[The Grid Transcript] Yoav Fisher - Head Of Technological Innovation and Digital Health at HealthIL
Medcase Health – The Grid by Medcase 01 Yoav Fisher
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Intro: Welcome to The Grid, the healthcare innovation podcast brought to you by Medcase, the global network of medical experts. On The Grid, we explore the stories of leading medical experts, startups, and organizations, bringing new technologies and services into the healthcare arena. The Grid is hosted by Kyle Giddens, the CEO of Medcase.
Kyle Giddens: Today we have the wonderful Yoav, and Yoav is the Head of Innovation and many, many other titles for HealthIL, a leading NPO here in Israel, where he sits on the pulse of everything to do with healthcare and technology. Welcome, Yoav.
Yoav Fisher: Hi. This is fun. I’m excited.
Kyle Giddens: Good, good, you should be excited. So, I want to start easy. And really, the goal is to have fun. So, just double tap when you stop having fun.
Yoav Fisher: I feel like we need to have a safe word.
Kyle Giddens: We need a safe word, we do. It’s health care.
Yoav Fisher: Fine.
Kyle Giddens: Anyways, it’s wonderful for you to be here. I’m going to ask, who do you think, from your perspective, is currently doing machine learning on your healthcare data right now? Whether it’s on your phone, or just in the general sense?
Yoav Fisher: Who is doing machine learning on my healthcare data?
Kyle Giddens: Yeah, who cares about you?
Yoav Fisher: Anybody. Anybody and everybody who can, especially in Israel, because Israel doesn’t actually have a policy for healthcare data ownership. So, if I was at the hospital, I’m a Maccabi member of the Ministry of Health, everyone here is selling my data to whoever they can and making money off of it except for me. So, my assumption is that anybody who has access to my healthcare data is trying to run some algorithm on it.
Kyle Giddens: Are you comfortable with that?
Yoav Fisher: It is what it is. We’ve all signed off on it?
Kyle Giddens: Yeah. It’s true. I love my tailored ads, why not tailored healthcare?
Yoav Fisher: Look, maybe it’ll get there. Hopefully, it’ll get there. But my assumption is that everything that you’ve touched on regarding healthcare, any system you’ve been a part of has access to data and is trying to utilize it for some purpose. Let’s hope and pray and assume that it’s for the purpose of saving other people’s lives and improving healthcare in general. But yeah, everyone’s running algorithms on my stuff and yours and yours, and yours.
Kyle Giddens: Yes, we’re all prey to the wonderful data overlords. And from that perspective, do you see large tech companies doing a better job in terms of eventually managing your health?
Yoav Fisher: That’s a really interesting question. Look, if you look at the stuff going on in the States and look at major tech companies, they’re making clear inroads to increase their footprint into health care. Whether they’ll be able to do it in a better fashion than traditional institutional healthcare is a major question. And I think it has yet to be proven. I do think if you parse out the different aspects of healthcare that the major tech companies clearly have a value at, especially looking at cloud services, as a component of healthcare, obviously, go use AWS, Google, Microsoft, whatever, as opposed to building some homegrown. Here is the Ministry of Health, we’re going to make our own cloud policy or a cloud service offering. So, with certain aspects techs can definitely do a better job.
With other aspects, the actual like, outcome of health has really yet to be proven. You can see hints of it, like Apple Watch, Atrial Fibrillation and this and that, whatever. I wouldn’t be surprised if healthcare is improved by certain aspects of tech, but the traditional healthcare system, in my opinion, will still remain. What can you do? People live and die in the real world and get sick, and at some point or the other, some of these people have to go to the hospital. I don’t foresee Microsoft, doing open heart surgery anytime soon.
Kyle Giddens: Yeah, probably not tomorrow, but in a decade from now. Amazon is making clear inroads in terms of Telehealth and prescriptions, probably carrying your home next.
Yoav Fisher: And a lot of the piping comes from these tech companies anyhow, as it exists and they’ll continue to do so. The best situation is the interplay of the best of both worlds.
Kyle Giddens: Both traditional players and tech coming together to do good things for our health.
Yoav Fisher: Yes, eventually that’s what will happen. I don’t know how it will play out economically. I don’t know what ownership tech companies will have, whether it be control or economic ownership, I don’t know. But eventually, there’s going to be some merging between the two.
Kyle Giddens: Yeah, like Amazon and Mayo Clinic, something like that.
Yoav Fisher: Yeah.
Kyle Giddens: They have to fight over whose name goes first on the building. Nice. And so you sit at the center of innovation here in Israel.
Yoav Fisher: I work in a really weird place. It actually is very hard to explain what this is. It’s the only national ecosystem for health tech innovation. What I mean by national is that it’s this totally separate nonprofit, but the people who sit on my board are the Israeli Ministry of Health, the Ministry of Economy, and the innovation authority. The overall mandate is to integrate technology into healthcare. But that’s extremely difficult. There are always issues with process and workflow differences, economic differences and motivation, whatever, all the stuff and regulation and policy.
So, the approach that HealthIL has is, let’s understand all these issues first, before just trying to plug in some startup or some tech company. So, the bulk of the work happens with the recipients or the people we’re interested in it, whether it be HMOs, pharma companies, device companies, etc. And we do two main things with them, is figuring out what they really need, their challenges, and their issues. How do you define that? How do you prioritize that? How do you strategize that? And the next point, which is equally important is, how do these organizations operate? What can we offer the startups on the other side?
Like access to data. Access to KOL. Access to money. What resources do they have? What resources do they not have? What is a resource? And then conversely, on this side of the equation is every startup in Israel in health tech, all of them every single one. I’ve passed already 1200 in my internal CRM. And with them, you also do a deep dive to figure out what they’re really offering, what they really need, what stage they’re at, and clinical validation. Yes, no, blah, blah, blah, blah, blah, blah, blah. And over the course of the year, you try to integrate one with the other.
The overarching goal is for the citizens of Israel and also abroad, can enjoy all this technology that’s being developed in one way or another. But getting to the point where you can enjoy it is extremely complex. And in order to make it work, you need to have a deep understanding of the complexity, otherwise, you’re just making ad hoc meetings that lead nowhere.
Kyle Giddens: So, you’re the best matchmaker.
Yoav Fisher: I’m like a matchmaker, I’m effectively like a natural matchmaker, 100%. It’s just a very deliberate deep dive process. But yeah, sure. I’ll go with it.
Kyle Giddens: Yeah, what have you seen from your perspective, is the biggest pain point facing the healthcare system here in Israel? And then we can zoom out and then say…
Yoav Fisher: From one perspective? From the perspective of the system. From the perspective of the startups?
Kyle Giddens: From the system. Like me, as somebody, if I broke my leg tomorrow, am I having a good time outside of the broken leg?
Yoav Fisher: First of all, the system in Israel is good. I will state that outright, right? There are issues like every other country, but when you look at it and compare it to other countries, the health care system in Israel works and it works well. People get high-quality care in a manageable timeframe. The economic structure behind it works, the money goes in, the money goes out. And the healthcare system here works and it works well, especially as compared to other countries, especially when compared to the United States – that’s a whole other topic we can discuss.
Kyle Giddens: We will.
Yoav Fisher: The issues here depend on what you’re looking at. There are always issues about data integration and data silos and how you overcome that, cloud policies still don’t need to be developed. Things like how you gauge the whole concept of health equity to peripheral populations, like the Jews community, the ultra-orthodox community, and the Arab-Israeli community, engage with the healthcare system in different ways. How do you bridge that gap? Whether it’s cultural, technological, or whatever, there are issues that are unique to here. But over-arching way, I will have to say that the Israeli healthcare system is really good, especially when you compare it to other countries. I mean, every country has its issues.
Kyle Giddens: For sure. But what would you say, like if you could wave a magic wand, and I give you the power, what are the three things that you would change tomorrow?
Yoav Fisher: To make the system here even better?
Kyle Giddens: Yes.
Yoav Fisher: Number one, the whole concept of data integration. Israel very much likes to tout that they have all these dreams and troves of digitized healthcare data. And that is true. But there’s a big gap between the existence of healthcare data, the access and the relevancy of it. And that step from existence, to access, and from access to relevancy is something that the country struggles with. There are a lot of agendas at the national level, and a lot of money, a lot of support, and a lot of programs to try to bridge that gap. But that’s a big thing. And sometimes gets into really technical things like different syntax, like is it Fire? Is it HL7? Is it Snowmen? Is it ICD 9? Is it ICD 10? Is it ICD 11 that just came out? All these things, data silos, the manual adaptation from one to another, all of these things, if you could solve that, that’d be a huge value add, not just for the startups that are touching this data and want to do stuff, but also really a continuation of care of the actual citizens, the pass off from one to the other. So, that’s a big one. Especially when you consider the fact that other countries are making a lot of strides.
Kyle Giddens: It is like a unified battle on the healthcare system.
Yoav Fisher: Yeah. So, what probably happens is that this primacy of Israeli healthcare data was a huge part of the narrative and a relevant part of the narrative, I would say, even ten, seven, five years ago. That primacy is decreasing quickly. So, you do need to play catch up, the country definitely needs to catch up from the data and the relevancy perspective. I would say that’s a big one that should be addressed. That’d be my number one.
Kyle Giddens: Basically, to normalize access to data.
Yoav Fisher: Standardized, normalized, yeah. Because once you solve those things, it also becomes more affordable, because you don’t have to spend the time, effort, and money to take the data that’s digitized, but still raw and make it accessible and relevant. So, if you can solve that you can also decrease the cost of all the operations behind it. Whether is the startup working with it, whether it’s the system paying for whatever. So, there’s a lot to be said there.
Kyle Giddens: And then it’s much easier to run those beautiful algorithms.
Yoav Fisher: Sure, on my data.
Kyle Giddens: On your data and on my data to gain that insight. Wonderful. And so that’s the number one. Is there another one that comes to mind?
Yoav Fisher: I mean, that’s the big one. There are other things that definitely could be addressed and proven like the variance and resources between the big three or four hospitals and those in the periphery.
Definitely, something that could be improved giving the hospitals and care centers that are not three, four big ones in the middle, the support they need, it’s not just for the health organization themselves or the institution, it is also for the population-based approach as it goes and utilizes these peripheral places. So, there are other stuffs, but now we’re getting to the really…
Kyle Giddens: The minutia.
Yoav Fisher: Yeah.
Kyle Giddens: So, let’s zoom out. And let’s say, COVID was a huge sea change for healthcare, access to healthcare, and changed my behavior and your behavior and everybody else’s behavior. When you look to the US – we will jump there now – what you see was a success in terms of gaining better access to health care if that happened, maybe through Telehealth or remote delivery of care. What are your thoughts on that system versus the Israeli system in terms of approach?
Yoav Fisher: Specifically regarding…? Okay, let me try to unpack this, because there’s a lot. So, first of all, the issues of healthcare, it’s not that suddenly they occurred because of Corona, right? They were always there, it was just exacerbated and put to the forefront because of COVID. They’re always way before that issues with access to care, the issue of Telehealth, all of these things already existed, COVID just put it in the face of everyone. The big difference between Israel and the US regarding it is that Israel, A, enjoys a small size, and B, it is centralized.
So, even if you look at the example of vaccine rollout, vaccine rollout in Israel was completely centralized, it was run like a military operation. Even logistically, there was only one point of entry where all the vaccines could go and that’s one airport. Across the street from the one airport is the storage facility, the cold storage facility, I believe it was Tevez that was used. And then the distribution I believe were trucks from the military – the IDF medical corps. And then it goes straight up to distribution. So, that’s something that you can do when it’s a centralized system.
Same thing, all the Telehealth stuff, because it is a small country, you don’t even need the cloud, you just lay pipes, connect all the pipes and that’s how you’re able to do a test in one location, have it appear the next morning, already in the app for your HMO. And that’s because it’s small, and you can literally just pipe these things. So, that size factor of it and the centralized factor of it was a very stark difference to how COVID was treated in the United States. I think that was a huge benefit to it. It was run like a military operation. Honestly, it was crazy.
But much like in the United States now that we’re in this post-COVID or COVID normalization world, where you saw this huge spike in usage of Telehealth and then a decrease and now it stabilized, same here in Israel, by the way, those are the same spike in Telehealth usage and then tapering out down normalization. Obviously, the data before and after is higher, but it still isn’t fully utilized, there are a lot of opportunities. I think we’re only in the beginning of the utilization of Telehealth as a concept, period.
Kyle Giddens: I tend to agree.
Yoav Fisher: Whether it’s remote diagnostic, remote treatment, remote monitoring, or remote alerting, however, you want to define it, there is so much more potential that can be tapped into.
Kyle Giddens: Yeah. And so from your perspective, I read your latest blog post in terms of value-based care.
Yoav Fisher: Oh, really?
Kyle Giddens: Yeah. I’m one of your fans, what can I say?
Yoav Fisher: All right. I don’t know if this is good or bad.
Kyle Giddens: Let’s get into it. Obviously, we want to measure outcomes. And it’s sometimes very hard to close the loop, because, as you mentioned before, data is everywhere and not centralized, and definitely not very accessible for insights. So, obviously, the United States has made a big push into value-based care.
Yoav Fisher: I totally disagree. The United States is paying lip service to value-based care.
Kyle Giddens: Well, in theory, that’s where they’re headed, and now dollars are being reimbursed for value-based care.
Yoav Fisher: More dollars are being reimbursed for episodes, I agree. But the issue of value-based care isn’t a data issue, it’s an economic issue. First of all, fee-for-service exists, because it works. It has negative ramifications because it can create a lot of bloat in a lot of ways. But people use it because it’s measurable, because you can quantify it. I did this specific procedure. This anesthesiologist was on site for this surgery for two hours. You can quantify all of this. Obviously, this creates a lot of bloats, a lot of waste and has no correlation to whether there was success or not.
So, value-based care looks to go the opposite and say, let’s look at if this whole thing was successful, and bought this entire thing. Which is great. But value-based care works well when there are two main conditions. The first is that it needs to be easily quantifiable. And that comes both at the beginning, the baseline, and the outcome. And that’s really hard to do with things that are chronic and long-term.
How really can you figure out the baseline of oncology? Each patient is totally different. The outcome is totally different. It takes years. And there are so many different things. This is different than an ACL surgery.
The baseline there is the same for all patients. Everyone has got the same ACL, they got the same surgery, the output is the same, and within 12 months you should be walking. That’s the first condition. The second condition is that it needs to be over a quantifiable timeframe. The reason for this is because whether the healthcare organization is public, private, or whatever, at the end of the day, there is a bottom line that has to come into some fiscal cycle that’s manageable. So, value-based care, the ones that I’m seeing, and especially the programs that are pushed by the CMS that are most successful, are the ones that have these two things where the baseline and the outcome are easily quantifiable and it’s a short timeframe. Orthopedics fits into this, stuff like that.
Kyle Giddens: Basically day surgeries.
Yoav Fisher: A lot of it can work. Yeah, frankly, that’s the stuff that could go. Eventually, it’s just really hard to quantify economically something that is so amorphous over a long period of time. So, that being said, there is this tendency for this or that whatever. It’s really, really, really complex. Israel at the end of the day is a fully capitated system, but it is also completely fee-for-service. Israel to this day has no actual value-based care program. It still works. It’s a national capitated system completely fee-for-service, which is interesting. But you would think it’s a fully capitated system, why not just do value-based care? And yeah, full capitation is a great starting point for value-based care. But it doesn’t have to be, it can be fee-for-service.
So, getting back to your point about the US, the CMS has various different tiers of progression in value-based care. And if you dig into it, the first three tiers are effectively just fee-for-service, they’re really just fee-for-service. So, I don’t buy it when some insurance company says, you know, half of our claims now are value-based care. It’s really not. It may be some episodic, whatever. It could be fee-for-service with some performance outcome on top of it, but it is not actually value-based care.
Kyle Giddens: So, what you’re saying is, it’s just very good branding, or…?
Yoav Fisher: I think the intent is right. I think it’s extremely nuanced. I think people make a lot of false claims about it, especially startups are like, “We’re going to do some value-based care”, whatever. Figuring out who is really actually implementing value-based care is really complex. And if you’re doing some value-based care, or we’re going to do value-based care... I see a lot of startups, we’re going to do some value-based care for…I don’t know, like, pick some crazy chronic disease that takes forever.
Kyle Giddens: Mostly likely.
Yoav Fisher: Sure. But value-based care isn’t yet at that point, people can’t quantify what they’re doing. So, how are you going to plug that into a system that’s overwhelmingly fee-for-service? So, there is movement, it’s progressing there. I think it’ll take a long time. You will see more and more bundled episodic payments that eventually get there. Countries that already have a national capitated system behind them have a much easier pathway to converting to value-based care. I think capitation or at least that full risk aspect of it is a major component that could help in transitioning value-based care, but it’s going to take a while.
Kyle Giddens: Interesting. And taking the same magic wand from before and then waving it in the United States. What would you change to enable a better system?
Yoav Fisher: Okay, so you and I both lived under the… well, you lived under the Canadian system, which is effectively the NHS, right?
Kyle Giddens: Yes.
Yoav Fisher: I lived under the US system for a long time. When I was in California, I was a Kaiser member. Now I’m a Maccabi member.
Kyle Giddens: Kaiser for life.
Yoav Fisher: Kaiser is great. Kaiser’s [Inaudible 24:34].
Kyle Giddens: They are, actually.
Yoav Fisher: That comparison is shocking. The comparison of living 20 years under the US system, now in the last 10 years, under the fully national system. And I’ll be totally honest with you, I think people in the United States make two major, major, major incorrect assumptions about the private versus public debate at the highest level. The first assumption that I see is that public health care is going to be more expensive. You hear that all the time, and the whole, “all of our tax money will go to payroll,” or whatever. That is a complete fallacy. And the reason is that most Americans get their insurance through their employer. So, at the end of the day, they get their monthly income statement, and there is a carve-out that goes to employer insurance. Our bill here has that same carve-out, it just goes to the tax base national system.
So, saying that it’s more expensive, is incorrect, it’s just a different person that’s getting your money. Instead of the employer, it’s going to the government. The other thing is that insurance is an economy-of-scale situation. The more people are signed up, the less it is per person. It is a major, major, major economic fallacy to think that stratifying all of the population into their own specific little unique insurance plan creates a cheaper thing. It doesn’t. It actually creates a situation where it’s more expensive for each individual. It is substantially cheaper for every single participant when there are more people in the pot. So, that’s the other thing.
The third big fallacy… well, the second is this whole, “I’m American so I can choose who I can go to.” They are super. But we can choose who we can go to because everyone in Maccabi is a doctor. But at the higher level, there’s this national pool of every care provider in Israel, who is also part of our system, we may have to pay a bit more, but I can choose to go to anybody, I want in Israel, because they’re effectively all in my system because it’s a national system. So, those two things, I see major incorrect assumptions that people in America, specifically of a particular political bend keep saying about public systems, it’s going to be more expensive, and there’s no choice. And the reality is the exact opposite. Public health systems are actually cheaper. And you get much more choice because everyone is in my system. Everyone is in my network.
Kyle Giddens: So, you would just make a broad…
Yoav Fisher: 100%. Trash the entire thing. To answer your question, trash the entire thing, and start all over with a capitated national system, honestly. You can see how the inconsistencies in quality and access to care is striking in the United States. The number of human beings who forget the whole pool of uninsured, the third of Americans are underinsured, who cannot afford… they would go bankrupt if they have a $1,000 medical bill. That’s a third of America. It’s unbelievable. It’s shocking to me that people fundamentally just don’t care about the health care of other systems. And this really has come about because I live in a totally different system than the United States system. And it’s not going to be more expensive. It’s just instead of giving money to your employer to pay for insurance, I’ll give it to the government. It’s the same amount. It just goes to a different source.
Kyle Giddens: Yeah. It reminds me of a buddy of mine who woke up from his surgery that was supposed to be in insurance, it was covered. And it was cleared with the insurance, and everything was great. But then he woke up with this $60,000 medical bill, because the surgeon who was overseeing the surgery, who he had chosen ahead of time was sick that day, and they had to sub in somebody from out of network on the surgery. And he spent six months fighting the bill so that they would cover it.
Yoav Fisher: Did he win?
Kyle Giddens: He did win.
Yoav Fisher: Good. But he still had to pay probably $10,000 out of pocket.
Kyle Giddens: Well of course. That’s part of his insurance premium. You got to do the co-pay on the first 10k and then everything else is there.
Yoav Fisher: So, it’s really shocking to me. And the private system in the United States creates so many middlemen, like the whole concept of a PBM doesn’t exist in Israel. The PBM is Pharmacy Benefit Manager. There is no such thing as nationalized, whether it’s in Europe, it’s not. The government buys pills in bulk.
Kyle Giddens: Makes sense. Like a wholesale. I love Wholesale. I love Costco.
Yoav Fisher: It is literally wholesale. Honestly, it’s really disturbing and shocking what’s going on in the United States. And I can’t believe people aren’t rioting in the streets just about this, really?
Kyle Giddens: Sometimes they do. But it’s just hard because they don’t have access to the health care that they need. I don’t know if you’ve been following Mark Cuban, have you seen what Mark Cuban has done?
Yoav Fisher: No. Oh, he made his own PBM.
Kyle Giddens: He made his own PBM—Maybe not PBM, Mark Cuban, made his own. And essentially, he is now buying drugs with a standardized markup, I think it’s 10% or 15%... don’t shoot me, Mark. And it is literally the cheapest pill that you can get. And it’s fulfilled by True Pill. And he negotiated everything, and it’s cheaper than your insurance like, 95% of the time. So, there’s a set of leukemia drugs, they just did this whole expose… it’s not really an expose, it’s on the internet, you could Google it. So, like two seconds of research. But basically, it was $10,000, under the typical plan to buy these drugs. And you know how much it was on his website?
Yoav Fisher: No, I have no idea.
Kyle Giddens: 50 bucks.
Yoav Fisher: How much is it elsewhere?
Kyle Giddens: Elsewhere, like, if you use RX or something like that?
Yoav Fisher: Sure.
Kyle Giddens: It is relatively more expensive, I don’t have the exact numbers, but like 10x, or 15x, depending on where you’re purchasing it from. And so that spread is the profit margin of many of these health care companies. I’m a big believer in better access. If we have better access, you have better outcomes, whether it’s to healthcare data, or whether it’s to pharmaceuticals when you need it, or the connection when you want to get to them. But when you make that easier, it becomes more affordable for everybody. And you hit the nail on the head there when you said that there are too many middlemen in many different systems, and if you can do away with it, then why not?
Yoav Fisher: Look at United Healthcare, United Healthcare is buying everything possible, ever, right? And they’re buying all this stuff. And it is yet to be proven that all of this purchasing and centralization of their market power actually benefits patients.
Kyle Giddens: It benefits somebody.
Yoav Fisher: Yeah. We will see in 10 years if this concentration of it. Because in a weird way, if United is purchasing all this stuff, it’s almost like they’re creating this one national system in a weird way.
Kyle Giddens: How many people are they covering now?
Yoav Fisher: Oh, God, I have no idea, tons. But they’re also purchasing the different aspects of that value chain, they’re purchasing different aspects of the whole value chain of healthcare. And maybe that’s what it is, maybe they’re going to be a de facto national system. I don’t know. We will see how this benefits patients in 10 to 15 years.
Kyle Giddens: Yeah, I think that everybody is seeing that 25% of the US GDP is going to health care. And we can do a better job with that.
Yoav Fisher: Sure, it’s gone to 25% of it and people are actually in a significantly worse situation health-wise now than they were 15 to 20 years ago. So, that begs the question of where is all this money going. If it’s not going to better the outcome for patients, then where is it going?
Kyle Giddens: Yeah, don’t follow the money. Whoever is listening, don’t follow the money.
Yoav Fisher: I don’t know. But it’s really glaring that living in a country that’s fully nationalized, as opposed to the United States, is really a major wake-up call.
Kyle Giddens: Yeah, it just aligns incentives, because it’s more transparent, and you’re able to see the players very clearly and where each dollar goes.
Yoav Fisher: There are still mixed incentives, and every country is radically different and it’s really nuanced. For example, I just had a meeting with people from Austria and they were telling me about their system. Their system is fully nationalized and whatever, but it’s so nuanced there too, they have 19 different regions, and each one has control of its own budget. It’s complex in every country.
Yoav Fisher: [inaudible 35:01]
Kyle Giddens: [inaudible 35:02] And so where do you see startups playing a role in changing the face of healthcare?
Yoav Fisher: It’s an interesting question because I was actually just talking about this recently, with a colleague of mine about specifically pharma companies. A lot of pharma companies in Israel are approaching startups in one way or another, have some track or have some internal innovation efforts or whatever. And then my question was, why? These are pharma companies sitting on billions of dollars, find some startup, just hire a Dev shop and do the same thing, right? So, startups fit in because they’re able to ideally fill gaps or move the needle using technology in a way that’s faster and more efficient than an incumbent doing it themselves.
Otherwise, Pfizer, Roche, or whoever is in Israel would see these startups be like, “This is great”. And just hire 400 developers and just do it. So, clearly, when you’re looking at an incumbent and they make that decision of. “We have this issue. We have this challenge that we’re going to approach”. And they make some internal strategic decision whether they’re going to buy something off the shelf, we’ll build it ourselves or we’ll partner with some startup. And there’s a value add to partnering with that startup, still. They can build stuff faster, they can address the technological components in a quicker way, integrating them is still really hard. I don’t know if I’ve answered your question, honestly.
Kyle Giddens: Yeah. I guess what you’re saying is, that startups exist because corporates are slower.
Yoav Fisher: I mean, that’s what everyone says. Corporations tend to move slower. But it’s not because the people there are slower, it’s because it’s just a heavy mechanism to move. And also, it’s not necessarily their core business, right? Innovation and technology is not the core competency of Takeda. It’s a core competency of maybe AWS. But it’s not necessarily a core competency of Ascension or SN or ZNHS. Their core competency is…
Kyle Giddens: Delivery of care.
Yoav Fisher: Yeah, delivery of care, and dealing with that mechanism. So, when you look at it from that perspective, innovation is always the second priority. And you really have to fundamentally prove as the startup that your innovation, your technology can tie into their core competency. That’s hard.
Kyle Giddens: What can a startup do in order to plant a flag and say, “Hey, we’re here and we can actually deliver on…?”
Yoav Fisher: Okay, so my assumption is that every startup in Israel or anywhere in health tech is saving lives or improving lives. I’m taking that as a given, Whatever these people were building is going to improve health. Great. The big questions I see are in improving or at least not harming healthcare economics, and improving or at least not harming existing workflows and processes. And on top of that, regulation, right?
Kyle Giddens: Right.
Yoav Fisher: So, everyone is saving lives, but these other two buckets are really what differentiates, honestly. And frequently, it is not necessarily technology that’s the innovative factor that makes a stellar startup. The startups in Israel here that I think are doing a fantastic job, if I look at the 20 that I really, really love, most of them are not doing what’s known as the deep tech. They’re not doing convoluted neural networks, some crazy algorithms, and blah, blah, blah, blah, blah. The tech is standard. Their innovation comes from understanding the other two buckets, understanding the healthcare economics, and understanding the workflows and the processes. So, innovation is the more operational strategic business aspect of it.
Kyle Giddens: So, it’s a business process innovation.
Yoav Fisher: It’s figuring out how to plug in what you’re doing into the existing status quo and showing relevancy that’s beyond just saving lives. Because everyone in Israel is saving lives. Every health tech startup in the world is saving lives.
Kyle Giddens: So, you’re saying saving lives but also saving time and money?
Yoav Fisher: Sure, you can call it to save time and money. But I call it something a little more… I think it’s really understanding fundamentally who’s paying for what and why. And who’s touching what and why? Those are the two aspects, the economic aspect, and the process aspect. That’s really what’s going to make a difference between some technological whatever, otherwise, there’s just a hammer looking for a nail. And there are tons of hammers looking for nails, in Israel, abroad, whatever.
Kyle Giddens: Yeah, I definitely hear that. So, if you had to give a line and it was your advice to two startups who are innovating within healthcare, what would be your statement?
Yoav Fisher: I would start with that, figuring out who is paying for what and why, and where you fit it fit into that, where you fit into that actual money chain. We’ll put it that way.
Kyle Giddens: I think it’s called value chain or money chain. It is a good rebrand.
Yoav Fisher: Sure, whatever. The value chain makes it sound positive. There is a flow of cash from one place to another.
Kyle Giddens: There is a flow.
Yoav Fisher: And you need to understand where that money is flowing and why and how you fit into that. The other aspect that I see frequently… going back to what’s on the board there, that concept of, I see a lot of founders who are making, you know, there’s always that slide. Yeah, here are our competitors. You make some matrix. Here is criteria A. Here is criteria B, and we’re super great, as compared to
Kyle Giddens: Yeah, hop into the greys.
Yoav Fisher: Hop into the greys.
Kyle Giddens: Yeah, hop into the greys It’s a two-by-two axis.
Yoav Fisher: Throwing buzzwords. And here’s the thing: the approach to competition needs to be different. I did this lecture recently for one of the accelerators here in Israel about… I gave you an example of this company that’s making this wearable jogging coach. So, I asked everyone there, and I was, like, who’s the competitor for this thing? I’m going to ask you, let’s say I have a wearable jogging coach, who is the competitor?
Kyle Giddens: I will say like a Fitbit, Air Pods, maybe.
Yoav Fisher: Okay, so I define competition totally differently. And the competition is running with nothing at all.
Kyle Giddens: Oh wow. Can you imagine running without music?
Yoav Fisher: So, this creates a different strategic decision for the startup. If you want to compete against the existing other, you know, Fitbit, whatever they are, that’s going to dictate how you sell that value proposition, because you’re selling yourself to a population that already is using whatever. And that can be added features, that can be this, that can be that, whatever. If you’re going to compete against the whole population, the people who run with nothing, which, by the way, is still the overwhelming bulk of people who jog, your value proposition is different, your value proposition is, look what added benefit you can get from using a wearable period.
Kyle Giddens: So, you’re talking about selling from nothing to something, versus selling something to something? Because then you can compare apples to apples versus…
Yoav Fisher: All I’m saying is that thought process is another area where I see a lot of startups struggle, especially here in Israel. I’ll see startups in Israel who are talking to me about, “Oh, we’re going to sell in the United States…”
Kyle Giddens: I can see it pains you.
Yoav Fisher: It pains me because I lecture about this stuff and I write about the stuff so much. And I consistently see these recurring
Kyle Giddens: Themes.
Yoav Fisher: Themes, right. So, the startup will come to me and say, “Oh, we’re going to sell us the United States. We’re going to sell this to VA, to Kaiser” whatever. And then you look at their competition, and their competition is that little matrix with three startups in Israel. And I was like, but there are five startups who are doing something very similar to you in the United States, each one has raised $100 million. Address that, if that’s your market.
So, I see that as another major area where startups are not… and that differentiation can be very subtle. It’s like Uber and Kareem. Exact same product, the only difference is Kareem is in Arabic. That’s it. And that can be your differentiation. And that’s a legit
Kyle Giddens: That’s all the difference, different target market?
Yoav Fisher: Just own it, saying we’re going to do the exact same thing as whatever Plus care but in Germany, and in German, that’s our only differentiation. Great. Own it. Go with it. Germany is a massive market.
Kyle Giddens: Know who you are. Know why you are special.
Yoav Fisher: Yeah. And so there is a lot of learning that I think… Israel is great at producing tech for tech’s sake. Israel has a high concentration of highly technical people, is very qualified, and can produce high-quality stuff in a short amount of time. And you see a lot of it. And it’s a wonderful place to do alpha testing for all this stuff. But if you want to expand and be legitimate outside of Israel, you need to think beyond just the tech, about the workflows, about the processes, about the differentiation, about trends that are going on, whether it’s in Europe, in the United States, economic models of how different players work and operate. That’s really what’s going to differentiate. I don’t know if that sounds right. I wanted a monologue.
Kyle Giddens: It’s a good monologue. You have an audience.
Yoav Fisher: It’s just you get to the point where you would expect some of this to…
Kyle Giddens: To sink in?
Yoav Fisher: Yeah, to sink in. And some people do, there are some amazing founders in Israel, amazing, amazing founders. The startups here have unbelievable power. I’m constantly learning more about the healthcare system in general, and all the nuances. Lately, I’ve been exploring more and more about Europe. I think there are unbelievable opportunities in Europe that at least people in Israel tend to overlook. The tendency is like, oh, we are going to the United States. The VCs are also like, we are going to the United States. So, I see a lot of incorrect assumptions about Europe, both from founders and also from investors. So, I’m personally just trying to understand it more.
Kyle Giddens: Europe is not a single market.
Yoav Fisher: Right.
Kyle Giddens: It’s multiple markets all at once. And so for a startup, looking to excel, you know, you want to go after typically big markets or be a big fish in a smaller pond.
Yoav Fisher: Which is just also fine.
Kyle Giddens: Yeah. So, as we’re coming to a close, what’s a piece of advice that you would give policymakers, health systems, and then startups?
Yoav Fisher: Oh, wow. I’m so not the person.
Kyle Giddens: That’s good. That’s why I asked you because you come from a different perspective.
Yoav Fisher: Am going to give advice to the Ministry of Health. I don’t even know where to begin with that. My advice to start-ups as we talked about. An advice to the health care system. I don’t know.
Kyle Giddens: Would you say listen to you more, is that what you will tell them?
Yoav Fisher: No, look, I work with the Ministry of Health a lot, day in, day out. And sometimes it’s push, we’ll push through stuff that we think is relevant. Sometimes it’s pulled, we like the pulls into stuff. And sometimes I’ll disagree with them and say you should put resources and money in this direction instead of this direction. And that’s fine. At the end of the day, my organization and the governmental organizations are actually all fundamentally on the same team. In many situations, I’m brought in as the mirror to what’s going on at the national level. What’s really going on with the pilot program in Israel? What’s happening with it? Funding gaps. What’s happening with it? Where is it going? We’re putting money in this or that, whatever. How is it going? So, I don’t really have… who am I to tell the government, like, “That’s what you should do.”
Kyle Giddens: Yeah, tell them.
Yoav Fisher: What would you tell the Ministry of Health?
Kyle Giddens: If I had the opportunity, I would say that standardization and access to healthcare data would be a big win.
Yoav Fisher: But then you’re just taking my answer from earlier.
Kyle Giddens: I didn’t say that was a bad answer. We know a few things about that area, from a different perspective. And when you increase access, both on the digital level, and combine that with education concurrently, that’s better for me as a user of the healthcare system. Being able to get my prescriptions at home, which was a big rollout that just happened, at least in Tel Aviv, doing so at a national level, so people don’t have to travel for their health. More health at home when you can, because that’s typically a comfortable environment, in most cases, in most homes. And really bringing the quality of care to the individual rather than expecting the individual to travel to the quality of care which in itself is very difficult.
So, I would say a reversion to the old school model where the doctor knocks on your door and then walked in. I don’t know how scalable that is. But we do have a phone that allows you and eventually remote wearables that allow you to have almost a similar type of experience within the home. But I do think that doctors need more time to do what doctors do which is actually listen to the whole set of problems after the first five minutes, to really understand the person.
Yoav Fisher: I agree with everything you’re saying, the difficulty is implementing all that.
Kyle Giddens: Oh, yeah. Somebody has to. And eventually, we’ll move more towards that. I’m not saying we’re going to have Tesla robots tomorrow. But in two or three decades from now, I don’t see it as such an absurd thing to really have healthcare at home as real reality.
Yoav Fisher: So, I want to show you something. I will show you through the camera. I found this recently, actually from my father. My father is a big antique radio buff. That’s what he does in his retirement. And yeah…
Kyle Giddens: That’s cool. CB radios.
Yoav Fisher: No.
Kyle Giddens: The vacuum tubes?
Yoav Fisher: Yes, he will buy the tubes.
Kyle Giddens: He’ll buy the tubes? That’s awesome.
Yoav Fisher: He’s an engineer, so that is what he does. And so he found this for me, and I had to show it. This was the image from…
Kyle Giddens: I’ll do a play-by-play for those that are listening at home.
Yoav Fisher: Check it out. The Radio Doctor. This is from 1930. Do you see this image?
Kyle Giddens: Yes, it looks like a TV.
Yoav Fisher: This was from a trade journal in 1930. It’s a TV, where there are all these dongles attached to the TV, thermometer, whatever. And on the other end, within the TV frame, you see the doctor. And the doctor is seeing the patient on his screen. So, telemedicine, as a concept has existed since 1930, probably before. But here is this proof of the concept. It’s been 90 years.
Kyle Giddens: Almost. All these things exist today, pretty much on your Apple Watch.
Yoav Fisher: It just took 90 years.
Kyle Giddens: It just took 90 years. So, you’re saying there’s hope.
Yoav Fisher: There is hope. Maybe for our grandchildren.
Kyle Giddens: No, there is hope.
Yoav Fisher: I don’t want to be too pessimistic about it. I just think it’s complex. I think it’s really difficult. I think it’s a lot of competing interests. Even in a national country like Israel, it takes a lot to align the stars.
Kyle Giddens: For sure. Well, I guess we could say health is complex, but hopefully today, we unraveled just a little bit of it.
Yoav Fisher: And those startups that understand the complexity, honestly, are the ones that are going to thrive. Those who enjoy and live and breathe the complexity are the ones that are going to thrive.
Kyle Giddens: There you go. Let’s tackle that Gordian knots. Until next time, thank you Yoav, it was a great pleasure having you. It was a lot of fun.
Yoav Fisher: It was a pleasure. I hope it was fruitful for you guys.
Kyle Giddens: Until next time. Thank you, everybody.
Yoav Fisher: Bye.
Outro: Thanks for joining us on The Grid, brought to you by Medcase. If you were a fan of this podcast, share, like and follow and visit us at www.medcase.health for more information.