又到了預(yù)測(cè)明年行業(yè)形式的時(shí)候了。雖然眼下經(jīng)濟(jì)和政治的不確定性與日俱增，但我們依然不會(huì)放棄一年一度的預(yù)測(cè)活動(dòng)。我們已經(jīng)對(duì)2019年的醫(yī)療行業(yè)做出了十大預(yù)測(cè)，而且也做好了被現(xiàn)實(shí)啪啪打臉的準(zhǔn)備。不過(guò)首先，我們還是應(yīng)該回顧一下去年我們預(yù)測(cè)的那些東西都實(shí)現(xiàn)了沒(méi)有。

去年我們的十大預(yù)測(cè)已經(jīng)實(shí)現(xiàn)了5個(gè)，還有兩個(gè)貌似有望在2019年實(shí)現(xiàn)。首先，我們正確地預(yù)測(cè)了Outcome Health公司的融資騙局；其次，我們正確預(yù)言了在藥品市場(chǎng)上，亞馬遜將不會(huì)通過(guò)B2C模式顛覆PBM行業(yè)，而是會(huì)選擇B2B模式，結(jié)果亞馬遜果然與摩根大通和伯克希爾-哈撒韋公司聯(lián)合成立了一家合資公司，并任命知名外科醫(yī)生、作家阿圖·葛文德?lián)芜@家公司的CEO。

去年，我們還正確預(yù)測(cè)了一些創(chuàng)業(yè)公司會(huì)成功進(jìn)行資本退出，F(xiàn)latiron、Landmark和Pillpak等公司的例子可以佐證。此外，隨著美國(guó)醫(yī)療保險(xiǎn)和醫(yī)療補(bǔ)助服務(wù)中心（CMS）出臺(tái)了更加利好的規(guī)則，美國(guó)的聯(lián)邦醫(yī)保優(yōu)惠計(jì)劃（Medicare Advantage）也獲得了廣泛歡迎，近50%的聯(lián)邦醫(yī)保受益人都選了優(yōu)惠計(jì)劃。最后，我們還預(yù)測(cè)了各大醫(yī)保平臺(tái)會(huì)積極收購(gòu)那些利潤(rùn)更高但監(jiān)管更少的公司，2018年，安泰并購(gòu)CVS、信諾并購(gòu)ESI，以及不久后哈門那（Humana）可能與沃爾格林公司的合并，都證明了我們的預(yù)測(cè)是正確的。

當(dāng)然，去年我們也有一些預(yù)測(cè)落了空。一是關(guān)于醫(yī)院招聘放緩。2018年美國(guó)各大醫(yī)院新增工作崗位約25萬(wàn)個(gè)，同時(shí)醫(yī)院行業(yè)通過(guò)提高價(jià)格抵消了勞動(dòng)成本的上漲。二是對(duì)人工智能的影響過(guò)于樂(lè)觀。雖然人工智能具有很大的潛力，甚至說(shuō)不定有一天會(huì)橫掃一切，但目前我們還沒(méi)看到任何有吸引力的商業(yè)應(yīng)用，除了每個(gè)創(chuàng)新產(chǎn)品在產(chǎn)品描述中都鼓吹自己用上了人工智能技術(shù)。三是錯(cuò)誤地預(yù)言了大型制藥公司會(huì)變得越來(lái)越大（不過(guò)明年就說(shuō)不定了）。四是關(guān)于基因編輯技術(shù)（CRISPR）的商業(yè)化，不過(guò)我們對(duì)此還是充滿希望的，今年11月，中國(guó)成功對(duì)一名嬰兒進(jìn)行了基因編輯的消息就充分說(shuō)明了它的前景。五是關(guān)于《平價(jià)醫(yī)保法案》的修改?？紤]到民主黨正在漸漸奪取國(guó)會(huì)控制權(quán)，奧巴馬醫(yī)改被廢除的可能性幾乎不復(fù)存在，而該法案的修訂很可能會(huì)在明年實(shí)現(xiàn)。

現(xiàn)在再來(lái)說(shuō)說(shuō)我們對(duì)2019年的十大預(yù)測(cè)。

1. 醫(yī)保機(jī)構(gòu)加速整合

美國(guó)醫(yī)療保險(xiǎn)行業(yè)的競(jìng)爭(zhēng)已趨于白熱化，首先是強(qiáng)勢(shì)的聯(lián)合健保公司（United Healthcare），它以低管理成本和高利潤(rùn)著稱；其次是有了PBM業(yè)務(wù)加持后利潤(rùn)更高的安泰和信諾等保險(xiǎn)公司。在這些巨無(wú)霸的擠壓下，業(yè)內(nèi)的很多小玩家很難阻止全國(guó)居民賬戶的流失，也無(wú)力在Medicare Advantage和Medicaid這種公立醫(yī)保市場(chǎng)上與專業(yè)玩家競(jìng)爭(zhēng)。為擴(kuò)大自身體量，家底還算雄厚的醫(yī)保公司便會(huì)謀求并購(gòu)。另外，美國(guó)已有數(shù)個(gè)州投票同意擴(kuò)大Medicaid醫(yī)保計(jì)劃的參保范圍，加之Medicare Advantage計(jì)劃的火熱，各大醫(yī)保公司也會(huì)考慮通過(guò)并購(gòu)來(lái)進(jìn)入這些快速增長(zhǎng)且利潤(rùn)越來(lái)越高的細(xì)分市場(chǎng)。

2. 醫(yī)生主導(dǎo)的責(zé)任醫(yī)療組織將快速增長(zhǎng)

這里首先要解釋一下什么叫責(zé)任醫(yī)療組織（ACO）。責(zé)任醫(yī)療組織是奧巴馬醫(yī)改的核心元素之一，是指不同的醫(yī)療機(jī)構(gòu)（包括不同層級(jí)的醫(yī)生）自愿組織起來(lái)成為一個(gè)協(xié)同合作的整體，為患者提供協(xié)同的醫(yī)療服務(wù)，以達(dá)到提高醫(yī)療質(zhì)量、控制醫(yī)療成本的目的。責(zé)任醫(yī)療組織首先在美國(guó)聯(lián)邦醫(yī)保Medicare中試行。Medicare的2.0版醫(yī)療責(zé)任組織規(guī)則強(qiáng)烈傾向由醫(yī)生主導(dǎo)的ACO，而不是由醫(yī)院主導(dǎo)的ACO。這樣一來(lái)，醫(yī)生很快就會(huì)意識(shí)到，他們可以獨(dú)立于醫(yī)院賺取更高的工資。另外，有了資金、管理良好的醫(yī)療協(xié)議和低成本的分析工具，醫(yī)生們也更容易享受到規(guī)模效益的好處，同時(shí)保持自身的獨(dú)立性。我們預(yù)計(jì)，一旦初級(jí)保健醫(yī)師們意識(shí)到，沒(méi)有了大機(jī)構(gòu)的枷鎖，他們可以做得更好，那么一些大型醫(yī)療平臺(tái)雇傭的醫(yī)師團(tuán)體便會(huì)破裂。另外我們認(rèn)為，由醫(yī)生主導(dǎo)的ACO和由醫(yī)院主導(dǎo)的ACO在績(jī)效上的差距也會(huì)愈發(fā)明顯。

3. 醫(yī)生的不滿有所降低

電子病歷系統(tǒng)糟糕的用戶體驗(yàn)和繁瑣的操作負(fù)擔(dān)，使它早已成為醫(yī)生們的吐槽對(duì)象，我們相信，醫(yī)療系統(tǒng)已經(jīng)聽到了醫(yī)生們的呼聲。如果醫(yī)生們以辭職或退休相要挾，任何一家醫(yī)院都是吃不消的。因此，他們肯定要做出一些投資來(lái)提高醫(yī)生們的士氣。我們認(rèn)為，下一代的電子病歷系統(tǒng)肯定會(huì)把提升醫(yī)生的用戶體驗(yàn)當(dāng)成優(yōu)先要?jiǎng)?wù)，在這方面，語(yǔ)音界面和機(jī)器學(xué)習(xí)等創(chuàng)新技術(shù)是大有可為的。谷歌以及很多創(chuàng)業(yè)公司都在大力開發(fā)語(yǔ)音識(shí)別技術(shù)，以減輕醫(yī)生們打字、點(diǎn)擊和搜索的負(fù)擔(dān)。有意思的是，在醫(yī)療行業(yè)應(yīng)用語(yǔ)音識(shí)別系統(tǒng)，其實(shí)要比在消費(fèi)電子產(chǎn)品上應(yīng)用更容易，因?yàn)獒t(yī)療行業(yè)的術(shù)語(yǔ)庫(kù)更小，上下文和語(yǔ)境也更容易預(yù)測(cè)。另外，亞馬遜公司最新發(fā)布的用于挖掘臨床數(shù)據(jù)的工具也有助于提高這些系統(tǒng)的效率。

4. 平臺(tái)互通終成現(xiàn)實(shí)

在宣布獲得成功五年后，各方力量終于將匯聚在一起，在跨平臺(tái)操作方面取得實(shí)際突破。目前已有多家做電子病歷系統(tǒng)的公司正在聯(lián)合商定數(shù)據(jù)交換標(biāo)準(zhǔn)（HL7 FHIR）。美國(guó)醫(yī)療保險(xiǎn)和醫(yī)療補(bǔ)助服務(wù)中心也表示，愿意動(dòng)用行政權(quán)力推動(dòng)所謂的“患者比文書優(yōu)先”倡議。美國(guó)各州也在積極推進(jìn)電子病歷系統(tǒng)的互聯(lián)互通，以更好地應(yīng)對(duì)阿片類藥物濫用和（貌似越來(lái)越頻繁的）自然災(zāi)害。而在地方層面，由于各個(gè)醫(yī)療系統(tǒng)中的醫(yī)生越來(lái)越積極管理風(fēng)險(xiǎn)，不同醫(yī)療系統(tǒng)之間的“囚徒博弈”也就沒(méi)意義了。

5. 數(shù)字健康行業(yè)迎來(lái)整合

對(duì)于產(chǎn)品與市場(chǎng)尚未完成匹配的公司，2019年留給它們的增長(zhǎng)空間將會(huì)更少。而這將帶來(lái)一系列的平臺(tái)整合。過(guò)去五年，醫(yī)療行業(yè)成立了很多創(chuàng)業(yè)公司，而現(xiàn)在我們差不多已經(jīng)能分辨誰(shuí)是成功的公司，誰(shuí)是“還算湊合”的公司了。同時(shí)，就業(yè)市場(chǎng)上的很多大雇主已經(jīng)度過(guò)了“早期采用者”的階段，它們更喜歡的合作伙伴，是那些能夠把市面上流行的各種單點(diǎn)解決方案納入標(biāo)準(zhǔn)化設(shè)計(jì)的醫(yī)保方案伙伴。這意味著很多處于早期階段的創(chuàng)業(yè)公司都要進(jìn)行艱難轉(zhuǎn)型，因?yàn)閷?duì)于付費(fèi)方來(lái)說(shuō)，它們的銷售周期要長(zhǎng)于那些大雇主，證明有效性的標(biāo)準(zhǔn)也要高于它們。

6. 保險(xiǎn)技術(shù)的發(fā)展不會(huì)一帆風(fēng)順

我們認(rèn)為，我們已經(jīng)接近保險(xiǎn)技術(shù)的炒作周期的頂峰了，2019年將是很多公司踢到鐵板的一年。其中，利用計(jì)算機(jī)編碼騙保是一個(gè)值得關(guān)注的風(fēng)險(xiǎn)領(lǐng)域，事實(shí)已經(jīng)證明，它是在Medicare Advantage項(xiàng)目中騙取保金最快的一種方式。由于利用計(jì)算機(jī)編碼騙保的行為十分猖獗，“貓捉老鼠”的游戲時(shí)時(shí)都在上演，支付方總是在尋找還沒(méi)被編碼的疾病，美國(guó)醫(yī)療保險(xiǎn)和醫(yī)療補(bǔ)助服務(wù)中心則對(duì)其進(jìn)行審計(jì)，而且CMS幾乎總能發(fā)現(xiàn)錯(cuò)誤，并處以罰款。這種騙保方式之猖獗，以至于CMS每年都要進(jìn)行“編碼強(qiáng)度專項(xiàng)調(diào)整 ”，來(lái)砍掉Medicare Advantage的一部分報(bào)銷金額。有些作為支付方的創(chuàng)業(yè)公司雖然在融資上獲得了巨大的成功，但他們很快會(huì)發(fā)現(xiàn)，實(shí)際業(yè)務(wù)運(yùn)營(yíng)之復(fù)雜，以及規(guī)?；D難，要比他們?cè)谌谫YPPT中暢想的艱難得多。

7. 透析中心將被顛覆

在一般人的印象里，一名病人如果要做透析，那么他通常每周有三天要去透析中心，每次要在一張椅子里躺三個(gè)小時(shí)。然而正如快遞行業(yè)的崛起葬送了西爾斯百貨，透析中心被新技術(shù)取代也只是遲早的事。對(duì)于病人來(lái)說(shuō)，每天在家中接受透析顯然更有利于康復(fù)，成本也更會(huì)便宜得多。瑞典已經(jīng)推廣自助式透析很多年了，實(shí)踐證明，自助式透析比透析中心更加安全和可靠。隨著美國(guó)醫(yī)保制度向風(fēng)險(xiǎn)型支付轉(zhuǎn)型，注重管理風(fēng)險(xiǎn)的醫(yī)生們顯然也會(huì)更青睞效果更好、更便宜的醫(yī)療方法。

8. 遠(yuǎn)程醫(yī)學(xué)迎來(lái)大發(fā)展

我們認(rèn)為，2019年，各個(gè)醫(yī)保支付方將終于認(rèn)識(shí)到，應(yīng)該充分鼓勵(lì)和利用遠(yuǎn)程醫(yī)療技術(shù)，而不是把它埋沒(méi)在無(wú)人問(wèn)津的網(wǎng)站和難用的手機(jī)應(yīng)用里。醫(yī)療健康應(yīng)用Oscar公司表示，目前，該公司有半數(shù)以上會(huì)員在使用遠(yuǎn)程醫(yī)療服務(wù)，并依賴Oscar應(yīng)用指導(dǎo)他們就醫(yī)。凱撒醫(yī)療（Kaiser）半數(shù)以上的就診即將通過(guò)虛擬技術(shù)完成。醫(yī)保公司多年積累的數(shù)據(jù)早已表明，遠(yuǎn)程醫(yī)療要比去實(shí)體醫(yī)院就診更省錢，而且也能讓患者感到更加輕松。目前，就連Medicare也增加了遠(yuǎn)程醫(yī)療費(fèi)用的報(bào)銷編碼。因此，我們預(yù)計(jì)，2019年遠(yuǎn)程醫(yī)療的使用量至少將翻一番，同時(shí)它的使用將不再局限于感冒或流感等小病，而是擴(kuò)展到臨床疾病管理等領(lǐng)域。

9. 藥品市場(chǎng)迎來(lái)顛覆

特朗普關(guān)于降低藥價(jià)的豪言壯語(yǔ)被啪啪打臉，制藥公司最近甚至漲價(jià)漲得更猛了。目前，美國(guó)有關(guān)部門正在對(duì)藥品流通環(huán)節(jié)的漲價(jià)進(jìn)行審查。在美國(guó)，平均來(lái)說(shuō)，藥品離開制藥公司后，在經(jīng)銷環(huán)節(jié)會(huì)漲價(jià)40%左右。由于經(jīng)銷環(huán)節(jié)不透明，患者為藥品支付了不合理的高價(jià)，而大量利潤(rùn)都被中間商賺走了。我們預(yù)計(jì)，改革藥品供應(yīng)生態(tài)系統(tǒng)的努力或?qū)⒃?019年獲得實(shí)際進(jìn)展。

10. 新的DNA測(cè)序平臺(tái)或?qū)⒂楷F(xiàn)

DNA測(cè)序是一個(gè)非常龐大且不斷增長(zhǎng)的商機(jī)。過(guò)去兩年間，以單細(xì)胞基因組為代表的一些新應(yīng)用有力推動(dòng)了這個(gè)領(lǐng)域的增長(zhǎng)。我們認(rèn)為，新的測(cè)序平臺(tái)（或者是它們的影子）將在2019年悄然出現(xiàn)，這將導(dǎo)致該技術(shù)的定價(jià)下降（但同時(shí)依然能提供健康的利潤(rùn)）。新平臺(tái)必將帶來(lái)新應(yīng)用和更多的業(yè)務(wù)量，同時(shí)也會(huì)侵蝕Illumina的市場(chǎng)主導(dǎo)地位。

我們很期待新的一年將發(fā)生什么，也很期待明年年底向讀者報(bào)告我們的預(yù)測(cè)是否靈驗(yàn)。（財(cái)富中文網(wǎng)）

本文作者鮑勃·科克和布萊恩·羅伯茨都是醫(yī)療行業(yè)的投資人，也是風(fēng)投機(jī)構(gòu)Venrock的合伙人。

譯者：樸成奎

It is soothsaying time again. Our annual plunge into the choppy waters of predicting the future, amid increasing economic and political uncertainty. Ever gluttons for punishment, we are ready to make 10 new predictions for 2019. But first, we should look back on how we did predicting what happened in 2018…

In 2018, five of our 10 predictions came true and two more seem on-track to become true in 2019. We correctly predicted another Theranos with the implosion of Outcome Health. We were correct that Amazon would not disrupt PBMs, rather they launched their Atul Gawande led collaboration with JPMorgan and Berkshire Hathaway.

Our successful exits prediction was validated by Flatiron, Landmark, and Pillpak. Also, Medicare Advantage gained in popularity with Centers for Medicare and Medicaid Services (CMS) issuing favorable rules and nearly 50% of new Medicare beneficiaries choosing a Medicare Advantage plan. Finally, we were correct that payers would aggressively acquire higher margin, less regulated businesses with Aetna merging with CVS, Cigna merging with ESI, and perhaps, soon, Humana merging with Walgreens.

We missed on our predictions that hospitals would slow hiring. In 2018, hospitals added about 250,000 jobs and were able to keep raising prices to offset rising labor costs. We were overly optimistic that AI would make a big impact. While AI has lots of potential and may eventually warrant “Intel Inside” status, we are yet to see meaningful commercial traction, outside of it being included in every innovative product description. We were also wrong about big pharma getting bigger (but next year…). We remain hopeful that our predictions about CRISPR commoditizing, as demonstrated by China’s gene editing of a baby in November, and the Affordable Care Act (ACA) being repaired, since we will soon have a Democratically controlled Congress that will no longer contemplate repeal, will both come true in 2019.

Now, onward with our 10 predictions for 2019.

1. More payer consolidation

There is stiff competition from not only stalwart United Healthcare, who boasts much lower administrative costs and higher margins, but also the rejuvenated higher margin PBM-enabled versions of Aetna and Cigna. As a result, many smaller payers will struggle to retain national accounts as well as compete against pure plays in the Medicare Advantage and Medicaid markets making them use their strong balance sheets to become acquirers. We also think the growth of Medicaid, with several states electing to expand, and Medicare Advantage will also trigger M&A in order to enter these growing and more profitable market segments.

2. Physician-led Accountable Care Organizations will grow rapidly

Medicare’s Accountable Care Organization (ACO) 2.0 regulations strongly favor doctor-led ACOs over hospital-led ACOs. Doctors will quickly realize that they can earn much higher wages independent from hospitals. Moreover, access to capital, managed care contracts, and low-cost analytical tools will make it easier to doctors to gain the benefits of scale while retaining independence. We anticipate the fracturing of some large health system’s employed groups, when the primary care doctors realize that they can do better if they break free. We also expect the performance gap between doctor-led ACOs versus hospital-led ACOs to become even more dramatic.

3. Doctors get less dissatisfied

We believe health systems have heard the cries from doctors about terrible user experience and administrative burden of electronic health records. Since health systems cannot afford to replace doctors who make credible threats of retiring or resigning, they will make investments to improve morale. We are bullish that electronic health records will move doctor user experience up the product roadmap priority list and that innovations like voice interfaces and machine learning will help a great deal. Teams at Google and many start-ups are making large strides in building voice technology to reduce typing, electronic medical record clicking, and searching burdens for doctors. Interestingly, it may be easier to use voice for healthcare than for consumer applications since the vocabulary is smaller and context is far more predictable. Amazon’s newly released tools to mine clinical data will help make these systems work better too.

4. Interoperability becomes interoperable

Five years after being declared successful, forces will finally come together to lead breakthroughs on cross health system and platform interoperability. Electronic health record firms are coalescing around standards for exchanging data (HL7 FHIR) and CMS is expressing willingness to use regulatory power to drive adoption with the “patients over paperwork” initiative. States are pushing for connectivity as one tactic to address the opioid epidemic and to improve resiliency from (seemingly more frequent) natural disasters, necessitating the need to access data. At the local level, the prisoner’s dilemma of health systems leveraging market power to impose three-week turnarounds and PDFs no longer makes sense when physicians on both sides of the transaction are increasingly trying to manage risk.

5. Consolidation in digital health

Growth equity will get tighter in 2019 for small companies that have not achieved product market fit. This will lead to a flurry of consolidation into platforms. Many new companies have been started over the last five years, and it is time to sort the true successes from the “just OKs”. Compounding this trend is large employers going from being the early adopters, to more willing to rely on their health plan partners who have responded to the proliferation of point solutions by incorporating many of them into their standard benefit designs. This will be a rough transition for many early stage companies since payers have even longer sales cycles and higher standards for proving effectiveness than large employers.

6. InsureTech takes a lump or two

We think that we are near peak hype cycle for insurance technology. 2019 is likely to be a year of toe stubbing for many. Upcoding is one area of risk since it has proven to be the fastest way to make money in Medicare Advantage. Coding has led to a cat-and-mouse game of payers mining charts for uncoded diseases and CMS auditing them and nearly always finding errors and levying fines. Upcoding is so pervasive that CMS actually cuts Medicare Advantage reimbursement annually using a “coding intensity adjustment.” Start-up payers that have enjoyed great fundraising success are likely to find the very complex operations and scaling required for their actual businesses much harder than investor PowerPoint pitch creation.

7. Dialysis disrupted

It is Norman Rockwell-esque that patients drive to brick-and-mortar dialysis centers three days a week and lay in a chair for three hours at a time. Just as Sears has been replaced by home delivery, dialysis centers will be supplanted too. It is far better for patients to have their blood cleansed daily and it is cheaper to have patients do it themselves daily at home. Sweden has embraced patient self-serve dialysis for years and it has proven to be both safer and more reliable than dialysis centers. As we move to risk-based payments, better and cheaper approaches to care will be embraced by doctors managing risk.

8. Telemedicine takes off

We think that 2019 will be the year that payers finally realize that it is far better to fully embrace and encourage telemedicine usage as opposed to burying it in their unengaging member portals and clunky mobile apps. Oscar compellingly reports that more than half of their members use telemedicine and rely on Oscar to route them to care, increasingly telemedicine. Kaiser will do more than half of all visits virtually. Health plans now have enough years of claims data to discover that telemedicine saves a bunch of money and makes members far happier than going to a doctor’s office. Even Medicare is adding codes to reimburse telemedicine. As a result, we expect telemedicine usage to more than double in 2019, while making substantive inroads beyond flu & cold into areas such as chronic disease management.

9. PBM disruption talk becomes reality

While Trump’s proclamations about lower drug prices have backfired, with drug companies raising prices even more aggressively, a byproduct of Executive branch rhetoric has been scrutiny over drugs getting marked up a bunch, after they leave the drug maker. Drugs are marked-up, on average, 40% by the distribution system. The current opacity about how money flows, leads to patients paying more for drugs and excessively large margins being captured by intermediaries. We expect next generation pharmacy supply ecosystem efforts to gain real traction in 2019.

10. Real progress with new DNA sequencing platforms

DNA sequencing is a very large, and growing, opportunity. New applications, such as single cell genomics, have driven growth over the last 24 months. We believe that new sequencing platforms (or at least the specter of them) will enter the fray in 2019, leading to decreasing per Gb pricing (while still providing healthy margins) which will both open up additional applications and volume as well as erode Illumina’s market dominance.

We look forward to seeing what happens and reporting back to you next year.

Bob Kocher and Bryan Roberts are both health care investors and partners at the venture capital firm Venrock.