaucracy. 0:25:40 Do you think they’ll try to catch up to you in any way 0:25:43 or they just like hopelessly slow 0:25:44 or how do you think about that? 0:25:46 – I think that in the long run, 0:25:48 we’re actually doing them a favor. 0:25:50 And that might sound a bit crazy to say, 0:25:53 but when Do Not Pay launched in Los Angeles 0:25:54 for parking tickets, 0:25:56 someone asked the head of the Los Angeles 0:25:58 parking enforcement, “What do you think about 0:26:00 all of these appeals that all of a sudden 0:26:02 come from Do Not Pay?” 0:26:04 And he said that, “Well, it’s actually quite good 0:26:06 because at least when they come from Do Not Pay, 0:26:07 it’s standardized. 0:26:09 People write such gibberish in their parking appeals. 0:26:11 It saves us processing time.” 0:26:13 And I think that Do Not Pay can actually help 0:26:17 in the long run by siphoning through the legitimate cases 0:26:19 and getting those people refunds quickly 0:26:21 and then also siphoning through the gibberish 0:26:23 and making sure everything is fair. 0:26:26 So hopefully a better, more efficient society 0:26:27 is good for everyone. 0:26:28 – So speaking of that, 0:26:30 I remember when I was in prison, 0:26:33 like guys would literally file lawsuits 0:26:35 for any and everything. 0:26:37 How have you seen any just kind of like 0:26:40 extremely ridiculous cases of people just being like, 0:26:43 oh, I want to litigate this or litigate that? 0:26:46 Or is there some type of way that it can kind of rule out 0:26:48 just frivolous like lawsuits? 0:26:51 – So we haven’t seen really any of that. 0:26:53 And I think the reason is that the crazies 0:26:55 already know how to abuse the system. 0:26:57 And really, this is a tool for people just entering in 0:26:59 to get their access to their rights. 0:27:01 The only frivolous lawsuit that I can think of 0:27:03 is when people try and test out 0:27:07 the sue product against us to get their $3 back. 0:27:09 And we just refund it in those cases. 0:27:12 – Probably lawyers from the big financial services firms. 0:27:15 – Yeah, and so Josh, one of the things that really stood out 0:27:19 is when you talked about how do not pay 0:27:21 is helping people establish their rights 0:27:22 and really get an understanding. 0:27:24 How does that work in a broader context 0:27:29 for people who may not on a normal circumstance 0:27:31 and know that they have a right to certain things 0:27:33 as opposed to just being disruptive? 0:27:36 – So I think that the system is stacked against everyone. 0:27:40 Like bank fees alone is $20 billion a year plus. 0:27:43 And that’s more than all election spending combined. 0:27:46 And so there are so many ways to get out of these fees. 0:27:49 So many laws that exist that have been created 0:27:52 to protect consumers, but nobody knows about them. 0:27:54 So there’s the small claims court process 0:27:57 where you can take companies to court for under $10,000 0:27:59 and lawyers are black band. 0:28:00 There’s the charge back process 0:28:02 where you can refund from your credit card. 0:28:05 All when companies are taking money out of your bank account 0:28:08 like we saw with the case we discussed earlier, 0:28:11 within 60 days, you can get that money back. 0:28:14 No questions asked based on the laws around ACH. 0:28:16 And so all of these laws exist 0:28:17 and the infrastructure exists, 0:28:18 but people don’t know about them. 0:28:20 And so do not pay can help fight 0:28:22 and get consumers their rights. 0:28:25 – So Josh McCurry, thank you for being here. 0:28:27 Thank you all for joining us today. 0:28:30 We’re really excited to see what the platform goes. 0:28:31 – Thank you. 0:28:33 (upbeat music) 0:28:36 (upbeat music) 0:28:39 (upbeat music) 0:28:41 you 0:28:51 [BLANK_AUDIO]
This is the next cycle (Q1 2020) of Hustlin’ Tech, a podcast series (from the a16z Podcast) about technology platforms that create opportunities for people. Recorded right before the coronavirus pandemic, these next 3 episodes touch on many things that are top of mind right now: from the profession of nursing and taking care of the elderly and the professionalization of caregivers; to fighting bureaucracy to get money back (and to now get help delaying utility bills and rent payments that are eligible for an extension or waiver of late fees due to the coronavirus crisis).
Episode #6, “The Hustler’s Guide to Suing the Man” features:
Joshua Browder, CEO and founder of DoNotPay, the world’s first “robot lawyer” which helps people automatically fight bureaucracy to get money back, whether parking tickets or hidden bank fees; find other hidden money or cancel free trials; sue others or go to small claims court — and now also helps people delay utility bills and rent payments that are eligible for an extension or waiver of late fees due to the coronavirus crisis.
Makiri Duckett, a small business owner who currently operates an adult on-demand delivery service (and therefore gets frequent parking tickets) and is a power user of the platform;
…both interviewed by Ben Horowitz and Shaka Senghor.
You can find the first cycle of this series (Q4 2019) — including more about the what and the why — here.
0:00:02 (upbeat music) 0:00:15 – Welcome to this episode of Hustling Tech. 0:00:19 Today we’re gonna talk about how to take way better care 0:00:23 of the elderly and make a living in doing so. 0:00:27 With me, I have Sesternberg co-founder and CEO of Honor. 0:00:30 I’ve got our hustler, Samantha, 0:00:33 who’s gonna tell us how she makes use of Honor. 0:00:36 And then I have with me as always my co-host 0:00:39 who hustled out of the joint to become a leader, 0:00:43 advocate, management consultant, Shaka Senghor. 0:00:44 – I’m really excited to talk to you. 0:00:47 What was the inspiration behind Honor? 0:00:49 – Yeah, so the inspiration was my mother. 0:00:50 When she picked me up at the airport 0:00:53 and was driving me home, she was just driving slowly. 0:00:55 And I was like, what does this mean for five years from now 0:00:58 or 10 years from now, ’cause she lives in Connecticut. 0:00:59 And I don’t wanna be the son 0:01:01 who ever has to say to his mother, 0:01:03 “Hey, I’m sorry, mom, you have to leave your home.” 0:01:07 And so myself and my co-founders looked for any solution 0:01:10 around helping the elderly remain in their homes as they age. 0:01:12 And we found home care. 0:01:15 It’s just really hard to figure out who to trust, 0:01:18 who to turn to, where to go. 0:01:20 And it’s not just hard for you, 0:01:21 someone who needs to figure out care 0:01:23 for your grandmother or your parents. 0:01:26 It’s hard for the folks who work in home care. 0:01:28 Really early on, we identified 0:01:31 that we’re not a normal tech company, 0:01:33 no customer cares about our technology. 0:01:36 They only care about the person who’s gonna go into the home 0:01:38 and serve their mom or their dad. 0:01:42 And so first of all, we call those folks care pros, 0:01:45 care professionals, and that’s a unique name to Honor. 0:01:48 And we did that because when we talked to care pros, 0:01:51 they told us that they generally feel disrespected. 0:01:52 And so starting Honor was really 0:01:53 about helping the elderly, 0:01:56 but then also doing what we call care for the care pros. 0:01:59 – You know, trust is an interesting word 0:02:02 ’cause it’s kind of beyond okay, are they competent? 0:02:06 It’s who do I trust to be in my home with me 0:02:09 who I can get along with and all that kind of thing. 0:02:14 And elderly people are not very flexible generally 0:02:16 in like who they can get along with. 0:02:20 – So it’s not just your classic like super hands-off, 0:02:22 everybody’s a contractor thing, 0:02:24 because training is critical. 0:02:28 All of our care pros are actually W2 employees of Honor. 0:02:30 In this space where someone literally will walk 0:02:33 into the home of your mom 0:02:37 and potentially give her a bath to your point bed on trust, 0:02:39 knowing that that person’s like really good 0:02:41 and vetted is a super big deal. 0:02:45 One of the issues about taking care of the elderly 0:02:48 is that their needs are very specific. 0:02:51 One specific kind of need is who they like. 0:02:54 Another specific kind of need might be the care pro, 0:02:58 who is dementia trained, who is not allergic to cats, 0:03:01 who she gets along with, who lives near where she lives, 0:03:03 who is available on her schedule. 0:03:06 And so to be able to get the right matches 0:03:09 is a really big deal also for the care pros 0:03:10 because one of the things that we found 0:03:15 is one of the dominant things that makes a care pro happy 0:03:17 and helps the care pro reform better 0:03:19 is if you put them in situations 0:03:22 that are more appropriate to their skills 0:03:23 and their personalities. 0:03:26 And then the technology that we build 0:03:29 is really just about how do we do that at scale 0:03:32 so that you can choose from thousands of care pros 0:03:34 against thousands of customers 0:03:36 and kind of know how to make those matches appropriately. 0:03:40 – So Samantha, tell us a little bit more about your journey. 0:03:42 – So I was working as a nurse in London 0:03:46 before I moved here around four and a half years ago. 0:03:48 I studied my nursing in the Philippines 0:03:52 and then in London, it’s different from the United States. 0:03:54 When I became a nurse, when I applied from the Philippines, 0:03:57 it was easier because they hired you 0:03:59 because you’ve already just give you a six months probation. 0:04:03 So they see how you work, how you interact with the clients, 0:04:06 what you know, the knowledge you know, how you do your work. 0:04:09 So that’s how they basically hire you. 0:04:10 And like here, it’s different 0:04:13 because there’s another exam that you need to pass, 0:04:16 the NCLEX, which is the licensure examination 0:04:17 that you have to take here. 0:04:19 And that’s everything. 0:04:21 And in the nursing field here in America, 0:04:22 it’s pretty challenging 0:04:24 because if you’re a foreign nurse, 0:04:27 they basically tell you you’re not qualified 0:04:29 to be a nurse in the United States. 0:04:32 You have to take some courses to enhance your studies. 0:04:34 Sometimes they tell you to do the whole thing. 0:04:36 Sometimes it depends on who assesses your grades 0:04:38 and your transcript of records. 0:04:40 So it can be luck sometimes. 0:04:42 – And that’s amazing that, you know, 0:04:45 we have care pro shortages, nursing shortages here. 0:04:50 And then we have a bureaucracy that makes only some sense. 0:04:53 I mean, it’s such an important thing just societally. 0:04:56 This is a lot about a society of how it cares for its elderly. 0:04:59 And we just don’t do a very good job of it yet, I think. 0:05:01 So did you grow up in the Philippines? 0:05:02 – I did grow up in the Philippines 0:05:04 and I finished my college there. 0:05:06 – Amazing, home of Manny Pacquiao. 0:05:09 – Yes, home of the champions. 0:05:11 And yeah, so that’s how it started. 0:05:14 And then I moved to Spain because I was half Spanish. 0:05:16 I was able to move there, live there, 0:05:18 and start my career there. 0:05:19 And I started working as a caregiver 0:05:22 because in Spain, you have to convalidate your studies 0:05:25 and it was not as easy when you’re a foreign nurse, 0:05:28 which is the same thing happening in the United States nowadays. 0:05:31 And so caregiving was always the first thing you do 0:05:33 when you start in the medical field. 0:05:35 And so that’s like the startup thing to do. 0:05:37 So your training starts from there, 0:05:39 obviously from what you’ve learned in college as well. 0:05:42 And then you put your practice all together. 0:05:43 And so it started there. 0:05:45 And so when I moved here a couple of years back, 0:05:47 I worked with different agencies. 0:05:48 – And how is that? 0:05:52 – It can be a challenge because the thing is with caregivers, 0:05:53 you have to be a match with your clients. 0:05:55 And your clients have to like you. 0:05:57 For them to have you keep coming back. 0:06:03 So once you go to their homes and you’re given a shift, 0:06:05 you have to make sure that you are confident. 0:06:07 You have to show them that you know what you’re doing, 0:06:08 especially with dementia patients, 0:06:11 that sometimes they will not know exactly 0:06:13 what they’re doing at certain times. 0:06:15 And they might forget exactly what they did 0:06:17 an hour or 30 minutes ago. 0:06:19 So you have to be that guide to them. 0:06:23 And you have to be that strong backbone that they can trust. 0:06:26 And also, you know, just feel safe. 0:06:28 I think that’s the most important thing. 0:06:30 Obviously there’s a personality match 0:06:33 because in this job it’s very interpersonal. 0:06:35 So you really have to be a match. 0:06:38 Not only with a client, sometimes with a whole family 0:06:40 because you’re not just dealing with a client. 0:06:42 You deal with a whole family. 0:06:44 And some families have different stories 0:06:46 and different things that they go through 0:06:48 and issues that they go through 0:06:50 that, you know, you need to be part of. 0:06:52 And one thing that with families that I always know 0:06:54 is communication is a big deal. 0:06:56 Yes, the app helps a lot. 0:06:58 Not only just to find work 0:07:01 because the app also you write your shift notes. 0:07:03 So basically it’s very beneficial for family members 0:07:06 that don’t live close to their families 0:07:08 or to the clients or to their parents 0:07:09 that we take care of. 0:07:11 Because there they can see what we did 0:07:13 throughout our shift. 0:07:16 So basically, if they ate what they ate, 0:07:18 the amount of food, 0:07:20 if they were able to go to the bathroom, 0:07:21 all of these things. 0:07:24 And so that way they’re able to check on their parents 0:07:25 and communication is open 0:07:28 based on the shift notes that we do. 0:07:29 So what is that experience like 0:07:31 from the family’s perspective? 0:07:34 For customers, we look like a normal home care agency. 0:07:37 So we will go into your mom’s home. 0:07:39 It cannot be done over the phone with you. 0:07:41 And then we figure out what the care plan is. 0:07:45 And then once we know what the care plan for your mom is, 0:07:46 then we can figure out which care pros 0:07:48 or the best care pros. 0:07:49 So it doesn’t matter who you are, 0:07:50 you want the phone. 0:07:55 Because this is who might give your mom a bath 0:07:57 in your mom’s home when you’re not there. 0:07:58 That’s scary. 0:08:03 And so people do not trust not hearing a human voice yet. 0:08:08 What we find is as people start to use honor, 0:08:10 then they switch over to the tech. 0:08:13 So then they change the schedule on the app. 0:08:16 Then they request more help on the app. 0:08:18 Then they change the care plan on the app. 0:08:21 But it’s after they’ve been using it for a period of time 0:08:22 because trust has been built up. 0:08:25 So stuff like the notes. 0:08:27 Samantha talked about that the care pros leave 0:08:29 is literally the customer’s number one favorite feature 0:08:31 because it brings them into the home 0:08:34 and they can see what mom and dad did 0:08:35 with the care pro from honor. 0:08:37 Or what we call the wellness check. 0:08:40 The wellness check is basically how their mood was 0:08:42 on that day, how they slept. 0:08:45 So there’s different tabs that you need to click. 0:08:48 How happy were they for that day from zero to 10? 0:08:51 Their pain level while you were on the shift. 0:08:54 So they are aware of basically what’s really happening. 0:08:56 Transparency, right? 0:08:59 So for the kids, right, which is usually the family. 0:09:01 And when I say kid, I usually mean a 40 to 60 year old. 0:09:03 Right, you mean me. 0:09:04 Yeah, exactly. 0:09:07 So the design point for the app for our care pros 0:09:09 is to empower them. 0:09:10 It’s professionalization. 0:09:12 So know what’s expected of you. 0:09:14 Give you the training. 0:09:14 Give you the tools. 0:09:17 Put you into the right environment 0:09:19 where you can use that training and tools 0:09:20 and be successful and then tell you 0:09:22 how you’re doing rewards consequences. 0:09:24 So that’s professionalizing care pros. 0:09:26 And that’s what our app is basically designed to do for them. 0:09:28 So like client profiles, because that’s a tool. 0:09:31 So for the customers, what we think about 0:09:33 is basically transparency. 0:09:36 So it’s scary because someone’s going to your home. 0:09:40 They’re very intimate with your mom or dad. 0:09:43 They’re going to be intimate with you as well at some level. 0:09:46 And so how can we show you and demystify 0:09:47 what’s actually happening? 0:09:49 So with that established that trust 0:09:52 and going into it from the wellness checkpoint, 0:09:55 is it like it’s an easy way to just notify them via the app? 0:09:57 Yeah, so one thing that happens 0:10:00 is they literally just get after every visit the note. 0:10:02 They could see like, you know, mom’s pain threshold 0:10:05 is usually four, today she said seven. 0:10:08 So like they can see, oh, something changed. 0:10:09 Like I should figure out what’s going on with mom. 0:10:12 And that’s a new level of kind of, you know, 0:10:14 data information that people didn’t have before. 0:10:18 But now, you know, we get literally a Dickens novel 0:10:22 worth of like notes from care pros every single day. 0:10:24 Humans can’t read that much information. 0:10:29 So our computer can literally read all the notes 0:10:33 and determine when it believes a fall may have occurred, 0:10:35 even when honor wasn’t at the home, 0:10:37 and even if the word fall was never used. 0:10:40 Literally, the note might say, you know, 0:10:42 it’s fall outside and we went for a walk, 0:10:43 the computer will ignore it. 0:10:45 But the note might say, I arrived at the home, 0:10:49 Mr. Smith was on the floor, I helped him get up, 0:10:51 he was a little bit sore, and the computer will see it. 0:10:53 And flag, there may have been a fall, 0:10:55 and then our care managers can intervene 0:10:57 and notify the family. 0:11:00 So this is just like crazy stuff that you can start to do 0:11:03 if you build it into your platform. 0:11:05 And are the family members, is it sometimes 0:11:08 that the family member had been the caregiver 0:11:09 and then is transferring it to honor? 0:11:12 So almost always the family members 0:11:14 at some level are the caregivers. 0:11:15 The question is, are they there or not? 0:11:17 And even if they live far away, 0:11:19 oftentimes they’re helping with like paying bills 0:11:21 and, you know, kind of lining up supports, 0:11:23 lining up to doctors, is it on the phone? 0:11:27 Usually 24/7 then we’re often like 0:11:29 the dominant provider of care. 0:11:31 Another thing I was curious about was whether 0:11:33 there’s this interact with insurance companies, 0:11:36 like how do families pay for the services? 0:11:39 So non-medical home care today, 0:11:41 which is like helping with activities daily living, 0:11:42 so these things like getting out of bed, 0:11:44 getting food, getting dressed, 0:11:46 is usually not covered by insurance. 0:11:49 So if you need something like IV changed 0:11:50 or if you need a wound pack, 0:11:53 like if you’re breaching skin, that usually is. 0:11:56 But in our world it’s either people 0:11:57 are usually paying out of pocket 0:12:00 or they’re using long-term care insurance. 0:12:02 So if they did purchase long-term care insurance 0:12:05 and about 30% of our customers have long-term care insurance. 0:12:09 And how does that cost compared to, you know, 0:12:11 putting them in a home or that kind of thing? 0:12:13 So basically the kind of crossover point 0:12:15 is about 50 hours a week. 0:12:19 So if they’re getting honor for like less than 50 hours a week, 0:12:20 it’s probably cheaper to use honor. 0:12:23 And if it’s more than 50 hours a week, 0:12:25 if it’s literally just about money, 0:12:26 you would choose a facility. 0:12:30 The trick with facilities is most people don’t want to be there. 0:12:33 A lot of my clients actually do prefer to stay in their homes. 0:12:37 I believe that a lot of my clients that have worked hard, 0:12:41 they believe that their money should be used towards them. 0:12:43 So they always fight, you know, 0:12:44 for the money to be spent on them. 0:12:47 Because sometimes there’s a connotation, 0:12:49 like family members think, 0:12:53 oh, because my mom is old, oh, let’s put her in a facility 0:12:55 and then let’s have somebody else take care of them. 0:12:56 But that’s not what they want. 0:12:59 And it’s a battle when it comes to that, 0:13:00 because they think, oh, 0:13:03 but I have all this money to pay for my care. 0:13:06 Why can’t I keep my caregivers in my house 0:13:09 where I feel comfortable, where this is my home, 0:13:10 I’ve lived here all my life, 0:13:12 then to go to a new home 0:13:14 and have to deal with other people that live there. 0:13:17 So that’s always a dilemma when it comes to the care industry. 0:13:21 – Do people want to put their parents 0:13:26 in a facility because of cost 0:13:28 and so they can get the rest of the money 0:13:31 they don’t know about in home care or what drives that? 0:13:34 – I think it’s all about the cost. 0:13:35 That’s what I feel. 0:13:36 Because some clients don’t have dementia. 0:13:38 I’ve had clients that I took care of 0:13:42 and they reach 100, 102 years old with no dementia. 0:13:45 Just basically you’re just helping them on the day to day, 0:13:48 like with their food, with their baths, 0:13:50 not everybody has dementia, 0:13:53 so they can still make decisions for themselves. 0:13:55 And sometimes it’s a battle with the family 0:13:56 because they feel like their decisions 0:13:58 for their parents are better than their own. 0:14:00 And so it becomes a battle. 0:14:03 But it’s always about the money, unfortunately. 0:14:05 – A lot of videos come out of elders 0:14:07 being abused in these places. 0:14:09 So with that in mind, 0:14:12 does honor interact with a nest or something like that 0:14:15 where people can actually visibly see 0:14:17 the care that’s going on in the home? 0:14:19 – Yeah, so we’ve run the experiment. 0:14:23 And oddly, when you ask our customers if they want cameras, 0:14:24 it’s very unpopular. 0:14:29 So the home care agency kind of industry today, 0:14:31 the way it does quality is either 0:14:34 what it hears from customers or random home visits. 0:14:36 We do random home visits. 0:14:38 We partner with our partners to do that. 0:14:39 We’ve actually started our own program 0:14:41 where we do it even outside of our partners. 0:14:44 But we get a ton of data from the app 0:14:46 that’s kind of inferred data 0:14:49 that can point you to where there might be problems. 0:14:52 And so even though you’re not seeing a signal 0:14:54 that says physical abuse, 0:14:57 you’re seeing signals that indicate 0:14:58 lack of care pro quality. 0:15:02 And then you can take action before, hopefully, 0:15:04 you end up in like a truly bad situation. 0:15:06 – How important is it for the caregivers 0:15:08 to be taken into consideration 0:15:12 in regards to their needs as a caregiver as well? 0:15:15 – So what you find broadly in the industry 0:15:18 is people usually will work 0:15:21 for like two or three agencies at a time 0:15:24 because each agency is too small 0:15:26 to have enough customers 0:15:29 that fit the very specific skills of that caregiver. 0:15:31 – I used to work with three agencies 0:15:35 because the thing is you always have to have plan A, 0:15:36 plan B, and plan C. 0:15:39 Because the thing is anything can happen with the elderly. 0:15:40 They can pass away. 0:15:42 They might have to budget. 0:15:44 So they cut down hours. 0:15:46 So you lose some of your hours. 0:15:48 And you don’t have that consistency. 0:15:49 Sometimes you lose a job 0:15:51 and what if you’re not a fit for the next client? 0:15:54 Then almost a week or two, you have no income 0:15:56 because you get paid as you work. 0:15:58 – So now all of a sudden you’ve got 0:16:00 like a 25 or 30% pay cut 0:16:03 because that agency doesn’t have new work for you next week. 0:16:04 So what do you do? 0:16:07 And so you have to kind of find another agency 0:16:09 that has work, which might conflict 0:16:10 with like one of those other agencies 0:16:11 you’re already working for. 0:16:16 And so thinking about how you can take care of someone 0:16:18 and even just like making sure 0:16:20 that you can get them very consistent hours 0:16:24 to support their needs in life is a really big deal. 0:16:25 And it’s part of the reason 0:16:28 why having a full network was very important. 0:16:30 So we’d have so much demand that Samantha, 0:16:34 and everybody likes Samantha, could keep consistent work. 0:16:36 – What does that look like when you log in 0:16:39 and like, you know, are you like a basketball player? 0:16:40 Like, yo, let me see what kind of numbers 0:16:41 I put up tonight. 0:16:42 Like, what do you? 0:16:45 – Yes, well, it actually some motivation, I think. 0:16:46 It helps a lot. 0:16:48 So you know, you keep yourself in check 0:16:51 because sometimes you could get very comfortable as well 0:16:53 when clients like you and you’re doing good 0:16:55 and you’re getting jobs and everything. 0:16:58 But you know, there are also times that it’s not the case. 0:17:02 So the app just doesn’t help you with how you’re doing. 0:17:04 Some clients will make you a favorite. 0:17:06 Some clients will give feedback to the agency 0:17:08 and then the care managers will let you know, 0:17:10 here are the things you can improve, 0:17:12 here are the things you’re doing really well. 0:17:13 So I think that helps a lot. 0:17:16 And then in the app also, you can see different clients. 0:17:18 And I think if you really know 0:17:21 which scope of practice you’re good at, 0:17:24 then by reading the care plans of different clients 0:17:27 that have available shifts, you will know if you’re a fit. 0:17:28 And when you apply for it, 0:17:32 it doesn’t really like approve you right away for that job. 0:17:34 The care managers normally check first 0:17:36 and then they allow you to work on that shift 0:17:39 based on your experiences 0:17:40 and if you’re a fit, 0:17:42 if they feel that you’re a fit for that work. 0:17:43 And Seth, with that, what would you say 0:17:45 that the average difference is 0:17:48 between somebody who’s on honor versus a caregiver 0:17:50 who’s not in terms of salary? 0:17:55 You know, that average difference is maybe 10%. 0:17:57 It’s not that much. 0:17:59 The difference is, do you get surprised 0:18:03 because all the sudden next week, the difference is 50%. 0:18:08 So what will happen is like, you’ve got two clients, 0:18:09 two different agencies, 0:18:11 half your times with one client, 0:18:12 half your times with another client, 0:18:13 one of those clients passes away. 0:18:16 50% pay cut next week. 0:18:19 So it’s like those moments of panic. 0:18:21 Because that literally can impact food 0:18:24 and that can impact transportation to school for your kids. 0:18:25 I mean, that’s a big deal. 0:18:28 And so it’s more about not having those 0:18:33 like momentary, extremely painful experiences. 0:18:36 I’ve never had no job. 0:18:38 Like I’ve always consistently have a job 0:18:41 because not only is their network big, 0:18:44 they work with different small agencies as well. 0:18:46 And they’re the ones that provide them with caregivers. 0:18:49 And especially me, I like to work during the nights. 0:18:52 And it’s always a challenge to have 24 hours 0:18:53 because of the expense as well. 0:18:55 Tell us a little bit about your life 0:18:58 and like at home and like, who are you taking care of? 0:19:00 Yeah, so I’m also a full-time mom. 0:19:03 So that’s why I always prefer to work during the night 0:19:04 so I can be with my son. 0:19:06 So yeah, I’m a full-time mom 0:19:08 and I’m also currently studying for my nursing 0:19:10 so that I can get back to my BSN. 0:19:13 So I’m doing that, I’m working on that. 0:19:14 And as at the same time, 0:19:16 I work at least four to five night shifts with honor. 0:19:20 So obviously the distance where you’re working as well 0:19:22 helps a lot because if you find clients 0:19:24 that are closer to where you live 0:19:25 or in the area where you live, 0:19:27 then that is also a bonus. 0:19:30 So those are one of the things that care professionals look for. 0:19:32 And of course, a start time as well 0:19:34 because like for me, 0:19:36 I have to drop my son to school and pick him up. 0:19:38 So almost I have to do a seven to seven 0:19:41 or seven 30 to seven 30 shifts 0:19:42 because if I do an eight to eight, 0:19:45 then I’m not going to be home enough to drop off my son. 0:19:47 And then like Seth was saying, 0:19:50 also what you’re trained to do, 0:19:52 what your capacity is as a caregiver, 0:19:54 because sometimes some clients are harder for you 0:19:56 and it’s just not going to work out. 0:19:58 When you look for a client as well, 0:19:59 it has to be a fit, 0:20:02 not only personality-wise, but also the job. 0:20:04 Am I going to be able to lift this person 0:20:07 or am I going to be able to help this person with his transfers 0:20:10 to help him go to the shower, the baths? 0:20:12 What are their expectations for my cooking, 0:20:14 for my meal preparation? 0:20:17 We don’t do any medications because we’re non-medical. 0:20:20 So that’s on the side, the families do that. 0:20:22 So these are things that you also look out, 0:20:25 the environment, what type of home I’m going into. 0:20:28 Obviously, you know, there are really nice homes 0:20:30 and there are homes that are different. 0:20:32 So those are things that you look for. 0:20:35 So the easy way to think about our heart 0:20:37 is to kind of match what people need 0:20:38 with what care pros can do. 0:20:42 Is if you think about like getting a car, Uber or Lyft, 0:20:45 a rider looks like a rider. 0:20:48 So like all of us look the same to Uber, basically. 0:20:51 And all the drivers, you know, look the same to Uber. 0:20:53 And so they just have to make a simple match. 0:20:56 We have to think about pretty complex stuff, 0:21:00 not just a personality basis, 0:21:03 but something like, okay, this person has diabetes 0:21:05 or this person has dementia. 0:21:07 This person has steps in their home 0:21:09 and they need lifting and transferring support. 0:21:14 So like, is this Care Pro a medium or a high 0:21:17 on the skill of lifting and transferring 0:21:20 because this customer needs support 0:21:22 to get out of bed and get into a wheelchair 0:21:24 and then get out of the wheelchair and get into a bath. 0:21:27 And then this person has cats. 0:21:29 And so the Care Pro for that home 0:21:31 has to be like a medium or a high 0:21:33 on lifting and transferring and not allergic to cats. 0:21:35 So now we’ve got like an innate skill, 0:21:39 which is basically, innately, you are or are not allergic to cats. 0:21:41 And then a learned skill, lifting and transferring. 0:21:45 And so matching is a very nuanced thing 0:21:49 because we would say that it’s a two-sided heterogeneous marketplace. 0:21:51 Everybody’s got different skills and different needs. 0:21:55 How do you find the caregivers to allow them to engage in this? 0:21:58 So we basically start top of funnel. 0:22:00 How do you find people in mass? 0:22:02 And most of that happens online. 0:22:04 So we tried stuff like going to nursing schools, 0:22:05 going to vocational schools. 0:22:08 We didn’t get the amount of volume that we needed. 0:22:12 So it turned out that online and using job networks 0:22:14 produced a pretty good top of funnel. 0:22:16 And then we have some automated systems 0:22:18 that basically figure out are people qualified 0:22:20 for kind of honor specific qualifications. 0:22:22 And then people go through a phone screen 0:22:25 and then people go through an in-person assessment. 0:22:28 And then ultimately they can be approved to be an honors platform. 0:22:31 Right now, it’s pretty hard to make it through the funnel. 0:22:34 Like the acceptance rate bounces between kind of five and 10%. 0:22:37 So we really are looking for like the best people. 0:22:38 What are you looking for? 0:22:41 Like, so if I wanted to get in, what do I need to be? 0:22:42 So it depends on the state a little bit. 0:22:44 So there are different requirements by state. 0:22:46 But fundamentally, you need to have six months 0:22:49 paid experience of being a caregiver. 0:22:51 You will have to have a clean drug test. 0:22:53 So we do drug tests to everybody. 0:22:55 And then we assess skills. 0:22:57 So like when people get to the point 0:22:59 where they’re coming in to honor, 0:23:02 they’ll literally do like a lifting and transferring exercise 0:23:02 in the office. 0:23:07 They’ll be assessed for like their familiarity with and comfort 0:23:08 with working with people with dementia 0:23:10 that Samantha was referencing. 0:23:12 So you’ve been for all these things. 0:23:13 So what about the families? 0:23:15 Like what happens when you run into that difficult 0:23:19 family member that’s just like all over the place? 0:23:21 And making it really difficult to get care for? 0:23:22 Like what happens there? 0:23:24 You know, so it’s really interesting. 0:23:26 There are customers who are super easy to serve. 0:23:29 There are customers that are super hard to serve, 0:23:31 kind of for two different reasons. 0:23:35 Either their needs, like their absolute needs are difficult. 0:23:39 Let’s say someone weighs 350 pounds 0:23:41 and they need lifting and transferring support. 0:23:42 That’s difficult. 0:23:45 Or let’s say someone’s kind of late-stage dementia. 0:23:46 That’s difficult. 0:23:48 And then there is this other kind of difficult, 0:23:49 which you’re referencing, I think, 0:23:51 which is personality difficult. 0:23:54 And it can be either the person who needs care 0:23:55 or it can be the family. 0:23:58 And so what we try to do there really is matching. 0:24:01 Again, it goes back to like this CarePro 0:24:04 with their personality and their skill set 0:24:06 is better for this particular kind of customer. 0:24:09 There’s also price differentiation. 0:24:13 So you might have a customer who is really difficult to serve. 0:24:17 And it might be that CarePros are paid more 0:24:21 to serve that person because of the unique needs of that person. 0:24:23 And so therefore, it earns a higher wage. 0:24:27 I agree with Seth that there can be very difficult clients 0:24:28 and difficult families. 0:24:31 And with my experience, it’s pretty amazing 0:24:33 because sometimes your client’s really awesome, 0:24:34 but the family’s not. 0:24:35 They’re hard. 0:24:36 We hear that a lot, actually. 0:24:36 Yes. 0:24:38 And I think that most of my clients, 0:24:39 that’s always been the problem. 0:24:42 That they’re pretty easy. 0:24:44 They get along with the caregivers. 0:24:47 But the family sometimes make it about themselves. 0:24:50 And they forget it’s about the people that we’re taking care of. 0:24:52 And that makes it a challenge. 0:24:54 So for example, I had a client before. 0:24:56 And then, well, he was living with a daughter 0:24:57 because the situation changed. 0:25:00 The mom couldn’t take care because she was elderly. 0:25:00 So he moved in. 0:25:02 The client moved in with a daughter. 0:25:04 And she was all over. 0:25:05 We are trained. 0:25:06 We do our jobs and everything. 0:25:07 But she was always there. 0:25:10 So it was hard to do your job. 0:25:11 And it makes it a challenge. 0:25:14 And she just sometimes tells you, oh, you need to do this. 0:25:16 And then she gives you instructions 0:25:18 and then changes it the next moment. 0:25:22 So that makes it challenging because you want to work in peace. 0:25:24 You want to go happy to your job. 0:25:26 Especially if you’re experienced. 0:25:27 You know what you’re doing. 0:25:30 You want them to trust you, but they don’t really trust you. 0:25:32 Literally looking over your shoulder. 0:25:32 Yeah. 0:25:33 So that makes it challenging. 0:25:35 And sometimes just family turmoil. 0:25:37 The siblings don’t get along. 0:25:39 Some people want different things for their parents. 0:25:41 The others want different things. 0:25:44 And they don’t get along so their parents go confused. 0:25:46 They’re like, so who am I going to follow here? 0:25:49 And then as a caregiver, that makes it challenging 0:25:51 because you go inside a job and then you’re like, 0:25:52 okay, so who are my bosses here? 0:25:53 Who do I listen to here? 0:25:55 Is it the client they take care of 0:25:58 or the children that are two sides telling me what to do? 0:25:59 Who do you listen to? 0:26:01 To my client and to honor. 0:26:04 So if I almost call honor and my care managers, 0:26:06 if there’s anything like that that happens 0:26:08 and I feel uncomfortable, 0:26:10 I make them deal with the family members. 0:26:12 And they’re the ones that call and say, 0:26:14 hey, the caregiver’s saying that this and this. 0:26:16 And if they really like you, 0:26:17 they’ll try to mend things a little bit 0:26:19 because they don’t want to lose you 0:26:21 because they know that they can trust you 0:26:22 to take care of their parents. 0:26:23 But you need to talk to them. 0:26:27 One thing that we find is honor’s platform 0:26:30 is great for noticing like, look, 0:26:33 this family member called and said a care pro is late. 0:26:35 But they weren’t late because we’re tracking the GPS check. 0:26:36 Yes, we have the app. 0:26:37 So you cannot clock in or clock out 0:26:40 unless you’re in the premises of the client. 0:26:43 And so why would the family say they’re late 0:26:43 if they’re on time? 0:26:47 Probably what happened is the mom or dad 0:26:50 told their son or daughter that the care pro is late. 0:26:52 And probably that person has dementia 0:26:54 or actually we’ve discovered 0:26:55 that it’s a good way to find out 0:26:57 when people are slipping into dementia. 0:26:59 So like no one knew. 0:27:01 And then they kind of tell their kids, 0:27:04 hey, you know, Samantha was late 0:27:06 and it’s like, well, she wasn’t. 0:27:07 And it happens too often. 0:27:10 You know, my grandmother had dementia at the end 0:27:12 and I was living with her in New York 0:27:13 because I was going to school there 0:27:16 and convincing my father that that was the case 0:27:18 because she would answer the phone to talk to him. 0:27:21 And she was, you know, like that was her. 0:27:23 She would say, okay, I’m going to get my best five minutes 0:27:24 in right now. 0:27:27 And she would be sharp, witty, interesting, 0:27:28 this and that and the other. 0:27:29 And then the next thing, you know, 0:27:31 she would watch the same news program 0:27:32 like six times in a row. 0:27:34 And I’m like, no, grandma’s slipping. 0:27:35 Oh, no, no, grandma’s fine. 0:27:36 And so it is- 0:27:38 I had a client that actually said I wasn’t there. 0:27:42 When her family called, she said, nobody’s here. 0:27:44 And I’m like, well, I’m right here. 0:27:46 And so they hear me over the phone. 0:27:49 And then they say, oh, Samantha, we’re glad we know you’re there. 0:27:51 You know, because they know that they hire you 0:27:53 and they know that you’re supposed to be there. 0:27:55 But when they talk, sometimes they’re like, 0:27:57 as if nobody’s there, like they’re on their own. 0:28:00 And that’s their part of, you know, 0:28:01 wanting to do things by themselves. 0:28:03 You know, because, you know, 0:28:05 they’ve lived all their life being independent. 0:28:06 You live here in America. 0:28:06 You have no help. 0:28:08 You do everything for yourself. 0:28:10 And then now you start to accept help from other people. 0:28:12 That’s kind of like a challenge for them. 0:28:14 How have families responded to that, though, 0:28:17 when there’s a recognition that their love one is slipping 0:28:19 into dementia and when they weren’t even aware? 0:28:22 So there’s a saying, the customer’s always right. 0:28:25 And so when you don’t have the data, 0:28:27 you assume the customer’s always right. 0:28:30 And you say to the family, oh, I’m so, so sorry. 0:28:32 We’ll make sure that that care pros not late again. 0:28:34 But when you have the data, 0:28:37 it’s so powerful because it helps the family. 0:28:39 You’re able to say, you know what? 0:28:39 You’re not right. 0:28:42 But that helps because now you recognize 0:28:44 that your mom has a new need. 0:28:48 And so we actually have a process around 0:28:51 what we call reevaluation, where we have a customer, 0:28:53 we’re serving them with a certain care plan. 0:28:55 And then we learn some stuff, either, you know, 0:28:57 care pros report something that happens in the home 0:28:59 or the family reports something 0:29:01 or our partner reports something. 0:29:03 And so then we will reevaluate their customer 0:29:06 because people actually do sometimes in honor, 0:29:08 believe it or not, get better, right? 0:29:09 So I had a knee replaced, a hip replaced, 0:29:12 they need us for a little while and then they get better. 0:29:15 But sometimes people, you know, progressively have more needs. 0:29:20 And so if honor can use our data to both kind of protect 0:29:23 care pros and treat them justly at the same time 0:29:26 that we help the family understand 0:29:28 like the real state of how mom is doing 0:29:31 and then provide better care for mom as a result, 0:29:32 everybody actually wins. 0:29:35 It might be hard in the moment, but everybody wins. 0:29:37 So Samantha, how did you feel like shifting 0:29:39 from the old model to the new model? 0:29:41 They make it very easy, you know, 0:29:43 for everyone to use, obviously, 0:29:45 my prior agencies, they didn’t have the app, 0:29:47 so you wouldn’t know what jobs you have there. 0:29:50 So basically you’re at home waiting for a call 0:29:53 to have a job with the prior agencies. 0:29:55 They would call you like a million times. 0:29:57 And sometimes you tell them, I’m not available. 0:29:59 And then they still call you and I’m like, 0:30:02 I just told you guys I’m not available today. 0:30:05 Aside from the communication was always, you know, 0:30:08 all over the place, there was no consistency of jobs. 0:30:11 Here it gives you like a sense like, oh, okay, 0:30:14 I don’t have a job today, but I’ll check the app. 0:30:15 And if they have other shifts, 0:30:17 then you have to make a little bit of a sacrifice 0:30:19 to take some shifts. 0:30:21 But at least you know you’re going to earn something 0:30:24 while you’re waiting for something that you’re looking for. 0:30:26 That’s one thing that caregivers like to know, 0:30:27 am I going to have a job tomorrow? 0:30:30 That’s very important, especially in the field 0:30:31 that you’re dealing with life. 0:30:33 Because you never know. 0:30:35 One of the design points when we were thinking about the app 0:30:39 that care pros use is we wanted to make sure it showed them 0:30:40 that there was always more work. 0:30:42 Because there’s this underlying stress. 0:30:43 It is. 0:30:45 Like sometimes I have clients that are, 0:30:46 you know are already in hospice. 0:30:49 So basically, you know what hospice, it’s pilotive care. 0:30:52 You already know that some point they’re going to go. 0:30:53 But you don’t look at it that way. 0:30:55 If you know that it’s okay, 0:30:58 I’m going to stay here until this happens. 0:30:59 Because this is my job right now 0:31:01 and my loyalty is towards my clients. 0:31:04 And being there for them in the hardest times of their life. 0:31:06 And being a support to the family. 0:31:07 And then after that, 0:31:09 you know that honors got your back. 0:31:11 They’re going to give you another patient. 0:31:13 Even if you love taking care of people, 0:31:16 like the job structure is so bad, 0:31:18 do you think that more people will want to go into 0:31:19 and stay in the field? 0:31:22 So I think there are two things that we measure 0:31:23 that kind of show that. 0:31:26 One is just how happy are care pros. 0:31:29 And so the net promoter score, 0:31:31 which is how likely are they to recommend something to your friend, 0:31:34 so our net promoter score is about twice 0:31:37 the net promoter score of Google employees. 0:31:40 The second thing that we really focus on 0:31:42 is what is the churn 0:31:44 or what’s the retention of care pros. 0:31:45 So this is crazy, 0:31:48 but in home care today, 0:31:52 on average, it’s 82% churn a year. 0:31:57 So that means only 18% of care pros on average 0:32:00 will stay for a year with an agency. 0:32:04 And at honor, two-thirds of our care pros 0:32:05 are what we call optimized. 0:32:07 They’re like in a market where we have enough work, 0:32:09 we’re dense enough, et cetera. 0:32:12 And their churn is 32%. 0:32:14 And what do you credit that difference to? 0:32:15 Like people will churn. 0:32:21 So you can literally decipher mile by mile in a given city. 0:32:23 Like if Samantha lives in one place 0:32:24 and a customer lives in another place, 0:32:28 what is that person’s likelihood of churning? 0:32:30 Mile by mile in a 30-day period. 0:32:33 So it’s the increasing satisfaction 0:32:35 then literally becomes density of the network. 0:32:36 One thing’s density, 0:32:38 but like another thing, 0:32:39 people have shadow schedules. 0:32:41 So if you schedule someone 0:32:44 for kind of a long-term assignment 0:32:45 in a shadow schedule, 0:32:46 which is when they don’t actually really want to work, 0:32:49 then they will not stick and they’ll churn 0:32:50 because it’s not good for them. 0:32:52 Another thing is like, 0:32:55 if someone is not, let’s say, 0:32:57 well-dementia trained in a home with someone with dementia, 0:32:59 other than a bad customer experience, 0:33:01 like the carepro does not like that 0:33:03 because they know they’re not doing a great job. 0:33:04 They don’t feel good. 0:33:06 They feel bad. 0:33:06 And so they churn. 0:33:10 So it’s all of this stuff kind of mixed together 0:33:13 that then drives this really low churn rate that we have. 0:33:16 And that I think is like super critical. 0:33:18 And to that end, like what do you do? 0:33:21 How do you approach training for care pros? 0:33:23 So there’s training when people start. 0:33:25 There’s annual or current training. 0:33:26 And then we’ve built training material 0:33:28 into the app on a website 0:33:30 and literally just even in the use of the app. 0:33:31 So it’s even little stuff. 0:33:34 Like one thing we found early on is, 0:33:36 oh my God, so many people are like checking in 0:33:37 when they’re not at the homes. 0:33:39 But you cannot say to everybody, 0:33:41 hey, like you’re fired, right? 0:33:45 It was clear the industry just structurally did this. 0:33:47 So it became a cultural norm. 0:33:49 We intentionally did this in a very specific way. 0:33:52 If you try to check in when you’re not yet at the home, 0:33:54 we don’t say you can’t check in. 0:33:58 We say, it looks like you’re not at the home. 0:34:00 Are you sure you want to check in? 0:34:01 And that’s training. 0:34:02 Yeah, yeah, I see that. 0:34:03 So you build it in. 0:34:05 Yeah, so that’s exactly what they actually build. 0:34:07 You build the culture into the app. 0:34:10 We work to treat the care pros as true professionals. 0:34:13 And what true professionals get is, 0:34:16 here’s what’s expected of you. 0:34:19 Here are tools to help you do that. 0:34:21 Here’s training to help you do that. 0:34:23 And we’ll put you in the right environment 0:34:26 where you are uniquely suited to succeed 0:34:28 and then tell you how you’re doing, 0:34:30 and then rewards or consequences. 0:34:32 And Samantha, what kind of training 0:34:34 do the other agencies provide? 0:34:37 So I actually used to train a lot of care professionals 0:34:39 for an agency that I used to work. 0:34:42 And basically, they hire you. 0:34:43 But the first two years, 0:34:44 you need to have experience already, 0:34:47 like working in another agency, 0:34:49 but not taking care of a family member. 0:34:51 Because sometimes they use that as experience. 0:34:52 Like, oh, I took care of my grandmother. 0:34:54 I took care of my son. 0:34:55 I took care of anybody that’s ill. 0:34:56 No. 0:34:58 And then we have a whole list of policies 0:35:00 that you need to follow, 0:35:02 what are the things that you can’t say, and all that. 0:35:05 So we run down different trainings. 0:35:09 Some agencies also provide different online trainings. 0:35:10 So like you watch a video, 0:35:12 and then at the end of the video, 0:35:15 they score you and then they give you a certificate for that. 0:35:17 So it’s not always physical training, 0:35:19 but you do every year. 0:35:20 You have to do at least, 0:35:23 I think there’s 10 prerequisite trainings 0:35:25 that you have to do every year 0:35:26 to continue your caregiving. 0:35:29 Just keep your license and all that, right? 0:35:30 And then so we train them 0:35:33 based on what they feel they’re locking. 0:35:35 Safety is very, very important 0:35:36 when you’re doing this type of job. 0:35:40 So yeah, we train them from safety precautions 0:35:43 and transferring and how to be polite 0:35:46 to even just proper hand washing. 0:35:49 Thank you so much for being here, Seth and Samantha. 0:35:51 Thank you so much for sharing and for creating the platform 0:35:54 to help healthcare providers get work, 0:35:57 but also help families get the type of quality care 0:35:58 that they need. 0:35:59 And thank you, Samantha, 0:36:02 for doing the most noble work that there is. 0:36:07 You know, we’re all owe a debt to you and your colleagues. 0:36:09 Thank you very much, and thank you for having me. 0:36:09 Thank you. 0:36:10 Awesome. Thanks, Samantha. 0:36:11 Thanks, y’all. 0:36:19 [Music] 0:36:29 [BLANK_AUDIO]
This is the next cycle (Q1 2020) of Hustlin’ Tech, a podcast series (from the a16z Podcast) about technology platforms that create opportunities for people. Recorded right before the coronavirus pandemic, these next 3 episodes touch on many things that are top of mind right now: from the profession of nursing; to taking care of the elderly; to fighting bureaucracy to get money and time back (and to get help delaying utility bills and rent payments that are eligible for an extension or waiver of late fees due to the coronavirus crisis).
Episode #5, “The Hustler’s Guide to Taking Care of Old Folks” features:
Seth Sternberg, CEO and co-founder of Honor, a home care company and national network of local home care agencies that brings high-touch, personalized care to elders while also scaling workforce management; matching special needs, skills, and unique demands; and offering tools that help caregivers with jobs and more.
Samantha Ludwig, a care professional who has always had a job thanks to Honor (and who journeyed from abroad as a foreign nurse);
…both interviewed by Ben Horowitz and Shaka Senghor.
You can find the first cycle of this series (Q4 2019) — including more about the what and the why — here.
0:00:02 (upbeat music) 0:00:15 – Welcome to Hustling Tech. 0:00:19 The show that helps you if you have ambition and drive 0:00:21 and need to get started, 0:00:23 get into the tech world 0:00:27 and take advantage of the opportunities. 0:00:32 Today with us we have Iman who is CEO of Incredible Health 0:00:37 and Stephanie who is a hustler on the platform. 0:00:41 Now also with me is my co-host as always Shaka Senghor 0:00:43 who hustled his way out of the joint 0:00:46 and became a bestselling author 0:00:48 and all kinds of other stuff. 0:00:49 – So we’re excited to talk to you all today 0:00:52 about all the amazing things that you all have been doing. 0:00:55 I think that the first question I have is like, 0:00:56 what was your why? 0:00:59 So my why, so by background, I’m a medical doctor. 0:01:01 I don’t practice at all anymore. 0:01:02 A lot of my family members and friends 0:01:04 are doctors and surgeons 0:01:07 and they were often complaining about understaffing, 0:01:09 especially not having enough nurses on the floor, 0:01:13 not wanting to rely on travel nurses or contract nurses 0:01:14 to take care of their patients. 0:01:17 And then at the same time, my co-founder, Rome Portlock, 0:01:19 he’s a software engineer from MIT. 0:01:21 He’s been building software for 15, 20 years 0:01:23 with sisters or nurses. 0:01:25 And even though they’re experienced and qualified, 0:01:27 they’re saying it still takes me at least two, 0:01:29 three months to get my next job. 0:01:32 And we’re like, okay, this doesn’t make any sense. 0:01:35 And what we discovered is a lot of the processes, 0:01:39 the tools, the software that HR teams at hospitals 0:01:41 are using are very outdated. 0:01:43 They haven’t actually changed since, 0:01:45 I don’t know, late ’80s, early ’90s. 0:01:47 We figured there just has to be a better way. 0:01:51 Incredible Health is the fastest growing hiring platform 0:01:53 for nurses in the US today. 0:01:55 Hospitals and health systems use the platform 0:01:59 to hire nurses in permanent roles in less than 30 days 0:02:01 instead of it taking 90 days or longer. 0:02:05 – Wow, and why did you do it the way you did 0:02:06 instead of just saying, okay, 0:02:08 well, build software for hospitals 0:02:09 or something like that? 0:02:10 Why did you– – I think there were a couple 0:02:13 of reasons why we took a more comprehensive approach. 0:02:16 One is we understood the market 0:02:18 and there’s some fundamental problems 0:02:19 like the nursing shortage. 0:02:21 And to put it in context, 0:02:22 that shortage is three times bigger 0:02:24 than the software engineering shortage. 0:02:28 And so our demand for healthcare keeps going up, 0:02:29 but there are just simply not enough 0:02:31 healthcare workers in the system. 0:02:34 – How do we land here where, like, what is the– 0:02:35 – They’re not paying enough. 0:02:36 – Yeah, they’re not paying enough, yeah. 0:02:40 – Yeah, there’s probably two bottlenecks. 0:02:42 The first is the number of people 0:02:44 getting accepted to nursing schools. 0:02:46 – Nursing school is very competitive. 0:02:48 It has a lot of wait lists. 0:02:50 Once you apply to go into the nursing school, 0:02:53 you’re not guaranteed to get in immediately. 0:02:54 You have to go through some process. 0:02:55 You have to wait. 0:02:59 So that’s why we have such shortage. 0:03:00 – And then the other big huge bottleneck 0:03:03 is what happens right after nursing school. 0:03:06 So unlike doctors, we have residency programs, 0:03:10 honestly, that are mostly funded by the government. 0:03:11 But when it comes to training nurses, 0:03:14 it’s the hospitals that bear the majority of that cost. 0:03:18 And so they don’t always see a strong ROI 0:03:19 on those training programs 0:03:21 because nurses go through it 0:03:23 and then they often leave 0:03:26 because they’re next opportunity. 0:03:29 So it is actually quite hard for a new graduate nurse 0:03:30 to land their first job. 0:03:33 They have to be very geographically flexible 0:03:34 in order to do that. 0:03:36 No, once you’re at a Stephanie stage, 0:03:38 when you have a few years under your belt, 0:03:40 and that is a sweet spot, 0:03:44 where if you have one or two years of experience, 0:03:46 you’re pursuing a specialty already, 0:03:51 you will get a job very quickly on our platform. 0:03:52 – Oh, wow. 0:03:54 So how long have you been a nurse, Stephanie? 0:03:55 – For three years now. 0:03:57 – Well, it started at the beginning. 0:03:58 – Well, I’m Nigerian. 0:04:02 I grew up in Nigeria, most of my adulthood, 0:04:04 and I left Nigeria at the age of 19. 0:04:07 There are two reasons that pushed me to become a nurse today. 0:04:11 The first one was I was sick back home in Nigeria, 0:04:13 and I had surgery. 0:04:17 It was appendix, just a minor surgery, 0:04:19 but it ruptured. 0:04:23 And I developed sort of an infection, 0:04:26 and they were incapable of handling it, 0:04:29 and it went to a point where I almost lost my life. 0:04:32 So the reason why I’m actually sitting 0:04:35 and talking to you guys is because my mom actually 0:04:38 walked with a doctor that she could rely on, 0:04:41 and she had to look for him to perform the surgery for me. 0:04:44 And that’s really saved my life. 0:04:47 So that was one of the reasons I decided to become a nurse. 0:04:49 And the second reason was 0:04:51 I didn’t immediately push through the nursing career. 0:04:53 I went into business 0:04:56 because I wanted to help my dad out in his business. 0:04:59 So that’s why I went into business administration. 0:05:01 But I was like, I’m not doing this for myself. 0:05:03 I need to do something for me. 0:05:06 And what triggered it was when I was doing my dissertation 0:05:09 in one of the biggest hospitals in Malta. 0:05:11 It’s called Matter Day. 0:05:14 I was able to communicate with nurses and doctors, 0:05:18 and I was like, no, this is where I belong. 0:05:21 So that was where I decided I was going to go into nursing. 0:05:22 I called my brother. 0:05:23 My brother was here. 0:05:25 He’s been here in America for the longest. 0:05:27 So he told me, oh, if you want to do nursing, 0:05:29 come to America and do it. 0:05:31 And that was where I started. 0:05:34 Like I came over, I started with cancers 0:05:35 where I did my pre-nursing, 0:05:39 and then I moved over to Atlanta, Georgia, 0:05:41 where I finished up the nursing school, 0:05:44 and I started walking at Northside Hospital Atlanta. 0:05:47 And then I finally moved here to California. 0:05:50 And the nursing program, it was difficult to get in. 0:05:50 I will not lie. 0:05:53 It was very difficult to get into the program. 0:05:55 And what made it difficult? 0:05:58 Was it the process was difficult? 0:05:59 The process was difficult. 0:06:00 There are a lot of waiting lists. 0:06:04 So you can imagine applying Wednesday’s waiting list. 0:06:07 So they go for those who are in the waiting list before you. 0:06:12 I actually stayed home one more year after my prerequisites. 0:06:13 And then when it was time for me, 0:06:17 I started at Chamberlain College of Nursing in Atlanta, Georgia, 0:06:21 because I just moved to California three months ago. 0:06:24 And then I stayed there for two years. 0:06:26 It was very– 0:06:29 nursing school is very chaotic. 0:06:31 We go through a lot. 0:06:33 I nearly gave up. 0:06:36 I nearly gave up nursing school. 0:06:39 I don’t know how to explain it, but it’s difficult. 0:06:41 Not everybody goes in that comes out. 0:06:46 I started with a lot of friends, and a lot of them left. 0:06:48 So that could be another reason to get away. 0:06:50 We’re having the nursing shortage, 0:06:54 because they make it very, very rigorous. 0:06:57 It makes sense once you get into the nursing itself, 0:06:59 because they’re training you to take care 0:07:01 of these critically ill patients. 0:07:04 So you have to meet up to that standard. 0:07:07 That’s why they really screen us in school. 0:07:09 The other thing, it’s a regulated profession. 0:07:12 So just like many other health care professions, 0:07:16 you have to have licenses, you have to have certain certifications. 0:07:17 Makes sense. 0:07:21 Yeah, so the regulation part, who puts the cost of getting 0:07:22 the licenses and all that? 0:07:26 Is that on the student nurse, or is it some type of stipend? 0:07:28 How does that work out? 0:07:31 The hospital I applied to, where I got my first nursing job, 0:07:33 paid for it. 0:07:36 So that was OK by me. 0:07:39 I got the job before I graduated. 0:07:41 So they told me, oh, they’re going to pay for it, 0:07:43 as long as you pass the boards. 0:07:46 So I paid, and they funded it back to me. 0:07:48 But Stephanie was in the fortunate position 0:07:50 of having the job already lined up. 0:07:52 So now, if you don’t have a job lined up, 0:07:54 many nurses have to pay out of pocket. 0:07:58 So before I found incredible health, 0:08:00 I decided I was going to move to California 0:08:02 to be close to family. 0:08:07 I was putting in my application in so many hospitals, 0:08:09 and I didn’t get any callback. 0:08:11 I just get this automated email saying, 0:08:14 oh, unfortunately, we consider other candidates. 0:08:16 It’s not that you are not qualified, 0:08:19 but there were too many people that applied. 0:08:22 Which is pretty weird, given there’s a nursing school. 0:08:25 Those same hospitals, you find them looking for nurses 0:08:26 to work for them. 0:08:30 So I didn’t just understand why that was happening. 0:08:32 So it was my brother that told me to try it. 0:08:35 So I just filled in my application with incredible health, 0:08:39 and I just got a call immediately, 0:08:43 and they told me, oh, this is how it works. 0:08:45 And once any hospital is interested in you, 0:08:48 they will send a message, you just respond, 0:08:52 and it was kind of like an easy way 0:08:55 and different process applying to hospitals. 0:08:57 The employers are coming for you, 0:08:59 not you going to them, they’re chasing you. 0:09:01 – So you’re an NBA player at the end. 0:09:03 – Exactly, exactly. 0:09:05 The employers apply to the nurses 0:09:07 instead of waiting for the nurses to apply to them. 0:09:08 – Yes. – No, that’s awesome. 0:09:13 – So with that model, do you end up at different hospitals 0:09:17 or private practice, how does that work, the model itself? 0:09:20 – So you have a lot of hospitals applying to you. 0:09:22 So you have that opportunity to be like, 0:09:25 oh, no, I don’t want this one, I want this one. 0:09:26 That’s what I was doing. 0:09:28 I had lots of hospitals that wanted 0:09:29 to have an interview with me, 0:09:33 but I already had the list of hospitals I wanted to go for, 0:09:35 and those are the ones I selected. 0:09:40 So you just as an advantage to choose what you really want. 0:09:42 – Yeah, so when a nurse, we say, 0:09:45 when a nurse goes live on our platform, 0:09:46 means they’re actively looking, 0:09:48 actually within days, 0:09:50 they can get several interview requests 0:09:51 from multiple hospitals. 0:09:53 And then we give them three days, 0:09:56 which interviews to accept and which ones to decline. 0:09:58 For those that get accepted, 0:10:01 our software also facilitates that first phone screen 0:10:03 with a recruiter, and we also, 0:10:05 our customer support team supports both the nurse 0:10:07 and the recruiter through the end, 0:10:08 all the way to the end of the process. 0:10:10 So no one gets dropped in the funnel. 0:10:13 – So in my source, that means that on any given week, 0:10:15 you can be at different hospitals. 0:10:16 Like, is that how it works? 0:10:18 What I’m getting at is, 0:10:20 so once that process happens, you get accepted, 0:10:24 can you work for this hospital today, Tuesday, Wednesday? 0:10:26 Am I at another hospital next week? 0:10:27 Like, does it work like that? 0:10:29 Or is it like, this is my place, 0:10:30 this is where I’ll be working for? 0:10:31 – Yeah, great question. 0:10:33 The nurses on our platform are getting hired 0:10:36 for, you know, as employees at the hospitals. 0:10:40 We’ve intentionally stayed away from contract work 0:10:42 and temporary labor, 0:10:45 because honestly, that’s not what the hospitals want. 0:10:47 They’re urgently looking for permanent labor. 0:10:48 And then the other thing we guarantee, 0:10:50 both to the nurses and the hospitals, 0:10:52 is hires in less than 30 days. 0:10:55 The average on the market is 82 days. 0:10:59 So we really dramatically try to bring down 0:11:01 that days to fill to less than 30 days. 0:11:02 – That’s amazing. 0:11:04 – I mean, I just think it’s really so interesting 0:11:07 that because of the struggles that so many communities go to 0:11:09 just to get quality healthcare. 0:11:11 So I think, you know, having something that’s bridging 0:11:13 that gap, how has it been received in the industry though? 0:11:16 Like, what has the response and reaction been? 0:11:18 – It’s been extremely positive. 0:11:20 When we started, we were just in California 0:11:22 and we’re currently expanding nationally. 0:11:25 So we work with all the top academic medical centers 0:11:26 like Stanford and Cedar Sinai. 0:11:28 Stephanie actually got her job at Stanford. 0:11:30 She’s at the brand new hospital here. 0:11:31 – All right, all right. 0:11:35 Yeah, so they, you know, my partner, Mark Andreessen, 0:11:38 his wife donated the Stanford emergency room. 0:11:41 Andreessen Ariaga emergency room. 0:11:42 – That’s awesome. 0:11:44 We work with all the big health systems 0:11:47 like HCA and Tenant and Providence St. Joseph 0:11:50 and lots of community hospitals too. 0:11:53 And so we really perfected the platform 0:11:55 and our processes here in California first. 0:11:58 And then a few months ago started to expand nationally. 0:12:00 And so now we have help, academic medical centers, 0:12:02 big health systems and community hospitals 0:12:04 and other parts of the country too. 0:12:07 – Now that you’ve got kind of the marketplace up and running, 0:12:10 generally, you know, we analyze marketplaces. 0:12:13 We always talk in terms of kind of supply and demand. 0:12:15 And like, where do you have the bottleneck? 0:12:18 And it seems like given there’s a nursing shortage, 0:12:21 you’re gonna, getting nurses is always gonna be 0:12:24 a little harder than getting hospitals, I would think. 0:12:25 Is that right? 0:12:25 – That’s right, yeah. 0:12:28 – And so how do you think, you know, 0:12:30 how do you think about that as things evolve 0:12:34 and what your role is in kind of getting more nurses 0:12:35 into the market? 0:12:37 – Yeah, I mean, in terms of getting the nurses 0:12:40 on our platform, all of it really starts with our mission 0:12:42 and the mission is to help healthcare professionals 0:12:44 live better lives and help them find 0:12:45 and do their best work. 0:12:47 In general, this is a group that isn’t, 0:12:51 this group of workers that’s not treated particularly well. 0:12:52 You know, there’s a lot of burnout. 0:12:56 So we wanted to be the one company and service 0:12:58 and platform out there that’s giving them 0:13:00 the best experience possible. 0:13:03 And so really that’s like the core of what attracts 0:13:05 the nurses to the platform is that very strong value 0:13:08 proposition that, hey, create a profile, 0:13:10 sit back and relax, hospitals will apply to you. 0:13:14 And now in terms of that, that actual messaging 0:13:16 and how it gets out, it’s a really a combination 0:13:18 of marketing and product. 0:13:20 What we’re doing on our platform is we’re also providing 0:13:23 a whole suite of free tools and software for nurses too. 0:13:27 So salary calculators and, you know, 0:13:29 completely free continuing education 0:13:31 that’s paid for by Incredible Health. 0:13:32 Where they can– 0:13:34 – So you can go from being like an LVN to an RN 0:13:35 and that kind of thing. 0:13:38 – Yeah, so that’s, and then the other thing is really 0:13:39 building community around this, 0:13:43 both offline community of nurses and also, you know, 0:13:45 creating more of an online community for nurses as well. 0:13:47 So there’s one place that they can congregate. 0:13:49 – Yeah, Stephanie, when you first, 0:13:51 when your brother introduced you to it, 0:13:53 like, how did you approach it? 0:13:54 So he comes to you and is like, 0:13:57 hey, here’s an opportunity, let me get you in the game. 0:14:00 Like, what was that, what was your initial reaction 0:14:03 to the introduction to the platform? 0:14:06 – It was different and I was like, 0:14:09 I was like, I want to see what this is all about. 0:14:13 And that was where I got to see it’s a better way 0:14:17 to like get nurses to get job faster. 0:14:19 And I was really impressed with it. 0:14:22 So that’s why a lot of my friends, nurses, 0:14:25 that are in Atlanta, Georgia that have plans to come over, 0:14:28 everybody’s looking forward to using it 0:14:30 because it’s just easy. 0:14:34 And you don’t have to like deal with the long wait, 0:14:37 the rejection emails that are automated. 0:14:42 You’re not like communicating with the hospital 0:14:44 on how to get your interview set up. 0:14:46 They are doing it for you. 0:14:47 All you just need to do is to get the dates 0:14:49 that is convenient for you and just show up 0:14:50 for your interview. 0:14:52 It was stress free, hustle free. 0:14:53 – And what does that look like? 0:14:55 Like in terms of the continuing education, 0:14:58 I’m always interested in different ways to learn. 0:15:00 So what does that look like on a platform? 0:15:03 – Yeah, so nurses annually have to get 0:15:06 continuing education like credits or units. 0:15:09 And that’s to maintain their specialization 0:15:11 or maintain their experience. 0:15:15 And in some cases, to get a specific state license, 0:15:16 you need to have a certain number 0:15:18 of continuing education like credits basically. 0:15:21 And a lot of these are online courses actually, 0:15:23 and they’re across different topics. 0:15:26 You know, we can cost hundreds of dollars a year. 0:15:28 And so we’re just bearing that cost for nurses. 0:15:30 Whether they’re using our platform 0:15:31 for getting a job or not, 0:15:32 it’s gonna be available to all nurses. 0:15:34 – So it sounds like it’s almost like 0:15:39 you are kind of CAA for nurses. 0:15:43 Which is Creative Artist Agency, 0:15:46 which is one of the biggest talent agencies in the world. 0:15:49 And so when you do that, 0:15:54 do you start to think about an individual nurse’s profile 0:15:56 and reputation so that you can market them better? 0:15:57 Or how do you approach that? 0:16:00 – Yeah, we spend a lot of time thinking 0:16:02 and working on improving nurse profiles. 0:16:05 And it’s everything from the actual profile itself 0:16:07 and the different fields that we’re collecting, 0:16:11 ’cause we are automatically with a lot of software screening 0:16:12 and matching them as well. 0:16:15 So this isn’t humans doing it, it’s all software doing it. 0:16:16 ‘Cause if you’re a recruiter, 0:16:18 you don’t want to log in and see 200 nurses. 0:16:20 You want to see 14 that are the right fit 0:16:22 for you at that time. 0:16:24 And that saves them a considerable amount of time too. 0:16:28 – And ’cause a nurse has got to have a specialization 0:16:30 and a location and some kind of background 0:16:32 for that to be a fit, okay. 0:16:35 – We’re matching on probably 40 or 50 different attributes. 0:16:36 Some of the attributes are things 0:16:39 like specialty licenses, certifications, 0:16:42 location preference, commute times. 0:16:44 And then in addition to the profile, 0:16:46 we’re also providing interview preparation too. 0:16:49 – You also apply this to like dating apps. 0:16:51 – So it’s funny you say that. 0:16:53 So chief nursing officers refer to us 0:16:55 as the match.com of hospitals and nurses, 0:16:58 which is kind of embarrassing, but it’s accurate too. 0:17:02 – So Stephanie, so listen to like the kind of the profile 0:17:04 and breakdown of like the matching process. 0:17:06 Like what were some of the things specifically 0:17:08 that you had to kind of share to figure out 0:17:10 how you matched up with the people 0:17:12 who you was looking to be hired by? 0:17:16 – So I was looking at my commute and the, 0:17:18 ’cause I wanted something in the Bay Area. 0:17:23 So I chose something I can, a place I can drive to. 0:17:24 I don’t need to drive more than 30 minutes. 0:17:26 That was my goal. 0:17:29 And that was one of the reasons I chose Stanford. 0:17:33 And I also chose Stanford because of the reputation 0:17:35 and the experiences there too. 0:17:40 So those were part of the, those were part of my selections. 0:17:40 – Yeah, I mean, 0:17:42 one of our goals is the nurse has no idea 0:17:44 what’s going on behind the scenes 0:17:46 when it comes to screening and matching. 0:17:49 And it just seems like a magical process. 0:17:50 – Well, that’s why the rejection letters. 0:17:53 You’re rejected, you’re qualified, 0:17:57 but you don’t match on some criteria 0:17:59 that you don’t know about. 0:18:01 And so that’s, okay, so that’s really interesting. 0:18:04 And then if somebody does an interview 0:18:06 and doesn’t get the job, 0:18:09 is there a feedback process for how does that work? 0:18:11 – Anytime a nurse doesn’t proceed in the hiring process, 0:18:14 we, we’re, you know, recruiters are able to enter 0:18:16 the reasons why they were not hired. 0:18:19 And each nurse on our platform is paired 0:18:21 with what we call a talent advocate. 0:18:23 These are members of our team. 0:18:25 They are all RNs as well. 0:18:28 And I think of them as like advocates 0:18:30 or career coaches for every nurse. 0:18:32 So that’s like a, also like a free service 0:18:34 that we provide to the nurses too. 0:18:38 – So one day every hospital in America 0:18:40 and every nurse is going to be on the platform. 0:18:43 What can you do at that point? 0:18:45 – So number one we talked about was the shortage. 0:18:47 And then the other one is just the inefficiency 0:18:48 in the market, like the right, you know, 0:18:52 the hospitals and nurses aren’t even finding each other. 0:18:53 A lot of what we’ve built so far 0:18:55 and what we’ve worked on so far 0:18:57 is to solve the inefficiency problem, right? 0:18:58 How do we get the right nurses 0:19:00 at the right hospitals quickly? 0:19:03 – Right, and that actually addresses the shortage 0:19:06 in many ways in that it’s not just 0:19:09 that the nurses and theorists said you can’t find them. 0:19:12 – Correct, yeah, it’s like ships passing each other 0:19:15 through the night, like they just don’t find each other. 0:19:20 And in terms of solving the actual underlying 0:19:23 nursing shortage, honestly, I know it’s something 0:19:25 we want to tackle because it’s part of our mission 0:19:26 and our vision. 0:19:28 I don’t know exactly how that’s going to look like yet. 0:19:32 One of the interesting pieces of the story of CAA is 0:19:36 before CAA, top actor or actress would make, you know, 0:19:39 maybe $500,000 on a film. 0:19:43 After CAA, 20 million, why? 0:19:48 Because every top actress and actor in the late 80s 0:19:51 was on the CAA platform. 0:19:54 So they could basically say you can’t make a movie 0:19:58 without us and the economics switched and flipped around 0:20:01 and put the power in the hands of the people 0:20:03 making the movies and in healthcare. 0:20:06 I mean, I know this just ’cause, you know, 0:20:10 my mother was a nurse, nurses are actually way more important 0:20:14 than the hospital hierarchy treats them often. 0:20:15 – Yeah. 0:20:16 – And that actually has more variance in your outcome 0:20:17 than anything. 0:20:22 So do you see a time in the future where by having 0:20:25 all the nurses collectively together, 0:20:29 you can actually make the profession more attractive? 0:20:29 – We’re already seeing that. 0:20:32 So on average on our platform, 0:20:35 the nurses salary increases by 17% 0:20:37 and commute time goes down by 15%. 0:20:41 There’s actually several reasons why nurses change jobs. 0:20:43 One reason is I want to get paid more. 0:20:45 Another is I want to shorten my commute time. 0:20:47 Another is I want to advance my career 0:20:48 and I want to get more skills 0:20:50 in a particular specialty area. 0:20:52 And then a fourth one is just I need to relocate 0:20:53 for whatever reason, like, 0:20:55 Stephanie probably had like, what, 0:20:56 two or three of those are valid. 0:20:57 – All of them. 0:20:59 All of the above. 0:21:01 – Advance my career I needed to experience too 0:21:02 and know that. 0:21:04 – So what we’re seeing in the marketplace dynamic is like, 0:21:07 yeah, overall, like the salaries are skewing higher 0:21:11 because well, if you’re an OR nurse in the Bay Area, 0:21:13 for example, or an LA, 0:21:16 every single hospital has that shortage. 0:21:18 So you can, you have the opportunity to optimize. 0:21:20 – And you can leverage that knowledge, right? 0:21:21 – Yeah, exactly. 0:21:21 – That’s incredible. 0:21:24 – And one of the things I’m always interested in 0:21:27 when, you know, talking to entrepreneurs is that leap, 0:21:28 that leap of faith. 0:21:31 What did it take for you to take that leap 0:21:34 from doctor to entrepreneur? 0:21:37 And were there moments where you were a little bit hesitant 0:21:39 or afraid or were you just like, 0:21:41 no, I want to just do this and make this thing happen? 0:21:45 – Yeah, and like dealing with, I’m going to build software. 0:21:46 – So we’re talking about 10 years 0:21:49 from the time I decided to not, 0:21:50 from the time I graduated from medical school 0:21:52 and decided not to do residency 0:21:54 to the time I founded Incredible Health. 0:21:57 So during that time, I had worked in management consulting. 0:22:00 I was exposed to hospital operations and strategy. 0:22:03 I had done my MBA at Wharton on the East Coast. 0:22:07 And then during that time in business schools, 0:22:09 where I was really starting to get more exposed 0:22:10 to entrepreneurs ’cause a lot of my classmates 0:22:13 were founders and CEOs. 0:22:15 And then the other thing is starting a business 0:22:18 is something I’ve always kind of had in the back of my mind 0:22:19 for a very long time. 0:22:21 Both my grandfathers are entrepreneurs. 0:22:23 I’m originally from Sudan. 0:22:27 And so yeah, I got some health hustlers in my family, right? 0:22:30 But I knew I needed to, like all the stars 0:22:33 need to align before you take the dive, right? 0:22:36 So I knew I needed to move to the Bay Area 0:22:37 because this is controversial, 0:22:39 but it still hands down the best place in the world 0:22:40 to build a technology company. 0:22:41 – No question, yeah. 0:22:43 – I needed to have the right co-founder. 0:22:45 When I moved out to the Bay Area, 0:22:47 I didn’t know anything about software. 0:22:49 I didn’t know anything about how to build a product 0:22:51 or ship or anything. 0:22:55 So I actually got, my first job was as a product manager 0:22:57 at an early stage healthcare technology company 0:22:58 in the Bay Area. 0:23:00 And that’s really where I learned to work 0:23:02 with software engineers and designers and data scientists 0:23:05 and what it takes to launch a product and grow a business. 0:23:06 And so after a couple of years of that, 0:23:09 left with one of the lead software engineers, 0:23:12 Rome, who’s my current co-founder, to work on this. 0:23:14 And so like multiple things had to come together 0:23:15 for me to make that decision. 0:23:17 So I needed to have the right co-founder. 0:23:19 I needs to be in the right location. 0:23:21 Honestly, I needed to have enough savings. 0:23:23 And of course I needed to have the right idea 0:23:24 and the right opportunity. 0:23:25 – Right. 0:23:29 Yeah, that’s a really great insight understanding 0:23:30 that you had. 0:23:35 You know, we see a lot of entrepreneurs who have an idea, 0:23:38 but not the skillset to go pursue that idea 0:23:42 and the fact that you recognized, okay. 0:23:44 Not only do I need the skillset, 0:23:45 and you not only got the skillset, 0:23:48 but you got the network to put together the team 0:23:50 to build the company that was gonna work. 0:23:52 That’s really impressive. 0:23:54 – So one of the things that when we started the conversation, 0:23:56 we talked about kind of like origins, right? 0:23:58 So you’re from your family’s from the Sudan 0:24:00 and your family’s from Nigeria. 0:24:02 I just came back from Makaragana. 0:24:06 And one of the things that I loved was just like the hustle 0:24:08 and just seeing people that was like, 0:24:09 no matter what the circumstance were, 0:24:11 they was gonna figure out how to get out there 0:24:12 and make it happen. 0:24:16 How much of that plays a role in where you are today? 0:24:17 And that’s for like both of y’all. 0:24:19 Like how much of that play a role? 0:24:22 – Well, I came from a hustling family. 0:24:26 My dad is a hustler and he brought us up to hustle. 0:24:28 Like you have to take care of yourself 0:24:30 and you have to take care of those around you. 0:24:32 So we always hustle. 0:24:34 And one of the way he taught us how to hustle 0:24:37 is by going to school. 0:24:40 He made sure we go to school and he always tells us, 0:24:42 you do not have to stop at the square cop, 0:24:44 you need the round cap. 0:24:49 So he was always bent on pushing us to advance our career 0:24:52 and do good for yourself. 0:24:54 – Similarly, my family, my Sudanese family 0:24:57 has had similar values in that you gotta pursue education, 0:24:59 you gotta do your best. 0:25:00 No matter what field you go into, 0:25:02 you just need to aim to be the best. 0:25:05 And no matter what it takes, whatever hurdles you face, 0:25:07 like you just have to overcome them. 0:25:10 And that has played out, I’m one of five siblings. 0:25:12 So that has definitely played out 0:25:14 and they’re all thankfully doing great. 0:25:17 You know, a lot of things that get people caught up, 0:25:19 a lot of just listening to your stories, 0:25:20 to have both of your stories, 0:25:23 you know, if something goes wrong 0:25:26 or you get rejected from a job and so forth, 0:25:29 a lot of times people here will interpret that as, 0:25:32 okay, that must have been something like, 0:25:35 you know, that systemically the country 0:25:37 is set up to stop me. 0:25:40 But neither of you had, I mean, whatever that was, 0:25:42 you just dusted it off. 0:25:43 How are you able to do that? 0:25:47 Because it is kind of a cultural outlier. 0:25:49 Yeah, great, that’s a good question. 0:25:51 Okay, so I’ll take the specific example 0:25:53 of raising venture capital. 0:25:56 When you look at the statistics, 0:26:00 it’s proven pretty much that the odds are stacked 0:26:02 against people who look like me, right? 0:26:03 And are your gender. 0:26:06 And yes, my gender and the fact that I’m a minority. 0:26:10 Black women raise 0.01% of the venture capital. 0:26:13 Yeah, that’s zero, that’s approximately zero. 0:26:17 Now, when I’m talking to other CEOs about this, 0:26:19 especially CEOs that look like me, 0:26:21 I’m like, okay, that’s what’s happening behind the scenes 0:26:23 and that’s what the data shows. 0:26:26 But you actually have to ignore that information. 0:26:28 You have to completely ignore it 0:26:30 and pretend it’s like not even there. 0:26:33 It’s a psychological web, right, and a trap. 0:26:38 So when you’re going into, you know, a fancy VC firm 0:26:41 and you walk in that room, 0:26:43 you have to be the way you communicate. 0:26:45 Your assertiveness needs to be the same 0:26:48 as your white male counterpart 0:26:51 that came in the room actually minutes before you probably, 0:26:54 right, and you have to match that level of confidence 0:26:58 and assertiveness in order to get like the term sheet. 0:27:00 So you really collect, 0:27:03 basically you just have to ignore all of that. 0:27:05 It’s still true, you know, like I still acknowledge 0:27:06 that it’s there, but. 0:27:08 But if you get it in your head, 0:27:09 then it’s definitely stopping you. 0:27:10 – Exactly. 0:27:13 – And what I see is that you need like a hundred percent 0:27:17 substance and competence 0:27:19 and then you also need a hundred percent confidence, right? 0:27:22 You need both, both are, both of those are required 0:27:24 if you’re going to do something that’s crazy ambitious 0:27:27 and probably the number one piece of advice 0:27:29 that I do give to minority CEOs is like, yeah, 0:27:31 you’ve got a hundred percent substance, 0:27:35 but like your confidence is only at like 40%. 0:27:37 That’s not, you’re not going to get that far. 0:27:39 You need to, you know, bump that up to a hundred percent. 0:27:42 – How do you teach people to get their confidence 0:27:43 where it needs to be? 0:27:46 Because that’s so easy to fall into that. 0:27:49 Well, they really didn’t understand me. 0:27:50 They really didn’t see me. 0:27:54 They, and like, how do you get people to get in that mindset 0:27:56 where they can cross that chasm? 0:28:00 And, and even racism aside, 0:28:03 just there is like a cultural bridge 0:28:05 that you have to cross getting into like high finance world. 0:28:08 – Yep, this is the hack I used. 0:28:11 I don’t need it anymore, but I used it in the beginning. 0:28:13 It’s very controversial. 0:28:14 (laughing) 0:28:15 – I love controversy. 0:28:16 Say more, say more. 0:28:17 – Let’s go with the controversy. 0:28:19 – So when I was first starting, you know, 0:28:21 raising that seed round or whatever, 0:28:24 I created like an alter ego for myself. 0:28:26 – Ah, all right. 0:28:27 – And the alter ego, okay. 0:28:28 – Who’s the alter ego? 0:28:30 – The alter ego is named Chad. 0:28:31 – That’s a very white name. 0:28:32 – Very. – Right. 0:28:35 – And Chad had a whole persona. 0:28:39 Like Chad was six feet tall, blonde hair, blue eyed. 0:28:42 Last four generations went to the Ivy League, 0:28:46 went to like Phillips Exeter or Hanover for high school. 0:28:46 – Yeah, yeah, I’ve heard of those. 0:28:49 – You know, just like the epitome of American privilege, right? 0:28:51 And when I was like, before I walk into that room, 0:28:55 and by the way, this is any situation where I’m selling 0:28:57 and CEOs have to sell a lot to investors, 0:28:59 to employees, to customers. 0:29:02 I’d be like, okay, for the next 60 minutes, 0:29:04 I’m not gonna be a man with like 30 years of baggage and, 0:29:08 you know, I’m just gonna be Chad for the next 60 minutes. 0:29:10 And you walk in the room and just act, what would, 0:29:12 you know, what would Chad do? 0:29:13 What would Chad say? 0:29:14 – Of course you’re giving me the money. 0:29:15 I’m Chad. 0:29:16 – Yeah, exactly, like Chad walks. 0:29:17 – Do you know where I went to school, bro? 0:29:19 – Exactly, Chad walks into the room, 0:29:23 like not only does he have insane amount of confidence, 0:29:24 like he owns that entire room, 0:29:26 he owns the entire block, right? 0:29:30 And so, you know, now I don’t need, 0:29:32 now Chad and he man have become one, right? 0:29:34 Like I don’t need the alter ego anymore, 0:29:38 but like when I was starting out, like it helped. 0:29:40 – See what’s so amazing is that you said, 0:29:43 I need that, as opposed to, that’s unfair. 0:29:45 – Yeah, I mean, it’s, you know, 0:29:48 I think about my life choices, 0:29:50 I realized most of it was choices. 0:29:52 And like I can choose how I want to show up in the world. 0:29:54 And it’s one of the things that, 0:29:57 like we really connect around, it’s just like, 0:29:59 if you’re an entrepreneur, like you’re an entrepreneur, 0:30:01 it doesn’t matter if you’re a black, white, ex-convict, 0:30:03 whatever, like those are, 0:30:06 that’s like the core of like your driver. 0:30:08 And I mean, I ran into every type of this, 0:30:10 I literally have every built in excuse 0:30:14 you can imagine one human being having, right? 0:30:15 But for me, I always just saw that as like, 0:30:18 how do you just show up in the world? 0:30:19 Like my alter ego is a rapper. 0:30:22 I grew up with hip hop from the beginning, right? 0:30:24 So when you listen to like the Sugar Hill gang, 0:30:27 and they would tell these just fantastical ass stories, 0:30:30 and you know, they probably still sleeping 0:30:31 on their grandma’s couch. 0:30:34 And then that started becoming reality 0:30:38 as rappers began to understand they can, you know, 0:30:41 monetize their skill set in a different way, right? 0:30:44 And so for me, it’s just like in order to get from, 0:30:46 you know, just making a record to like, 0:30:49 turn it into a business and just hustling, you know, 0:30:51 you got to work in different ways. 0:30:53 Like I’m like, okay, that mentality works, 0:30:57 but also they were telling our story. 0:30:58 You know, if you listen to like the rappers 0:31:00 who are hustlers, they’re talking about 0:31:01 the guys in the streets, you know, 0:31:03 but they monetized it in a way 0:31:05 that accelerated beyond the street. 0:31:08 So for me, it was just like tapping into that identity 0:31:10 of like, okay, I’ve done this before. 0:31:12 I’ve done it, but it was all the wrong product. 0:31:13 You know, all the things that come with that. 0:31:16 So for me to walk into a meeting with somebody 0:31:18 and say, hey, I got this idea, you know, 0:31:20 here’s what I’m trying to create or whatever, 0:31:24 like that’s small things to overcome, you know, 0:31:27 but the conversation internally is, 0:31:29 ’cause those voices of doubt never go, 0:31:30 at least for me, they never go away. 0:31:32 So it’s always like, how do I counter it, right? 0:31:33 How do you counter the voice? 0:31:34 It’s like, you’re not good enough 0:31:36 for this is going to stand in your way 0:31:38 or that’s going to stop you. 0:31:39 Sometimes you got to get out of your own head. 0:31:43 You got to get out of how that internal dialogue 0:31:45 can be disruptive when it comes to like 0:31:47 stepping over those bridges and gaps. 0:31:49 And so Stephanie, what’s your alter ego? 0:31:50 (laughing) 0:31:51 Like super-nurse? 0:31:52 – I don’t need an alter ego. 0:31:54 But I don’t have an alter ego. 0:31:57 I just be like, I just bring myself out 0:31:59 and I don’t see the fact that I’m a black woman. 0:32:01 I just see myself as this human being 0:32:03 and I’m just going to have that confidence 0:32:06 and do what I want to do and that’s it. 0:32:10 Because I feel if we stop putting it in our head, 0:32:12 you can’t go where you want to go. 0:32:13 It’s going to come in your way 0:32:15 in being who you want to be. 0:32:18 – So Stephanie, like when you introduce a friend 0:32:21 to the platform, you know, do they believe you? 0:32:22 Are they skeptical? 0:32:23 What do they think? 0:32:25 – I would say they were shocked. 0:32:28 – Yeah, ’cause like four people right now 0:32:31 want to like know more about it and they called me, 0:32:32 I explained it to them and they were like, 0:32:35 wow, they didn’t know such a thing exists 0:32:37 because it’s easy. 0:32:40 Like I have a friend right now that sends an application in 0:32:41 and she has not heard from them. 0:32:43 It just shows still reviewing. 0:32:46 And she applied to four positions to already, 0:32:50 they’ve sent her an automated email saying, no. 0:32:52 But I know that place is short. 0:32:55 So I told her to just fill out the application. 0:32:56 She sent me a link. 0:32:59 She said, I need to refer her or something like that. 0:33:01 So I explained how it works. 0:33:03 I was like, once you fill out the application, 0:33:06 they’ll get back to you and tell you how it works more 0:33:10 and employers will apply to you 0:33:11 and you choose which one you want. 0:33:12 And she was like, oh, wow. 0:33:14 – So it’s interesting that you talked about going 0:33:18 to different hospital websites for the application 0:33:20 because there are other worlds where people are trying 0:33:22 to find employment like LinkedIn 0:33:26 and other social media or other online platforms 0:33:27 where people can apply. 0:33:32 – So LinkedIn and Indeed and even the own hospitals job board, 0:33:34 these are basically job boards, post a job 0:33:37 and then waiting for people to apply. 0:33:40 The issue is that from the hospital standpoint, 0:33:42 it’s quantity over quality. 0:33:43 So there’s a ton of applicants. 0:33:47 But there’s usually a very small in-house recruiting team 0:33:49 that’s sifting through all of that manually. 0:33:51 They don’t have a supportive software or anything. 0:33:54 And so what happens is a lot of people fall 0:33:56 through the cracks, like they’re doing all the screening 0:33:58 and the matching manually. 0:34:01 And because we use our software to do a lot 0:34:03 of that heavy lifting for the recruiter, 0:34:06 the screening piece, the matching piece, 0:34:08 they’re looking at a much smaller group 0:34:10 in order to hire, right? 0:34:12 That’s how we’re able to speed up the process 0:34:15 to less than 30 days and reduce the amount of work 0:34:17 and increase the efficiency by 25 times 0:34:20 for the recruiter compared to using a job board. 0:34:23 – And what about the age of nurses in the field? 0:34:26 Like have they all been consistently responsive 0:34:27 to the technology? 0:34:29 I know sometimes that can be a little bit intimidating 0:34:32 for people who are of a different generation. 0:34:36 Like how is that translated well to across generations? 0:34:37 – Great question. 0:34:40 I think the average number of years of experience 0:34:43 of nurses on our platform is about 12, 0:34:45 but we have everything from one year of experience 0:34:46 to 30 years. 0:34:50 So we have to cater to the entire demographic. 0:34:53 What that means, I mean, that just puts the onus on us 0:34:55 to make sure our software is incredibly easy to use 0:34:57 even if you’re not tech savvy. 0:35:01 So for example, we use a great service called Twilio, right? 0:35:03 For SMS. 0:35:06 We put a lot of emphasis on our iOS and Android apps 0:35:08 because nurses are on their phones. 0:35:10 They don’t really check email. 0:35:12 Many of them don’t even have laptops, right? 0:35:16 So it’s on us to accommodate all the different demographics. 0:35:20 So now that you made the leap and the platform is up 0:35:21 and it’s working and things are happening, 0:35:23 what are some of the biggest lessons learned 0:35:26 that you can look at the before and then after? 0:35:29 What are some of the lessons that you learn? 0:35:30 – That’s so many. 0:35:31 They’re all summarized in your book actually. 0:35:33 (laughing) 0:35:34 – Trauma. 0:35:35 – Yeah. 0:35:37 First one is one I referred to earlier 0:35:40 is just about the importance of confidence and assertiveness. 0:35:44 And that alone just helps you overcome a ton of obstacles. 0:35:49 The second lesson is CEOs to manage your own psychology. 0:35:54 I completely underestimated the mental impact 0:35:58 of starting a business from scratch, 0:36:02 especially one that has a big ambition and vision. 0:36:05 And so what I’ve, you know, I have a therapist 0:36:07 and that’s cool, right? 0:36:11 And I have an executive coach and I surround myself 0:36:13 by other CEOs who are also going through 0:36:15 similar issues. 0:36:18 So really paying attention to my own psychology 0:36:20 has been a really important lesson. 0:36:21 – Very important. 0:36:23 So Stephanie, with that in mind, 0:36:24 kind of like the same question. 0:36:27 Like you talked earlier about having this moment 0:36:29 where you almost quit. 0:36:31 Like what is the biggest lesson you’ve learned 0:36:33 from just forging through? 0:36:36 – Keep going and have the patience. 0:36:37 – Patience. 0:36:37 – Yes. 0:36:40 And I’ll say another lesson I learned was change. 0:36:44 I’m not the type that I don’t like change at all. 0:36:47 So coming to California is a huge change 0:36:49 and I don’t regret doing it. 0:36:52 So I’m always open now to change. 0:36:53 – Some major life lessons in life. 0:36:57 – From Nigeria to Europe to Atlanta to California. 0:36:58 – I mean, I think this is just really, 0:37:00 of all things, it’s incredible to hear. 0:37:04 And I’m always excited just about how they get to spaces 0:37:07 of success and how they overcome obstacles. 0:37:10 So this conversation has been really insightful 0:37:12 and I’m deeply appreciative of y’all being here. 0:37:12 – Yeah. 0:37:13 – Great, thank you. 0:37:14 – That was great conversation. 0:37:17 – I hope, you know, from listening to this episode 0:37:20 that it inspires more people to go into nursing, 0:37:22 especially more men. 0:37:24 So I hope we can get rid of some of the stigma 0:37:25 around nursing that it’s just for women. 0:37:28 Like we definitely need more men in nursing. 0:37:30 – Thank you so much for joining us on this episode 0:37:31 of “Hustling Tech.” 0:37:35 And thank you to our guests, Iman and Stephanie, 0:37:37 so much knowledge of this episode. 0:37:39 If you’re a real hustler, listen to it twice. 0:37:42 (upbeat music) 0:37:45 (upbeat music) 0:37:47 (sighs) 0:37:49 you 0:37:59 [BLANK_AUDIO]
This is the next cycle (Q1 2020) of Hustlin’ Tech, a podcast series (from the a16z Podcast) about technology platforms that create opportunities for people. Recorded right before the coronavirus pandemic, these next 3 episodes touch on many things that are top of mind right now: from the profession of nursing; to taking care of the elderly; to fighting bureaucracy to get money and time back (and to get help delaying utility bills and rent payments that are eligible for an extension or waiver of late fees due to the coronavirus crisis).
Episode #4, “The Hustler’s Guide to Nursing Jobs” features:
Iman Abuzeid, MD, CEO and co-founder of Incredible Health, a hiring platform for nurses in the U.S. used by hospitals and health systems that helps hospitals find nurses faster, offers free continuing education to nurses everywhere, and puts nurses at the center.
Stephanie Anyanwu, RN, who found her nursing job on the platform and also journeyed to the U.S. from abroad;
…both interviewed by Ben Horowitz and Shaka Senghor.
You can find the first cycle of this series (Q4 2019) — including more about the what and the why — here.
0:00:06 Hi everyone, welcome to the A6NZ podcast. I’m Sonal, and today we’re releasing the next 0:00:13 cycle of Hustlin Tech, a podcast series co-hosted by bestselling authors A6NZ co-founder Ben Horowitz 0:00:20 and Chaka Senghor, a leading voice in criminal justice reform. Each episode is a hustler’s guide 0:00:26 to a new technology platform that creates opportunity for people. We previously released 0:00:31 three episodes in this series last quarter, and this quarter are releasing three new episodes that 0:00:36 follow in this feed over the next few days. These episodes were all recorded right before 0:00:42 the coronavirus pandemic. However, given what’s going on in the world, they touch on many things 0:00:47 that are top of mind right now, from their profession of nursing, including online communities for 0:00:54 nurses and free continuing education from home, to taking care of the elderly, many of whom live 0:01:01 alone or need other in-home assistance, and fighting bureaucracy to get money back or to get help delaying 0:01:07 utility bills and rent payments that are now eligible for an extension or waiver of late fees 0:01:12 due to the coronavirus crisis. You can read more about the what and the why of the entire 0:01:21 Hustlin Tech series and sign up to be notified about future episodes at a6nz.com/hustlintech. 0:01:26 The first episode that follows is the Hustler’s Guide to Nursing Jobs.
This is the next cycle of Hustlin’ Tech — a podcast series co-hosted by bestselling authors, a16z co-founder Ben Horowitz; and Shaka Senghor, a leading voice in criminal justice reform.
Each episode is a “Hustler’s Guide” to a new technology platform that creates opportunity for people. We previously released 3 episodes in this series last quarter, and this quarter are releasing 3 new episodes that follow in this feed, over the next few days.
These episodes were all recorded right before the coronavirus pandemic. However, given what’s going on in the world, they touch on many things that are top of mind right now: from the profession of nursing (including online communities and free continuing education from home); to taking care of the elderly (many of whom live alone or need other in-home assistance); and fighting bureaucracy to get money back — or to get help delaying utility bills and rent payments that are eligible for an extension or waiver of late fees due to the crisis:
#4 The Hustler’s Guide to Nursing Jobs
#5 The Hustler’s Guide to Taking Care of Old Folks
#6 The Hustler’s Guide to Suing the Man
You can read more about the what and the why of the entire Hustlin Tech series — and sign up to be notified about future episodes — here.
0:00:05 Hi, and welcome to the A16Z Podcast Goes Remote. I’m Doss, and in this podcast, 0:00:11 I call A16Z security expert Joel Delegarza to chat about what the rapid, widespread 0:00:16 move to remote work means for security. With so many people going remote the same way that we are, 0:00:22 what’s top of mind for you as a security expert? There is a concept in information security, which 0:00:28 is the belief in defense in depth. And that means that you don’t rely on any one thing to protect 0:00:33 you. You have a series of things that you use, and you stack them on top of each other, and you 0:00:38 use those series of things to offer multiple layers of protection. You don’t just put a moat 0:00:44 around the castle. You also put walls, and you have archers, and you have hot oil ready to pour on 0:00:49 people that try to storm it. And so in security, we have those same sorts of controls. The challenge 0:00:55 for security teams is that a lot of those controls for a lot of companies only live in their office 0:00:59 and only live in their corporate network. And so when users take their machines home with them, 0:01:04 or they’re remotely accessing, they don’t necessarily have the same controls in the office 0:01:09 as they do at home. And if you look at some of the large breaches over the last, let’s say, five 0:01:15 years, you’d see that there are a number of instances where remote employees using a home 0:01:20 computer that’s perhaps shared with someone in the house that doesn’t have protections on it, 0:01:24 is used to access internal corporate information by an attacker that’s hacked it. 0:01:29 Are the things that we’re dealing with new things or just things that are underway happening a lot 0:01:34 faster? We’ve had multiple scenarios in the corporate and enterprise world where we’ve had to 0:01:40 make employees work from home and work remotely. The first real encounter in at least my adult life 0:01:45 with this sort of a scenario was obviously 9/11, when we had fundamentally a city that became 0:01:50 unavailable in the workforce there being mostly unavailable or having to move to disaster recovery 0:01:57 sites. And I think 9/11 really taught a lot of large corporations about the importance of building 0:02:03 really resilient business continuity programs. The actual new thing about this is just the scale, 0:02:07 is just the entirety of a workforce for a company being forced to work remote, 0:02:13 as well as their suppliers, as well as their customers. We had the advent of things like 0:02:19 SaaS and Salesforce and Box and all these tools that were basically derived so that people could 0:02:25 access their work materials anywhere. And that it sort of became expected that some percentage, 0:02:29 usually salespeople because they’re in the field, but some percentage of your workforce would be 0:02:35 remote. And so we’ve been building infrastructure to support that workforce for some time now. 0:02:39 This is less of like, oh, it’s a new way to work and we have to change everything. This is more 0:02:45 like, we have to re-engineer everything to handle the capacity and just the sheer number. 0:02:49 How are the best security teams you know, properly preparing their organizations 0:02:52 with this really rapid shift to remote work? 0:02:58 I think the right way to think about it is to just build a matrix in your mind that sort of 0:03:03 enumerates all the different security controls you have available to you in the workplace, 0:03:08 in the office, and have some understanding of how they translate to the different scenarios 0:03:13 all of your employees will find themselves in now. And so I think there’s two things that the 0:03:17 really good security teams are fundamentally doing. The first is getting their people stood up 0:03:23 online outside of the office because security teams don’t necessarily always have great disaster 0:03:28 recovery and business continuity plans. And then second, making sure that what they’re doing is 0:03:31 actually safe and secure. If you were in an organization right now and say you were going 0:03:39 from 20% to now 90% of your workforce is remote, break down for me very specifically how you would 0:03:44 do a risk assessment. Over the last couple years, most things have left the building. And so most 0:03:50 services are provided by third parties. Most of the infrastructure that you run isn’t running 0:03:55 on your premise. And so for the last three or four years, most CISOs or Chief Information 0:04:00 Security Officer have spent a tremendous amount of time thinking about their third party risk. 0:04:05 Who are their vendors? Who are their counterparties? Who are the people that they transact with? 0:04:10 And you have to think about them not just from a security perspective because that’s 0:04:14 a little bit narrow in terms of impact of the business, but you need to be more comprehensive 0:04:21 and think of terms of like confidentiality. So is shifting all of your voice traffic to this 0:04:25 third party, does that provide you with the confidentiality you need to run your business? 0:04:30 Well, it may be okay to have a sales call with a customer where you don’t discuss anything 0:04:35 confidential over a video conferencing system. Now you’re having your board meetings over this 0:04:39 video conferencing system. Does it meet the requirements that you have? And then you have 0:04:44 to think in terms of integrity. Do the systems that you’re relying on, now that you’ve moved 0:04:50 everybody onto them, have the controls in place to ensure the integrity of the operations of your 0:04:54 business? Are they going to lose your data? Is there going to be some sort of a disruption 0:04:59 to the quality of the output? Are the systems of record truly capable of being systems of record? 0:05:04 And then finally, you have to think in terms of availability. Not just you as a company are 0:05:09 moving your entire workforce to this service provider. The entire planet is, will the service 0:05:15 provider be up and running in the face of this kind of demand? Or will they just fall over because of 0:05:20 the excess utilization? I like the way that you broke that down. So it sounded like the first 0:05:26 bucket there was really around confidentiality and what transactions were happening in person, 0:05:31 providing a measure of security now happening virtually. So let’s focus in on that for a second. 0:05:37 How would you go about assessing that? It really depends on the vertical. And it depends on the 0:05:43 industry. There’s a very, very rich tapestry of requirements and regulations that you have to 0:05:47 really understand. And it’s very specific to the business that you’re in specifically if you’re 0:05:53 regulated. And you have to make sure that the tools that you’re using can support those industry 0:05:59 specific regulations. If you are, for example, in the healthcare industry, and let’s say you’re a 0:06:06 hospital network, and hospitals right now are rushing to provide telemedicine and to remotely 0:06:12 treat potentially sick people, the issue with that is that there are these regulations called HIPAA 0:06:17 and high tech that mean that you actually have to work to maintain the confidentiality of your 0:06:22 patient’s information. So then I guess looking at the second bucket that you talked about, 0:06:26 which was really selecting these new tools and introducing these new third party vendors that 0:06:32 you maybe weren’t using before. So for instance, you and I are using a totally new tool for A16Z 0:06:36 that we rolled out as soon as we went remote so that we could keep running our podcast. 0:06:41 How are you or security professionals thinking about these third party tools and how do you go 0:06:46 about assessing them? Well, it’s always about the data. For example, we’re recording a podcast, 0:06:50 this is public information, eventually it’s going to be released. And so the sensitivity of our 0:06:55 discussion that we’re recording right now is low. It’s fundamentally public data. 0:07:00 Whereas if we were talking about a portfolio company, this might not be an appropriate tool 0:07:06 because it might not adequately protect those discussions. And so we really have to understand 0:07:11 first the sensitivity of the data and then match that data sensitivity to the security features 0:07:17 and capabilities of the tool. Generally, marketing teams are kind of free to experiment with tools 0:07:21 that are maybe not industrial grade security. But the moment that you start talking about 0:07:26 transferring customer records or transferring personal information of your customers or 0:07:31 any intellectual property, then you really need to understand the tools and a very quick adoption 0:07:35 and migration path could potentially get you into a not so great place. 0:07:39 It’s interesting you mentioned quick adoption because that is absolutely what we’re seeing 0:07:44 right now. When you suddenly have, in our case, all of A16Z going remote, we suddenly needed all 0:07:49 these new communication tools that we didn’t use before. So we are rolling them out relatively 0:07:54 quickly. How are IT and security teams keeping up with the fact that people are rapidly adapting to 0:07:59 this, things are changing daily? How do they balance that with security? 0:08:06 At A16Z, we’ve been fortunate in that we’ve probably spent the last two years really focusing 0:08:12 on eliminating any kind of custom solutions, not having servers under people’s desks, 0:08:17 not having servers at all, focusing on using cloud infrastructure and SaaS. 0:08:21 And so when this event happened and we had to pivot credit to our IT team, they did some 0:08:26 wonderful work, but we were really well positioned. There wasn’t a whole lot of stuff other than 0:08:31 adding a few new services that were disruptive. I think the way that the modern enterprise has 0:08:36 built their data stores is somewhat similar so that a lot of the data that a company has that 0:08:41 could very easily flow out of the organization are generally pretty well controlled. 0:08:45 Often we’re used to these large enterprise rollouts of new tools. They take a long time, 0:08:50 but now you have a workforce going remote and you maybe need to roll tools out faster. 0:08:56 What steps are you seeing people cut or needing to add to get the tools out and into the hands of 0:09:03 workers in order to do virtual work? Usually one of the longest pulls on any of these kinds of tool 0:09:09 deployments is the legal and contract negotiations. It’s the kind of thing where the length of your 0:09:12 proof of concept is probably half the length of the debate you’re going to have with the 0:09:17 vendor about limits of liability. Like people complain about IT, but if you really want to 0:09:23 prolong something, bring a couple lawyers. And especially when you have to have IT people, 0:09:28 technical people work with lawyers, it compounds it. So I think where I’ve seen things getting 0:09:33 quicker is just on the procurement side, on the contracting side. We’ve gone through a three-year 0:09:40 process of large enterprises telling employees, don’t use your credit card to buy a SaaS service. 0:09:46 That window seems to have opened up a little bit. And so you’re seeing people paying for things with 0:09:51 personal or corporate cards to get services deployed and unrolled. And I think IT and legal, 0:09:54 they’re going to be flexible. They’re going to keep the business moving. There’s probably going to be a 0:09:59 lot of contract review and a lot of teeth gnashing over the next couple months as they figure out 0:10:05 what they’ve allowed into the enterprise. What in your mind works and doesn’t work to be communicating 0:10:10 out to the organization at this time? And what would you be reiterating to individual workers? 0:10:15 The user tends to be the weakest link in any security system. And so there is this desire to 0:10:20 blame. And then the products that grow out of the desire to blame users tend to be of the variety 0:10:27 that look to shame users into behaving better. So building tests that try to get users to fail 0:10:32 and then highlighting their failure. And we’ve seen more tools that take that approach. They’re 0:10:37 really good at getting the level of compliance up, but only to a certain point. I think the real 0:10:43 key is going to be figuring out how to decadetize employees and users, how to make them feel part 0:10:49 of this, instead of smacking them on the hand for making mistakes. And then that’s really hard for 0:10:53 security people because we do tend to be a bit pessimistic. But building systems that reward 0:10:59 good behavior, I think will go a lot further than the desire to name and shame. From a most 0:11:04 important tips perspective, I think for me, it’s always two-factor authentication. At its most 0:11:12 simplest level, two-factor authentication is the way you log into a system using two factors or two 0:11:18 things. And from a security perspective, you want one of those things to be something you know, 0:11:22 like a password. I’ve got a password and that’s the thing I know. And then the other one of those 0:11:28 things to be something you have, like a hardware security key. And so it becomes very difficult 0:11:33 for an attacker to get access to your system because not only do they have to have your 0:11:38 password, they also have to have access to your key. And so it really frustrates what is ultimately 0:11:44 the single largest source of hacking in the world, which is stealing someone’s username and password. 0:11:49 In general, while using a phone is better than just using a username and password, from our 0:11:54 perspective, it’s not as strong as using a dedicated piece of hardware to protect your login accounts. 0:11:59 So that text message that gives you the code on your phone, probably not as good as some sort of 0:12:03 hardware key you’re plugging into your computer when it comes to two-factor. 0:12:07 Correct. And for systems that you care about, I mean, you should really use a hardware 0:12:13 security key. And if you’re at home and you’re not using strong two-factor on your corporate 0:12:18 resources or even on your personal laptop, then certainly make sure that you enable that. I also 0:12:25 think at home, if you’re not using a corporate-issued laptop or workstation and you’re using your own 0:12:30 equipment to access your workplace, double-click on the security of your own machines, you make 0:12:35 sure that they’ve got usernames and passwords, that you’re running some kind of antivirus software, 0:12:39 that you’re patching your systems. Ideally, you’re not sharing computers. 0:12:44 So you’ve mentioned business continuity planning a couple of times. Explain to me kind of what 0:12:49 that concept means to a security professional. It’s kind of the job of a security professional 0:12:53 and more broadly risk professionals in an organization to sit around thinking about what’s 0:12:58 the worst possible thing that could happen to the business. And so you come out with this 0:13:02 list of things that could potentially disrupt your business. Now, they may be hurricanes, 0:13:07 they could be earthquakes, it could be a hacker attack, it could be a breach, it could be ransomware, 0:13:12 it could be a nation state attack, it could be war, whatever the case may be. You estimate their 0:13:16 risk to the business, like if this happened, how big of an impact would it have? What’s the 0:13:20 probability of a global pandemic happening, for example, or an event that forces all of your 0:13:25 employees to work from home. And a business continuity plan is developed to help manage 0:13:32 those risks so that you can continue to run your business through any sort of adverse changes. 0:13:36 It’s not dissimilar from what a CFO or a financial planner would do where they 0:13:40 try to figure out their risks from a credit perspective, like our credit market’s going to 0:13:46 shut. Do we have market risk? Is our stock price going to fall? Which industries and orgs are having 0:13:51 a harder time with that business continuity and maintaining going remote? And why? What are the 0:13:56 unique challenges if you start to break it down by industry? I think if you break it down by industry, 0:14:01 you’d see that the businesses that are having the biggest challenges are the ones that have never 0:14:07 had a significant disruption. Whereas if you look at banks who were primarily the ones impacted by 0:14:12 9/11, they’ve been able to fairly seamlessly transition to remote work. They’ve been able 0:14:17 to take up different locations and implement their pandemic response plan. There haven’t been 0:14:23 any disruptions to the financial system. We’ve seen people doing panic ATM withdrawals and the ATM 0:14:28 and banking infrastructure doing just fine with it. And if you look at Deutsche Bank on 9/11, 0:14:32 Deutsche Bank invested a bunch of money in business continuity. They could seat their 0:14:37 employees on the other side of the river. They had backups. They were running off-site. In response 0:14:41 to that catastrophe happening, they were able to quickly resume business, settle their trades, 0:14:47 not suffer material financial impacts. I’m sure in every meeting leading up to the event, 0:14:52 there was probably someone saying, “We should cut that budget.” But lo and behold, you hold fast and 0:14:56 it turns out to be an investment that’s worthwhile. I also feel like there’s certain industries where 0:15:01 either regulation or the nature of the critical infrastructure, say a power utility, they have 0:15:06 some unique challenges. I’m curious if that’s something that you’re seeing or hearing about. 0:15:10 I think the power utilities and a lot of these critical infrastructure components, 0:15:15 they sort of have their zombie apocalypse plan. They plan for that and I generally have faith 0:15:19 that they’re doing it well. I think the one industry, the one segment that’s going to be 0:15:24 really impacted and we’re seeing that is actually pharma and healthcare. I think that there are 0:15:30 just major capacity constraints in a lot of countries that just won’t be able to handle a 0:15:36 major flood of inbound requests for care. Ultimately, the reason why we are all 0:15:41 working from home is to protect our healthcare system. Whether we’re conscious of it or not, 0:15:48 we are all engaged in a business continuity plan for the public health system right now. 0:15:53 I mean, that is what working from home is doing so that we can keep capacity available to treat 0:15:58 and care for people. I want to shift now and talk a little bit, not just about the security 0:16:05 practices, but what this means for the architectures that organizations have, because as the workforce 0:16:10 goes more distributed, it does seem like there might be a need to rearchitect the way that we do 0:16:15 things. What are your thoughts on how this might impact organizational architectures? 0:16:20 I think the cleanest example of where there needs to be a massive rearchitecture is when it comes 0:16:28 to traditional VPN or virtual private networking technology. VPNs are mostly based on IPsec, 0:16:34 which is an internet security protocol that was developed many years ago. These protocols and 0:16:38 these infrastructures were designed to be point-to-point. You would have many, many points 0:16:44 around a central hub that would aggregate all of that information and then send it to other 0:16:49 central hubs. In that architecture, if one point on the hub wants to talk to another point, 0:16:55 it has to go through a central point. When you move your entire workforce onto that kind of hub 0:17:01 and spoke point-to-point infrastructure, you get traffic jams. Security systems tend to fail closed. 0:17:09 If a VPN or a firewall starts falling over, they tend to shut down and stop all traffic. It’s 0:17:14 really clear that we have to get away from the centralized, the ring of trust model. We’ve got 0:17:19 to go more towards a web of trust. You’re seeing this with a lot of the new security technology 0:17:23 that’s coming out where they’re creating these more distributed trust environments, 0:17:27 cryptocurrencies, and blockchain are very much about that distributed trust model. 0:17:33 Is it too broad of a generalization to say that the ability for us to scale and to 0:17:39 not be real-time stress testing our systems is really directly related to how fast we can 0:17:46 re-architect to distributed trust? The point-to-point architecture scales fairly linearly, 0:17:51 and so for every increase in capacity or increase in utilization, you have to add 0:17:58 a fixed amount of capacity, and it’s just not a great way to scale from an infrastructure 0:18:03 perspective. And so we have to get to a way where we can use capacity that’s more at the edge 0:18:08 and get away from the centralized infrastructure. You talked about this process of re-architecting, 0:18:13 and I’ve also heard about this concept of shifting to zero trust. Is that the same shift or are those 0:18:19 things different? They kind of cohabitate the same space, and I’d say there’s a lot of overlap, 0:18:25 but zero trust is, it’s an idea that was kicked off, I think, by a forester researcher in the late 0:18:32 ’90s, and the idea was that you have to eliminate transitive trust. Transitive trust is basically 0:18:38 the principle that if I trust you and you trust Bob, then I trust Bob. And as you could imagine, 0:18:42 that is what attackers would use to exfiltrate data, to get access to intellectual property, 0:18:48 to do generally bad things. Transitive trust is a very dangerous thing, and I guess the layman’s 0:18:54 way to say that is, in the old world, if you went to the office and you plugged into the corporate 0:18:58 network, on your corporate network, you had access to a bunch of systems, and a lot of that data 0:19:04 didn’t have passwords or logins or encryption, because it was on the corporate network, and the 0:19:09 corporate network was considered safe. The moment that you got access to the corporate network, 0:19:15 if you were an attacker, you had access to all the data. And so zero trust is about creating 0:19:19 a distributed trust environment. We’re taking away the castle and moat, and every person’s 0:19:25 home is becoming a castle, to reuse that phrase. With the changes that you see underway, with the 0:19:31 shift away from a hub and spoke, how would you advise startups to start thinking about 0:19:35 security and their products? I think that you’re going to see a lot of companies that historically 0:19:41 wouldn’t use bleeding edge technology, actually moving towards adopting a lot of bleeding edge 0:19:47 technology just because of the disruption. And I think it’s a really wonderful opportunity for 0:19:51 entrepreneurs that are making enterprise tech right now. I think this is their time to really 0:19:57 get significant adoption from customers that in the old days would have wanted to see something on 0:20:02 prem, but now you can’t get access to your premises. So you’ve got to try something new. 0:20:07 Generally, we tell our startups, obviously, security is important, but as you get bigger and 0:20:11 larger and later in your fundraising, it becomes more and more important. And then finally, 0:20:17 when you IPO, there are specific public company security requirements that you have to meet before 0:20:22 you even get to go public. So it is a blocker at that level. I think the focus on security is 0:20:28 kind of shifting. I think it’s going to come a lot earlier now. Typically, you’d see series B 0:20:32 companies, sometimes series A companies focusing on security. I think it’s going to be like a seed 0:20:38 stage thing. So as we wrap up, what here is a passing challenge security teams have to meet 0:20:45 and what is just a longer term shift in how we think about security? What’s our new world order? 0:20:50 I think the growing pains are a passing challenge. I think a lot of the large cloud providers and 0:20:54 service providers are going to add capacity. And to be quite honest, a lot of the services I’m 0:21:00 using right now are working fine. So I’m not super concerned about the capacity. I think the 0:21:06 longer term change is just going to be more about keeping the security mentality. I think a lot of 0:21:13 this ultimately comes down to users. And in a workplace where we see each other every day, 0:21:18 you still had people falling for scams where a co-worker sends you a request for money from a 0:21:23 sketchy Gmail account and you send the money. So I think that when you put more of a social 0:21:30 isolation in there, I think the risk of targeting users going for social engineering to defraud 0:21:35 people will potentially become more successful. And so I think the real focus for these organizations 0:21:40 is finding ways to keep employees who are at home in their pajamas, still thinking like foot 0:21:44 soldiers in the battle to protect their company and their data. That’s going to be a real challenge. 0:21:49 And I think training is always proven to be one of the best returns on investment. 0:21:54 That is a terrific note to end on. Joel, thank you so much for joining. 0:21:54 Thank you. My pleasure.
We are in the midst of a rapid and unprecedented shift to remote work. What does it mean for security when the airgap between work and life is gone? How prepared are organizations? And what should security professionals as well as individual workers be doing to protect themselves and their companies?
In this podcast, a16z security expert Joel de la Garza breaks down the current risks and how to defend against them. But beyond just immediate security needs, he explains what bigger transformations may be happening, most notably a shift from the traditional hub-and-spoke, point to point, security architectures to a more distributed approach to workloads as well as trust.
0:00:05 The content here is for informational purposes only, should not be taken as legal business 0:00:10 tax or investment advice or be used to evaluate any investment or security and is not directed 0:00:14 at any investors or potential investors in any A16Z fund. 0:00:17 For more details, please see A16Z.com/disclosures. 0:00:21 Hi, and welcome to the A16Z podcast. 0:00:25 I’m Lauren Murrow, and today we’re talking about the delivery optimized grab-and-go future 0:00:26 of food. 0:00:31 The spike in online ordering and food delivery, a trend that’s particularly relevant now, 0:00:35 is evidence of how tech is fundamentally changing how and what we eat. 0:00:40 In this hallway-style conversation recorded on-site at the A16Z summit, we discuss what’s 0:00:45 driving this transformation, how tech can cut costs both to get food delivered and operate 0:00:50 a restaurant, the infusion of data into the restaurant industry, and what this all means 0:00:52 for the future of dining and cooking. 0:00:57 Joining me and general partner Andrew Chen are guests Ken Chong, CEO of Virtual Kitchen 0:01:02 Co., which is a network of delivery-only kitchens that partners with existing restaurants, 0:01:07 and Kevin Tan, CEO of SnackPass, a food ordering app currently on college campuses in which 0:01:10 customers can order ahead at restaurants and skip the line. 0:01:14 The first voice you’ll hear after mine is Ken of Virtual Kitchen Co., followed by Andrew, 0:01:16 and then Kevin of SnackPass. 0:01:21 We’ve seen a shift in the past five years or so from fine dining establishments to the 0:01:25 kind of fast casual to delivery-only and take-out-only. 0:01:27 What do you think is driving this trend? 0:01:31 Millennials in Gen Z is the generation that grew up with a smartphone, grew up with the 0:01:36 Internet, and with everything at the press of a button on the phone, whether it’s a 0:01:41 car with Uber rides or packages from Amazon, they’re growing up with this behavior and 0:01:45 this convenience and this habit, and I think we’re seeing that demand in food as well. 0:01:51 Yeah, I think if you live in a major city and you’re used to the conveniences of using 0:01:57 tech to enable everything in your life, you’ll almost end up with this baseline expectation 0:02:01 where everything ought to act this way, and over time, the question then becomes, is this 0:02:08 generation who grows up on this level of convenience and choice, once they are 21, 22, 23, they 0:02:13 move to the cities, are they going to give that up and revert back to maybe what their 0:02:17 parents did, or are they just going to expect that, “Yes, I do have a remote control for 0:02:22 food and it’s my phone,” and so for both cities and for college campuses as well, where there’s 0:02:27 so much density, there’s so much choice of different food options around you, that’s 0:02:32 the best possible setting to begin the food delivery trends enabling all of this to happen. 0:02:36 But as they say, the future is here but unevenly distributed, right? 0:02:40 So I think the next thing that will end up happening is a lot of this technology that 0:02:45 ends up working in these highly urban places can then ultimately go to places that are 0:02:50 suburban and rural the same way that a lot of technology ends up spreading. 0:02:54 Consumers love food delivery, they love the convenience of it, and at the volumes we see 0:02:58 and what we’re projecting going forward, it just requires a totally new infrastructure 0:03:03 layer to power that, so we’re building the delivery optimized kitchens of the future. 0:03:07 What Amazon did for retail, we’re hoping to do for local restaurants and on-demand food. 0:03:14 If you are a restaurant or a local food truck, you can sign on and deliver your food region-wide, 0:03:15 nationwide even. 0:03:19 Well, I think a lot of people underestimate the cost of owning an operating restaurant 0:03:24 today, and that’s whether that’s a Michelin star restaurant or a food truck, right? 0:03:28 Traditionally maybe dining restaurants are limited by how many people they can seat per 0:03:33 hour, and then there’s also spikes in which times are rush hours, so they really need to 0:03:37 maximize and squeeze every dollar out of it to cover all their fixed costs, but at least 0:03:41 for pickup and delivery, a lot of restaurants are using that as another revenue stream, 0:03:44 and you don’t have some of the limitations, you can have a kitchen in the back or in the 0:03:48 basement or a virtual kitchen, and so, yeah, it really helps restaurant owners survive 0:03:52 with all these other things that they have to worry about, like rent and labor increasing. 0:03:54 I think Kevin hit on a lot of really good points. 0:03:59 It’s no secret that owning an operating restaurant is really tough as a business, and what we 0:04:06 can do is decouple that upfront investment risk, the real estate build out lease and commitment 0:04:10 that a restaurant tour and a chef has right now before even opening the restaurant, we 0:04:15 can remove that and build it into a platform that allows restaurant tours to come in, experiment, 0:04:21 expand, and move with food trends, consumer trends really quickly with a lot less turnover 0:04:22 overhead. 0:04:27 Because of the digital nature of it, we can change the menus, the concepts in a much more 0:04:30 lightweight way, and not only that, when you look at the whole value chain of where all 0:04:36 the money is, the cost of delivering food, thus, in my mind, the biggest thing that needs 0:04:40 to be solved before this can unlock for people on a daily basis. 0:04:43 And research shows that that is the single biggest barrier that is preventing people 0:04:46 from ordering delivery as it’s cost, correct? 0:04:47 That’s right. 0:04:48 That’s right. 0:04:52 And the industry is moving to an interesting place where the costs are a little bit obfuscated. 0:04:55 You have the delivery fee, you have the service fee, you have the tip, they’re all kind of 0:04:56 separate. 0:04:57 You also have the potentially markup on the food. 0:05:03 As a consumer, how many times have we been ordering food on one of these services, and 0:05:05 everything seems like it should be okay. 0:05:09 And then you look at the bill and somehow you end up with a $60, $70 order, and you’re 0:05:10 like, how did that happen? 0:05:11 Right? 0:05:12 It’s like, yeah, it happens one screen at a time. 0:05:17 So when you add that all together, what that means is it’s very, very hard for the current 0:05:22 conception of food delivery to be something that you can do every single day. 0:05:26 So I think we need a more fundamental solve to that before this can be widely available. 0:05:31 I know both of your companies are largely based on customer analytics and data. 0:05:33 How does that translate for your restaurant partners? 0:05:34 Yeah. 0:05:35 I can use the analogy. 0:05:38 Restaurant owners right now, when you have customers go to the store and order at the 0:05:42 cash register, it’s almost like anonymous web visits, and you don’t know who those users 0:05:43 are. 0:05:47 Like if you have a website and you’re just getting anonymous traffic, whereas on a digital 0:05:51 platform, they can retarget their loyal customers, they can incentivize new customers, and they 0:05:54 can incentivize loyal customers to bring new customers in. 0:05:58 So that is definitely a big part of the play is helping them have that additional customer 0:05:59 relationship layer. 0:06:00 What are you tracking? 0:06:06 So we actually work with the restaurant brands to figure out the best locations to put these 0:06:10 virtual kitchens, what people in those zip codes want, and then we work really close 0:06:15 with them as a very tight feedback loop in terms of ordering behaviors, time of day, 0:06:17 what’s selling, what isn’t. 0:06:21 We’re bringing what e-commerce businesses have had the luxury of in the last decade 0:06:26 in terms of analytics and tracking to that business as well, so a very data driven approach. 0:06:31 Can you give any examples of an instance in which having that data fundamentally changed 0:06:32 away? 0:06:33 An owner operated? 0:06:34 Yeah. 0:06:36 For some restaurants, they’ll have a lot of slow hours. 0:06:40 And so if they want to target customers during those slow hours, right now they can put a 0:06:45 sign on their store or on the sidewalk saying we have a happy hour, but I think with a digital 0:06:48 platform, they’re able to market that even better. 0:06:51 And we’ve recently worked with a really great restaurant partner to figure out what are the 0:06:57 optimal basket size ordering behaviors for delivery and how can they optimize and change 0:07:01 the menu to really, really take advantage of what people want, how they’re ordering 0:07:05 with their friends or with their families, or maybe a dessert with their meal. 0:07:10 I think what that means is as the very, very first e-commerce experiences on the internet 0:07:16 when Amazon were among the first to actually figure out how to use web analytics to present 0:07:20 you the right products and all of that, the restaurants that are able to think through 0:07:24 that and adopt the right tools will be able to hugely, hugely succeed. 0:07:27 And the ones that don’t, I think will remain the restaurant on the corner or maybe not 0:07:28 even exist at all. 0:07:32 So the food industry is obviously a hyper competitive place. 0:07:36 What is it about your companies that makes people want to partner rather than a restaurant 0:07:39 developing their own online mobile ordering app? 0:07:42 So we do partner with a lot of restaurants that have their own apps, but I think they 0:07:45 have trouble getting people to use their apps. 0:07:49 What we bring to them is a bigger customer base that they can tap into and grow their 0:07:51 brand and get incremental revenue. 0:07:53 And you’re growing pretty quickly now. 0:07:54 We’ve been around for two years. 0:08:00 We’re at 11 campuses and we plan on being at 100 campuses in the next 20 months. 0:08:05 And take that playbook that we started at Yale, brought it to Brown, brought it to Berkeley, 0:08:10 and maybe taken a page out of Tinder or Facebook’s campus to campus model. 0:08:14 And Ken, I know there’s a lot of competition in the virtual kitchen space. 0:08:18 A lot of restaurant tours we’ve talked to have considered building their own dark kitchens 0:08:22 and have considered all the options out there, but we’re really focused on building the best 0:08:24 platform for restaurant tours. 0:08:30 And we work really closely with them to help them scale and grow their delivery presence 0:08:31 in the most turnkey way. 0:08:36 What they care about is really how do they bring their food to as many people as possible? 0:08:38 And so that’s been really our focus. 0:08:42 And we make it as easy for the restaurant tour to go from their existing three locations 0:08:46 to four than it is to go from three to Bay Area wide. 0:08:47 I was just going to add that. 0:08:53 I think the proliferation of technology for many of these small restaurants presents huge 0:08:57 opportunities and also there will be also check out and changes in the industry as a 0:08:58 result. 0:09:02 First, I think you can see that if you’re a neighborhood Italian restaurant, if you do 0:09:07 really, really well, if you’re like a beloved local brand, what ends up happening is you 0:09:09 can serve a much, much larger audience, right? 0:09:13 Obviously through food delivery, you end up being able to serve pretty much everyone 0:09:17 in the city versus the people that were maybe in walking distance before would have thought 0:09:18 to drive over to you. 0:09:22 And so on one hand, it really grows the addressable market for any restaurant. 0:09:25 There’s a regionalization to what a restaurant actually can face. 0:09:31 And then on the flip side, it also means that restaurants competition can come from everybody 0:09:32 within the city as well. 0:09:37 When you combine that with the complexities around having every restaurant needing social 0:09:42 media accounts and you got to manage all your Yelp reviews, you have to think about what 0:09:46 is the whole technology stack for how you’re going to do checkout and all this other stuff. 0:09:50 These restaurants that maybe previously didn’t actually need a ton of technology in order 0:09:55 to succeed, all of a sudden need to master this very, very different stack of tools and 0:09:57 applications to be there. 0:10:00 Let’s say your grand vision comes to fruition. 0:10:02 What do you see as the future of restaurants? 0:10:05 Is this the end of the restaurant experience as we know it in some ways? 0:10:10 But it’s also the beginning of basically having every meal become a restaurant experience. 0:10:11 How so? 0:10:15 I think with delivery and with pickup, you can basically turn food into a press of a 0:10:16 button for every meal. 0:10:20 If you’re walking on your way to class or you have a 30-minute lunch break and you don’t 0:10:24 want to wait in line or you want to get pasta for dinner, but you don’t want to sit down 0:10:27 in the restaurant and take an hour to do that. 0:10:30 And I think that’s just going to become a bigger part of people’s eating habits. 0:10:35 I think that in the not too distant future, people will be eating the majority of their 0:10:40 meals either through delivery or pickup, the level of convenience and the ability to give 0:10:45 people back their time and really open up the accessibility to different types of foods, 0:10:48 healthy dietary options is really powerful. 0:10:49 And I think that trend is going to continue. 0:10:50 Yeah. 0:10:55 And I think the other angle we’re approaching is anytime someone’s buying something by themselves, 0:10:58 like single player, we’re going to make that multiplayer. 0:11:01 So right now when you buy something, it’s largely a solo experience. 0:11:05 But on snack pass, every time you buy something, you get to share something with a friend, 0:11:09 whether it’s a discount or a future credit that makes sense for everybody involved. 0:11:14 You, your friend and also the merchant in organic referral. 0:11:18 And because it’s categorically rational, but also extremely fun and has an emotion attached 0:11:22 to it, I think that’s just going to become a really powerful e-commerce trend. 0:11:26 You bring up an interesting point, which is the role of social and all of this. 0:11:30 Can you talk about the growing role of social and where you see that in the food space? 0:11:34 I do think there’s a misconception when we talk about this delivery only model that people 0:11:37 are kind of holing up in their apartments or homes. 0:11:41 And in fact, you’re both telling me it’s about expanding access and making it more social 0:11:43 to eat out or to eat at home. 0:11:44 Yeah, absolutely. 0:11:48 Someone posted a meme on the Yale memes page that was, we don’t say I love you. 0:11:51 We send each other gifts on snack pass. 0:11:55 And the social mechanics we’ve created on the app, give people a way to connect that 0:11:58 isn’t like a text or snap. 0:11:59 Actually food is super social. 0:12:03 And so we found a way to weave that together, social and commerce. 0:12:04 So people are flirting through food. 0:12:05 Yeah. 0:12:11 And your boyfriend or girlfriend, a smoothie, if they’re sick, you can even see who’s sending 0:12:12 gifts to each other. 0:12:16 You can see who’s hooking up with other people by who their gifts are being sent to. 0:12:20 So yeah, it’s like this other social network that you wouldn’t really expect. 0:12:24 And it’s definitely not going to replace a visual feed like Instagram or Facebook, but 0:12:27 it’s augmentation of your social life at college. 0:12:29 It’s kind of like a Venmo of food. 0:12:30 Yeah. 0:12:31 I guess you can say that. 0:12:34 What’s the role of social when it comes to virtual kitchens? 0:12:39 I think hitting at the parallels with retail and how that has gone in the last decade from 0:12:41 brick and mortar to more digital. 0:12:47 You see the opportunity for brands to really experiment and build their presence in a digital 0:12:48 first manner. 0:12:53 We’ve seen a lot of direct to consumer products rise in popularity over Instagram and social 0:12:58 media and really reach and connect with their customers in a very direct way. 0:13:01 You can see the same with restaurant brands and food. 0:13:04 Food trucks have been doing this because they don’t have that permanent brick and mortar 0:13:08 presence, but with virtual kitchens, you’ll see that go even a step further. 0:13:11 So if you don’t have a physical kitchen, are these brands spending more on marketing 0:13:12 than? 0:13:13 Potentially. 0:13:17 It depends on how you view Instagram and Facebook and Twitter. 0:13:23 It’s I think really just a new channel for the brand to create its presence and to reach 0:13:25 their customers in a more direct way. 0:13:30 So when we talk about the future of food, it’s impossible not to talk about robotics, everything 0:13:34 from robot chefs to robot delivery. 0:13:38 What role do you think robots will play in the next five years or so? 0:13:42 We’ve seen some interesting things on the kitchen automation side in terms of robotics, 0:13:47 but I think that is a little bit nascent sidewalk robots and autonomous vehicles, obviously 0:13:48 coming later. 0:13:53 I think we’ll really reduce the cost of fulfillment, the actual delivery piece, which then makes 0:13:55 it even more accessible to more people. 0:14:00 The funny thing about robotics that I’ve seen and let’s use autonomous vehicles as a good 0:14:04 linchpin, I know there was so much excitement about the field just a couple of years ago. 0:14:08 You’d ask people that were just reading the news and you’d say, hey, how long before we 0:14:11 have self-driving cars on the road? 0:14:14 And if you talk to some people, they would tell you five years. 0:14:15 Some people would say six years. 0:14:20 And what I noticed at least was when I started to talk to people that were closer and closer 0:14:24 to the problem, working on self-driving, the number of years that it would take before 0:14:28 it was widely available would increase to the point where the people directly working 0:14:31 on it would be like, I don’t know, it might be a long time. 0:14:36 And so going back to the question on how automation and kitchens will come together, I think first, 0:14:41 as Ken mentioned, there’s a lot around what’s going to happen with delivery. 0:14:45 There’s a number of really interesting companies out there like Starship and Kiwi that are 0:14:50 thinking about that and are thinking about it in a way that hybridizes human teleoperations 0:14:54 in addition to having completely software-based navigation. 0:14:58 And then the other big question that I think is super interesting is in the kitchens themselves, 0:15:03 do you get to a point where you have robots making the burgers and making the pizza and 0:15:04 all that stuff? 0:15:07 Or is this something that humans have to be involved? 0:15:11 And what I’ve seen on the research and the companies that we’ve encountered is that, 0:15:16 yes, that will eventually happen, but each food type is actually very different than 0:15:17 the next one. 0:15:22 Like it is an entire company to just solve automation plus smoothies. 0:15:26 And it’s another whole startup that needs a lot of money to go figure out burgers and 0:15:30 a whole other company that needs to be successful to figure out noodles. 0:15:35 When you look at that in comparison to still being able to have human labor, I think there’s 0:15:40 still quite a gap before we’re going to be able to fully realize that robotics vision. 0:15:43 Andrew, you look at food, gaming, social. 0:15:47 When you look at the food landscape, do you have some vision for the future of food? 0:15:53 So much ink has been spilled about the driverless car, but I think more realistic even is the 0:15:55 idea of the kitchenless home. 0:15:59 And it’s really the notion that if this becomes so convenient and you can have amazing food 0:16:05 that exactly fits your dietary needs for your whole family and it’s at the right price and 0:16:10 it’s in the right packaging, the everyday need for people to actually have a kitchen 0:16:13 in order to do this chore might go away. 0:16:17 And so if you think about that as a general idea and then you say, okay, what actually 0:16:23 needs to happen in the entire flow of the customer experience in order to enable that, 0:16:27 what you end up seeing is a lot of room for really interesting, great companies. 0:16:31 Is this the end of cooking in that everyone is getting everything delivered all the time? 0:16:37 I think what’s going to happen with this combination of delivery and dark kitchens is that one day 0:16:41 somebody who’s gluten free is going to open up the app and they’re going to have dozens 0:16:45 upon dozens of amazing, high quality food available to them. 0:16:50 I’m sure that once all of these platforms like Virtual Kitchen and SnackPass have fully 0:16:57 proliferated, the kinds of chains that we’ll see will not just be burgers and pizza. 0:17:01 Very recently, in fact, over 60% of food delivery was just pizza, just because that was the 0:17:04 thing that would keep you could deliver. 0:17:05 Dominoes. 0:17:08 Dominoes as a stock has performed just as well as the top tech companies. 0:17:13 And so when you start to unlock everything, I think that it will be a golden age for food 0:17:14 entrepreneurs. 0:17:19 The other angle is for those that have dietary restrictions, it can be a huge thing as well 0:17:25 because if you’re gluten free, if you’re keto, if you can’t eat nuts or whatever, it’s not 0:17:28 like you have dozens of choices. 0:17:32 There’s a lot of really, really interesting things that will happen through these platform 0:17:33 shifts. 0:17:37 So is this the end of the traditional restaurant experience as we know it? 0:17:41 The big thing for me is really thinking about the bifurcation of how people are going to 0:17:42 think about food. 0:17:46 There’s the everyday sort of utilitarian view of food. 0:17:51 This is the quick bite that you want for lunch or for dinner on a day where you maybe have 0:17:52 a lot of work to do. 0:17:57 And then there’s also the kind of experiential evenings that you might want out with your 0:18:01 significant other, which is where the presentation of the food matters, the story behind the food 0:18:02 matters. 0:18:08 And so first, how do you up level food overall in all its different capacities and bring 0:18:13 the sort of super high quality ingredients designed by a chef who really cares about 0:18:19 the food to consumers in all forms, and even delivery, even fast casual pickup type experience. 0:18:21 I think that bifurcation is going to be really real. 0:18:25 We’ve seen it in the retail space with showrooms versus ordering online. 0:18:29 And I think it’ll actually be a great world for both sides. 0:18:34 We’ll see great restaurant experiences for Dine-In, and then we’ll have great convenience, 0:18:36 great selection, and great price points for delivery. 0:18:37 Great. 0:18:39 Well, thank you so much for joining us on the 16T Podcast.
The spike in online ordering and food delivery—a trend that’s particularly relevant now—is evidence of how tech is fundamentally changing how and what we eat. Is this the end of the traditional restaurant experience as we know it?
In this conversation between Virtual Kitchen Co. CEO Ken Chong, Snackpass CEO Kevin Tan, a16z general parter Andrew Chen, and host Lauren Murrow, we discuss what’s driving this transformation, the infusion of data into the restaurant industry, how take-out and delivery is becoming surprisingly social, and the specter of the “kitchenless home.”
Virtual Kitchen Co. is a network of delivery-only kitchens that partners with restaurants to expand their reach without opening additional brick-and-mortar locations. Snackpass is a food-ordering app currently on college campuses in which customers can order ahead at restaurants and skip the line. In this discussion, both CEOs explain what their business models could mean for the future of dining and cooking.
This episode was recorded on-site at the a16z Summit in November 2019.
0:00:04 The content here is for informational purposes only, should not be taken as legal business 0:00:10 tax or investment advice or be used to evaluate any investment or security and is not directed at 0:00:17 any investors or potential investors in any A16Z fund. For more details, please see a16z.com/disclosures. 0:00:22 Hi, and welcome to the A16Z podcast. I’m Lauren Murrow, and today we’re talking about the rise 0:00:27 of remote work and virtual networking, especially among knowledge workers amid the spread of the 0:00:32 coronavirus. For this quick pulse check, I’m joined, all remotely, of course, by General 0:00:36 Partners Connie Chan and David Yulovitch to talk about the platform’s powering this homebound 0:00:42 workforce, creative new use cases for videoconferencing and streaming from education to therapy, 0:00:47 and whether remote work and online events is the new normal. The conversation begins with Connie, 0:00:52 describing how, for many of these videoconferencing tools, the line between professional and social 0:00:58 use is already blurring. People are trying to use existing and new tools for a variety of things. 0:01:03 I mean, even teenagers who want to interact are using Zoom to hang out with each other. 0:01:08 So I think the use case is very wildly. If you are having a one-on-one conversation and both 0:01:14 people are using Apple products, FaceTime is fantastic. If you are doing a small group setting 0:01:20 where it’s the same repeat users, Zoom might be more relevant. If you are hosting a large event 0:01:24 where a lot of the audience members are trying to look for networking opportunities, 0:01:28 we’re on the world has a solution for that. One platform you mentioned, Zoom, 0:01:33 has really risen through the ranks. It’s the third most popular app in the app store at the 0:01:39 moment. Why do you think Zoom has been so emergent? I think one of the reasons Zoom has sort of broken 0:01:45 out is that they have observed all the friction that all videoconferencing platforms have had in 0:01:49 the past, where it’s hard to get an account. It’s hard to set up. It’s hard to invite people to 0:01:54 people who have less patience these days for products that have too much friction to onboarding. 0:01:58 You know, there’s always sort of the joke of conference calls of like, “Hey, who just joined 0:02:03 the line?” or like, “Who are you?” or “Hey, did you get the right link?” Zoom has fixed almost all of 0:02:08 those usability issues. And I’d say there’s also little moments of user delight, right? I think 0:02:13 virtual backgrounds have been one of the ways that people are breaking the ice or making 0:02:18 conversations more friendly when they’re on Zoom. For those listening, it’s a way that you can 0:02:24 completely obfuscate your background and make it look as if you’re in a green room and put any photo 0:02:29 in the back. And I think people underestimate the amount of technology that’s behind the scenes. 0:02:34 They’re running a global network. They’re carrying hundreds of thousands of minutes of calls at any 0:02:38 given time. They’ve built an infrastructure that’s scaling to a dramatic degree. And that’s really 0:02:44 hard to do. And they’ve spent a lot of time over the last few years as they’ve grown up as a company 0:02:49 to build a reliable, high quality, high fidelity system. That’s why they’ve broken out. 0:02:54 To your point, David, this is new ground as millions of people are flooding these online 0:03:00 platforms. We’ve already seen some outages with tools like Microsoft Team last week. Several 0:03:05 gaming platforms have had outages over the past week or so, including Nintendo Switch and Xbox 0:03:10 and Discord. So there is some trepidation among people that all of us working and learning from 0:03:15 home is straining that underlying infrastructure of the internet. And that’s something that could 0:03:20 particularly impact home networks. What are the limitations of some of these collaboration tools? 0:03:25 Well, first, we all owe a debt of gratitude to the network operators that are running the global 0:03:29 infrastructure. They’re adding capacity that are making sure that the quote unquote the pipes are 0:03:33 not getting too full. That is not an easy job. And these are the people that are working and 0:03:37 they’re probably working from home right now. But they’re working tirelessly. And as somebody 0:03:41 who comes from an infrastructure operations background, I always think it’s good to give a 0:03:44 shout out to those people that are generally thankless until there’s a problem. Right. I think a lot 0:03:49 of people don’t recognize their actual people who are keeping their net running. Totally. And adding 0:03:55 capacity and rerouting things and reprioritizing traffic. We’re all the beneficiaries of that 0:03:59 for all of us who network from home. Broadly, what you end up seeing though is companies that 0:04:04 invest in infrastructure, the ones that know how to scale and have planned for sort of elastic 0:04:08 capacity. And when you’re seeing these platforms, like how teams had an outage and things like that, 0:04:13 these are platforms that have been sort of cut and paste put together over the years from different 0:04:18 products from legacy products. And when you’re building on top of legacy infrastructure or legacy 0:04:23 technology stack, legacy video codex, it’s very hard to then be able to scale up and deliver the 0:04:28 kind of experience people are expecting. So you are seeing new technologies like run the world 0:04:33 and a company called tandem as well. That’s a way to do real time water cooler like conversations 0:04:36 when you’re not doing a scheduled meeting. And companies like zoom that are really taking 0:04:43 advantage of this opportunity. So it’s one thing to have these tools that help us work in small 0:04:50 teams. It’s another thing when these events get at a much larger scale. Many, many conferences, 0:04:55 festivals, sporting events have been canceled in response to the pandemic. What are some of the 0:05:00 promising alternatives you’re seeing to physical events? I think virtual conferences is this brave 0:05:05 new world that we’re all going to start exploring and realize that there’s actually a lot of benefits. 0:05:10 In addition to being able to access it from anywhere from your phone or your laptop and not 0:05:17 needing to pay for travel for hotels for airfare and so forth, there’s also just a lot more engagement 0:05:23 that can happen in an online context that quite frankly is easier in many ways than the offline 0:05:28 in real life version. So think about when you go to a conference and that awkward moment during 0:05:34 cocktail hour and you’re not sure who to approach, you’re not sure how to break into that conversation 0:05:39 or even who you should be meeting with, right? Well, in an online context, now people can be 0:05:44 chatting with other folks but have full context of who they are, why they’re there, who they’re 0:05:50 looking to meet and so forth and platforms can do better matching. So you are making sure every 0:05:55 minute is a good use of time. Look, you always look for silver linings in moment of crisis or 0:06:01 dramatic change and as an introvert, I think this is our golden moment. There’s a lot of people 0:06:05 that don’t get an opportunity to speak up, that don’t have an opportunity to participate 0:06:09 or that the conversation gets steered into a certain direction just because there’s a lot of 0:06:13 voices in a room. There’s somebody who is both often on panels and somebody who’s listening 0:06:19 to people that are on panels. I think panels are like the lowest fidelity form of communication. 0:06:23 I love the idea that in an online conference, you can maybe suggest questions, do a lot more 0:06:28 Q&A, you can help prepare the panel much better and people can better socialize and surface 0:06:31 questions. You don’t just have a moderator trying to decide what’s interesting. There’s 0:06:36 so many opportunities in an online format through all those different communication mediums 0:06:41 to just cultivate and curate a much better experience. The way that you connect with someone 0:06:47 can be through video, it can be through audio, it can be through text and by allowing the various 0:06:52 options, you also attract different types of personalities that otherwise would have been 0:06:56 too intimidated to go to a conference. What’s interesting is when you see a lot of these 0:07:01 conferences switch into an online format, not only do more people join because quite frankly, 0:07:07 the bar to attend is much lower, but more people participate because they’re not so afraid to 0:07:13 chat in an online chat room. The courage required to do that is a lot lower than it is to go speak 0:07:18 to someone in real life. I’m not to mention that it can be recorded and chronicled so that somebody 0:07:22 who maybe can’t make it in real time can go catch up later. There’s an auto chronicling 0:07:27 and auto documenting and archiving capability that is inherent that most conferences just 0:07:31 opt out of because of the cost or complexity. I think that’s really powerful because it means 0:07:36 that especially when you pair it with where we are with automatic transcription, a voice, 0:07:40 it allows people to really consume the information in whatever format works best for them. It makes 0:07:44 it much more accessible to people, whatever prevents them from engaging, not just as an 0:07:49 introvert, but as somebody who also likes to participate sometimes a little bit more voyeuristically 0:07:54 than sort of dive into a full two-day conference session. It’s perfect for people like me and I 0:07:59 think there’s a lot of people out there that feel the same way. So as the coronavirus has spread, 0:08:05 we’ve seen people get creative with ways to keep connected. What other apps are you seeing on the 0:08:10 rise? Are you seeing any particularly creative use cases? Education, I think, is a very big one. 0:08:15 Parents not only need to figure out how to entertain and how to occupy the children, 0:08:19 but they want to make sure that it’s still a good use of time and educational, right? 0:08:25 The V1, of course, is you watch a streaming video of your teacher and you’re basically 0:08:32 watching this person on a screen versus seeing them in real life. But I think the V2 of education 0:08:37 is going to incorporate a lot more different types of media such that the actual course content 0:08:43 could possibly be even better or more engaging. So imagine, for example, an online coding class 0:08:48 that is teaching children how to program, but it’s not just showing you the teacher’s face and 0:08:53 having the teacher talk you through your workbook or through your program, but actually recreating 0:08:59 something that’s half video game, half problem set, and having a teacher talk you through it. 0:09:04 So as you go into these different types of verticals of curriculum, I think the V2 of online 0:09:11 education is going to go beyond just video streaming and be really a mixture of video streaming 0:09:19 plus animation, AR, or really just interactive ways to learn. So I think there will be a lot of 0:09:24 new experiments that happen in distance learning. There are startups out there like OutSchool that 0:09:30 allow all kinds of parents to find teachers who are teaching a variety of courses. And I think 0:09:35 existing teacher-student relationships are going to use things like Zoom or other new platforms 0:09:42 that focus on online education. Now that my own child is at home, I’m seeing that firsthand. 0:09:48 I see my own daughter taking art classes through Zoom, having her piano class through FaceTime. 0:09:53 I know that there’s an artist in San Francisco, Wendy McNaughton, and she’s now been doing these 0:09:58 free drawing classes for kids using Instagram Live. And I think yesterday she did a class and 0:10:03 there were almost a thousand kids that were in this class doing drawing. It’s great for the 0:10:08 parents who need to be working. It lets their kid pay attention to somebody who’s giving instruction 0:10:11 and lets the parent maybe do some work while they’re at home with the kids. 0:10:16 This online format still is very, very effective. Teachers are still able to see what the kids are 0:10:22 doing, give real-time feedback. Another use case I’ve noticed is online tools that facilitate 0:10:27 virtual therapy sessions as well. Right. Yeah, I think there’s a lot of really interesting 0:10:31 use cases. You know, I wouldn’t say I’m a yoga practitioner, but I have many friends who are, 0:10:36 and I probably should be. But one of the things that they lament is that classes spill up. 0:10:40 But now these classes have moved to Zoom and you can do it from home on your yoga mat. 0:10:45 Now the classes never fill up by definition. And so that’s really a transformative shift. 0:10:51 One other interesting trend I’ve seen is third-party video conferencing add-ons. 0:10:57 So apps like Crisp, Crisp with a K, which cancels out background noise like typing or wrappers. 0:11:02 There’s Muzzle, which silences pop-up notifications during screen sharing. 0:11:07 I think I could use both of them. One thing that’s sort of amusing is, you know, I used to work at 0:11:12 Cisco, which has a large collaboration business in Edge WebEx. And so maybe I’m more used to the 0:11:16 always-on video conference call, the constant videoing. But I think for a lot of people, 0:11:20 it’s a new experience and they’re learning all kinds of things. You need to be cognizant of when 0:11:24 your camera’s on. Even if you think your camera’s off, it’s probably on. You need to be much more 0:11:28 aware of whether you’re on mute, whether you’re connected. And there’s a certain sort of video 0:11:33 conferencing hygiene that comes along with that. I’m a big believer in believing the video camera 0:11:37 on. I think it keeps you more engaged and paying attention. Isn’t that one of the features of 0:11:43 Tandem in that it shows which apps you’re on as you’re collaborating with coworkers? Totally. 0:11:47 And they do this in a very privacy-aware way. You can disable it. They show you what application 0:11:52 you’re using and what your coworkers are using. And so what’s cool is I can see, oh, hey, if Connie’s 0:11:57 in a Google Doc, if I have permission to that Google Doc, I can actually see which file it is. 0:12:01 And let’s say I want to collaborate with her. I can just click on it and immediately jump into 0:12:04 that Google Doc. And because Google Doc’s multiplayer by default, we don’t have to 0:12:08 screen share. We don’t have to even have our video on. We’re just collaborating and talking. 0:12:12 It’s sort of like having somebody at the desk next to you and be looking at the same file. 0:12:17 Then if you’re busy, you can jump into a focus mode either permanently or for a period of time. And 0:12:22 so they’re really focused on the usability to create this virtual office environment that’s both 0:12:26 not distracting, but also creates a level of closeness and intimacy with your 0:12:31 coworkers so you can still feel that connection and say, hey, how’s your day going? Or what are you 0:12:36 up to? Or what are you eating for lunch? Right. We’re experimenting using these platforms to even 0:12:41 just hang out with each other, right? Like to David’s point, making sure people don’t feel lonely 0:12:46 during this time of self-quarantine is really important. And so there are teams in our firm, 0:12:50 my own team included, where once or twice a week, we will have an hour set aside where we’re all 0:12:55 online, we’re not allowed to talk about work, and we’re eating lunch together. And that’s funny, 0:13:01 because years ago, I talked about how in China, live streaming for eating was a thing. And everyone 0:13:07 used to make fun of me for that. But we are now doing it here, right? We’re using video platforms 0:13:11 to eat lunch with each other, to hang out with each other. Well, in my team, we’ve been eating 0:13:16 lunch together virtually more than we were when we were actually physically in the office. 0:13:24 It’s actually upping our sociability. So in addition to these online collaboration, 0:13:29 video conferencing tools, some other categories of companies that are seeing somewhat of a bump as 0:13:35 we become increasingly homebound, some of them are obvious, like streaming services, delivery 0:13:40 services, like Instacart. But are there other examples of categories of companies that you’re 0:13:48 seeing more use cases of? Gaming and entertainment is a very big one. Roblox, I can only imagine 0:13:53 how many kids are now wanting to play all the time, because Roblox is not just a one-way game 0:13:56 where you’re playing against a computer, you’re playing with other kids, you’re playing with 0:14:02 your friends. And so for a lot of children, this is their way of maintaining those relationships. 0:14:05 And David, you can speak to that, right? You just installed a Xbox? 0:14:10 I did. I never thought of myself as a gamer. I realized I’m going to be home alone. 0:14:14 I’m up in the mountains. So I bought an Xbox one. I played it a little bit. 0:14:18 I think I still am more of a programmer than a gamer, but I certainly have become a gamer 0:14:24 as a result of this. And whether that endures, I would say work from home, time will tell. 0:14:26 David, have you noticed larger macro trends? 0:14:31 Yeah, there are certainly companies that facilitate more collaboration in terms of 0:14:37 coordination. So whether it’s task management, whether it’s OKR, there’s a whole set of tools 0:14:40 that I think are going to see a lot more usage in the workplace. 0:14:45 It’s things like Asana, where people are using more shared task managers across teams, 0:14:49 instead of just doing their daily huddle, they’re moving some of these team huddles online. 0:14:54 And a company called Workboard aligns goals across teams in a very transparent way. 0:14:57 And they are seeing a lot more interest in people saying, hey, how do I communicate? 0:15:01 What’s important to people? And let them know how we’re doing against our goals. 0:15:05 And so I think there will be a whole trend of applications that create more organizational 0:15:10 transparency so that people understand what they’re working on, why they’re working on it, 0:15:14 and how they’re doing against their goals. And one of the other use cases now that’s really 0:15:19 interesting is telehealth and telemedicine, which is a video conference call with either a nurse 0:15:23 practitioner, a nurse or a doctor. It’s much more efficient. It’s much safer for all the 0:15:28 practitioners and the emergency medical professionals. And I think as a consequence of 0:15:32 all this, the telehealth would become a norm instead of just something that was maybe a little 0:15:36 overpromised and underdelivered. Now I think it’ll become totally mainstream. 0:15:40 Yeah. And I think the common themes you’re seeing here are that when you switch things to this online 0:15:46 digital communication format, not only are they cheaper, they save more time, but they also can, 0:15:51 in many cases, up the quality of care or teaching that you would otherwise receive. 0:15:56 All right. So in the teaching context, when you have one teacher teaching thousands, 0:16:01 you can afford to get one of the most amazing teachers there to create that course. 0:16:07 And same thing, when it’s in medicine, if there are not enough doctors in that particular city, 0:16:13 you now can access doctors from all over the world and unlocking a big supply of service 0:16:18 providers, whether it’s teachers, doctors, therapists and so forth. What it does is it not 0:16:23 only ups the quality of what you can typically access, but it does that simultaneously with 0:16:28 lowering the costs. I want to talk about the longer term impact of this. This is likely not 0:16:34 short-lived. Even before the coronavirus began to spread, our workforce was already becoming 0:16:39 more distributed. So as more and more people are likely to go remote in the coming months 0:16:46 for work, for school, how do you see this pandemic shaping the workforce in the future? 0:16:48 Do you think that remote work will become the new normal? 0:16:54 One thing I would say is certain is that the myth that there are so many jobs that quote-unquote are 0:16:58 not possibly done remote clearly is shattered because people that are doing jobs that when 0:17:02 they were hired into it, they were told that it was not possible to successfully do the job 0:17:07 remote and proven that that’s not true. There’s just a tremendous number of jobs that people can 0:17:14 do remote. It’s an unfortunate but an interesting test case in that, as you noted, most people 0:17:20 probably aren’t that comfortable video conferencing into work. But with this scenario, many are being 0:17:27 forced to, once people realize that these tools are available and that they’re someone intuitive 0:17:31 and easy to use, I wonder if this is the beginning of a more permanent shift. 0:17:34 I think a lot of people like going to an office. They like the separation of 0:17:38 home life and work life. And so there’s a lot of people that will be very happy to go back to the 0:17:42 office. But there’s certainly going to be an enduring trend. I would have to imagine where 0:17:46 people want to live, where they want to live, and then work at the companies they want to work at, 0:17:50 even if those two things are not co-located. And certainly this is showing that that’s very 0:17:53 possible for the vast majority of professional use cases. 0:18:00 Right. It’s still too early to call whether or not consumers prefer working at home or in a physical 0:18:04 office right next to their colleagues. I think distributed teams, especially teams that have 0:18:09 global workforces, are going to realize maybe they don’t have to do all of their hiring in a 0:18:14 very small radius around their office. You know, all three of us are in three separate cities and 0:18:20 three separate rooms all recording this podcast digitally using digital podcasting software 0:18:24 that’s delivered as a service. And so, you know, I think people will find that there’s a tool for 0:18:30 almost every use case that they have. And, you know, I think if I had asked you six months ago, 0:18:34 “Hey, we can start recording podcasts all remote and distributed,” you all would have said, “No, 0:18:38 that’s not going to be good. It’s not going to work out okay.” But of course it’s working out fine. 0:18:44 The other thing I would mention is we don’t know how long this particular phase is going to last. 0:18:48 And as a lot of entrepreneurs are seeing these opportunities, they’re seeing also these gaps 0:18:52 in existing products, I think there’s going to just be more innovation in this space. 0:18:57 Just think about the possibilities when you add things like AR. You know, you can have a fashion 0:19:02 show where things are coming to life or you can look at an item and save it for later, right? 0:19:08 There’s all kinds of things that you can do once you overlay a digital screen in front of a real 0:19:12 life event. So inevitably, I think that means you’re going to get better products serving this 0:19:16 particular use case, too. You know, if you think about video streaming as a new browser, 0:19:20 what are all the extensions you’re going to need? What are all the different destination websites 0:19:24 that are going to have to be built? And I think it’s an open question for some of these verticals, 0:19:29 whether or not it’s a horizontal platform that wins or whether it’s a vertical platform that wins. 0:19:32 Great. Well, thank you so much for joining us on the A16Z podcast. 0:19:33 Thank you.
We discuss the rise of remote work amid the novel coronavirus pandemic, and the platforms powering our newly homebound workforce (and student body) including creative use cases for video conferencing and streaming.
0:00:03 – Hi, and welcome to the A16Z podcast. 0:00:05 I’m Hannah, and this is another in our series 0:00:06 of all remote podcasts. 0:00:08 We’re at a moment where we’re now seeing medicine 0:00:10 go virtual faster and at a scale 0:00:12 that it has never done before. 0:00:15 So in this conversation with A16Z Bio General Partners, 0:00:17 Vijay Pande and Julie Yu, 0:00:20 who come from the worlds of biotech and care delivery, 0:00:22 we talk about what exactly virtual care 0:00:24 and telemedicine is and what it isn’t, 0:00:27 what it works well for, what doesn’t yet, 0:00:28 and where there’s potential. 0:00:30 And finally, the current pain points, 0:00:33 including regulation and what we’ll learn 0:00:36 from this current moment for the next generation of tools. 0:00:37 Stay tuned for another episode soon 0:00:39 where we’ll also cover the clinical perspective 0:00:42 from the field next. 0:00:43 – I’m gonna tell you guys right now 0:00:46 that there may be some dog barks and kid stuff 0:00:47 in the background. 0:00:49 Okay, so we’re all getting these messages 0:00:53 from all our providers telling us to use virtual chat, 0:00:56 to use all these different telemedicine tools. 0:00:58 So we’re in a moment where medicine 0:01:01 is really going virtual at scale. 0:01:02 Can we start by just talking about 0:01:06 what virtual medicine or telemedicine actually means? 0:01:07 What those different categories are? 0:01:08 Is it all the same thing? 0:01:11 Like, what are we actually talking about here? 0:01:12 – Typically what people think about 0:01:14 when we say virtual care 0:01:17 is probably the traditional sort of video visit 0:01:18 where you have two screens, 0:01:21 the patient and the provider are talking to each other live. 0:01:22 Virtual care I think is much more 0:01:25 of like a broader paradigm around, 0:01:27 how do you sort of overcome 0:01:30 the constraints of the traditional healthcare system 0:01:32 which are largely I would say two things. 0:01:36 One is geography, which is that typically you as a patient, 0:01:38 the demand side of the market only really has access 0:01:41 to the supply side that is within a reasonable radius 0:01:42 of where they physically are. 0:01:44 And then also the physical brick and mortar 0:01:46 component of healthcare. 0:01:49 – So basically a way to get around the fact that you, 0:01:51 at the moment you have a certain doctor 0:01:53 within your geographic range 0:01:55 and a certain provider and a story. 0:01:55 – Yeah. 0:01:57 And it’s more than just video visits as well. 0:01:59 It could be asynchronous messaging. 0:02:01 It could be continuous monitoring. 0:02:03 It could be, you know, sensing. 0:02:05 – Frankly, it could even be a telephone call. 0:02:08 I mean, we can go low tech in addition to higher tech. 0:02:09 And as an alternative, 0:02:11 just everybody goes to the emergency room 0:02:12 ’cause they don’t know what they’re doing. 0:02:14 Just even the triaging of the telephone call 0:02:15 goes a long way. 0:02:18 – In terms of on the biological side, 0:02:21 what works for telemedicine and what doesn’t? 0:02:25 – I can say like, oh, I have a fever and my ear really hurts. 0:02:26 I’m highly suspicious of an earache. 0:02:29 And like probably you could make that diagnosis 0:02:30 based on a lot of stuff 0:02:31 without actually looking in my eardrum, 0:02:34 but like listening to lungs or listening to heart. 0:02:37 Like how, what are the limitations of what works 0:02:39 and what doesn’t for this particular medium? 0:02:41 – For a general practitioner, 0:02:45 you could probably do a vast majority of what is done there. 0:02:46 I mean, certainly not everything. 0:02:48 Let’s say just even in the routing function 0:02:50 where we’re trying to just understand 0:02:52 what are the more serious cases and what has to be done? 0:02:55 You could probably do a lot of triaging 0:02:57 and that might be the most important thing. 0:02:59 And the key thing is especially in a situation 0:03:00 like we have today, 0:03:03 you have routing with the benefit 0:03:06 of not having to bring someone in physically. 0:03:09 And it’s natural thing about what you can’t do, 0:03:11 but just the unique things of what you can do, 0:03:13 reaching people immediately 0:03:16 and also keeping them sort of quarantined 0:03:17 is particularly intriguing. 0:03:20 In many ways, like an ER or a hospital 0:03:23 as well as most dangerous places to be just in general. 0:03:26 – So you’re saying essentially it’s not really about diagnosis, 0:03:28 it’s about triage? 0:03:31 – I think diagnosis goes hand in hand with triage, 0:03:33 but that might be one of the biggest wins 0:03:35 just to know what to escalate and how to handle it. 0:03:38 In some ways that’s what a GP’s job is, you know, 0:03:40 to say, oh, this is something that can be dealt with home care 0:03:42 or this is something that can be escalated, 0:03:43 that needs to be escalated. 0:03:48 The telephone call, the call your kind of pediatric nurse stuff, 0:03:51 right, like there’s been some level of that already. 0:03:54 We’re starting to lean on that a lot more 0:03:55 in this particular moment. 0:03:58 The video chat is definitely one of the things 0:04:00 we’re seeing most, where are we right now 0:04:03 in how much we’re using these tools 0:04:08 and how kind of robust they are in their rollout in the system. 0:04:09 – When you think about like the traditional phone call, 0:04:12 which yes, is a form of virtual care, 0:04:13 one of the challenges of that model 0:04:17 is that every single caller is treated the same 0:04:18 and when they’re waiting in the queue, 0:04:21 there’s no way to understand how to effectively triage 0:04:24 the ones that might have higher risk versus lower risk. 0:04:26 And so there’s a whole slew of companies 0:04:29 that have a virtual agent or like a chat bot 0:04:32 that essentially can ask you questions in a digital form 0:04:35 in a self-service way that, you know, 0:04:38 sort of prioritize the level of risk of a patient 0:04:41 prior to them even engaging with the healthcare system. 0:04:43 That’s one thing that will unlock a bunch of capacity 0:04:45 is, you know, rather than just brute force 0:04:46 putting everyone in a line and waiting 0:04:48 until they human answer the phone 0:04:50 to figure out where they need to go, 0:04:53 these technologies can actually sort of be more intelligent 0:04:55 about how to route people in the right direction upfront. 0:04:58 – And is that happening yet now 0:05:00 when we have this telemedicine conversation, 0:05:02 it feels like I’m in line, I’m waiting 0:05:04 and then the nurse, you know, pops up 0:05:05 and we have a conversation. 0:05:07 I mean, may type a few things in, 0:05:11 but is it actually being sort of prioritized? 0:05:14 – In pockets, so there are a set of larger employers 0:05:16 and a set of larger health plans 0:05:18 that have partnered with these digital health companies 0:05:21 to make those tools available to their members 0:05:22 or to their employees, 0:05:24 which not by any means in the mainstream, 0:05:26 but you are seeing, you know, all over the web, 0:05:28 all these companies are broadcasting the fact 0:05:31 that they have intelligence in those virtual chatbots 0:05:34 that can help people assess what their level of risk is 0:05:36 with regards to COVID specifically, 0:05:38 but also all sorts of other things 0:05:41 and essentially allow them to determine 0:05:43 whether or not they actually need to come in 0:05:44 to a physical brick and mortar clinic. 0:05:46 – You know, compared to what we could be doing, 0:05:48 it’s really intriguing in that 0:05:51 it wouldn’t take much for people to do vitals at home. 0:05:53 If you think about the sort of virtual paradigm 0:05:57 is how can the doctor connect with measuring things? 0:05:59 The fact that now you can measure a lot of things at home 0:06:03 such that maybe even $100 would get you a kit 0:06:07 that your family could use to get basics plus plus, 0:06:10 you know, maybe even includes like a stethoscope 0:06:13 that can send the sounds of your heart 0:06:16 and your lungs and so on to the doctor. 0:06:17 I think there’s a lot more that could be done 0:06:19 than what we’re doing right now. 0:06:21 – When you think about like the tools that we all, 0:06:23 like the vast majority of Americans 0:06:27 at least have like in their household set of things, 0:06:29 like thermometer is definitely one where it’s pretty much, 0:06:30 you can assume that, you know, 0:06:33 most most citizens have a thermometer in their house, 0:06:35 but there’s many, many other categories 0:06:38 of like tests essentially that either aren’t available 0:06:40 to consumers off the shelf at your CVS 0:06:43 and actually require either you to send a sample 0:06:45 into a central lab somewhere and, you know, 0:06:49 wait for the cycle to run to get back the results 0:06:50 or that you still need to come in. 0:06:52 And that’s one of the big challenges right now 0:06:55 that we’re seeing with COVID is that there is no at home test 0:06:58 and you have to actually come into these physical facilities 0:07:00 to, you know, both have the sample taken 0:07:01 and the lab test run. 0:07:03 And that’s like just exacerbating 0:07:06 the supply side problem right now with regards to capacity. 0:07:08 And so I think that’s going to be a big area 0:07:11 where we’re already starting to see tremendous movement. 0:07:13 I think this moment is highlighting the fact 0:07:14 that there is so much more 0:07:16 that we need to be investing in as far as innovation 0:07:20 to bring those tests truly into a package modality 0:07:22 that allows human, that allows consumers 0:07:24 to actually do them in their home. 0:07:25 – But so Julie though, are you thinking 0:07:28 if it is like just a blood or urine sample 0:07:29 that probably could be collected 0:07:31 by a mobile full bottomist as well. 0:07:32 – Correct, yeah. 0:07:35 Where essentially like the sample collection kit 0:07:36 can be sent to your house. 0:07:38 And it’s either a urine sample 0:07:42 or a simple blood prick or a saliva sample. 0:07:44 And that, you know, that kid still needs to be sent 0:07:46 to a central lab to be actually run. 0:07:48 And then again, there’s a latency 0:07:49 to getting the results back. 0:07:51 But you also have other tests. 0:07:52 Like, I mean, the pregnancy test 0:07:53 is the most canonical example of this 0:07:57 where you can run the entire end to end test in your home 0:07:58 and get immediate results. 0:08:01 And so I think that’s what we should aspire to 0:08:05 is that a larger portion of sort of what we call 0:08:07 standard blood tests should be available 0:08:09 in that kind of packaging. 0:08:11 – Yeah, no, it’d be great if it was done at home, 0:08:13 but I think even like sending to a central lab 0:08:15 isn’t really that different than what a GP would do. 0:08:18 – Well, what is, I mean, what are the limits? 0:08:19 Because I hear you pointing out a lot of different things 0:08:21 that we could theoretically be doing even right now, 0:08:24 but where are the limits right now of like, 0:08:27 no, this is really the opportunity 0:08:28 for virtual medicine does end here. 0:08:31 You need human to human care delivery. 0:08:34 – The obvious one is if you need a procedure done, 0:08:36 like a surgery, then clearly today, 0:08:38 that is something that does require coming 0:08:41 to a physical operating room type setting, 0:08:42 like a facility that can actually handle 0:08:44 that kind of high-risk procedure. 0:08:46 – But that seems so far out on the spectrum. 0:08:47 Like, is that– 0:08:48 – Yeah, I know. 0:08:50 It’s kind of a while until everyone has like, 0:08:53 a DaVinci robot in their home that a surgeon 0:08:56 can control remotely, but hey, we can all dream. 0:08:58 But that portion of the market has been 0:09:00 unbundling as well in terms of it used to be the case 0:09:01 that you had to go to a hospital. 0:09:03 Now we have these ambulatory surgery centers 0:09:06 that specialize just on outpatient surgical procedures. 0:09:09 So, I mean, there are certain components of that 0:09:10 that you could predict ultimately make it out 0:09:11 to the community. 0:09:13 So that’s kind of one category. 0:09:14 The other thing that that’s worth mentioning 0:09:16 is when we talk about virtual care, 0:09:20 we typically think about the patient-to-provider interaction 0:09:22 as the component that needs to be virtualized, 0:09:24 but there’s a whole backend, 0:09:26 like provider-to-provider communications 0:09:29 still are not virtualized either. 0:09:31 Like a lot of what you are seeing out there 0:09:33 on social media and physicians sort of speaking out 0:09:35 about what’s happening with coronas 0:09:37 is that they themselves don’t have the means 0:09:40 to communicate with each other in a real-time fashion. 0:09:42 – So at the moment, where does that break down? 0:09:45 So even if you have like a fantastic virtual visit 0:09:48 with your doctor, you don’t have to go in, 0:09:49 your doctor can call you antibiotics, 0:09:51 or like, where does the system start failing 0:09:53 in that data sharing behind the scenes, 0:09:54 provider-to-provider? 0:09:57 – Yeah, I would say like the best case scenario 0:09:59 is that it just slows things down, 0:10:03 where you have to have more manual processes in place 0:10:06 to aggregate information that the next provider who you see 0:10:09 needs to be able to make the right decision. 0:10:11 Worst case scenario is that you actually 0:10:12 don’t have access to that data 0:10:14 and you either are blind to that 0:10:17 and therefore make an incorrect or inaccurate decision 0:10:20 or that you have to repeat whatever was done to you before, 0:10:22 which obviously adds cost to the system. 0:10:26 So I think those are a couple of the examples that we see. 0:10:29 That’s rampant today in terms of where a lot 0:10:31 of the unnecessary costs in the system are, 0:10:33 is simply because we don’t have data liquidity 0:10:36 and therefore there’s a lot of repeat testing 0:10:37 and assessment that needs to be done 0:10:39 to get a holistic view of every patient 0:10:41 at every individual encounter. 0:10:44 It’s kind of a weird juxtaposition of kind of the good 0:10:46 and the bad that’s happening right now, 0:10:49 but CMS and ONC just polish their interoperability rules 0:10:53 that mandate the adoption of certain interoperability 0:10:56 standards and technologies for hospitals 0:10:58 to exchange medical information. 0:11:01 And, you know, until that is in place, 0:11:03 I think one of the biggest constraints 0:11:06 to actually virtualizing care models 0:11:08 is the exchange of data that enables all 0:11:11 of the decentralized players to have access 0:11:13 to the same information. 0:11:15 – You know, it’s fun to connect to what Julie’s talking 0:11:18 about about virtual care being not just sort of a GP 0:11:21 to a patient at home in that you could imagine 0:11:22 having a sort of virtual care 0:11:26 where you have a specialist consult done virtually. 0:11:27 – Exactly. 0:11:29 – Because right now, often the patient has to reschedule 0:11:33 a whole nother meeting and having that done 0:11:36 briefly, virtually would be particularly intriguing. 0:11:38 And then another topic that this connects to 0:11:40 that’s I think a proud brother of stuff 0:11:42 that we’ve spoken about in the past 0:11:44 is sort of the unblundling of the hospital. 0:11:47 It’s interesting just to think how far you can unblundle it 0:11:49 with the goal of keeping people out of hospitals 0:11:50 as much as we can. 0:11:53 Keep them at home and do as much as you can do at home. 0:11:55 Do it in local centers as much as you can do there 0:11:57 and only escalate to a hospital. 0:11:59 If, you know, if you’re having like a triple bypass, 0:12:01 I don’t think that’s ever gonna be done at home. 0:12:02 Certainly not a damn soon. 0:12:04 – But like, I kind of want to know like, 0:12:06 what’s the farthest you can imagine it, you know, 0:12:08 right now with what we’ve got right now, 0:12:10 short of a triple bypass. 0:12:11 – I think all the reading, 0:12:12 you could do a lot of reading at home 0:12:13 because you could do the blood tests, 0:12:15 you could do urine tests, 0:12:16 you could do various measurements, 0:12:20 but like the writing where you do anything to a person, 0:12:23 I think probably that might be just way too far. 0:12:24 – Although I have to say, 0:12:28 I had like a weird foot thing, you know, last year 0:12:31 and my doctor prescribed a virtual physical therapist to me 0:12:33 who like, you know, we had an appointment, 0:12:37 we did exercises and it was much easier than going somewhere. 0:12:39 – Exactly, physical therapy is probably one of the places 0:12:41 where it’s an intervention that traditionally 0:12:43 has required going to a clinic, 0:12:45 but that is one of the big areas 0:12:48 where you start to see kind of at-home innovation. 0:12:49 – Yeah, that’s a great point too, 0:12:51 especially since, you know, for physical therapy, 0:12:55 but for medicine in general, compliance is such an issue. 0:12:57 And if this just helps with compliance, 0:13:00 I mean, to some extreme, just having someone watch you 0:13:01 to make sure you take your meds 0:13:05 and so I’m like having a parent or something like that 0:13:06 or a buddy. 0:13:08 So PT often says about compliance, 0:13:10 there’s all this compliance stuff 0:13:12 that probably could be improved with sort of virtual care. 0:13:14 Part of the problems that were in many ways, 0:13:15 we’re not even trying. 0:13:19 I think that there’s a lot more that we could be doing, 0:13:22 but it means sort of a capital outlay 0:13:26 to get the programs going and then to get rolling. 0:13:29 But that, you know, so that’s on the provider side. 0:13:31 On the patient side, you could argue too 0:13:33 that there are a lot of people that don’t take advantage 0:13:35 of even what we could do now. 0:13:40 And that part of what is powerful about the doctor’s visit 0:13:42 is just sitting there with the doctor 0:13:47 and how much that is a form of medicine and so on, right? 0:13:49 I think, you know, they’ve done these interesting tests 0:13:53 where they have sort of these different variants 0:13:56 of the doctor visit and just the doctor giving attention 0:14:01 has a huge sort of placebo effect or sort of positive effect. 0:14:04 And so we wouldn’t want that human connection part 0:14:07 to be lost and how to do that is tricky. 0:14:10 On the other hand, maybe even just cultural things change 0:14:12 and it just becomes much more of a norm 0:14:14 to connect to people virtually. 0:14:16 That may change, that may change a lot. 0:14:18 I remember even like when the history of the telephone 0:14:21 people originally thought the telephone would be seen 0:14:24 as such an impersonal kind of like, 0:14:25 no one would ever want to use that 0:14:28 versus, you know, connecting in person. 0:14:30 I think we sort of just got over that and got used to that. 0:14:33 I mean, ironically, we’re doing this remotely 0:14:34 where none of us are in the same room right now, 0:14:37 but it’s kind of, I feel like it’d be just like, 0:14:38 it would be the same as we were. 0:14:41 – Right, yeah, almost the same, yeah. 0:14:44 If we can just get over it and get used to it, 0:14:46 that may actually still incur a lot of those benefits. 0:14:48 – What else in terms of stress points? 0:14:49 Because we’re starting to see, you know, 0:14:53 this is gonna be like a fast, big, hard rollout 0:14:55 of a whole bunch of stuff for a bunch of people 0:14:57 that have never used telemedicine 0:14:59 in immediate use all over the place. 0:15:03 So what are some of the other stress points 0:15:05 that you think we’re gonna start see popping up 0:15:07 that like, well, you know, next generation 0:15:10 of virtual medicine tools we’ll learn from? 0:15:12 – Well, two structural things that we should definitely 0:15:15 mention are on the regulatory and like the payment side 0:15:18 where if I’m a doctor and I see what’s going on 0:15:20 and I have a motivation to spin up 0:15:22 my own virtual care practice, 0:15:24 it’s very non-trivial to do that on the fly 0:15:28 because of regulation around licensure. 0:15:31 So it is not the case that I can treat virtually 0:15:33 every patient across all 50 states 0:15:36 unless I am appropriately licensed in the states 0:15:38 where the patients are located. 0:15:39 It’s definitely a source of friction 0:15:41 that prevents a lot of companies 0:15:44 from actually like turning this on from day one. 0:15:46 – So in other words, even though it’s virtual, 0:15:48 it’s still very local. 0:15:50 – It’s still very local, exactly. 0:15:52 There’s actually an interesting study that came out 0:15:55 that showed that there are literally no two states 0:15:58 in the US that have the same policies. 0:16:00 And even within the states, some of the policies conflict 0:16:03 between like state law and Medicaid law 0:16:05 and it’s very convoluted. 0:16:09 So that whole sort of jungle of policy is one big thing 0:16:11 that there’s been talk of change. 0:16:13 And I wonder, given the current situation, 0:16:16 how much that will rise to the top 0:16:18 as a potential regulatory change 0:16:19 that might be put on the table. 0:16:21 – What sort of change do you think could happen? 0:16:23 – Well, just to relax the constraints on licensure 0:16:26 so that there’s essentially, imagine like a common app 0:16:29 type construct where you could apply once 0:16:32 and have coverage across multiple states. 0:16:33 And then the reimbursement one is interesting 0:16:37 because we just saw that the White House signed 0:16:40 an emergency bill that relaxed the constraints 0:16:42 on reimbursement for telehealth services 0:16:44 for the Medicare population. 0:16:46 ‘Cause historically that’s been another huge constraint 0:16:48 that it was only reimbursable 0:16:50 under very specific circumstances. 0:16:53 For instance, like if patients were located in rural areas 0:16:57 that were deemed sort of low access, 0:16:59 those were the only situations where you could get reimbursed 0:17:01 but now they’ve taken that off the table. 0:17:03 We already see positive tailwinds there 0:17:05 but that historically has also been a big challenge 0:17:08 is just getting paid for doing the service. 0:17:09 – Interesting. 0:17:10 – How about scalability? 0:17:12 One of the things I’m very curious about 0:17:14 is how this could help scaling. 0:17:16 And there’s different variations of scaling. 0:17:21 One of the real challenges is just how do you schedule 0:17:24 and sort of do the people matching problem? 0:17:29 And if you had just a bank of virtual doctors or RNs 0:17:31 that could then be much more easily routed 0:17:33 to anyone throughout the country, 0:17:35 you could do load balancing between regions and so on. 0:17:39 In a way where everyone would be at very high capacity 0:17:43 and in situations where there is just extreme need, 0:17:47 you could have a five minute virtual visit 0:17:48 that maybe gets the basics done 0:17:52 in a way that just really wouldn’t be possible to do 0:17:56 in person where you’re just with the rooms packed 0:17:59 and the parking packed and the roads packed. 0:18:01 There’s just things that you could do at scale 0:18:03 that you couldn’t do in other ways. 0:18:05 – And I think that gets to a broader point of like 0:18:08 when healthcare goes virtual, 0:18:09 you don’t think about just like taking the way 0:18:11 that things work in the physical world 0:18:12 and then just like translating it 0:18:13 to a virtual version of that, 0:18:16 but you can sort of like reinvent from the ground up 0:18:19 the actual operating model of how that works. 0:18:23 Today’s healthcare system is the patient has to, 0:18:26 like everything is optimized for the provider’s schedule. 0:18:28 Even the notion of like pre-booking an appointment 0:18:29 and making it work for us, 0:18:32 us meeting patients going out of our way 0:18:36 to accommodate the schedules on the supply side. 0:18:38 Like you could entirely flip that on its head, 0:18:40 especially if you think about a world 0:18:42 in which you’re continuously monitoring patients. 0:18:44 It’s not the patient sort of determining 0:18:46 that he or she needs to go see a doctor, 0:18:48 but rather the data saying, 0:18:51 hey, this patient needs intervention 0:18:52 and actually having the provider’s side of the market, 0:18:54 you know, reach out to the consumer side. 0:18:56 So I think there’s like lots of opportunity there 0:18:58 to make it much more patient centric 0:19:01 as well as much more proactive so that it’s not, 0:19:03 again, the burden is not on the patient 0:19:06 to have to figure out when it’s appropriate to go in. 0:19:08 – So it’s not just you reaching out to your doctor 0:19:09 to get virtual care, 0:19:11 it’s the virtual care reaching out to you 0:19:13 when you need it and you may not even realize it? 0:19:16 – Yeah, then the whole notion of like provider networks 0:19:18 and even like what is a provider 0:19:20 sort of changes fundamentally 0:19:24 where this is also potentially a cultural shift 0:19:29 where in order to do like really intelligent load balancing, 0:19:30 it might be the case that you’re not necessarily 0:19:33 gonna have an established long-term relationship 0:19:34 with like a single human being, 0:19:36 but kind of more of a care team. 0:19:38 And this is a model that’s been talked about, you know, 0:19:40 for a while, this notion of like the medical home 0:19:42 or medical neighborhoods where you have 0:19:43 more of a care team model 0:19:45 and therefore you’re not constrained 0:19:47 by any one individual player in the system, 0:19:50 but rather can tap into multiple resources. 0:19:53 And that’s, I think that’ll be a big cultural change, 0:19:55 at least here in the US. 0:19:57 – It’s funny because, you know, we do, I, you know, 0:20:00 I have a dermatologist and I have like, 0:20:02 I don’t know, dentist and I have a PCP, 0:20:05 but it does seem that the way you develop a relationship 0:20:08 with one PCP and you sort of assume they know you 0:20:11 and they’re looking out for the 360 degrees of you, 0:20:13 whether or not that’s actually true, 0:20:16 that is like a very, that does feel like an important cultural 0:20:19 and emotional thing in this particular culture. 0:20:23 Is there a way to do both in the virtual? 0:20:26 – I mean, we’ve seen this in other aspects of our lives, right? 0:20:31 Like you can still have a phenomenal customer experience 0:20:33 when you have like really good CRM 0:20:38 and just really good 360 data on who you are as a consumer 0:20:41 and like retail and, you know, like every time I interact 0:20:43 with an airline, like they know my whole history 0:20:44 and all that kind of stuff. 0:20:47 I mean, we’ve seen this in OB, you know, 0:20:50 I think these days most, at least the larger hospitals 0:20:53 and larger OB clinics, 0:20:55 knowing that it might not be your OB 0:20:57 who’s actually delivering you based on, you know, 0:21:00 when you go into labor, they try to actually introduce you 0:21:04 to the entire care team as part of the prenatal experience 0:21:06 so that no matter who ends up being there, 0:21:10 like during game time, so to speak, 0:21:12 you’re gonna have at least some established relationship 0:21:13 with them. 0:21:14 I think it’s more about like, 0:21:16 how are you setting expectations to the patient upfront 0:21:20 and giving them the room to actually meet everyone 0:21:23 in a low risk way such that when stuff hits the fan, 0:21:25 you have that preexisting relationship. 0:21:27 – But it does, and even in your example with the OBs, 0:21:30 it sort of reminds me of like, okay, so yeah, 0:21:32 I sort of knew all along that whoever I got at the hospital 0:21:34 was gonna be the person I got at the hospital. 0:21:37 And in a way that was a totally separate event 0:21:41 from my pregnancy and like tracking me through the pregnancy 0:21:43 and understanding what was going on with me, you know, 0:21:47 in a way it’s almost unbundling the experience, right? 0:21:48 – Yeah, you could take this virtual idea, 0:21:49 you know, one step further, 0:21:52 whether it’s like a really good chatbot, 0:21:55 a chatbot that could answer a sort of standard question 0:21:59 to the chatbot that knows your history and connect to that 0:22:01 and naturally would and could escalate 0:22:04 to the human being and beyond. 0:22:06 That gets really interesting in terms of scale. 0:22:11 And the question is in my mind, can that type of service, 0:22:14 you know, what fraction of what a doctor does 0:22:15 could be serviced by something like that? 0:22:17 Obviously there’s a lot that couldn’t, 0:22:19 but in terms of just having that with you at any time 0:22:22 that you could just asynchronously connect with, 0:22:23 ask any sort of health question 0:22:26 and with the sort of knowledge 0:22:29 that the answers are completely accurate and so on, 0:22:31 which is a very high bar to make sure the way we reach, 0:22:33 that’s a whole nother direction. 0:22:35 And you could see how that just gets smarter 0:22:36 and smarter as time goes on. 0:22:38 – You guys have heard me talk about Baymax 0:22:40 from the movie “Big Hairy Sex”, 0:22:42 like we’re all gonna have a Baymax at some point. 0:22:43 Japan is like way ahead on this. 0:22:45 So if you actually look at like the landscape 0:22:47 of companion robots in Japan, 0:22:50 they actually have like pet robots, right? 0:22:53 And in some ways, like a lot of why the promise 0:22:56 of like humanoid robots has kind of fallen short 0:22:58 is like we have such high expectations 0:23:00 for the level of intelligence 0:23:02 that those quote unquote human robots have. 0:23:05 Whereas like if it’s a pet, you know, your bar goes down, 0:23:07 but there’s still like a tremendous amount 0:23:10 of therapeutic benefit to having that kind of companion. 0:23:12 And so like, especially with the silver tsunami 0:23:14 and the elderly population and what have you, 0:23:16 there’s like a pretty meaty set of things 0:23:19 that you could do in a very basic form 0:23:20 that are not clinical in nature, 0:23:21 that don’t require clinical judgment, 0:23:24 that would still hugely benefit the system, 0:23:26 both in terms of just like reducing anxiety, right? 0:23:27 That they had a basic level. 0:23:29 – Yeah, wasn’t there some kind of study 0:23:33 where they had baby seal robots in the elder care facility? 0:23:34 – That sounds about right. 0:23:38 – For the, no they did, for the empathy and the comfort 0:23:42 as a particular clinical need in that setting. 0:23:43 So if we’re at the tipping point, 0:23:46 if this moment is sort of the tipping point 0:23:49 for virtual medicine, two questions. 0:23:53 One, why did it take a pandemic to get here? 0:23:57 And then two, what do you think is the most, 0:23:59 the sort of most immediate near term things 0:24:03 that we’re gonna see start rolling out right now 0:24:05 as you know, not just video chat, 0:24:07 but are there other things we’re gonna start seeing today, 0:24:09 tomorrow with COVID going on 0:24:11 that we’re gonna all be getting more familiar with? 0:24:14 – It’s unfortunate that this had to be the forcing event 0:24:16 to sort of bring all of this to light, 0:24:19 but there are a number of tailwinds 0:24:23 that have been in motion that enabled us to actually respond 0:24:26 in a way that’s reasonable in light of this kind of crisis, 0:24:28 which definitely would not have been the case, 0:24:30 I would say, five or six years ago, 0:24:32 like just like the very visceral understanding 0:24:34 that costs are spiraling out of control 0:24:36 in the way that we deliver medicine 0:24:39 in the physical world today is just not sustainable 0:24:41 to patients just being at their wit’s end 0:24:44 with regards to access and convenience 0:24:47 and therefore being willing to adopt 0:24:49 these types of novel technologies, 0:24:51 combined with what we talked about earlier, 0:24:53 where in other parts of our lives, 0:24:55 we are now getting much more comfortable 0:24:58 with the notion of either asynchronous communication 0:25:00 or video based communication. 0:25:03 And then now like the actual virtual care platform technology 0:25:07 is mature enough to actually be delivered at scale. 0:25:08 I was like one of the very early adopters 0:25:10 of some of the early telehealth solutions 0:25:13 and it was super choppy, like the video quality was bad 0:25:16 and it was just not a smooth experience, 0:25:18 but if you do it today, it’s very streamlined. 0:25:20 So I think the confluence of all those things 0:25:22 like had to be in place such that we could respond 0:25:24 in a situation like this in the way that we are. 0:25:26 – But do you think that we would be doing it without 0:25:28 something like this to push us over into it? 0:25:30 Do you think it would just have taken longer? 0:25:31 – I think it would have just taken longer. 0:25:34 I think the forcing function is not just like adoption, 0:25:38 but it’s also again, like there’s top down regulatory change 0:25:39 that’s enabling reimbursement. 0:25:43 There’s, I hope more relaxing of the regulation 0:25:45 around like medical licensure. 0:25:48 And I think we will see like in the next year, 0:25:50 a tremendous uptick in adoption 0:25:53 by at least the enterprise side of the market 0:25:55 for access to virtual care services, 0:25:58 which has always been like an emerging area. 0:26:01 It’s definitely gotten a lot of early uptake, 0:26:03 but this could be the thing that pushes it 0:26:04 into the mainstream. 0:26:07 – The UIs for these things are kind of clunky, 0:26:09 especially in a world where people have like Google 0:26:11 and Facebook and things where these consumer products 0:26:13 have really elegant UIs. 0:26:17 And it’s clear the utility, 0:26:19 if we can get people to use them, be comfortable with it. 0:26:22 I’m just imagining while we’re talking like a Facebook 0:26:24 like feed where I’m chatting with, you know, 0:26:27 my various doctors and everything’s in there 0:26:28 and like my records are there 0:26:30 and these are coming up as posts 0:26:32 and I can just look through it. 0:26:34 Maybe I can even look through my kids’ feeds 0:26:36 to see how their medicine’s going. 0:26:39 That really wouldn’t be that hard to do in principle 0:26:42 and practice, you know, UIs are an art and so on. 0:26:46 But I think if we can force the tools to sort of come up 0:26:49 to speed with what people’s expectations are, 0:26:51 I have a feeling the engagement could be comparable 0:26:54 to engagement in other sort of consumer-like products. 0:26:56 – And it’s interesting ’cause it seems to me like right now, 0:26:59 you know, the sort of incentive to do so 0:27:01 is aligned on both sides, right? 0:27:02 Like nobody actually wants to go 0:27:04 into their doctor’s office right now. 0:27:05 Doctors also don’t want you to go 0:27:07 into the doctor’s office right now. 0:27:10 Like it’s unusual for everybody to be aligned in that way 0:27:12 where we’re all incentivized to use something like this 0:27:14 at the same time. 0:27:15 – Well, I’ll add one more thing, 0:27:18 which is that these difficult times 0:27:21 often create some of the most exciting startups 0:27:23 and that we have this combination now 0:27:26 for sort of the fire to do that, 0:27:29 combine with all of these things just in our face. 0:27:30 You don’t need a world pandemic 0:27:32 for it to be an individual crisis. 0:27:36 And what can we do to handle my crisis in the future? 0:27:38 Hopefully this will give us a model for that. 0:27:39 – Hold this out of tools. 0:27:41 – Virtual care is actually in some ways 0:27:43 like the perfect solution at a time 0:27:46 when we need lower cost ways to deliver care 0:27:48 because the actual way by which you can just eliminate 0:27:50 so much of the cost structure 0:27:53 of the traditional healthcare system. 0:27:54 – Thank you so much for joining us 0:27:58 both on the A16Z podcast goes remote. 0:27:59 – Thank you, stay healthy. 0:28:09 [BLANK_AUDIO]
We’re at a moment where we are now seeing medicine go virtual faster, and at a scale that it has never done before. In this conversation, a16z bio general partners Vijay Pande and Julie Yoo, who come from the worlds of bio, technology and care delivery, talk with Hanne Tidnam all about what exactly virtual care and “telemedicine” is… and what it isn’t; what it works well for, what doesn’t (yet), and where there’s potential; and finally, the current pain points (including regulation), and what we’ll learn from this current moment for the next generation of virtual medicine tools.
0:00:02 – Hi, and welcome to the A16Z podcast. 0:00:03 I’m Hannah. 0:00:05 A lot’s going on in the world of healthcare right now, 0:00:07 and one topic that’s especially relevant 0:00:10 is how diagnostic labs work. 0:00:11 The conversation that follows, 0:00:12 which was actually recorded 0:00:15 at our A16Z Innovation Summit in November, 0:00:18 covers everything from the evolution of the modern lab 0:00:20 over the past 50 years, 0:00:23 especially as new technologies and new tests are added, 0:00:25 how tests go from being specialized 0:00:27 to mainstream and widely available, 0:00:31 to who pays, how, and how reimbursement works. 0:00:34 We also discuss where information from the lab flows 0:00:36 in electronic health records or elsewhere 0:00:37 in the healthcare system, 0:00:40 a topic we’ve covered before on this podcast, 0:00:42 so be sure to check out those past episodes 0:00:43 with General Partner Julie Yu, 0:00:47 and touch on what the lab of the future might be like. 0:00:48 Joining this conversation with me 0:00:51 and General Partner Jorge Conde is Dave King, 0:00:55 Executive Chairman and previous CEO and President at LabCorp, 0:00:57 one of the largest clinical laboratory networks 0:00:59 in the world. 0:01:00 – So where should we begin 0:01:03 when we talk about the evolution of the modern lab? 0:01:05 What’s the history and what do you think of as the timeline 0:01:07 of where we began to what brought us 0:01:08 to the modern lab today? 0:01:10 – Our original founder, Dr. Jim Powell, 0:01:13 was talking about why he came up with the idea 0:01:16 of a reference lab, and he’s a pathologist, 0:01:17 and one of the things he pointed out 0:01:21 is that in the day in 1969, 0:01:23 when a test was sent to a laboratory, 0:01:25 sometimes it would be five, six days 0:01:26 before a response came back 0:01:28 and the patient either had progressed 0:01:30 or as he said, progressed, released or died. 0:01:31 – Too slow. 0:01:35 – Too slow, not super reliable or reproducible 0:01:37 in terms of overall quality. 0:01:40 A lot of work was done in hospitals or small laboratories. 0:01:44 Jim’s idea was, let’s put the instruments in one place 0:01:45 and bring the specimens, 0:01:47 instead of sending the specimen somewhere 0:01:49 and waiting for the answer to come back. 0:01:52 And obviously that’s evolved over the course of time 0:01:55 into reference laboratories that look like warehouses. 0:01:57 I mean, look, manufacturing facilities. 0:02:00 You know, large numbers of very high throughput instruments, 0:02:04 very IT and tech connected. 0:02:06 We have a robotic sorting machine 0:02:07 that we’re putting into all of our laboratories, 0:02:10 which basically replaces all of what we used to do 0:02:12 at the front end manually, you know, 0:02:14 uncapping, shaking, pouring off. 0:02:17 And so the business has not changed a lot 0:02:19 over the 50 years, what we do, 0:02:21 but the way in which we do it and the quality 0:02:23 and the scope and the, you know, 0:02:26 the breadth of our business has changed quite dramatically. 0:02:27 – What is the sort of, like, 0:02:29 the spectrum of diagnostics for each lab? 0:02:31 How do you specialize in different labs or not? 0:02:33 Like, what does that look like, that lay of the land? 0:02:37 – So we perform about 4,400 different tests. 0:02:39 Not all labs have a menu as big as ours. 0:02:41 There are also some highly specialized labs 0:02:43 that do, for example, oncology testing 0:02:46 or do coagulation testing for blood cancers 0:02:48 or do thyroid testing. 0:02:50 We think of an SHR test as anything 0:02:53 that is performed by a sort of non-standard methodology. 0:02:56 So if you come to our laboratories, 0:02:59 there’s a huge set of chemistry instruments 0:03:00 that just, they run chemistry tests, 0:03:02 all day long, glucose, potassium. 0:03:05 There’s a huge set of hematology instruments 0:03:06 that run CBCs. 0:03:08 We look for infections in high white blood cell counts. 0:03:11 And then there are DNA tests, 0:03:13 which are in the SHR category. 0:03:15 There are specialized thyroid testing. 0:03:16 There’s allergy. 0:03:19 All things kind of outside what we would consider 0:03:21 the norm of basic wellness testing. 0:03:23 – And so over time, you would imagine 0:03:27 the definition of a test will move from esoteric 0:03:31 to non-esoteric as it becomes more commonly used. 0:03:32 – Absolutely, yeah. 0:03:34 There’s definitely an arc when you introduce, 0:03:39 you know, when ACOG dictated that within their guidelines 0:03:43 all pregnant couples should be tested for cystic fibrosis. 0:03:45 I mean, we had offered cystic fibrosis for years. 0:03:46 Nobody ever ordered it. 0:03:47 Now all of a sudden it exploded. 0:03:49 And so it really went from being 0:03:53 a pretty esoteric test that was not commonly ordered 0:03:57 to very much a routine part of prenatal screening and care. 0:03:59 And there are many examples like that over time. 0:04:00 – So how does that happen? 0:04:03 How does a new test get integrated into this system? 0:04:05 Is it partially about whether you have the tools available 0:04:07 or whether the demand for the test is there? 0:04:08 What is the driving factor? 0:04:10 – We always start with what’s the unmet clinical need. 0:04:12 I mean, obviously market size matters 0:04:14 ’cause there has to be enough market demand 0:04:16 to justify bringing up a test. 0:04:18 But, you know, what is an unmet clinical need? 0:04:21 So if you look at non-invasive prenatal testing, 0:04:24 for example, the unmet medical need was 0:04:29 that invasive prenatal testing, whether Amnio or CVS, 0:04:32 you know, pose risk to both mother and the fetus. 0:04:35 And as the technology improved 0:04:37 to where this could be done through blood testing, 0:04:38 it clearly made sense to integrate that 0:04:41 into the sort of the more standard test menu. 0:04:43 When you do it through blood, 0:04:45 it’s a simple, relatively painless process. 0:04:49 There’s literally no risk to the mother or the fetus. 0:04:50 The results come back faster 0:04:52 and the reliability is very much concordant 0:04:54 with the more invasive procedure. 0:04:55 So that’s a good example 0:04:57 of where there was a clear clinical need 0:05:01 for a better way of doing what we’re doing. 0:05:03 Other tests like companion diagnostics, 0:05:06 where a drug comes out and we’re able to demonstrate 0:05:08 either in the clinical trial 0:05:10 or through use in the marketplace, 0:05:13 that there’s a diagnostic test that can tell you 0:05:16 whether this drug is gonna be efficacious 0:05:17 for this patient with this condition. 0:05:20 There, the clinical need is almost always very compelling 0:05:23 because you’re talking about potentially 0:05:26 a very expensive drug and you wanna know, 0:05:27 is it gonna work for this patient 0:05:29 or is it just gonna be, you know, 0:05:32 more healthcare resources that are not gonna be well spent? 0:05:34 – So how about the information flow? 0:05:36 In some ways, the lab is sort of the ground truth, you know, 0:05:38 and that it doesn’t mean anything 0:05:41 if that information doesn’t go somewhere and have an effect. 0:05:42 So can you describe to us, 0:05:44 is it more complicated than we think 0:05:46 or is it just lab to provider? 0:05:48 What is the kind of information flow at the moment? 0:05:50 How does that work in the system? 0:05:52 – That’s one of the big changes that’s occurred 0:05:54 when I started a lab core. 0:05:57 We still used to drive around with paper reports 0:05:59 in the courier vans and drop them off 0:06:00 at the doctor’s offices. 0:06:03 In most cases, you know, we drop them the next day 0:06:05 and those were the days when the doctor would have 0:06:08 the folder out, a test would go in the chart and the, you know, 0:06:12 so now I think upwards of 85% of what we return 0:06:14 is returned in some electronic fashion 0:06:17 and it may flow directly back into the doctor’s medical record, 0:06:19 you know, electronic health record. 0:06:21 It may go back in some other electronic fashion 0:06:23 where it goes to the doctor’s office 0:06:26 but it doesn’t directly integrate into the health record. 0:06:29 And this, in my opinion, is actually one of the big obstacles 0:06:34 to a more seamless coordination of care system for patients 0:06:36 because I agree with you, the lab is the ground truth. 0:06:40 I mean, you know, 70% of clinical diagnoses 0:06:42 start with a laboratory result 0:06:45 and doctors always, you come into the doctor 0:06:46 and you say, I’m not feeling well. 0:06:47 The first question is, well, you know, 0:06:49 let’s look at the labs and see what they say. 0:06:51 Do you have an infection? 0:06:53 If you’re overtired, is it your thyroid? 0:06:56 The problem is we have many participants in the system 0:06:59 who don’t facilitate the exchange of information. 0:07:02 And so, you know, we have local hospitals 0:07:04 near our headquarters that won’t allow us 0:07:06 to return information electronically 0:07:07 into the medical record. 0:07:08 – Is that still happening? 0:07:11 – Oh yeah, and if the doctor wants to order from LabCorp, 0:07:13 like my physician works at a local hospital, 0:07:16 you know, he receives the reports back as a PDF. 0:07:19 – Those hospitals want to use their own labs, essentially. 0:07:21 – Very much so, because this is where the interest 0:07:23 in the system are not well aligned. 0:07:25 The hospital labs are able to command 0:07:28 much higher pricing from the payers than we are, 0:07:30 so they have a vested interest in using their own labs. 0:07:33 And, you know, I think this will evolve 0:07:35 as we, two things happen. 0:07:37 One, we move into the value-based care environment 0:07:41 where the dollar cost of services is less relevant 0:07:45 than the overall kind of bundle of care and outcomes. 0:07:49 And number two, healthcare is a truly unique ecosystem 0:07:52 because we don’t have pricing transparency. 0:07:53 You don’t know what it’s gonna cost you 0:07:55 to have a service done. 0:07:57 We have our phones, we can tell exactly what we’re gonna pay 0:07:59 for this service or for this product, 0:08:01 we can comparison shop. 0:08:02 We don’t have that in healthcare, 0:08:04 and all of the pricing transparency work 0:08:07 that’s being done now is more about list price 0:08:10 than it is what is gonna cost the patients. 0:08:11 You know, the consumer is smart. 0:08:15 They can make sound, both economic and quality decisions 0:08:16 about their lab services. 0:08:19 – But it does feel like, I hate when I get a test result 0:08:21 back directly through my medical chart, you know, 0:08:24 without it having been seen by the doctor 0:08:28 because it feels like so often there’s this context 0:08:29 that I don’t have. 0:08:31 So like, something will come up and I’ll like Google, 0:08:33 okay, there’s some range here and this looks a little weird, 0:08:35 you know, and then the doctor will be like, well, X, Y, 0:08:36 and Z, that’s why it’s totally fine. 0:08:39 You know, in that information flow, 0:08:40 how do you think about both the translation 0:08:43 and the context when it’s going direct to consumer like that? 0:08:45 – I think some test results are binary, right? 0:08:47 I mean, you tell the consumer you have or you don’t have 0:08:49 and that’s fairly simple. 0:08:51 Things that are much more nuanced, you know, 0:08:53 thyroid stimulating hormone. 0:08:57 The difference between 0.3 and 0.4 is probably 0:09:00 pretty much irrelevant, but the difference between, you know, 0:09:02 0.3 and 1.3 can be quite relevant. 0:09:04 And I think two things are critical there. 0:09:08 One is, you know, as we move more into direct consumer, 0:09:12 we need to figure out in a more comprehensive way 0:09:13 how we provide context. 0:09:16 So one of the things I’ve always thought is, 0:09:19 it would be great to be able to provide a link 0:09:21 on the report that goes to the patient kind of. 0:09:23 – So I don’t just go to Dr. Google, 0:09:25 who’s terrifying always. 0:09:27 – Everybody goes to Google and when you’ll find a lot 0:09:29 of chat groups where people say, oh yeah, you know, 0:09:32 I had a 1.3 and the next thing I knew I was in the hospital 0:09:35 for two months, oh, so I think that’s really important. 0:09:37 And again, part of that runs up against the current 0:09:40 regulatory environment and what you can do in terms of claims 0:09:43 for the testing or how you can interpret the testing 0:09:45 when you’re not a physician in the practice of medicine. 0:09:48 But it’s an area that we need to get our arms around 0:09:51 because it’s only gonna grow and consumers are only getting 0:09:52 more and more interested in. 0:09:53 – Yeah, that’s the direction. 0:09:54 – Absolutely. 0:09:57 – One of the things you mentioned was physicians themselves 0:10:00 being well positioned to interpret tests. 0:10:03 When you look at something like genetic testing, 0:10:06 the vast majority of physicians can’t go very, very deep 0:10:08 on interpreting those results. 0:10:12 And so as a result, there’s a need for genetic counselors 0:10:13 and the like. 0:10:15 So actually on the topic of the consumer, 0:10:19 what’s your view in terms of what consumers should be able 0:10:20 to order directly? 0:10:22 ‘Cause there’s been a rise of direct to consumer diagnostics 0:10:26 type services and you know, the pro argument is 0:10:29 consumers should have control over their own information. 0:10:30 It is their healthcare data. 0:10:32 They are the ultimate decision makers. 0:10:35 The con argument is that consumers may not be equipped 0:10:39 to fully comprehend what a diagnostic test is telling them. 0:10:41 Where would you come out on that? 0:10:45 – I am not a believer in the sort of paternalistic 0:10:47 healthcare system of, you know, everything has to go 0:10:50 through some learned third party who’s gonna interpret it. 0:10:55 The truth is with the explosion of genetic information, 0:10:58 for example, there are many physicians who practice 0:11:01 in the community who are not fully informed about 0:11:03 what these tests mean or how they should be ordered 0:11:04 or interpreted. 0:11:07 So it’s really in my view a little short-sighted to say, 0:11:10 well, the consumers, you know, quote unquote, 0:11:12 doesn’t have the information to be responsible 0:11:14 for the consequences of the testing. 0:11:17 The other side of that, which I, you know, fully respect 0:11:20 the regulators position is consumers need to understand 0:11:22 and we need to help the consumer understand. 0:11:26 Like a lot of these tests are complicated. 0:11:30 And so if you get a result that says that you have 0:11:33 sensitivity, for example, to warfarin or you’re a 0:11:37 fast metabolizer, gosh, the consumer can’t go out 0:11:39 and adjust their own dose with that information. 0:11:43 And so there’s a fine balance, health and wellness, 0:11:45 sexually transmitted diseases, things that I would say 0:11:49 are more kind of in the mainstream of what the consumer 0:11:50 would be able to understand. 0:11:52 But you have to respect the fact that, you know, 0:11:54 consumers want more information and the broader flow 0:11:58 of information is a positive for decision-making 0:11:59 and for our system. 0:12:02 – But what does it look like the push towards value-based 0:12:04 or outcome-based care in the healthcare system overall, 0:12:07 where we’re all trying to maybe shift towards valuing 0:12:11 those outcomes instead of paying per price, per service? 0:12:14 – In my view, the fundamental challenge with providing 0:12:17 well-coordinated care was the total lack of alignment 0:12:18 between the interests of the parties 0:12:19 in our healthcare system. 0:12:22 We have the largest cohort of genetic counselors 0:12:23 in the United States as a result of the 0:12:27 GenSIME Genetics acquisition, and we do not get reimbursed 0:12:29 for genetic counseling services for the most part. 0:12:30 – That’s still the case, wow. 0:12:31 – Because most of the genetic counselors 0:12:34 are advanced doctorates, they have a doctorate degree 0:12:36 or they have an advanced degree, but they’re not physicians. 0:12:38 So they can’t get paid off the physician fee schedule 0:12:41 and there’s no code on the clinical fee schedule 0:12:43 to pay people for the test interpretation. 0:12:45 This is really a vexing problem because, you know, 0:12:49 again, our system categorizes people as you’re a doctor 0:12:51 so you can get paid for this or you’re a lab 0:12:52 so you can get paid for that. 0:12:53 And, you know, the genetic counselor provides 0:12:56 just as much interpretation to the physician 0:12:58 as they do directly to the patient, 0:12:59 but you can’t get paid because you’re kind of 0:13:00 in that never, never land. 0:13:02 It should be in the interest of the payers 0:13:04 to pay for genetic counseling. 0:13:06 We’ve had a lot of pushback from the payers about, 0:13:08 well, the genetic counselors have a conflict of interest 0:13:09 ’cause they work for you. 0:13:12 We’ve done a study that shows that there are more instances 0:13:14 in which our genetic counselors recommend 0:13:17 against a genetic test than when outside 0:13:20 genetic counselors are used by the payers. 0:13:21 – What do you attribute that to? 0:13:23 – Because our genetic counselors, 0:13:27 their sole responsibility in their view is to the patient. 0:13:29 The outside genetic counselor is in a much more 0:13:32 difficult position because if they recommend 0:13:34 against the test, hey, you work for Blue Cross, 0:13:37 you work for United, you’re recommending against my test, 0:13:38 you know, the physician gets angry, 0:13:40 the patient gets angry, so there’s much more of a default 0:13:42 of, you know, let’s just go with it 0:13:43 even though it might not be valuable. 0:13:45 And in my personal experience, you know, 0:13:48 I’ve had an instance in which a physician ordered a test 0:13:52 for a family member that really exactly replicated 0:13:54 a different test that had been done. 0:13:57 Genetic tests, you know, from a snip microarray 0:14:00 to a gene sequence, and nobody other than, you know, 0:14:02 once we sent it to our laboratories, 0:14:03 they’re like, you’ve already done this test. 0:14:04 There’s no point doing it again. 0:14:07 So yes, genetic counseling, I still think 0:14:09 it’s vastly underutilized and it will be more 0:14:12 and more important as people get deeper into genetics 0:14:14 and more is known about the genome 0:14:16 and how it’s interpreted. 0:14:19 You mentioned you have a menu of 4,400 tests. 0:14:23 What tests do you think are underutilized, 0:14:24 generally speaking, that would help physicians 0:14:26 make better decisions, right? 0:14:28 ‘Cause the old axiom is the only reason 0:14:30 you would order a diagnostic is if it’s going 0:14:32 to somehow change a decision that your physician 0:14:34 would make in terms of your care. 0:14:37 So the opposite is probably also true 0:14:39 that there are probably tests out there 0:14:41 that the physicians would order would change 0:14:44 the direction in which they manage your care. 0:14:45 – Is there sort of an underutilized category 0:14:46 of tests in your mind? 0:14:48 – You know, again, if you think about 0:14:51 the payer’s interest, it’s pretty simple. 0:14:53 You know, we want you to provide more services 0:14:54 for less price. 0:14:57 From the patient’s perspective, you have the sick, 0:14:59 the chronically sick, you have the worried well, 0:15:01 so, you know, what should be the balance 0:15:03 between what’s ordered and what’s paid for. 0:15:05 And from the provider perspective, 0:15:08 you have a whole array of new tests 0:15:10 that come to market all the time 0:15:12 and what’s the right way to introduce them 0:15:14 and to educate doctors and patients about their use. 0:15:17 I think the most underutilized tests 0:15:20 are actually probably the most common tests. 0:15:24 So I think thyroid testing is very much underused 0:15:27 and not well understood by most primary care physicians. 0:15:29 I think Hemoglobin A1C for management of, 0:15:32 you know, patients with chronic diabetes, 0:15:34 which of course, when you have diabetes, 0:15:37 most patients have two or three other comorbidities. 0:15:38 I think the whole menu of tests 0:15:41 around chronic kidney disease is vastly underutilized 0:15:44 because we know that most patients, 0:15:46 most consumers with chronic kidney disease 0:15:48 don’t even find out about it 0:15:49 until they’re beyond stage two 0:15:51 and, you know, potentially into stage three 0:15:52 of their kidney disease. 0:15:55 And yet the simple EGFR tests, you know, 0:15:58 indicates when your kidney is not performing adequately. 0:16:03 So there’s a whole range of what you and I would characterize 0:16:05 as kind of, quote unquote, routine core tests 0:16:07 that could be much better used 0:16:09 if we had a willingness on the payer’s part 0:16:10 to make that investment. 0:16:12 So can we stay on that for a second? 0:16:14 You talked about price, value. 0:16:15 There’s one thing that I think characterizes 0:16:19 the diagnostics industry, at least historically, 0:16:22 is that reimbursement has always been under pressure 0:16:24 and in many cases declining. 0:16:26 The ability to capture value 0:16:30 has been somewhat challenging or limited. 0:16:32 If you look from the companion diagnostic side, 0:16:34 at least historically, and this is changing, 0:16:36 you know, pharmaceutical companies 0:16:38 actually had little interest or limited interest 0:16:40 in having companion diagnostics 0:16:43 that would exclude patients from undertaking a therapy, 0:16:45 although I think that is shifting. 0:16:47 So when you take all of that together 0:16:48 and you combine that with the fact 0:16:50 that you in some ways have a frenemy in the hospitals, 0:16:52 right, because they have their own labs, 0:16:54 so they wanna keep as much of the testing 0:16:55 that they can themselves 0:16:56 and they will send stuff out to you 0:16:58 when they have to or need to, 0:17:01 what do you think the future of this industry looks like? 0:17:04 – Look, one of the things that I’ve observed 0:17:07 in my career in healthcare and in the lab industry is, 0:17:10 our industry hasn’t changed much 0:17:11 in terms of what we really do. 0:17:13 And yes, it’s changing how we deliver, 0:17:15 it’s changing the throughput of the instruments, 0:17:17 but basically the industry hasn’t changed much. 0:17:18 Why is that? 0:17:20 It’s because we are, you know, 0:17:23 the foundation of diagnosis and care. 0:17:26 And so you can see a healthcare system 0:17:30 in which there are way fewer hospitals 0:17:31 and much more is done in the home 0:17:33 or is done in outpatient centers 0:17:35 and the hospitals are facing that reality. 0:17:39 You can see a system in which there are, you know, 0:17:40 way fewer independent physicians 0:17:43 and they work for somebody or you can see a system, 0:17:46 but I just can’t envision a system in which there’s no lab. 0:17:49 So our position in the infrastructure is essential. 0:17:51 – Let’s talk about reimbursement pressure. 0:17:53 How do you get paid today? 0:17:55 What do you get paid for? 0:17:56 Who pays you? 0:17:58 – There’s always gonna be reimbursement pressure 0:17:59 in healthcare. 0:18:01 I mean, we were engaged in a discussion recently 0:18:02 with an analyst who said, 0:18:03 “Well, I don’t understand why you can’t get 0:18:05 “three to 4% price increases a year 0:18:07 “because, you know, you’re the low-cost provider 0:18:08 “and you bring high value.” 0:18:11 And, you know, it’s just not a realistic way 0:18:14 to look at healthcare and say people are gonna get 0:18:15 three or 4% price increases. 0:18:17 And we know that, you know, 0:18:19 the drug companies are under pressure about their pricing 0:18:21 and the hospitals are under pressure about their pricing. 0:18:24 And so we have to assume that prices 0:18:26 will continue to be under pressure 0:18:29 and that new innovative things 0:18:33 that have a decent price set will erode over time. 0:18:35 Government is actually the largest payer 0:18:37 and the payer of default in our system today. 0:18:39 I don’t think a lot of people realize that, 0:18:42 but Medicare Advantage, which is a government-run program 0:18:44 that’s administered by private companies, 0:18:47 Medicaid, which is a traditional fee-for-service program, 0:18:48 and then Manage Medicaid, which, again, 0:18:50 is a government-funded program 0:18:51 that’s administered by private companies. 0:18:54 Then you add in federal employee benefits, 0:18:56 railroad retirement, you know, I mean, there’s just enough. 0:18:57 So there’s– 0:18:57 – It sounds pretty straightforward. 0:18:59 – Yeah, exactly. 0:19:00 Just send out a bunch of bills 0:19:02 and hope somebody pays them. 0:19:03 So the government is the largest payer 0:19:05 and then Manage Care is the second-largest payer, 0:19:07 the large managed care plans. 0:19:09 We have our CFO, who’s now been with the company 0:19:12 for five years, came from the industrials world. 0:19:13 And he’s a terrific CFO, 0:19:15 but we were talking about the billing system 0:19:16 and he said, “Well, I don’t understand why 0:19:18 “we just don’t go out to Oracle or something, 0:19:19 “just buy one and put it in. 0:19:20 “It just can’t be that complicated. 0:19:21 “You send a bill, they pay.” 0:19:24 I said, “Oh no, it’s a little more, you send a bill. 0:19:26 “They adjudicate it. 0:19:28 “It may go to the patient’s deductible, 0:19:30 “back to the patient. 0:19:33 “It may be that the service is not a coverage service. 0:19:34 “It may be that there’s a coverage policy 0:19:35 “that hasn’t been met. 0:19:38 “It may be that they pay part of it 0:19:40 “and you have to send part of it.” 0:19:43 So billing is a huge and complex area for us 0:19:45 and we have over 2,000 people 0:19:47 who just manage the billing side 0:19:49 of our provision of services. 0:19:50 – And lengthy. 0:19:53 I mean, it sounds like much, much time passing. 0:19:56 – Which is super frustrating for the patient 0:19:57 because by the time they get a bill, 0:19:59 it may be months after they had the service. 0:20:02 And I can’t tell you how many complaints we get about, 0:20:03 I don’t even know who LabCorp is. 0:20:05 My doctor drew some blood 0:20:06 and the next thing I know, I’m getting a bill from you. 0:20:09 So it’s a very complex billing system. 0:20:11 So to your earlier question, Jorge, 0:20:13 about what we do about margins. 0:20:17 I mean, our laboratories are only a small part 0:20:18 of our infrastructure. 0:20:21 We have several thousand cars and couriers 0:20:22 that pick up specimens. 0:20:24 We have our own aircraft. 0:20:26 There’s a whole logistics piece that underlies it. 0:20:30 We have 1,700, 1,800 patient service centers 0:20:31 where people can come and get their blood drawn. 0:20:33 We have people sitting in doctor’s offices. 0:20:36 All of that has to be coordinated underneath the testing. 0:20:40 We’re working on how do we make that more automated, 0:20:43 more digitized, how do we take paper out of the process 0:20:46 so that we can actually deliver the customer 0:20:47 a better experience. 0:20:52 We moved from, you used to go to LabCorp and get there 0:20:54 and it was a laborious process. 0:20:56 You had your requisition for your lab test. 0:20:58 You had to get a driver’s license, your insurance card. 0:20:59 We scanned it. 0:21:01 You fill that information. 0:21:03 Now we have check-in kiosks. 0:21:04 You can check-in online. 0:21:06 I went and had my blood drawn not long ago. 0:21:09 I checked-in online for my testing. 0:21:12 When I got to the patient service center, 0:21:14 I had a QR code if that’s what they’re called on my phone. 0:21:15 I scanned it at the kiosk. 0:21:17 I was checked in, that’s it. 0:21:18 And, you know, five minutes later, 0:21:20 I’m called, testing’s done and I’m through. 0:21:23 So these are ways in which we’re working on 0:21:25 preserving our margin and at the same time 0:21:28 providing a better experience for the consumer. 0:21:30 And I know it’s 4,400 tests. 0:21:31 It’s a pretty broad range. 0:21:34 So it’s going to be an over-generalization, 0:21:37 but on average, what do you get paid per test? 0:21:40 And on average, what is the sort of collections rate? 0:21:42 ‘Cause that’s one of the things that I think is so shocking 0:21:44 to people outside of the healthcare system 0:21:48 that a significant number of percentage of bills 0:21:49 just go unpaid. 0:21:54 – Yeah, so our average encounter price is about $45. 0:21:57 We do about two million patient encounters a week. 0:22:01 And so it’s a big, high-scale, high-throughput business. 0:22:04 We see about 110 million patient encounters a year. 0:22:07 In terms of the bills, you know, our bad debt rate, 0:22:10 our non-collected rate is in the range of 4%. 0:22:11 But when you think about that, first of all, 0:22:13 it’s a very substantial amount and almost all of it 0:22:16 comes from the patient side of the equation. 0:22:19 But what that doesn’t speak to is the amount 0:22:22 of service that we provide that physicians order 0:22:25 that patients need that doesn’t get paid for to begin with. 0:22:27 ‘Cause that doesn’t actually get down to the bottom line. 0:22:29 That all gets adjusted out at the sales level. 0:22:34 So payer policies, we only cover a vitamin D test 0:22:36 with these diagnoses. 0:22:40 Or we have a payer that only covers prenatal screening 0:22:45 for women if the putative father appears at the appointment. 0:22:47 Which when you think about the Medicaid population 0:22:49 or the underserved population, 0:22:51 the chances of getting the putative father 0:22:53 at the appointment are pretty small. 0:22:57 And yet, we know that it’s important for that patient 0:23:00 to have the genetic screening that the physician has ordered. 0:23:04 So there’s a lot of leakage in the system of, you know, 0:23:07 where we’re, and look, you know, we’re a public company, 0:23:09 we’re a for-profit organization. 0:23:10 We have to try to maximize what we can do 0:23:13 for our shareholders, but we also have a real sense 0:23:16 of the mission of improving patients’ health and lives. 0:23:18 And so we do a lot of things that do benefit patients, 0:23:20 even though we get frustrated with the payers 0:23:23 that they have restrictive policies. 0:23:25 – So in this model where the test is ordered, 0:23:27 it’s paid for, and then the information goes on, 0:23:29 there’s lots of leakage in the system, as you say, 0:23:30 and there’s problems with this model, 0:23:32 but it is a very entrenched model. 0:23:35 How do we move towards this value-based 0:23:38 or outcomes-based shift where we’re trying to value 0:23:41 what happens as a result of all these things in the future? 0:23:43 What would that look like in the lab? 0:23:46 – So to me, what that looks like is the hospitals 0:23:48 think about their laboratory, and instead of saying, 0:23:52 well, gee, I can run a thyroid panel in my hospital lab 0:23:54 and get paid $300 for it, 0:23:57 and maybe the patient gets a bill for $16. 0:24:00 To the doctor, it looks like I have a bundle of dollars here 0:24:02 to spend on this patient. 0:24:05 I’m at risk if I spend more than is allocated, 0:24:06 but I also have potential upside 0:24:08 if I spend less than allocated. 0:24:11 So I’m completely good 0:24:14 with sending the test to LabCorp for $40 0:24:16 and using the hospital lab in a different way, 0:24:19 which is supporting the emergency room, 0:24:23 supporting the operating theaters with pathology. 0:24:26 I’m actually optimistic that as we move to value-based care, 0:24:27 there’ll be a much more rational approach 0:24:31 to how we think about where the site of service 0:24:32 should be for everything, right? 0:24:36 I mean, we do way too many non-acute things 0:24:38 in the hospital today. 0:24:41 You should be paid the same price by Medicare 0:24:43 for doing the same service at every site. 0:24:45 The hospital shouldn’t make more 0:24:46 for doing a colonoscopy in the hospital 0:24:48 than they get from doing it 0:24:49 at an ambulatory surgery center. 0:24:52 The doctor should not be getting paid more 0:24:54 for doing chemotherapy in the office 0:24:55 than it can be done at a remote cancer center. 0:24:57 – Yeah, that does feel appropriate. 0:25:00 – And certainly, the hospital should not be getting paid more 0:25:02 for doing chemotherapy in the hospital setting, 0:25:04 which is the worst setting for the patients 0:25:06 to get chemotherapy in than for doing it 0:25:08 in a less acute environment. 0:25:12 So in my mind, it will bring real economic rationality. 0:25:14 It has the potential to bring, if done right, 0:25:15 real economic rationality 0:25:17 to the ancillary services part of the system. 0:25:19 – So you touched on something really interesting, 0:25:23 that healthcare delivery is being pushed out 0:25:26 of the four walls of the monolithic hospital 0:25:27 out into the periphery. 0:25:30 The consumer is increasingly becoming more empowered, 0:25:32 or at least it’s demanding more of healthcare system 0:25:35 as they, in turn, are being demanded to pay more 0:25:37 for their own healthcare employers as well. 0:25:39 What do you think the coming decades look like 0:25:41 from a technology standpoint 0:25:43 for the laboratory diagnostics industry? 0:25:45 I can see how technology will make coordination of care 0:25:49 easier, I can see how it would make logistics more efficient. 0:25:52 I can also imagine how technology will enable us 0:25:55 to test for things that we can’t test for today, 0:25:58 to derive insights that we don’t have today. 0:26:00 But I can also imagine that at some level, 0:26:02 as technology gets better, 0:26:05 it will make less sense to send a sample to the diagnostic 0:26:07 and it’ll become increasingly feasible 0:26:10 to send a diagnostic to the sample. 0:26:14 So is sort of point of care diagnostics technology, 0:26:15 is that an existential threat, 0:26:19 or will there always be things that have to be done 0:26:21 in a centralized lab setting, 0:26:23 even if there are more things over time 0:26:26 that can be done in a sort of point of care setting? 0:26:27 – So are you asking essentially, 0:26:29 will the lab be unbundled too? 0:26:31 – Yeah, my question is will the lab disappear? 0:26:33 – There will always be some tests 0:26:34 that need a venous blood draw, 0:26:37 that need a relatively significant amount of specimen, 0:26:38 and that can only be done in the lab environment. 0:26:40 And particularly, you know, 0:26:43 the complex and esoteric testing will, in my mind, 0:26:46 there will always be a central laboratory. 0:26:47 – So you’re not worried about genome sequencing 0:26:48 on the iPhone? 0:26:50 – Not today. 0:26:52 It’s funny, years ago I was at a personalized 0:26:53 medicine conference and one of the panelists 0:26:55 was talking about, oh, you know, within three years, 0:26:57 you’re just gonna put your saliva on the iPhone 0:26:58 and it’s gonna measure all your vital signs, 0:27:01 and you know, including all your laboratory values. 0:27:02 But it didn’t come to pass, 0:27:05 so many things in healthcare, it’s way slower 0:27:06 than people think. 0:27:10 But I’m a big believer in, you know, 0:27:12 laboratory testing needs to be democratized. 0:27:16 I mean, part of the reason that we don’t have 0:27:19 as much of an impact on patient care as we should is, 0:27:21 when you think about the way the system works, 0:27:23 so you go to the doctor, 0:27:26 now my doctor actually is, I was actually very impressed, 0:27:29 he sent me the lab that slipped before my appointment 0:27:32 to have the blood drawn, so he could have the results. 0:27:34 – But there’s a good chance he knows who you are. 0:27:38 – Yeah, he’s probably, that’s right, he does know who I am. 0:27:41 But most of the time you go to the doctor, 0:27:42 you get your blood drawn, 0:27:44 you get the results back three days later, 0:27:46 now it’s like, well, now I gotta call the doctor, 0:27:47 I gotta figure out the interpretation, 0:27:50 or you get the lab slip, you went to the doctor, 0:27:52 you weren’t feeling so great on a Friday, 0:27:54 you woke up Sunday morning, you felt okay, 0:27:57 and the lab slip just kind of, you know, goes in the trash. 0:28:01 – A shocking number of drug prescriptions never get filled, 0:28:04 and obviously the drug you don’t take cannot work. 0:28:08 Do you have a sense of what percentage of diagnostic tests 0:28:12 that are ordered by a physician are actually done? 0:28:16 – I don’t, and it’s a major point of frustration for me 0:28:20 that most physicians and health systems 0:28:24 have a follow-up system for ancillary services, 0:28:26 like if you go to the doctor and they say get an MRI 0:28:27 and you don’t show up for the MRI, 0:28:29 you’re gonna get pestered, you know, 0:28:30 or you get a referral for physical therapy, 0:28:32 you’re gonna get pestered. 0:28:34 If they give you a lab slip and you don’t do the labs, 0:28:36 you probably never hear anything about it. 0:28:40 There’s, you know, kind of urban lore about, oh, you know, 0:28:41 10, 15% never get performed. 0:28:44 There was a study done years ago at Harvard Medical School, 0:28:47 even there, there was a relatively high non-compliance rate, 0:28:49 as I remember, you know, 15, 20%. 0:28:53 And so I think that being able to move care 0:28:57 closer to the patient, if, this is a big if, 0:28:59 if the technology is good enough 0:29:03 that it is clinically relevant, that it’s reproducible, 0:29:04 and that the quality is there, 0:29:06 that’s a good thing for patients, 0:29:07 and it’s a good thing for our industry. 0:29:09 We can collect testing in the home, 0:29:12 and as long as it’s performed in our main laboratory, 0:29:16 we can integrate that into the patient’s health record. 0:29:18 So one of the big issues with point of care testing 0:29:20 has always been, you know, you do it, 0:29:23 and then you get a printout, 0:29:24 and, you know, unless you literally staple it 0:29:27 to the patient’s forehead and they go to the doctor’s office, 0:29:28 half the time it never gets to a place 0:29:30 where it’s gonna be well-interpreted. 0:29:31 – So the information flow gets messed up. 0:29:33 – And I don’t think there’s gonna be sort of, you know, 0:29:35 the quote-unquote killer app 0:29:38 that’s gonna just completely turn the business upside down, 0:29:40 ’cause believe me, enough people have tried to find it 0:29:42 in the last 10 years, and, you know, so far we’re not there, 0:29:45 but the technology will change. 0:29:48 Bringing lab testing closer to the patient is an imperative, 0:29:50 just to make lab testing more effective 0:29:51 and more valuable in the system, 0:29:53 and in the value-based care model, 0:29:56 when we’re engaged with patients in their homes 0:29:58 around not only your actual health, 0:30:01 but, you know, your social determinants of health, 0:30:03 and then we’re gonna have much more opportunity 0:30:04 to bring those tools to the patient 0:30:06 and actually, you know, help them manage their care. 0:30:08 – So when we think about the lab 0:30:09 and the way it’s changed over time, 0:30:12 from, you know, pipettes and beakers to microarrays, 0:30:15 what do you see coming next as the big new tools 0:30:16 or the new innovations 0:30:17 that you’re trying to think about how to integrate? 0:30:20 – So from a technological standpoint, 0:30:23 obviously the increasing miniaturization of instruments, 0:30:25 the tabletop instruments, 0:30:26 which, again, goes back to what we talked about 0:30:29 with democratizing the range of services. 0:30:31 Sequencing as a tool for diagnostics, 0:30:34 you know, the cost of sequencing is rapidly coming down. 0:30:37 The competitive landscape is becoming much more competitive 0:30:38 than it has been historically, 0:30:42 and so genetic testing that we have traditionally done, 0:30:43 you know, again, I remember when we started 0:30:46 with cystic fibrosis, you know, we looked at 30 markers, 0:30:48 and then it was 60 markers, then it was 90 markers, 0:30:51 and now we just sequenced the cystic fibrosis gene, 0:30:53 and there’s way more information in there, 0:30:55 which has pluses and minuses. 0:30:57 The pluses, there’s way more information in there. 0:30:59 The minuses, a lot of it is not well understood, 0:31:01 and so, you know, that takes me to what I think 0:31:03 is really gonna be what’s revolutionary 0:31:06 in the next 10 years is the understanding of the data 0:31:08 and the integration of the data 0:31:11 that comes from laboratory medicine. 0:31:15 That’s gonna be the huge transformation in our business. 0:31:17 It’s not gonna be the underlying technology. 0:31:19 People think, oh, you know, sequencing, 0:31:20 that’s a great new thing. 0:31:22 Sequencing is just another methodology 0:31:24 to do many of the things we already do today. 0:31:26 It’s a more efficient methodology, 0:31:28 but what comes out of the sequence 0:31:29 is a wealth of information 0:31:32 that we haven’t been getting historically, 0:31:34 and integrating that information into the coordination 0:31:37 and the arc of patient care is gonna be where 0:31:39 we’re really gonna see diagnostic shine 0:31:40 in the next five, 10 years. 0:31:43 – So as we look five, 10 years into the horizon, 0:31:46 if I’m an entrepreneur starting out, 0:31:48 and I have an idea or a technology 0:31:51 that I think is applicable as a diagnostics 0:31:54 or applicable to the diagnostics industry, 0:31:56 what do you think are the opportunities 0:32:00 or the blue sky opportunities for entrepreneurs 0:32:01 coming into this industry today? 0:32:04 – I mean, there are so many areas of diagnostics 0:32:07 that we just, fertility is an area 0:32:10 that we just don’t have really good tools. 0:32:13 And so, an entrepreneur who could bring to the market 0:32:18 something that would increase the rate of success in IVF. 0:32:19 Great area. 0:32:21 – What are some of the other ones? 0:32:23 – I think that emerging infectious disease 0:32:25 is an area of real concern. 0:32:28 I mean, the public health services 0:32:30 were overwhelmed with Zika testing, 0:32:32 so they ended up sending it to the commercial labs 0:32:34 without going through full regulatory processes, 0:32:35 the tests that they were doing, 0:32:38 ’cause they just couldn’t handle the specimens. 0:32:41 Anything that addresses new and emerging disease states, 0:32:44 in my mind, is a real area of opportunity. 0:32:48 The caution is, one, the history of the diagnostics industry 0:32:52 is littered with the small laboratory 0:32:54 that offered one test 0:32:56 and had a great arc at the beginning 0:32:59 and then ran up against the reality, 0:33:02 which is that the doctors want to order everything 0:33:04 from one place. 0:33:06 So, go back to non-invasive prenatal testing. 0:33:07 There were three companies 0:33:10 that did non-invasive prenatal testing, 0:33:11 all of them were independent, 0:33:14 and now one of them is independent, 0:33:15 one of them was bought by Roshan, 0:33:16 one of them was bought by us. 0:33:19 Why? Because the OBGYNs, 0:33:21 who were doing the non-invasive prenatal testing, 0:33:25 didn’t want to have to put a box over here, 0:33:27 a specimen over here to go to that company 0:33:29 and everything else from my office goes to Quest 0:33:30 or everything goes to LabCorp. 0:33:34 So, the distribution channel is really, really critical. 0:33:37 And the second thing that’s really critical is reimbursement. 0:33:39 You can’t imagine how many people come 0:33:43 with a really cool test and great data, 0:33:44 but the payers just, you know, 0:33:46 they’re just not going to pay for things 0:33:48 that even if they should, you know, 0:33:51 broad-based screening for whatever disease it is 0:33:53 of the asymptomatic population, 0:33:54 payers don’t want to pay for it 0:33:56 because there’ll be too many false positive, 0:33:58 too much treatment and while saving the long run 0:34:02 for screening the whole asymptomatic population, 0:34:03 I’m not going to do well. 0:34:05 But in a value-based care model, 0:34:07 in which the reward is for early detection 0:34:08 and early treatment, 0:34:11 then payers should be enthusiastic 0:34:12 to pay for early detection and early screening. 0:34:15 So, the reimbursement piece and the distribution channel 0:34:16 are really critical for the entrepreneur 0:34:18 who comes up with a great idea. 0:34:19 – And so, in that spirit, 0:34:22 how does an entrepreneur work with LabCorp? 0:34:24 Do I knock on your front door? 0:34:25 – So, there’s two ways. 0:34:28 One is we invest in ideas that we think are interesting 0:34:31 and often those are ideas that are, 0:34:33 well, the whole goal of it is invest in ideas 0:34:35 that are disruptors, invest in ideas 0:34:36 that are potentially competitive 0:34:38 so we can see what’s going on and understand the lens, 0:34:39 because that’s one way. 0:34:42 The other way is, we’re not a research company, 0:34:43 we’re a development company, 0:34:45 so we take other people’s good ideas 0:34:47 and we scale them so we can run them 0:34:49 100 million times a week if we need to 0:34:52 and that’s why we welcome the idea of entrepreneurs 0:34:55 doing things that will enhance the value 0:34:57 of diagnostics in general. 0:34:59 – So, yes, essentially, come knock on your front door. 0:35:00 – Knock on our front door. 0:35:01 Knock on the side door, we got plenty of doors. 0:35:02 We welcome it. 0:35:05 – Thank you so much for joining us on the A16Z podcast. 0:35:06 – Thank you, it’s been great being with you.
A lot’s going on in the world of healthcare right now, and one topic that’s especially relevant is how diagnostic labs work. In this episode with Dave King, Executive Chairman of Lab Corp (one of the largest clinical lab networks in the world) and a16z’s General Partner Jorge Conde and Hanne Tidnam, we cover the evolution of the modern lab over the past 50 years, especially as new technologies and new tests are added; how tests go from specialized to mainstream and widely available; and who pays for most tests and how reimbursement affects all this. We also discuss where lab information flows—in electronic health records and in the health system at large—and touch on what the lab of the future might be like.