Category: Business

28 Feb 2019

11 Ways to grow gastroenterology practices through ancillary services

Reduced insurance reimbursements continue to create pressure on medical practices, particularly gastroenterology (GI) – a specialty that I’m most familiar with. Ancillary services offer a way to buffer a practice from financial pressure.

Before considering ancillary services, it’s important to streamline billing and technology at your practice. Efficient billing maximizes reimbursements. Better technology-driven processes minimize waste and improve efficiency.

When you operate an efficient practice, you’ll create savings (or increases) in revenues that can be utilized towards starting ancillary services. Below are 11 ancillary services for gastroenterology practices to consider.

What exactly to offer depends on these factors:

• the size of your practice
• patient needs
• availability of space and staff
• ability to invest or take a loan
• alignment with practice philosophy of care
• geographical concentration of your services
• competitive dynamics with local hospitals
• inclination to partner with an outside company
• regulatory restrictions in your state
• insurance coverage

  1. Move procedures from the hospital to your ASC. Building an ambulatory surgery center (ASC) requires time and effort. However, an ASC has the potential to significantly increase revenues through facility fees that would otherwise go to the hospital. Further, it’ll result in better efficiency through common technology and more coordinated care for patients. There are companies that partner with GI physicians to start ASCs.

  3. Start a pathology lab. Gastroenterology groups generate a variety of lab samples. Insourcing the technical component (TC), professional component (PC) or both will add significant revenue streams. Note that insurances do not easily go in-network with most new labs. To maximize reimbursements, you’ll need to have the ability to conduct ongoing negotiations on out-of-network claims with third-party administrators and insurances.

  5. Offer infusion and/or other biologics. Drugs for inflammatory bowel disease are expensive with small margins. You can’t afford to receive any denials from insurances because you already pay upfront to buy these drugs. However, if billing is rigorous on all claims and there’s suitable patient volume (e.g. patients of Crohn’s disease), then biologics can be a profitable endeavor.

  7. Start imaging services. If there’s enough need for imaging in the area and a large patient volume, a practice could consider investing in CT and ultrasound equipment. This creates a new channel of revenues for the practice.

  9. Offer hemorrhoid banding. One gastroenterology practice we know improved its overall patient satisfaction levels when it began offering this procedure. It’s relatively simple to offer this procedure and provides faster relief to patients. It can be performed both in the ASC and in an office setting with promising reimbursement levels.

  11. Build anesthesia partnerships. Several gastroenterology practices offer anesthesia as an ancillary service at the ASC with great success. It reduces pain for patients during procedures and therefore improves patient satisfaction. Again, anesthesia claims might require separate tracking and negotiation if fee schedules aren’t agreed upon. Note: the Centers for Medicare and Medicaid (CMS) recently made coding changes in anesthesia resulting in a reimbursement drop.

  13. Earn from clinical research. If the practice is academically inclined, you can develop a clinical trials program to evaluate new drugs, medical devices or tests. This can add a new revenue stream. For example, gastroenterology practices run trials for ulcerative colitis, irritable bowel syndrome, opioid-induced constipation and so on. It’s important to note that comprehensive research programs have inherent risk and take longterm commitment from doctors to create value.

  15. Add nutrition and weight management programs. Unlike some other ancillary services, adding a nutrition program requires less upfront investment. These income streams sometimes work better with a cash payment model. Focusing on diets specific to digestive disorders (e.g. anti reflux diet, FODMAP diet, gastroparesis diet etc.) can help patients manage their conditions better. Some practices offer procedures such as Endoscopic Sleeve Gastroplasty (ESG) and gastric bypass to help patients with weight management.

  17. Dispense medicines at your practice. You can consider partnering with an in-house dispensing company and dispensing your top 20 drugs at the office. It saves patients a trip to the pharmacy. Note that laws in some states strictly prohibit drug dispensing at doctors’ offices. Some practices also sell nutrition supplements, vitamins and probiotics that aid in digestive care.

  19. Add advanced GI procedures. Procedures such as Peroral Endoscopic Myotomy (POEM) and Endoscopic submucosal dissection (ESD) are advancing the field of endoscopy. Smart Pill and small bowel capsule are others to consider. One of the practices we work with has a partner who focuses mainly on advanced gastroenterology procedures most of the time. Billing and coding is complicated and requires continuous attention to get paid correctly from insurance companies. Adding advanced procedures help practices be recognized as leading the field.

  21. Specialized centers of care. Some practices offer specialized centers of expertise for conditions such as Crohn’s Disease, combining endoscopic services, biopsy reviews, infusion therapy, diet, and onsite lab testing. Another example is a liver center to manage liver disease and transplants. More advanced GI groups can consider starting centers of care based on patient needs


Bonus: Offer genetic counseling and diagnostic testing for gastroenterology. More and more patients are getting a genetic test and seeking their doctor’s counsel. While the areas of billing and coding for genomics is still evolving, you can expect this area to grow in demand.

(Aside: Blueprint Genetics offers the following panels for GI: cholestatis, congenital diarrhea, congenital hepatic fibrosis, gastrointestinal atresia, pancreatitis and so on).

Outside of direct contribution to revenues, ancillary services have the benefit of helping patients more comprehensively, improving satisfaction and even attracting new doctors to work at your practice.

These services enhance the practice’s reputation in the community. They create opportunities to serve new patients (and their families) who might’ve otherwise not known about your practice.


  1. GI Practices: Don’t Overlook Ancillary Services For Revenue Growth, Expert Roundtable by Gastroenterology & Endoscopy News.
  2. 9 Ancillary Services That Can Boost Practice Revenue, Medscape.


Originally published on LinkedIn,  by Praveen Suthrum, President & Co-Founder, NextServices. 

This article is part of an upcoming 50+ page ebook, Navigating the Next Wave: Private Equity in Gastroenterology (releasing on March 6th, 2019). Click here to receive it first.

Image Credit: Singkham from Pexels

07 Feb 2019

Understanding 6 trends shaping healthcare through one specialty: gastroenterology

If you throw a pebble today, it’s likely to land on an article that talks about how artificial intelligence and its brother machine learning are changing healthcare.

Yes, I get it broadly. But I was curious to explore how exactly healthcare’s trends are shaping any one medical specialty. I chose gastroenterology (GI) because I’m most familiar with the space. And here’s what I found.

Trend #1: Manipulating bacteria in your stomach (Microbiome)

We are still a long way from fully understanding the microbiome (the microorganisms in our body). However, fecal transplants (it’s what you think – restoring bacteria by infusing stool of a healthy donor) have shown promising results. Especially for inflammatory conditions such as C. Diff Colitis and autoimmune conditions such as inflammatory bowel disease.

The human microbiome industry is expected to be worth $3.2B by 2024. The company, Commense develops approaches to “guide the priming, seeding, and maintaining of the microbiome in infants and children”. Openbiome is a non-profit stoolbank promoting safe access to fecal transplants (by the way, they offer $40/session).

Just as with genetic editing, the future may offer the ability programmatically manipulate a patient’s microbiome to result in better health.

Refer: Is The Future Of Microbiome Research Already Here?

Trend #2: Genetic editing for stomach cancer (Genomics)

In 2018, a Chinese scientist claimed that he produced the world’s first CRISPR babies (gene-edited ones). There are several companies (e.g. Myriad Genetics) working to tackle specific conditions such as beta-thelassemia (blood disorder).

GI isn’t too far. Research suggests that CRISPR-Cas9 technology can be used to genetically modify organoids. To understand GI diseases such as pancreatic cancer, gastric cancer better.

Refer: Modeling Human Digestive Diseases With CRISPR-Cas9–Modified Organoids

Trend #3: Computer vision to detect polyps (AI)

Detecting adenomas (benign tumors) is the holy grail of colonoscopies that GI doctors routinely perform. With the help of AI, doctors could potential detect adenomas with greater accuracy.

As an alternative to traditional colonoscopy, video capsule enteroscopy offers videos via a capsule that traverses through a patient’s digestive tract. 50,000 images are captured over a period of 8-72 hours. AI can ‘view’ these images and videos and highlight polyps (small growths) that the human eye can miss.

Refer: Development and validation of a deep-learning algorithm for the detection of polyps during colonoscopy (Nature)

Trend #4: Fitbit for the abdomen (Wearables)

Monitoring electrical activity of the stomach has been in the works. The stomach sensor syncs with an app to send signals of gastrointestinal events (think bowel moments).

Startup GI Logic developed a biosensor to listen to the abdomen and classify the signals via Abstats. The Wearable device suggests a new way to monitor patients to before/after GI procedures.

Refer: Tummy Tech Tracks Electrical Activity for Signs of Indigestion (IEEE Spectrum)

Trend #5: Minimally invasive GI procedures (Robotics)

Endoscopic procedures such as Peroral Endoscopic Myotomy (called POEM, to treat achalasia), Natural orifice transluminal endoscopic surgery (called NOTES, to remove gallbladder) are on the rise. They offer benefits of faster recovery, less pain, potential for scarless procedures and so on.

A variety of devices, instruments, scopes, imaging techniques are making these advanced endoscopic procedures possible.

Refer: Robotics for Natural Orifice Transluminal Endoscopic Surgery: A Review

Trend #6: Customizing accessories to remove difficult lesions (3D printing)

Not limiting itself to printing models of damaged parts, 3D printing aims to print tissues of organs themselves.

Closer to the present, gastroenterologists are experimenting with 3D printing custom endoscopic caps (accessories that attach to a scope) to remove difficult-to-target lesions in procedures such as endoscopic mucosal resection (EMR). EMR is yet another procedure to remove cancerous lesions from the stomach.

Refer: Mo1520 New Technique for GI Endoscopy Using 3D Printing (GIE Gastrointestinal Endoscopy)

Connecting the dots: So what?

The science part of healthcare has always progressed rapidly. Making it easier for patients and doctors alike. There’s nothing really new about that.

What’s new this time is this: the pace of change outside of healthcare is changing.

AI. 3D printing. Robotics. Sensors. Programmatic tools to edit genes.

These trends are converging. Creating new combinations.

So what?

Majority of the GI space circles around traditional procedures such as colonoscopy. Patients have abdominal pain or are at risk of colon cancer. GI doctors perform colonoscopies. Bill for them. Insurances reimburse. Even software is developed around these themes.

But this everyday model for GI is changing. Not exactly because of changes in GI. Not even limited to changes within healthcare.

But because of changes outside of healthcare.

And when you delve into one specialty, it has the potential to tell you the story of all others.

That’s exactly why it’s important to connect these dots.


Originally published on LinkedIn,  by Praveen Suthrum, President & Co-Founder, NextServices. 

Image Credit: Pixabay

22 Jan 2019

Four insights from healthcare’s imminent future

Instead of driving on the highway, let’s imagine you drove upwards from wherever you are…you’ll reach space in about an hour.

On your way up, you’ll begin to see everything differently. Cities, roads and trees slowly blur out to make way for a new kind of reality. Converging. Diverging. Both at the same time.

What appears dissimilar on the ground (trees and shrubs) will appear similar (green). What unites on the ground (mountains and rivers of a country) will appear cleanly fragmented (land and water).

Observing healthcare from space. Playing the game with healthcare…

When you zoom out, you’ll see the industry differently. You’ll see it in tandem with other changes that are changing it.

You’ll see how quickly it’s changing. And where. You might even discover why.

View #1: A smaller, similar, consolidated world

In 2018, 715 private equity deals created a value of $103.72 billion. It’s a new record for healthcare. One big driver for this frenzied deal-making is targeted consolidation. Private equity is zooming out to connect disparate dots to create newer, larger formations. They are creating a forest out of the trees.

I’m seeing this unfold live in the space that we largely serve (gastroenterology).

View #2: Unrelenting, unstoppable changes driven by technology

If your job hasn’t been touched by AI, it’ll surely soon be. Many millions in healthcare will be displaced, especially those dealing with routine, repeatable, pattern-oriented work. Not just transactional activities like billing but also medicine itself.

In 2018, FDA-approved watches began reading EKGs and using that data to detectconditions such as hyperkalemia (high potassium). In the future, algorithms would allow “self-driving” in procedures such as colonoscopy.

View #3: Societal aspirations of living healthier, stronger, sexier and longer 

What we want out of our bodies is no secret. If we are sick, we want to be healthy. If we are healthy, we want to be strong. If we are healthy and strong, we want to be sexy. If we are healthy, strong, and sexy, we want our bodies to last forever.

Biotechnology research is keen to make these desires possible. In 2018, a Chinese scientist claimed he’s produced the world’s first CRISPR babies (gene-edited ones).

Read: Yuval Noah Harari’s writing offers an in depth analysis of where such developments might lead to in the future. His latest book deals with the present.

View #4: Data dominance 

Amazon, Apple, Google, Microsoft have all made big healthcare moves in 2018. Amazon bought an online pharmacy, launched its own healthcare venture and created a medical AI cloud service. Apple created an app to detect irregular heart beats. By tinkering body’s information, Google plans on extending life.

You’d note that all of them are data-hungry, technology Goliaths. With data, they will learn how to do healthcare even better by connecting disparate dots (e.g. Alexa detecting that you have a cold, Amazon suggesting cold meds).


Let’s connect the dots

When you connect these dots, you’ll observe some straightforward maps.

  1. The healthcare industry will consolidate, corporatize and be more and more unified.
  2. Reliance on data and technology will limit us from functioning outside the grid. No more doctors without computers or computers without doctors.
  3. The industry will go through many phases of frustration and confusion before the dust settles. And then it’ll disrupt all over again because of further advancements.
  4. Scope of healthcare will range widely. From fixing sickness to designing babies.
  5. Our healthcare decisions will be guided (and possibly manipulated) by countless algorithms and people who control them.


What do we do?

At some point this year, I realized that we are in the middle of a massive wave. And there’s no stopping it.

Healthcare is changing for good.

No one can tell us where this wave will take us. So, what do we do?

Instead of worrying about the wave or trying to escape it, we must choose to shape what’s to follow. Not with newer technological widgets. But with our moral and ethical compasses. That we are already genetically blessed with.


Originally published on LinkedIn,  by Praveen Suthrum, President & Co-Founder, NextServices. 

Image Credit: Ky0n Cheng @Flickr

31 Dec 2018

Uber and Lyft ride into healthcare. What to expect (and what not to)

Here’s the premise.

36 million American patients miss their medical appointments. If only they had a ride waiting outside, they’d make it to the doctor’s office.

Uber and Lyft have both made announcements in healthcare this month. And why not? In recent months, Apple, Amazon, Google, Berkshire Hathaway have all plugged into healthcare.

Here are a few headlines that recap this ride-sharing story.

Uber wants your doctor to call you a ride to your next checkup

Know the Risks When Using Uber Health, Lyft

Whoa, Uber’s New Service Will Drive You to the Doctor for Free

New BCBS Institute working with Lyft, CVS, Walgreens to tackle social determinants

Lyft announces integration with Allscripts EHR system, allowing 180,000 doctors to hail rides for patients

Five Things to Know About the Uber and Lyft Provider Partnerships

Basically, the doctor’s office or the hospital would hail a ride. A patient would hop in, possibly share the ride with other patients. Helping providers not lose money in missed appointments ($150 billion per year). Helping patients not fall sicker by skipping those appointments. Further, sick patients end up in acute care burdening the system more and more.

I get the logic.

Just that I see a few bugs in it. More so because we are practically in the trenches with doctors everyday.

Why patients don’t show up (really)

JAMA just published findings from a clinical trial of 786 adults with Medicaid. This is what they found:

“Offering a rideshare-based transportation service may not decrease missed primary care appointments.”

The Annals of Family Medicine published this study in 2004. Why We Don’t Come: Patient Perceptions on No-Shows. Before Uber or Lyft existed.

Patient “no-shows” is a big problem for doctors. But you rarely hear that they didn’t show up because they couldn’t get a ride.

The 3 big reasons that the Annals of Family Medicine study found were:

  • Emotions
  • Perceived disrespect
  • Not understanding the scheduling system

Here’s quoting from the study:

“Appointment making among these participants was driven by immediate symptoms and a desire for self-care. At the same time, many of these participants experienced anticipatory fear and anxiety about both procedures and bad news. Participants did not feel obligated to keep a scheduled appointment in part because they felt disrespected by the health care system. The effect of this feeling was compounded by participants’ lack of understanding of the scheduling system.”

This does sound right.

There’s another study, Why do patients not keep their appointments? Prospective study in a gastroenterology outpatient clinic. The findings:

“Forgot to attend or to cancel (30%); no reason (26%); clerical errors (10%); felt better (8%), fearful of being seen by junior doctor (3%); inpatient in another hospital (3%); miscellaneous other (20%). 13 (27%) of the review patients had not kept one or more previous appointments.”

In our experience, this sounds perfectly reasonable. More than a quarter of them cited “no reason”!

There are also unexpressed financial reasons. By showing up, patients need to face up to deductibles and co-pays. It’s not always that they want to pay up.

Several articles talked about how the rides would help lower income populations.

The reality is doctors struggle to get paid by Medicaid (insurance that covers lower income). They never know if they’d get paid for the service they are about to provide. They do it anyways.

It seems unreasonable to expect that over-stretched doctors and staff would now hail a ride for patients via the EHR.

EVEN IF we do call Uber from the EHR

I was recently in a meeting at a large hospital in the east coast of US. It’s easily considered one of the world’s best. The doctors don’t really have a problem patients showing up. It’s what happens after they do.

Here’s where they are stuck.

They see a patient. Order a test. Or schedule a procedure. The billing office calls the insurance to get “prior authorization” for the procedure. Insurances make it difficult to provide prior auths. The game goes on for several days. The billing office is overwhelmed by the many prior auth requests. Finally after 30+ days (on average), the patient ends up on the procedure table. Getting the care she rode in for.

Now imagine in the above everyday scenario, the doctor or her staff does call Uber for their patient. Possibly via their EHR. Of course, the integration is cool (for tech folks, not necessarily for doctors). It won’t necessarily help the patient get care faster. It won’t help doctors get paid for that care or service.

In fact, what it is is this. It’s convenient. Like ordering food online. It may not really solve our clinical or economic burden in healthcare. It adds a layer of easy. And that’s a good thing too.

May be we should say just that.


Originally published on LinkedIn,  by Praveen Suthrum, President & Co-Founder, NextServices. 

Image Credit: Pexels

31 Dec 2018

4 Takeaways from Practice Fusion EHR’s $100M sale to Allscripts

Two years ago, Practice Fusion, an electronics health record company was rumored to be valued at more than a billion dollars.

Last month, the company sold for a fire sale price of $100 million.

Having raised $157 million, you can imagine that most people didn’t make any money. Apparently parachute deals help senior executives and the board make a few million (including $2million for the company lawyer).

But nothing really for employees who stayed on and ordinary shareholders. Few who exercised options earlier will even lose money via taxes.

Read: Employees at Practice Fusion expected IPO riches, but got nothing as execs pocketed millions (CNBC)

Apparently, the company has been looking for a buyer for 2+ years. And got offers ranging from $50-$250M. Allscripts, an EHR giant that recently acquired McKesson’s Health IT portfolio, initially offered $250M. But got nervous after a Department of Justice investigation last year (of another company – eClinicalworks which settled with prosecutors for $155million).

Read: Allscripts offered to buy Practice Fusion for $250M. A DOJ investigation changed everything

That’s the story. What does it all mean?

The evolving healthcare industry landscape will show what it eventually means. But here are a few takeaways.

1) A nod to the cloud

The EHR world’s market leaders are Cerner, Epic and Allscripts. All of them are client-server based. Epic is based on 52-year old MUMPS technology.

In a world of client-server dominance, Allscripts acquisition of Practice Fusion is a nod to the cloud. That’s clearly where the industry is going. Or, will be compelled to go.

Here’s what the company’s president Rick Poulton said: “Plus, Practice Fusion’s affordable EHR technology supports traditionally hard-to-reach independent physician practices, and its cloud-based infrastructure aligns with Allscripts forward vision for solution delivery.”

2) It’s tough to make ‘free’ a sustainable business model in healthcare

Practice Fusion started on the premise of offering a free EHR to physicians. And in turn, monetizing de-identified healthcare data. Supported by ads etc.

Investors bought into it. Including Peter Thiel (he wrote the founder a check of $1million in 2011 before leading that round).

Then the valuation game caught up with itself. Investors put in money assuming someone else is going to put in at a higher valuation. Later. But when the company isn’t making real cash, the valuation cycle eventually catches up.

Someone says, I can’t agree to that valuation – it makes no sense. And then everything goes down-hill. Down rounds begin. Terms change. Dilution for earlier investors happens. People get fired. CEOs get ousted.

The problem with healthcare is that regardless of how fast the world moves, the industry moves at its own pace. Like life and death, the industry whiffs of a certain permanence.

You can’t do a Google or Facebook here by offering free service and making money via ads or data. At least, not yet.

3) The landscape is freezing

Industry changes happen like lakes freezing and unfreezing.

Rules of the game shrink. Consolidate. Big boys dominate. They make it harder for each other and others to change rules.

In US, Meaningful Use incentive dollars that spurred the industry have dried up. Tech giants like Apple have made healthcare announcements (“effortless solution to bring health records to iPhone”).

Companies like Allscripts bought McKesson (to go after smaller markets), now Practice Fusion. They’ll keep looking for more deals to spread their reach.

Tired of their healthcare costs, Amazon, Berkshire Hathaway, and J.P. Morgan announced that they are teaming up to disrupt the industry.

When industry landscapes freeze, it’ll take time before it melts again. But because it’s healthcare, the freezing – while it’s definitely begun – will happen slowly, slowly.

This leaves doors open for specialty and niche opportunities that are small for the big boys to focus on. That means there’s no point building a new plain vanilla EHR. But there’ll be strong needs for EHRs and products that go a mile deep in specific areas. That naturally plug into the new rules that are bubbling to the surface.

4) Practice Fusion’s real asset is its data. But no one’s talking about it

Practice Fusion has a dataset of 81 million patient records. Imagine applying AI on that data. Creating newer products for the same target group based on their data.

It may be tough for Allscripts because market commands their vision to focus on getting bigger faster. Not develop cool technology tools.

Practice Fusion’s idea was a good one. To build a company around data. But their business couldn’t sustain itself until that point where the industry is mature enough to make that data useful.

What’s the moral of the story?

Practice Fusion’s founder Ryan Howard moved on to build a heart-activity wearable device called iBeat (after differences with the board).

Is there a lesson here? That the healthcare industry is trying to tell us. Perhaps it’s this.

It’ll be slow. You can disrupt but not quickly or suddenly. You’ll need stable, sustainable business models. The boring stuff makes money. Regulations can disrupt your life. And yes, it’ll all be up in the cloud. Eventually.



Originally published on LinkedIn,  by Praveen Suthrum, President & Co-Founder, NextServices. 

Image Credit: Pixabay

06 Jul 2017

To survive (and thrive) in healthcare, you need a pipeline of ideas


There’s this myth that entrepreneurs take great risks. It may be true while starting out. But in reality, most long term entrepreneurs methodically de-risk. Do everything to reduce risk for their companies. Not increase it.

Several startups go belly up in risking too many eggs in one product or one investor or one client. Including some very large startups.

More times than not, market forces work against you. Not for you.

You already know this.

To survive (and thrive), you need a pipeline of ideas. Particularly in healthcare. A complicated, slow-moving beast.

Sometimes in this industry, the function of one product or service is to simply lead to the next. Or, the one after that.

In such a game, your ability to acutely focus on what clients want and will pay for is key. It’ll keep your lights on.

Then when something takes off, it’ll get the rest of your portfolio to take off.

A “page turner” that no one cared about

Entrepreneurs (like me) often obsess about things that no one cares about. We burn time and money on those obsessions.

When we first built our enki electronic health record (EHR), the mobile version excited us. One of the doctors we interviewed indicated that he’d love for the EHR to resemble his paper charts.

We took that feedback to heart. Spent inordinate amount of resources in building that feedback into a feature in our mobile app. Each section of the patient’s chart would flip like a real page. It looked great and we loved it!

But our clients really didn’t care much for that feature. All that mattered to doctors was the ability to complete a chart quickly. Move onto the next patient. Flipping a page was lower in the order of priorities.

This “page-turner” and other features delayed our launch endlessly. We spent our time making our creation more and more beautiful (not just “good enough” to move onto the next step). It left no money or time for marketing.

Thankfully we had other sources of revenue that kept us going. Even while we learnt from these mistakes and built our next product or service. And the next.

What we now observe is one service or product often triggers our clients to buy our other products. Because they already love us and what we do. Now many of our clients use everything we’ve built.

Allow them take complete advantage of you

Say you wish to start a smart footwear company for senior citizens. The sensors would alert an app when there are abnormalities in mobility.

Instead of running after funding first, spend $500 online. Buy sensors and strap it to footwear. Figure out how to send basic signals to your phone. Build a prototype that your potential buyers can use.

Then just give it to your customers to use it. And watch.

Your beta users will show you what they like and dislike.

If you listen keenly, they will exactly tell you what they will pay for.

Focus on what they want versus what you want.

Observe your users (senior citizens in this example) and their environment. So closely that you know them more than they know themselves.

Ask yourself this question: How can they take complete advantage of you?

You will be surprised with the number of ideas you would get when you answer that question. Because you would be bringing the focus to them.

May be there are caregivers and doctors who have certain needs in monitoring your customer. Or, may be there’s everyday furniture that can become smarter. Or, may be there’s a need for “smart” walking canes that sense movement.

May be, the footwear needs to connect with other devices giving richer analysis of data. Or, you could develop a subscription plan and offer the footwear free.

You’ll arrive at endless possibilities for growth. When you bring all your attention to your customers. They will tell you what you need to build next. You simply need to listen and respond. With everything you got.

Never run out of ideas

A tree with many roots doesn’t get blown away when the winds are strong.

Not only do the roots keep it grounded, they also provide renewed sources of water. If one root dries out, it can feed itself from another. Roots run long and source water from many different terrains.

Successful healthcare businesses are no different. Longevity helps in this industry. With experience, you will find many sources of revenues. One product leads to another. One service evolves into many branches.

All you have to do is listen. And respond to your sources of water.


Originally published on LinkedIn,  by Praveen Suthrum, President & Co-Founder, NextServices. 


27 Jun 2017

How to grow your startup…even if VCs don’t love you


Big meeting rooms with shiny tables make me uncomfortable. Like that room inside the offices of that big-name VC firm.

Even as I waited, I lusted after the logos of many a known startup. They were displayed on plaques outside the room.

(Some of them are bust today. But back then it didn’t matter.)

Then he came. The investor. Eating something. Crumbs.

“Show me something that you have that no one else has!”

That was almost the opening line.

Right, I thought. Imagine hearing something like that on a first date.

My next thought was to recall the cost of the flight tickets that brought us to this meeting. Then my time. I could’ve met clients. Trained our people.

Or, I could’ve at least gone for a movie.

Ouch, I thought. But decided to go along since I was already there.

“Look,” he said midway through the demo. He was staring into his phone. “We would want you to get to a $500 million valuation. Or, go bust!”

Go bust? But what about our clients? And our people?

(Wasn’t it a 50 Cent movie? Get Rich or Die Tryin’)

Just valuation.

Not real money. Like profits. Or even revenues.

“But that’s our model,” the investor said. He was looking at me now.

“Oh,” I responded.

A day later, to close the loop I told him we weren’t a fit.

Well, he already knew that.

Thinking about growth differently

No meeting really is futile. Those kind of meetings (yes, there were a few) helped me discover the Healthcare Footprint Finder. A practical strategy to grow your business in healthcare.

Another VC-friend-of-a-friend told me this in confidence:

In reality, most of us don’t understand healthcare. Or, how to sell to businesses within healthcare. The industry is too complicated. That’s why we ask for traction. If there’s demand then it reduces the risk for us.

I know. Healthcare is complex.

Everything takes time. Your first product is often the means to your next one or the one after that.

If you can’t stay put, you’ll surely go bust.

In 2012, 2,000+ electronic health record (EHR) companies went through the gate of Meaningful Use Stage 1 (part of the erstwhile Obamacare). By 2015 the time of Stage 2, only 200+ companies passed through the gate.

It’s now time for Stage 3. The game gets narrower.

Healthcare requires staying power. Where you need to make real money. Not just play the valuation game.

Because even if you get an investor onboard, they will lose patience in trying fuel you again and again.

But how do you stay on in healthcare? By finding your next big idea.

And how do you find your next big idea? By looking around your existing footprint.

Observe your clients in action. You will discover many unmet needs. They may not be able to verbalize them for you. But if you work closely with them, those needs will begin to leap out at you.

Our company started by selling billing services to gastroenterologists. Today we sell sophisticated endoscopy report writing software to the same clients. We also sell MACRA compliance services and a cloud-based EHR platform. To the same clients.

We got the idea of creating software by looking around our existing footprint. Looking for newer ways to be useful to people who already love us and our work. Observing what was bothering them. Solving their problems.

That’s how it happens. We use the Healthcare Footprint Finder model to grow.

When you approach growth this way, you will have a pipeline of services and products to develop. Because client needs become the starting point. Not random ideas. This way, your new product is likely to sell from Day 1.

Without hankering for funding, you would focus on the right things for your company.

So, VCs or not?

There’s no right answer. It depends on what you want and what the business wants. At that point of time. It also depends on finding the right investor. Does the person getting on your board understand you and your vision?

There are many fine examples of entrepreneurs who’ve ditched the elevator pitch altogether. Built fantastic companies.

Jason Fried from Basecamp. Ramit Sethi from IWT. Ben Chestnut from Mailchimp. Steve Rayson from BuzzSumo.

It’s the market that sustains them. Their business models are regenerative. Always alive. In tune with client needs.

They focus on quality vs quantity. User success vs user acquisition. Sustainable growth vs quick exits.

Mara Zepada of Switchboard and Jennifer Brandel of Hearken call these companies Zebras. An alternative to the Unicorn fantasy.

But such a strategy seems counterintuitive.

At a time when everybody wants to Uber-this and Uber-that.

Even when it all comes Uber-ing down.



Originally published on LinkedIn,  by Praveen Suthrum, President & Co-Founder, NextServices. 

Image: Photo by Ashley Bean on Unsplash

21 Jun 2017

Global convergence in the future of healthcare. Are you ready?


This wasn’t the usual South African clinic.

We were inside a high security prison for illegal immigrants. On the outskirts of Johannesburg.

Stroking his beard the doctor told me, “Some of them get arrested for a free ride home. First, the authorities bring them here for a few days. Then they drop them at the border. Our clinic has to make sure they don’t get sick.”

Then he began sounding so much like doctors in America.

“We must digitize. But it mustn’t slow us down.”

“Patients don’t listen to instructions.”

“Nothing integrates here. We need our systems talking to this, this and this.”

Global like your local Starbucks

Healthcare issues are so local that we fail to realize how global we’ve actually become.

South America. Africa. Asia. Middle-East. Whichever part of the world you look. Healthcare is looking more similar than dissimilar.

With increased sanitation, communicable diseases like malaria are on the decline. With increased prosperity, non-communicable diseases like diabetes are on the rise.

In a city like Mumbai or Johannesburg, you’ll find that both disease conditions co-exist often within walking distance.

4 pillars of healthcare delivery

Observe these four essential pillars of healthcare. These are applicable wherever healthcare is delivered. Notice the convergence.

  1. Disease: Types of diseases are more common (e.g. hypertension). Reasons of disease are also more common (e.g. stress). Country after country, disease burden is on the rise.
  2. Diagnosis. Our approach to arrive at a diagnosis is getting similar (e.g. via lab tests, examinations and consultations).
  3. Cure. Therapies are common (e.g. procedures are similar, guidelines are more common).
  4. Pay. Sometimes it’s the government or the individual that pays. But today it’s more likely that you have an insurance company covering you.

You will notice that everyone is moving in the same direction. Everywhere.

Future of healthcare needs a global mindset

Extrapolate these trends of disease and healthcare delivery. What do you think is going to happen in the future? Yes, a lot more convergence.

You could delve into a specific area such as in Health IT. You will hear the same language. Technology standards. Interoperability issues. Burdensome complexity.

Healthcare administrators fret about the same issues from Manama to Miami. Productivity of doctors and staff. Expensive technology. Lack of available skills.

In global healthcare, the good and bad news is the same: Whether we sink or sail, everyone is in this together.

So where do you begin?

Today’s business environment is unpredictable. Technological changes are wiping out old business models faster.

A global mindset reduces risk for business. Particularly in healthcare because things are changing quickly.

But where do you begin?

1) Think differently about talent

Start by exploring new-age outsourcing tools like Fiverr or Freelancer or Upwork. From drawings of the anatomy to voice-overs, we’ve used these tools to reach global talent. It’s made our work richer.

A friend from a Fortune X company recently hired material science engineers in East Europe. These engineers reinvented a core product design for the company without really knowing who they were working for.

As head of R&D, my friend told his bosses only after he completed the pilot. It cost the company 1/20th the expense and brought about a shift in mindset.

Salim Ismael writes about this evolving exponential organizational mindset.

Today’s companies are built for a linear world – closed and topdown. They evolved more than a hundred years ago.

That world doesn’t exist anymore. Changes are exponential today.

2) Build partnerships with your global colleagues

Do this little experiment.

Go to LinkedIn and search for what you do in a completely different geography. Search for an industry-specific health IT standard like “HL7”. You’ll find people in UK, Australia, Egypt and elsewhere.

Reach out and build partnerships. You will find a need in the most unexpected places.

U.S. certifications are sought after in emerging markets. Like JCAHO, operated by Joint Commission, a non-profit body based in Chicago.

Brazil introduced ICD-10 in 1996. China in 2002. South Africa in 2005. U.S. shifted from ICD-9 to ICD-10 much later in 2015.


Healthcare is changing.

To think differently, look beyond what you can see.

And ask this question: what’s not so different here?

Get healthcare insights more directly at redo/healthcare.


Originally published on LinkedIn,  by Praveen Suthrum, President & Co-Founder, NextServices. 

Image: Facebook Connections by Michael Coghlan/Flickr

17 Jun 2017

4 steps to find your footprint in healthcare


Creating a business is fun. It’s also tedious.

It’s the tedious parts that are difficult. Because it takes patience to figure things out.

Building a product is fun. But when it doesn’t sell, do you add more features? Or, learn how to sell?

Like creating products, hiring is fun. When you are on the choosing end. But developing someone who’s not yet ready – that takes effort.

When new clients sign up, it’s fun. But when they complain about your support or when quality wobbles – that’s tedious.

It’s easy to gravitate towards the next shiny thing. And the next after that. But the magic lies in figuring the tedious things out.

To market and sell. To build stable operations. To develop people. To be responsive to clients. To manage cashflow. These take time and discipline.

How we found our focus in healthcare

There are more than 120 medical specialties and subspecialties in medicine. Each is an industry in its own right. But we found our center in the gut!

My company started by providing billing services. It so happened that one of our first clients was a gastroenterology practice.

We loved the David and Goliath fight with insurance reimbursements. In doing so, we learnt the business problems that GI doctors face.

When our clients struggled with old EHRs, we knew we could do something about it. With a lot of effort and of course money, we built our own cloud-based EHR called enki.

We didn’t stop there. We kept learning and digging the well of gastroenterology.

We noticed that clients had to deal with the complexity of compliance. We figured that out. Helped them win audits and incentive dollars.

We saw that our doctors lived with old endoscopy software. Expensive. Requiring frequent upgrades.

That prompted us to build endoscopy report writer software. We used our knowledge of building cloud-based products and compliance. Applied that to the endoscopy market.

Our clients continue to have many needs. Our company simply needs to make sure we meet those needs by being on top of the game.

That becomes our focus.

4 steps to find your healthcare footprint

If you are starting or growing your business in healthcare, find your footprint using these four steps. Here’s the Healthcare Footprint Finder.

Step 1: Find your market within the industry

Healthcare is too big. You need to find a market within the industry. Something with gaps and frustrations but also expanding. A specialty that’s branching into subspecialties.

Before you start developing anything, be clear (by testing) that someone is willing to pay you for it. How does it ultimately benefit a doctor or a patient?

(I’m not a fan of the user-volume game that certain startups play. It burns a lot of other people’s money. Doesn’t guarantee a method for profitability.)

Step 2: Find a footprint within your market

Once you know there’s a market need, find your footprint. If you can serve ONE client well enough for them to say, “We love what you do for us!” then you are in business. You can do this many times over.

If you can’t find even one to say so and pay you, then something is wrong.

Step 3: Learn how to sell your footprint

Several entrepreneurs abandon this step because it’s too difficult. Or they throw money on the problem by hiring more salespeople or paying for clicks.

Marketing forces you to deeply probe and ask yourself whom you wish to serve. Why? How? What differentiates you? How could you be better? What should you be doing to offer maximum value to your footprint?

Step 4: Look around your own footprint

Once you have a footprint and know how to sell, look around your footprint. What do your clients do before and after they use your product or service? How could you make their life better?

That becomes your next product or service. That’s how you grow.


Get healthcare insights more directly at redo/healthcare.


Originally published on LinkedIn,  by Praveen Suthrum, President & Co-Founder, NextServices. 

Image: Christopher Sardegna/Unsplash

08 Jun 2017

Here’s something that many healthcare entrepreneurs ignore


Despite innovation in medical science, healthcare is usually behind other industries. By 3-5 years or more.

The industry gets by with old technology and processes. People resist change. Regulations slow progress. Companies market and sell using traditional approaches.

Such an environment sets the stage for new healthcare businesses. Some startups succeed. Several fail.

These failures aren’t sudden or dramatic like in other sectors. You can’t really fail-fast in healthcare. They are slow deaths. Companies drag on. Then they die when the money dries up.

The healthcare mousetrap

You have an idea. With your passion, you raise money. Or, you invest your own.

You build a team. Spend many months building a product or service. After toiling for many nights, you finally produce something beautiful.

Now you want people to buy your creation. At least a handful of customers.

You push for sales. But it’s tough.

You spend money on website traffic. SEO. Facebook Likes. Twitter campaigns.

You think – may be if you offer it free, you can get users onboard.

You use the “users” number to show traction and raise more money. You use the money to “buy” more users.


Doctors or hospitals aren’t buying. Sales people are too expensive. Google Adword clicks in healthcare are pricey.

You need sales to raise more money. You need more money for sales. With no money, your product will age. But you can’t spend more on product until you at least sell some.

You are trapped.

Finally, many founders end-up writing post-mortem essays on Medium.

CB Insights analyzed numbers from 101 of those essays. Here are two big reasons for startups going belly-up.

  1. No market need (42%)
  2. Ran out of cash (29%)

Something so obvious that we love to ignore

Healthcare has many layers of complexity. Entrepreneurs often lose sight of what to focus on in this maze.

You can be a new hospital or software product or device maker. It doesn’t matter. Your success depends on understanding two main players in healthcare. Build something that they really need.

#1: Patient – because of whom healthcare exists

#2: Doctor – without whom healthcare cannot exist

(I know some of you technologists are thinking – but AI will soon replace doctors. It’s a separate topic. But for now, let’s agree that we won’t be seeing Elysium-style medpods anytime soon.)

It’s not that entrepreneurs entirely ignore patients or doctors. They simply assume that they already know enough.

But then healthcare is peculiar.

Even if your product or service doesn’t directly serve patients or doctors (e.g. something for insurance companies). It will still need to finally serve patients or doctors.

Patient behavior changes depending on context. She may agree to something in front of the doctor. But may do something else at home.

Treatment patterns also vary. The same patient could be treated differently depending on place of service, her insurance plan and where she lives.

Entrepreneurs love focusing on better technology. Or a better looking website. Or an ideal notion of how healthcare must be. Or quality processes. Or marketing tactics.

All those are important. But could become meaningless. If patients or doctors ultimately have no pressing need for your product or service.

Instead of building what you want and finding buyers later. Build what they want.

Flip your thinking.

Talk to them. Ask them deep, probing questions. Observe them closely. At work and beyond. Know them more than they know themselves.

It might take you longer to get started. But it saves you from going down a tunnel with no end.

Patients and doctors. It’s where all healthcare begins. It’s also where it ends.


Related: You have a healthcare product idea? Avoid these 5 dead-on-arrival mistakes

Get healthcare insights more directly at redo/healthcare.


Originally published on LinkedIn,  by Praveen Suthrum, President & Co-Founder, NextServices. 

Image: geralt/Pixabay

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