$1.5 billion digital-health startup Ro wants to be your online doctor. Here's how its coronavirus response rooted in rapid at-home testing fits into the new unicorn's long-term strategy.

Ro covid test

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Ro, a hot digital health startup best known for selling generic Viagra, is taking another big step in expanding its healthcare ambitions.

Ro is teaming up with computer vision startup Gauss to offer at-home rapid COVID-19 antigen tests that provide results in 15 minutes, the companies announced Wednesday. The test is still awaiting emergency clearance from the US Food and Drug Administration. Ro doesn’t take insurance and declined to say how much it’ll charge for the test. 

The launch comes just a month after Ro announced it acquired Workpath, a startup that allows hospitals and clinics to send phlebotomists into patients’ homes to perform routine blood tests, furthering its goals to expand beyond its initial suite of mail-order pharmaceuticals for conditions such as hair loss or erectile dysfunction.

Ro’s aggressive moves into all parts of healthcare come at a pivotal moment for the industry, which has been upended by the coronavirus pandemic. Unlike hospitals or clinics, Ro’s virtual care model combined with its network of real-world pharmacies and logistics makes it poised to tackle distribution for rapid tests and eventually vaccines, cofounder and CEO Zachariah Reitano told Business Insider.

“Right now there are two things universally needed in healthcare: access to the vaccine and easy access to rapid testing,” Reitano said. “We have the technology and the infrastructure to distribute tests to patients across the country, and we have the unique capability to facilitate a connection to a doctor if it requires a prescription to get the test. We can mail it to them and guide them through the next steps. Not many other companies can do that.”

Read more: The 26 billion-dollar startups to watch that are revolutionizing healthcare in 2021

Ro’s ambitions extend well beyond telemedicine

Ro started with a modest proposal: patients could virtually meet with a care provider and get generic prescription medications for conditions like hair loss or erectile dysfunction sent to their homes for a nominal fee.

Nearly four years later and the startup has skyrocketed to a $1.5 billion valuation while aggressively adding new products and services for its growing group of patients. 

When the coronavirus pandemic took root, companies like Ro and its competitor Hims added new patients as doctors’ offices shuttered and people remained hesitant to venture out to a nearby pharmacy, Reitano said. The virtual care model and easy shipping appeared tailor-made for a pandemic that left most Americans house-bound.

“Growth isn’t a problem right now,” Reitano said. “We’re going to expand and add services to try and keep up with the demand of the country.”

At present, that means building specifically for the coronavirus pandemic, Reitano said. The Gauss partnership is the first step in what Reitano said was his company’s responsibility in lowering transmission rates and saving peoples’ lives.

Reitano also said Ro is interested in helping with vaccine distribution, but declined to discuss the plans.

Ro’s future lies in testing

A more ambitious future for Ro could rely heavily on building a network of traditional healthcare services instead of relying on the partnership model it’s worked on in the past, repeat healthcare founder and investor Nikhil Krishnan said.

The ability to control pricing and cut out middlemen is key to the company’s long-term success because it relies on patients paying cash for services instead of working with insurance plans. The lower Ro’s costs, the lower it can keep prices.

“Lab testing, depending on how it’s structured, can be really expensive to outsource so it makes sense to bring it in-house at some point,” Krishnan said. “Ro has been pretty ahead of the curve in bringing those pieces of the value chain in-house.”

Part of the appeal of launching an at-home COVID-19 test is that Ro can substantially cut costs of currently available at-home tests that retail for between $100 and $150 per testing kit. 

“We’d like to put pressure on the market and bring the prices down across the board,” Reitano said.

To stay competitive, Ro wants to play a bigger role in its customers’ lives but needs more patient data to be effective. For instance, by offering lab tests and screenings from Workpath, it can help treat a larger variety of conditions through telemedicine and eventually in-person, Reitano said.

Krishnan said Ro is building an experience for patients in the real world after establishing a relationship with them online. Testing, and to some extent screening, can help companies like Ro gather more information on patients and better compete with physical healthcare practices.

“I don’t know if there’s necessarily a right way to strike a partnership, but I definitely think a lot of the telemedicine companies will have to figure out how to get this information eventually,” Krishnan said.

Reitano said he is eager to expand into other forms of testing with the goal of becoming what he calls a “fully integrated” primary care provider that can host virtual visits and ship a host of medications directly to patients while freeing up in-person care for those patients that truly need it.

“It’s just the beginning of us for testing,” Reitano said.

SEE ALSO: 2 former Sequoia VCs just raised $500 million for their firm’s second fund. Here’s how they plan to spend the funds.

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A startup that raised $175 million to fix primary and urgent care is still struggling with what its CEO called the 'most complex' problem in healthcare

Summary List PlacementSome of healthcare’s problems are so complex that even the most well-funded startups struggle to fix them.
Carbon Health cofounder and CEO Eren Bali found out as much as his company tried to make prices for doctor’s visits, routine procedures like blood tests, and comparative prices for diagnostic tools like MRIs and x-rays transparent for patients, a feat that sounded simple at first but quickly ballooned into a much larger, systemic problem.
In a Twitter thread posted on December 27, Bali ran through the challenges he and his team had identified in trying to create a menu of sorts for different procedures and treatments for Carbon Health patients.
In the end, he ultimately said the fix lies with insurance companies — not healthcare providers — to fix the way patients and clinics are expected to pay for healthcare in the United States.
“The problem is on the payer side,” Bali told Business Insider. “The payer systems are old and antiquated, and that’s opaque to providers. We are doing all we can on the provider side.”
Read more: $1.5 billion digital-health startup Ro wants to be your online doctor. Here’s how its coronavirus response rooted in rapid at-home testing fits into the new unicorn’s long-term strategy.
Calculating prices ahead of visits proved difficult
Carbon Health serves a wide variety of patients with its urgent and primary care services. It offers booking through an app, and also added virtual visits to any patient seeking care but hesitant or unable to go into one of its physical clinics.
Ideally, Bali said, Carbon would be able to show patients the costs of these services upfront so that the doctor and patient can decide on the best course of treatment together, but hasn’t made as much progress as he would like.
Some relatively new healthcare entrants like Walmart have similar ambitions in making shopping for healthcare just as easy as shopping for groceries. Patients can find Walmart’s cash prices online, such as a primary care visit that costs $40.
Carbon Health has developed a system that works well for patients without insurance, Bali said, because pricing is more straightforward. It created a data analysis tool that looks at different inputs such as existing conditions, Carbon’s cost of service, and other factors to provide an up-front cost to uninsured patients, Bali said. For example, Carbon charges uninsured patients $195 for a primary care sick visit and $69 for a virtual visit, according to its website.
But it was when that same system was trained for patients with insurance that things started to unravel, Bali said. The calculated costs for patients with similar backgrounds, insurance plans, and symptoms only matched 40% of the time, Bali said.
“We can’t explain the difference,” Bali said.
Insurance companies are built on out-dated systems
Part of the variance can be explained by how complex insurance plans are, Bali said. Each plan is essentially unique to the individual that has it, and coverage can range widely even among similar plans offered by the same insurance company.
That’s not something that even the most sophisticated data analytics model can fix, Bali explained. If healthcare providers like Carbon want to tell patients how much they can expect to pay for a visit and associated procedures, insurance companies need to update how they bill both patients and providers.
“It’s driven around the inadequate system,” Angela Miles, head of revenue cycle at Carbon Health, told Business Insider. “We need to rebuild that from a payer standpoint to get to a more modern standpoint.”
More complexity leads to increased costs
Startups like Oscar Health are already attempting to bring insurance companies into a more modern model, Bali said, but larger companies have yet to shift in a meaningful way.
Those that do change, albeit in a more superficial way, actually make the problem worse by making it even more complicated, Bali said, because the added complexity adds time, which adds costs.
“A lot of work that goes towards decreasing healthcare costs is making the system more complicated,” Bali said. “My theory is that things that drive increased cost in healthcare is due to increasing complexity because you can’t be transparent and compete on price.”SEE ALSO: The founder of a healthcare venture fund that just raised $200 million shares why she wants to back founders that are building businesses for their communities
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A healthcare startup serving LGBTQIA+ patients just raised $25 million, and its growth reveals a key area of opportunity for other primary care startups

Summary List PlacementPrimary care, and healthcare more broadly, is largely one-size-fits-all in the US. 
A growing group of entrepreneurs and investors are trying to dismantle it and rebuild a more equitable healthcare system in its wake.
One such startup is Folx, a consumer healthcare startup for LGBTQIA+ patients, although there are tens more startups hoping to build trust among other long-neglected and underserved communities of patients. 
On Tuesday, Folx announced it raised $25 million in Series A funding from Bessemer Venture Partners, Polaris Partners, Define Ventures, and Red Antler. 
Although Folx is launching with direct-mail hormone replacement therapy treatments for transgender patients, founder and CEO A.G. Breitenstein told Business Insider of her long-term goals to unseat traditional care avenues for the LGBTQIA+ community, which is often discriminated against in traditional primary care settings. In the coming years, Breitenstein sees Folx drastically expanding the conditions it is able to treat through telemedicine in addition to expanding into owned-and-operated in-person clinics across the country.
“Discrimination is newly legal,” Breitenstein said of the Trump administration’s retraction of protections for transgender patients. “It allowed providers to discriminate against our community. Care has always been unstable for them, but we can be there for them and that’s what we’re here for.” 
Read more: This startup’s pricing model based on health insurer data was wrong almost half the time, and it reveals a huge challenge to reshaping healthcare
Startups like Folx want to reimagine the US healthcare system based on overcoming patients’ negative experiences, and that means building new models that don’t rely on the current network of doctors and clinics. 
“Our big takeaway is that other groups have underestimated the immense market size for advances in healthcare for distinct populations,” Bessemer Ventures Partners investor Morgan Cheatham told Business Insider. “We’re more bullish than ever that these niches aren’t so niche.”
That could contribute to a boon of highly specialized care startups, Cheatham said, in addition to those like his latest investment, Folx, that are already seeing growth among target populations. In fact, he said niche care could become the default for all primary care in the United States after the massive inequities were unearthed during the coronavirus pandemic.
Underserved patients need new healthcare solutions
Since 2014, highly targeted healthcare companies like Folx have collectively raised more than $1 billion, according to Pitchbook data.
The future of primary care could look like Cityblock Health, a $1 billion startup serving primarily low-income communities by addressing external factors like access to reliable transportation and clean drinking water as part of its holistic healthcare model. Its goal is to offset medical costs by addressing those factors, leading to better long-term health in the community. 
Until recently, investors didn’t consider these external factors, now commonly referred to as the “social determinants of health,” as a key area of cost reduction and innovation, one investor told Business Insider. It took a pandemic, and the cracks in the system it illuminated, to prove the environmental aspects of many Americans’ health. Now, it is an area of top investment for VCs going into 2021.
The future could also look like Oak Street Health, a more traditional primary care clinic model for elderly patients on Medicare, or ChenMed, for seniors with complex chronic conditions that need to be actively monitored by doctors. Oak Street went public in August, giving an air of legitimacy to the growing eldercare space.
Startups like One Medical have a broad-strokes approach to primary care but tend to focus primarily on city-dwelling young professionals with a subscription-based payment model and perks like cucumber water in waiting rooms. Village MD is another primary care startup with a broad appeal that works with physicians to provide care and has in-person clinics in select Walgreens locations. Those companies’ successes, however, have helped paved the way for tech-enabled challengers to grow while serving other groups that aren’t able to afford or access care through their networks.
Read more: Meet the 8 primary-care companies building a new future for medicine during the pandemic
Of more interest to Cheatham and other VCs are the communities that don’t yet have tailormade healthcare solutions. He pointed to communities like recent immigrants, undocumented individuals, low-income communities, and even racial or ethnic-specific groups as developments he is hoping for in primary care. 
“The One Medicals of the world focus on the upper end of that income spectrum, but there’s a lot of work to do on the other end,” Cheatham said, referring to the membership-based primary care model primarily targeted at healthy, working-age upper-middle-class patients.
Healthcare equity will have to come from outside
Getting patients to trust upstarts, a monumental task in healthcare broadly, still remains a challenge for the community-based care companies. Winning them over requires an entirely new perspective on medical care and clinic experience, Breitenstein said, even if that perspective comes from someone largely outside the existing system.
That approach involves lots of educational materials, Breitenstein said, so that patients know of and are able to adjust to complications from medications and make informed decisions about their own courses of treatment. 
That “informed consent” model differs from traditional symptom-based care in that it is more proactive and takes more stock of a patient’s lifestyle and goals, Breitenstein said, all in an effort to win patients’ trust.
“The paradigm shift around informed consent model of care, where you come to us and tell us what your goals are so we can help educate and guide you through the healthcare system, it’s informative and empowering,” Cheatham said, adding that he sees the model moving into other aspects of healthcare in the future.
Breitenstein has big ambitions for Folx and believes the market opportunity is large enough to support its growth. Beyond adding new capabilities like STI testing and mental health visits, she sees Folx expanding into in-person clinics across the country that could eventually include surgery centers for gender confirmation surgeries. She also has an eye on family planning and fertility, an already booming market with several startups serving heterosexual couples.SEE ALSO: SIGN UP HERE: Hear from healthcare’s biggest VCs on the future of digital health, biotech, and startups
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The founder of a healthcare venture fund that just raised $200 million shares why she wants to back founders that are building businesses for their communities

Summary List PlacementOne of digital health’s only early-stage venture firms just raised a fresh tranche of funding to help the youngest startups get off the ground during a pivotal year for the industry.
Define Ventures raised $200 million for its latest fund, the second since it was founded by ex-Kleiner Perkins investor Lynne Chou O’Keefe in 2018.
The early-stage firm will continue making new investments in companies in the incubation stage all the way up to Series B, Chou O’Keefe told Business Insider.
The new fund’s timing, coming after a record-setting year of private investment in healthcare startups, was purely coincidental and on track with the typical two-year fundraising cycle at most firms, she said.
“We’ve had well-timed investment cycles,” Chou O’Keefe said “But the activity has increased, overall, post-COVID.”
Read more: A former Kleiner Perkins investor is staking out the future of digital health. Here’s why she just made an early bet on an in-home care startup founded by a former Uber exec.
Define wants to back early startups rebuilding the healthcare system with patients at its center
Chou O’Keefe said she anticipated keeping up the pace in 2021, writing more checks to companies she believes are reimagining what it’s like to be a healthcare patient in the United States. In Define’s first $87 million fund, she backed a wide range of digital health startups, including LGBTQIA+ primary care startup Folx and in-home care provider MedArrive.
She said to expect more of the same coming from Fund II, with consumer-focused healthcare startups taking center stage over other companies that want to sell services to hospitals or insurance companies. The firm’s thesis formed around backing companies that use technology to reimagine the patient’s experience of healthcare was successful enough in Fund I to earn a vote of confidence in Fund II, Chou O’Keefe said.
“We haven’t seen our strategy shifted, it’s more that the time to market has really shortened,” Chou O’Keefe said. 
In practice, the consumerization of healthcare Chou O’Keefe wants to back varies widely. It can look like Dawnlight, a startup that makes remote monitoring products that track fall risks, among other specialties. It can also look like Lightship, a startup that runs decentralized clinical trials that are easy for participants and researchers to use. All these startups, however, share the unique challenge of marketing to regular patients instead of working directly with hospitals, doctors, or insurance companies.
“The make-or-break of digital health is the commercial side of the business,” Chou O’Keefe said. “That’s something that is so critical, and when I started Define the lack of sector-focused early-stage players was a window of opportunity for us because these entrepreneurs need help to build. It takes a village to change healthcare for all of us.”
Chou O’Keefe is betting that founders want to build for their own communities
Chou O’Keefe will write checks from $1 million all the way up to $15 million, depending on the company’s needs. As a former Livongo board member and current Hims board member, she said Define can lead funding rounds that require the active board support, but ultimately leaves that decision to the entrepreneur. 
“Entrepreneurs recognize the oil from water here,” Chou O’Keefe said. “There are people that can partner with you and build these companies with you, but the lessons learned from tech don’t apply in the healthcare space.”
Her investment strategy is in part a bet on authentic founders, she said.
She is particularly interested in supporting the entrepreneurs that are building solutions for their own communities because that perspective can be a differentiating factor that contributes to a company’s success.
Of Define’s 12 portfolio companies, four are founded and led by women, one of the many communities Chou O’Keefe feels has been left out of high-level healthcare business decisions in the past.
“It’s important we have women founders and CEOs in this space because we make the decisions, and it’s really the right business decision as well,” Chou O’Keefe said.SEE ALSO: The 26 billion-dollar startups to watch that are revolutionizing healthcare in 2021
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THE RISE OF GENETIC TESTING IN HEALTHCARE: How leading genetic testing companies like Ancestry and 23andMe are carving into healthcare with the promise to fuel more personalized care

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Insider Intelligence publishes thousands of research reports, charts, and forecasts on the Digital Health industry. You can learn more about becoming a client here.
The following is a preview of one Digital Health report, The Genetic Testing in Healthcare Report. You can purchase this report here.

Since the first human genome was sequenced in 2003, the genetic testing market has evolved rapidly alongside consumers’ interest in how their genetic makeup affects their health.
The human genome was sequenced — or read in its entirety — for the first time in 2003 after more than 20 years of work and nearly $5 billion was put into the National Institutes of Health’s (NIH’s) Human Genome Project — which marked a huge step in helping scientists and medical researchers understand how genes and gene interactions impact disease development and progression. In the ensuing decades, genetic information catapulted into mainstream healthcare, driven largely by the rapid decline in cost for DNA sequencing technology.DNA testing firms like Ancestry and 23andMe broke onto the genetic testing scene via direct-to-consumer (DTC) tests, and consumers have flocked to their products seeking to gain insights into their individual health risks. Ancestry and 23andMe both offer cheaper, but less comprehensive, DNA testing — their products come at a price point between $100-$200, which is likely more enticing to average consumers than higher-cost tests that explore the entire, or a larger portion of, the genome.
Of the 26 million global consumers who took a DNA test in 2019, Ancestry and 23andMe tested 25 million. This marks a meteoric rise in consumer adoption over the course of the 2010s: In 2015, for example, fewer than 1.5 million global consumers had taken at-home genetic tests. 
The ability to provide genetic tests at a lower cost has opened up new opportunities in preventative medicine. For example, chronic illness accounts for 90% of the US’ more than $3.7 trillion of annual healthcare spending — and healthcare stakeholders are actively looking for ways to assess population health risks and intervene earlier. Genetic testing is an attractive proposition for healthcare players that want to paint a picture of an individual patient’s health risks — and use that information to help guide care plans that could mitigate the development or progression of a condition and steer drug development for more precise medications.
In this report, Insider Intelligence will examine the industry forces that have helped evolve genomic information from a consumer novelty to a transformative healthcare technology. We outline how some of the key players in the genetic testing space have altered their business models to appeal not only to consumers but also healthcare players across the industry, including health systems and pharma companies. We provide a glimpse at what’s next for the implementation of genomic information — namely, the barriers that are holding genetic testing companies back from reaching new customers, including how the coronavirus pandemic could impact growth in the space.
The companies mentioned in this report are: 23andMe, Almirall, Ancestry, Apple, Calico, Color, Diploid, Genelex, GlaxoSmithKline, Google, Helix, Illumina, Invitae, Jungla, LunaPBC, Mayo Clinic, Microsoft, MyHeritage, NorthShore University Hospital , Novartis, Ochsner Health, Pfizer, PWNHealth, Salesforce, Stanford Medicine, TrialSpark, Verily, Veritas, and YouScript.
Here are some key takeaways from this report: 

The use of at-home, direct-to-consumer genetic tests skyrocketed during the 2010s, but has been tapering off over the last couple of years. 
The slowdown in the DTC market has catalyzed genetic testing companies to veer into healthcare — teaming up to give legacy healthcare players access to rich sets of data that could guide care and treatments, which could help boost customer bases. 
Health systems can add genetic testing into care regimens to gain a more comprehensive image of patients’ health risks. Payers can front the costs of tests for their members, the results of which could empower them to take proactive approach to care management and reduce costs in the long-run; and drug-makers can unlock troves of genetic data in order to design more precise medications.
Myriad barriers are still holding back genetic testing companies from cementing their position in the healthcare industry, including privacy and accuracy concerns, the inability of healthcare professionals to operationalize genetic data, and a continued drop in consumer interest. 
The coronavirus pandemic and accompanied economic slowdown could weigh on genetic testing companies further, as consumers will likely put off nonessential purchases like genetic tests, and healthcare companies may focus resources and time on initiatives more directly related to the virus and recouping lost revenue.

In full, the report: 

Provides an overview of the ways in which prominent US genetic testing companies are using their products to edge deeper into the healthcare landscape.
Highlights how leading telehealth vendors have reacted to a sudden, rapid uptick in adoption of their services.
Outlines how legacy healthcare players — including health systems, payers, and drug-makers — are leveraging genetic testing companies’ products to make use of insights into genetic variants.
Identifies the barriers that genetic companies are staring down that could hinder growth and adoption. 

Interested in getting the full report? Here’s how you can gain access:

Join other Insider Intelligence clients who receive this report, along with thousands of other Digital Health forecasts, briefings, charts, and research reports to their inboxes. > > Become a Client
Purchase the individual report from our store. > > Buy The Report Here

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