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Launch HN: Shift Health (YC S19) – Understand Your Healthcare Costs Pre-Visit

Hi HN,

We're Lance, Lance, and Dallin (Yes...2 founders named Lance :)). We are the founders of Shift Health (https://shifthealth.io). We help patients understand what they will owe pre-visit and provide flexibility to pay overtime.

Purchasing health care is unlike anything else you buy in our society today. You wouldn’t expect to walk into a grocery store, take home a loaf of bread not knowing the price and then receive a surprise bill 3 months later. So why is this the standard experience for buying health care services? The surprising thing is that the standard experience for doctors offices is not much better. Antiquated billing processes compounded with the fact that patients are responsible for more and more of the bill out of pocket is creating a scenario where doctors offices are only collecting 40% to 60% of the patient out-of-pocket responsibility. We partner with doctors offices to tell patients what their expected out-of-pocket price is before they see their doctor and provide flexibility to pay overtime. Our mission is to make healthcare costs understandable and affordable for all.

We all met working on a marketing venture together that we have since exited. While working on our marketing company we carved out time each Friday to discuss big problems that we had the right talents to solve. Those Super Duper Friday’s (as we called them) were really valuable for us. Lance R. (Rodela) has worked in healthcare tech for most of his career (Medicity, Aetna, SolutionReach), and he cued us into the trend of High Deductible Health Plans (HDHP’s). These plans are being rapidly adopted and are having adverse impacts for patients and healthcare organizations. Patients owe more and more out of pocket (up 12% just last year), and healthcare organizations are ill equipped to collect effectively from patients. We set out to validate the problem, and everyone else we talked to agreed that medical billing is almost never a positive experience. So we set off to fix it.

Even with Rodela’s background we didn’t realize how hard this was going to be in the beginning. Healthcare has been very resistant to disruption to date. Antiquated legacy systems abound, political lobbyists hover over everything and administrative staff have to be extra cautious not to find themselves on the wrong side of countless regulations and legislation. In short...it’s gnarly. Not sure if it was insanity or inspiration that drove us forward, but onward we went. First, we went out and talked to clinical leaders near us. It did not take us very long to find an excited pilot partner to innovate with us. We did a lot of discovery work with their billing, front office, and operations teams to understand their workflow and requirements. Next we spoke with dozens of patients to better understand their needs, pain points, and challenges. Once we had a firm grasp, we presented mockups and prototypes to the clinic and to their patients to refine an MVP. Finally, we set to work constructing our solution.

As we neared completion on the MVP the next hurdle (prior to even getting launched) appeared. We needed to integrate with the practice’s Electronic Medical Record (EMR) system. Fortunately, our partner had a strong relationship with their EMR provider, which saved us months of what would have otherwise been frustrating back and forth. Whew… we made it, right? Yup! Well, we made it to stage one at least. We launched the pilot and saw excellent feedback from both sides. Patients would text us saying “I love love love this” and our pilot partner saw patient collections grow by 30%.

We are not stopping there though. To build the best estimations we needed to build into insurance networks and more, and that is what we are pioneering today. There is still a lot of tech to build (calling all health tech pros hungry to work on something big!), but we are excited to announce that today we are able to text obstetrics patients 48 hours before their appointment how much their care will cost them out of pocket with 95% accuracy.

Healthcare payments have been a giant mess for a long time, but all of this is approaching a massive tipping point for change with 3 important market forces:

1. Financial Forces: Due to the rapid adoption of HDHP’s, patients are financially responsible for more of their bill. Doctors offices are ill-equipped for this paradigm shift and are collecting less (40%-60% of patient balances are written off). Patients want to know their costs ahead of time, and we have proven that doctors will collect more when they communicate ahead of time and provide flexible payment options.

2. Social Forces: Healthcare costs and spending has been catapulted to the center of the upcoming presidential debates, and an executive order requiring price transparency in the United States was signed in June 2019.

3. Technological Forces: Platforms are emerging providing more health data access than ever before.

I've recently seen some posts on HN about the executive order and price transparency (https://news.ycombinator.com/item?id=20275097) so we’re looking forward to a really good discussion.

Please reach out with your ideas, help, and connections!

86 pointsHydrick3232 posted 5 months ago57 Comments
sidlls said 5 months ago:

How is your service different from the many other players in this space that have failed or are struggling to succeed?

To provide context: price transparency is basically a commodity, and the actual prices a patient will be deemed to owe for services rendered isn't just hard to predict, it's sometimes literally not possible. I've worked in this space for years. The problems with this industry aren't technology problems, they're people (political) problems. From what I can see, your company isn't actually doing anything that isn't already available and in some cases implemented. That's the motivation behind my question.

jaredhansen said 5 months ago:

>The problems with this industry aren't technology problems, they're people (political) problems

This is an underappreciated insight. I am working on something in a related field and I appreciate your insight here. I'd like to discuss with you at your convenience, but don't see any contact info in your profile. If you're up for more detail, can you please drop me a note via email in profile? Thanks!

lawlorino said 5 months ago:

> The problems with this industry aren't technology problems, they're people (political) problems.

This is a great point that I feel could be copy pasted to a lot of Show HN business ideas. This SV bubble mindset is that everything is an engineering problem and can be solved with some kind of tech, ignorant of understanding the real root of the problem.

Edit: Relevant XKCD https://xkcd.com/1831/

VRay said 5 months ago:

All these guys are missing is a blockchain

Hydrick3232 said 5 months ago:

Great question. A lot of early success for us has been through our fully automated and integrated billing approach and our ability to communicate a customized estimate for a patient pre-visit. Also, timing plays a huge roll in success. Never before has there been such an emphasis on creating a retail like experience in healthcare.

staticautomatic said 5 months ago:

This is not a substantive answer to the question you were asked.

Hydrick3232 said 5 months ago:

Good to get the context. Yes, legislation will definitely help but we feel that technology can definitely make a large difference in healthcare.

sidlls said 5 months ago:

Yes I understand you feel that way; you wouldn't have invested time and sweat and money otherwise. Your company is basically a feature that has been considered (or attempted) at other, bigger, more established, and currently struggling health tech companies in the bay area, and then discarded. There's a reason for that (it's harder than it looks and isn't profitable at scale.

Have you investigated and understood why and what differentiates you from them?

sourc3 said 5 months ago:

I was part of the founding team of a startup that did exactly this about 2 years ago. I wish you the best of luck but sales cycles are excruciatingly long and the larger players that are working with razor thin margins may find the 4.5% bit too expensive. Happy to chat and best of luck with the startup!

Dpalm said 5 months ago:

Thanks for the well wishes! We believe that the timing component is really important, and there is evidence that the winds of change are blowing right now. Would love to learn from your experience.

treelovinhippie said 5 months ago:

The US is an absolute joke of a country. Just vote candidates in who will make universal healthcare a reality rather than spawn new industries to further extract value. /Australian

bhupy said 5 months ago:

This is a solid step towards making universal healthcare a reality. Remember, universal healthcare != socialized healthcare. The US has “universal food”, as does Australia. Food isn’t just “free” for everyone.

gigatexal said 5 months ago:

That won’t change the costs if anything it will make them rise and rise faster. You have one payer: one large, infinitely wealthy entity paying the bill it’s human nature for participants to jack up rates

said 5 months ago:
ceejayoz said 5 months ago:

This would be a great argument if we didn't have literally all of Europe, Japan, Australia, etc. to conclusively debunk it.

> The U.S. spends about twice what other high-income nations do on health care but has the lowest life expectancy and the highest infant mortality rates, a new study suggests.


technics256 said 5 months ago:

Awesome work. Are you planning on integrating with multiple EMR systems or just insurance systems themselves? What are your thoughts on Epic's AppOrchard etc, or FHIR?

Good luck, I work in the health tech space....it's "fun" ;)

Hydrick3232 said 5 months ago:

We are planning on integrating with multiple EMR's to make sure we're able to offer a fully automated, fully integrated approach to practices. I love the steps Epic is taking to open up API's. My hope is that more EMR's will follow suit. Healthcare is fun...and challenging :).

aaron425 said 5 months ago:

FHIR APIs are definitely becoming more and more broadly deployed, which is awesome! Scaling wise, it might be worth looking into the interoperability partners that specialize in standing up FHIR endpoints for providers like Datica & Redox.

kyloon said 5 months ago:

Agree on FHIR APIs are becoming ubiquitous especially with Apple Health pushing its adoption in consumer facing applications, not so much on the legacy enterprise side from what I've seen thus far (I work primarily in the clinical trials side of things) and we prototyped our own integration stack to help with wrangling with different standards (more like the lack thereof). It is worth actually building that ourselves in the early days as we have learned so much about the challenges to integrate with our partners and will at some point looking into interoperability partners as we scale.

Hydrick3232 said 5 months ago:

Awesome, thanks for the insight!

technics256 said 5 months ago:

Good luck! How long did mvp/integration take from idea? Us was long....over a year

Hydrick3232 said 5 months ago:

Thanks! Idea to MVP/integration was 3 months. I feel your pain on the integrations. Would love any insight you have on streamlining that process.

technics256 said 5 months ago:

As mentioned above, redox or other similar systems is your best bet!

But redox is stubbornly expensive.

godelski said 5 months ago:

Since there's a non-zero chance that America does get single payer healthcare in the next 5-10 year how would your company adapt? Or are you gambling that it won't happen (I would understand this gamble, because if it doesn't happen then this could be extremely useful to consumers/patients and is really needed).

systemtest said 5 months ago:

I'm from the Netherlands and I like this website. For us it can take months before you know how much your hospital visit will cost you. I broke my arm a couple of years ago and it took 6 months for the bill to arrive. I maxed out my €885 deductible, an additional €65 for uncovered medicine and €20 for the sling. I sort of knew this so I could save up for it but knowing this up front would have made me less nervous.

Hydrick3232 said 5 months ago:

At this point the gamble is that Single Payer won't happen. There's a chance but we think it's slim. Our bet is that we're positioned well to take advantage of the recent Executive Order.

godelski said 5 months ago:

I don't see single payer as a likely outcome either (even if Sanders, Warren, or Yang wins). Thanks for the quick response. Even though I wish we didn't need this kind of company I'm glad someone is taking the gamble.

Hydrick3232 said 5 months ago:

Thank you so much! It's hard to know what's going to happen but something has to happen. The system is broken.

claudeganon said 5 months ago:

I’m just curious, from a moral perspective, how does it feel to bet against many of the poor being lifted out of death and medical bankruptcies for the sake of your own profit?

sidlls said 5 months ago:

Your question is a bit harsh, but it strikes at one of the more insidious truths in this space right now: most if not all these health tech companies' business models simply wouldn't work if we had a functioning health care system, and they end up participating in the negative feedback loop that further entrenches the problems they claim to want to solve.

Dpalm said 5 months ago:

Whew... Loaded question ;) I understand where you are coming from. One way to look at it is that in the world that we currently live in there is much to be done to increase transparency and affordability. One of the statistics that propelled us to work on this problem was a survey that showed almost half of Americans avoid or delay care despite illness or injury because they don't know the cost. By at least starting that conversation about finances up front we hope to alleviate a lot of those fears, and the good news is that about 5% of patients have responded to our partners with messages saying "I can't afford this." and 100% of the time we have been able to connect them to a payment plan or to charitable funds to help them get the care they need. To us that seems better than not having the conversation and sending people to collections when they could never have afforded the service to begin with.

It's definitely not perfect, and there are many that are suffering, but we do feel strongly that our solution is a force for good in the current environment.

surfmike said 5 months ago:

Most candidates still support keeping private insurance and making Medicare 4 all one of the available options.

godelski said 5 months ago:

When someone says "non-zero chance" it topically means "low chance of happening". There are a few front runners like Warren and Sanders than push single payer. But it also requires more than them getting elected at president for such a thing to pass.

ceejayoz said 5 months ago:

> Doctors offices are ill-equipped for this paradigm shift and are collecting less (40%-60% of patient balances are written off)... our pilot partner saw patient collections grow by 30%.

I'm not seeing how a mission of decreasing patient costs fits with these stats.

tl said 5 months ago:

"Cash pay only" doctors compete with the existing system today. With the rising upfront costs each year, there's an increasing trend of a cash pay doctor's office visit being cheaper than the co-pay of your insurance provider.

Why this is true a separate discussion (possibly overhead of dealing with the healthcare system or insurer).

Dpalm said 5 months ago:

We have seen that trend of more and more cash-pay only physicians and think it is great!

Hydrick3232 said 5 months ago:

Ultimately more transparency leads to more competition which leads to lower costs.

rficcaglia said 5 months ago:

Not necessarily when the choices are constrained by the health insurer. We (a big VC funded primary care provider) experimented with full transparency pricing. Never moved the needle. But that was 10 years ago so maybe things are different now.

Hydrick3232 said 5 months ago:

Agreed, insurance companies are typically a big cog in the wheel. We're starting to see things change as high deductible health plans have grown so rapidly. The consumerism of healthcare is starting to create change (i.e. price transparency executive order signed in June).

paulddraper said 5 months ago:

Medical billing is very complex. Others have tried and shown mediocre results.

So 95% accurate is very impressive!

Anything you attribute the reliability to?

Dpalm said 5 months ago:

That is part of the secret sauce ;) And your right, this is all painfully complex!

thiscatis said 5 months ago:

Congrats on the launch even though this feels like a "faster horses" solution instead of something like, I don't know, universal healthcare like the rest of the developed countries (and actually also non-developed).

bhupy said 5 months ago:

Remember, universal healthcare != socialized healthcare. The US has “universal food”, as do most developed nations. In these countries, food isn’t just “free” for everyone.

chintan said 5 months ago:

Hey guys - this is a great initiative! Something i have been so frustrated about the current system. We work with large medical centers in clinical trials space (and worked with hl7, fhir, cqm, hipaa etc) - happy to help in whatever way i can. My profile has my contact.

Dpalm said 5 months ago:

Thanks so much for the offer! Would love to learn from your insights.

novalis78 said 5 months ago:

Good luck guys! Any attempt to better this abhorrent mess gets my biased upvote.

Hydrick3232 said 5 months ago:

Thank you! We're looking forward to tackling this head on. Appreciate the support!

yding said 5 months ago:

This is great. Healthcare is a mess. Glad you're working on fixing it.

Hydrick3232 said 5 months ago:

Thanks! We agree healthcare needs to change. We're excited to be a part of that change.

davedx said 5 months ago:

Typo in front page:

We integrate with with over 50 EMR systems

(extra with)

Good luck!

ftyers said 5 months ago:

why is this even a thing. just use the NHS.

systemtest said 5 months ago:

You don't have healthcare cost under the NHS? I'm Dutch and I have lots of healthcare costs. A bit over €3000 in tax, €1100 in insurance, €885 deductible, €300 dental, €300 physiotherapy, €50 in uncovered medicine.

I would love a website that broke these costs down for me in a logical way so I could streamline my personal finances.

ceejayoz said 5 months ago:

> A bit over €3000 in tax, €1100 in insurance, €885 deductible, €300 dental, €300 physiotherapy, €50 in uncovered medicine.

That sounds heavenly, frankly.

Here's my monthly $2,144.69 insurance bill for a family of four. https://imgur.com/ldA372o

It doesn't cover dental at all, and I pay up to $4,000 annually in co-pays on top of those monthly premiums. Counting dental, my family of four pays roughly $32k/year for medical expenses.

pjc50 said 5 months ago:

The NHS costs are limited to £9 per prescription (England only, waivable on low income). Hospital visits are free; people complain about having to pay for parking, because they lack all perspective on how bad it might be.

The tax is not hypothecated but is about £3k each. https://www.bbc.co.uk/news/uk-42950587

(Dental and optical you may have to pay up to a few hundred £ for)

Dpalm said 5 months ago:

Only about 9% of the population is "literate" when it comes to health insurance. There are definitely some super users out there who can find tools and use them, but for most of the population we need to provide simpler tools and more straightforward explanations on their benefits and costs. That is where we come in.

usaphp said 5 months ago:

What is going on with a source code of that simple landing page? It's over 11Mb in size. Also you have over 500 declarations of @font-face, and inline css is just bizarre. I would recommend you taking a look into that, it's not good.

Hydrick3232 said 5 months ago:

We'll look into it. Thanks for the heads up.