Healthcare is in the midst of a dramatic transformation. This may seem obvious, but the culmination of this week’s news – CVS buying Aetna to create a new healthcare platform and Apple partnering with Stanford to carry out a medical study on AFib using the Apple Watch – brought the pace of change into perspective. Healthcare is transforming before our eyes, and new players are moving into the space that accounts for 18% of U.S. GDP.
Taking a step back, healthcare 100 years ago was fundamentally the same as it is today. We go to the doctor for two reasons – we’re sick, or it’s time for an annual checkup. The effectiveness of this approach is dreadful, illustrated by the fact that about half of all Americans have one or more chronic condition, diabetes and heart disease are on the rise, almost 40% of us are obese, and 7 out of 10 deaths are attributed to chronic diseases. All the tech advancements we’ve made have not kept Humpty Dumpty together. The reason for this is that healthcare is generalized, impersonal, and reactive in nature. The individual must fight the day to day battle of preventative care, not the provider who the average American sees only 4 times per year.
Today, we see a shift toward two themes – personalization and prevention – and the future of healthcare will be grounded in the frequency of health monitoring. CVS and Aetna are coming together to create what CVS CEO calls the country’s “front door to healthcare,” because more doors means more frequent access to care. Apple and Stanford aim to collect data on more people more frequently. The concept of increasing health monitoring frequency holds the greatest promise of actually making people healthier and the easiest approach to increasing frequency is through wearables.
Today wearables are seen as a luxury gadget for geeks and health nuts. In the future (7-10 years from now), we will be inseparable from our wearables, similar to our current obsession with smartphones. Today, the smartwatch is the wearable of choice. Soon, however, that could include things like hearables (think AirPods), contact lenses, and connected fabrics.
Driving with your eyes closed. Healthcare monitoring today is comical. Nootrobox CEO Geoffrey Woo on an a16z podcast put it into perspective by saying “imagine that we’re driving cars and we only let ourselves open our eyes every minute. That’s essentially the snapshot of information we get when we go to the doctor.” We go in for a checkup, make a course correction, then drift back into our old habits until the next time we see the doctor. Continuous health measurement is the most effective approach to stay our course corrections. We now have biometric sensors in common devices and the computing power to make sense of that volume of data. The benefit of continuous health measurement is twofold – it allows for large-scale data collection from which AI algorithms can derive insights, and it keeps your health top of mind. And it appears to be working, studies show that 70% of Apple Watch users track their heart health, even weeks after purchasing the device.
Apple’s got a tiger by the tail. Investor opinions on the Apple Watch range from “it’s a rounding error” (4% of overall revenue), to “it’s a dud.” The reason is investors had been spoiled by Apple’s vertical growth in new product categories with the iPod, iPhone, and iPad. Apple Watch simply didn’t live up to its predecessors. While it has been a slow start for Apple Watch, we believe the Watch and future (7-10 years) wearables (notably hearables) will account for a material part of future Apple revenue. As the health advantages of wearables begin to resonate, we foresee Apple selling as many them (Apple Watch and hearables in the future) as they do iPhones. At a wearable ASP of $300 (below current Apple Watch ASP assumption of $450) and 250M units a year, that would equate to $75B in annual revenue (not in our model today).
Apple has been engaged with the concept of healthcare since it introduced the Apple Watch in 2015, releasing ResearchKit that year and CareKit in 2016. While their new Heart Study is technically their first true medical study, the Watch has been used in the past for similar crowdsourcing of biometric data (along with Fitbit and others). So this begs the question, why is Apple interested in healthcare? Their core competencies are well-aligned to benefit from the shift toward personalized and preventative care. They also have a platform in their device user base and software frameworks, the data and AI power to carry out large-scale operations, and the design expertise to integrate sensors into devices that consumers want to use.
A word on hearables. Apple has tipped their hand. Earlier this year, the company filed patents suggesting AirPods may have a future as in biometrics. The patents outlined the addition of a photoplethysmogram, or PPG sensor, that can measure heart rate, VO2, galvanic skin, EKG, impedance cardiography, and temperature. We don’t have enough details to guess when these features might be integrated into a product, but do see a future when these hearables are continuously worn, giving users volume control of the world, as well as next-level, real-time health monitoring.
What about other tech companies. Don’t forget about Google and Amazon. One of Google’s other bets, Verily Life Sciences, is focused squarely on making healthcare more preventative and data-driven. Verily argues, “a new car has up to 400 different sensors. You know the oil pressure and how much air is in your tires, but we don’t do that with people.” They have undertaken an array of different projects from glucose monitors in contact lenses to eradicating vector-borne diseases by engineering and releasing fertile mosquitos. Verily’s efforts are largely complementary to Apple’s health ambitions, and their engagement in the space is confirmation that big tech companies have a place in healthcare. The opportunity here is substantial enough to accommodate more than a few entrants. While it is unlikely that Amazon will be a player in data or wearables, the company has the DNA to reinvent the logistics around how care is delivered.
It will take time to win over the “I don’t want to be monitored” segment. It’s going to take years for widespread adoption of health monitoring wearables, as defined by more than a billion daily users. As a point of reference, we’re at 40-50m today, with about 25-30m of those being Apple Watches. Some people resist continuous monitoring on the grounds of privacy, inconvenience, and anxiety around knowing their true health. That said, the resistance group will shrink over time (some due to poor health).
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