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US Healthcare System, Market Dynamics, & Business Opportunity

Jan. 2018 Julian Lee, 이주형

juhlee71@gmail.com

Cost

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Price tag – California OSHPD Chargemasters

•  Stanford Medical Center, 2015 (published in 2016) –  Kidney/Pancreas Acq CTDN : $191,750 –  STNT GRFT Tag 8X31X10: $96,250 –  OR MAJOR 8HR: $94,844 –  Gastric Endoscopic: $4,888 –  Emergency room visit: $9,344 / $2,666 / $1,469 –  Med/Surg PRIV: $9,901

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Players’ Dynamics

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Patient

Government

Private Insurer (HMO, PPO)

Providers (Hospitals, Clinics,

Pharmacy)

Out of Pocket

Subsidy

Tax and Medicare

Insurance Premium

Medicare, Medicaid

Reimbursement Public worker subsidy

Device Manufacturer

GPO

Discount

Contract & Commission

Product

Pharma Wholesalers

Product

Product

FDA AMA

Providers (Physicians)

Players’ Dynamics

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Patient

Government

Private Insurer (HMO, PPO)

Providers (Hospitals, Clinics,

Pharmacy)

Out of Pocket

Subsidy

Tax and Medicare

Insurance Premium

Medicare, Medicaid

Reimbursement Public worker subsidy

Device Manufacturer

GPO Contract & Commission

Product

Pharma Wholesalers

Product

Product

Providers (Physicians)

Discount

FDA AMA

사업을 위한 고려 사항

•  Who pays for your product or service?

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•  Is insurer willing to pay your product or service?

•  Is there a CPT code? •  Stakeholders’ benefit maximization*

신제품 부터 판매까지

•  Regulatory & Reimbursement –  FDA (Class II 510K, Class III PMA) –  CPT(Current Procedure Terminology) code by AMA –  Reimbursement (CMS, Private Insurer)

•  Sales channel development –  Direct sales network –  Distributor –  GPO(Premier, Vizient, HPG) –  Wholesale(McKesson, Henry Schein, Cardinal)

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Lo~~~~ng Business Cycle

•  Google Health – 2008 ~ 2011 –  Allscripts, Cleveland Clinic, Walgreens, BCBS of MA, etc

•  Microsoft PHR – 2007 –  Mayo Clinic, Johnson & Johnson, NY Pres, AHA, etc

•  Intel Homecare, 2008 –  Prototyping –  Reimbursement issue

•  Patient/Consumer driven healthcare •  Insurance, Hospital, Data, HIPAA, EMR/HL7, DICOM

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실패 사례

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•  Amazon – Pharmacy business •  Google – Verily (glucose monitoring or working with GSK,

Novartis, J&J) Data science and machine learning for drugs or medical devices.

•  Microsoft – IT solution for hospital or insurer •  Microsoft – Blood test data to screen diseases using big data,

artificial intelligence and machine learning •  Personal health management by Apple, Samsung, Fitbit

–  Healthcare product? Or Who pays for it?

세로운 시도

비즈니스 사례 – Ultrasound guided injection

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CPT Code: 76942

비즈니스 사례 – Ultrasound image guides

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vs

비즈니스 사례 – Electronic Health Record

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•  American Recovery and Reinvestment Act, 2009 •  $19 billions for EMR implementation, part of Obama Care •  Incentive per physician: $44K ~ $63K

비즈니스 사례 – Electronic Health Record

12 Source: The Office of the National Cordinator for Health Information Technology, Health IT Library

비즈니스 사례 – IT 인프라

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•  Image management, DICOM •  EMR/EHR, HL7 •  Interoperability among vendors •  Interoperability among hospitals •  Interoperability among physician groups in the same hospital

How do we implement new imaging technology such as Artificial Intelligence?

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- Our IT infrastructure is not mature enough to consume AI and deep learning systems. We need to improve IT infrastructure go beyond PACS and EMR centric perspective to be able to feed big data type of decision support.

RSNA 2017, Paul Chang MD, U of Chicago

비즈니스 사례 – IT 인프라

Inner Circle in the US

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시사점

•  Money drives market •  Who pays for your product or service? •  Don’t try to sit in driving seat •  Forget “Consumer Driven Innovation”

–  A patient is just sick •  Better patient care •  Cost reduction, workflow orchestration

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