Some Notes On MACRA For Digital Health Startups

Over the weekend I spent some time reviewing the 2015 Medicare Access & CHIP Reauthorization Act final rule (MACRA) that was released by HHS last week.

MACRA was a bi-partisan law focused on the Obama administration’s goal of moving 50% of Medicare payment away from fee-for-service and towards alternative payment models. The final rule lays out details on how the program will work and how clinicians can participate.

For those of you that are new to this stuff, the goal of all of this is to allow clinicians to focus on (and get paid for) the quality of care they provide as opposed to the quantity of care they provide; with a focus on disease prevention and improving coordination between clinicians. This is a major part of how we're going to reduce the $3 trillion cost of healthcare in the U.S.

The overarching set of policies that make up MACRA are referred to as the Quality Payment Program.

The document released by HHS last week that explains all of this is 2,398 pages long though the majority of it is made up of responses to public comments made regarding the proposed rule (you can find a 24 page summary of the document here). The rule will be implemented beginning in January of 2017 and will impact nearly all stakeholders across the healthcare system.

I thought I’d capture some of my notes on the rule here with a particular focus on those things that might matter to digital health companies. If your company is focused on improving outcomes, patient engagement, patient volume, interoperability or care coordination then you should take some time to understand MACRA. Key points from the rule below:

• For context, Medicare covers 55 million people and accounts for more than 20% of all U.S. healthcare spend. Medicare’s approach to payment is generally followed by commercial payers — in fact, many of these payers are farther down the road in payment reform than Medicare is at this point.
• MACRA is a statement by the government that they are dead serious about paying clinicians for value. If your business relies on a flat fee-for-service model it's time to start thinking hard about how you can get ahead of this change.
• Medicare has setup a transition year for the Quality Payment Program (2017), but physicians must act in some form during 2017. If clinicians do nothing in 2017 with regard to the Quality Payment Program, they’ll receive a 4% penalty against their Medicare payments beginning in 2019.
• With all of these acronyms the Quality Payment Program can seem confusing. It's really not. There are two simple payment programs that clinicians can participate in: 1. Merit-based Incentive Payment System (MIPS) or 2. Alternative Payment Model (APM) — NextGen ACO, Medicare Shared Savings ACO, etc.
• If a clinician is already in an APM nothing will change for them and they'll receive a 5% lump sum incentive payment that will run through 2024 and they can avoid the reporting requirements that will come with MIPS.
• Some of the APM options in 2017 will include Comprehensive ESRD (end-stage renal disease), Comprehensive Primary Care (CPC+), Next Generation ACO. Medicare Shared Savings Program - Tracks 2 and 3 (Track 2 allows clinicians to take up to 60% of shared savings; Track 3 - 75%).
• If a clinician is not participating in an APM, they can participate in MIPS. MIPS will focus on 3 areas: quality measures, advancing care information and general improvement activities. Medicare has created a nice set of guidelines to help better under the measures associated withe each of these areas. Vendors should take a hard look at these measures as these are major business drivers that non-APM clinicians will be thinking about next year.
• The MIPS program allows for more flexibility than previous programs in that clinicians can select their own pace and the amount of data they would like to collect and submit to Medicare. There are three options to participate in MIPS in 2017. 1. Test the program by submitting a minimum amount of quality data. 2. Submit 90 days of 2017 data. 3. Submit a full year of data.
• The timeline for implementation looks like this. At some point in 2017, clinicians must collect some amount of performance data and collect data documenting their use of technology and submit that data to Medicare by March of 2018. Medicare will give feedback on that data during the remainder of 2018. If eligible, clinicians will then earn a positive MIPS payment adjustment or APM incentive beginning in January of 2019. The payment adjustment will start at 5% and increase to 9% in 2022.
• MIPS will consolidate three existing programs: the Physician Quality Reporting System, the Physician Value-Based Payment Modifier and the Medicare EHR Incentive Program.
• The program will impact 600,000 clinicians.
• Clinicians must participate if they receive $30k+ in Medicare billings and care of more than 100 Medicare patients per year.
• “Quality” will be measured using both evidence-based standards and practice-based improvement efforts.
• The payment program applies to physicians, physician assistants, nurse practitioners,  clinical nurse specialists, certified nurse anesthetists.
• Medicare is putting aside $100 million to be paid over 5 years to train small practices on the rule.
• CMS will also allow “reporting as a group” for clinicians that put themselves under the same tax identification number.
• MIPS replaces meaningful use with the "advancing care information" program which speaks to use of technology. This program is focused on only 5 key areas: 1. Security risk analysis, 2. e-prescribing, 3. patient access, 4. summary of care, 5. request/accept summary of care. Again this is a good area for digital health companies to dive in.
• The rule is set to be finalized on October 19th.

For the most part, commentators are praising this effort by Medicare. The Quality Payment Program does a nice job of setting up clear objectives for clinicians, with flexible levels of participation and lots of concessions for smaller providers that don't have the infrastructure or resources to facilitate complicated reimbursement activities.

With a new administration coming next year and the inevitable confusion around what will come next, the Quality Payment Program does a nice job of making it much easier for clinicians to embrace those activities that will significantly lower cost and improve quality and ultimately patient health.

Exciting times in healthcare.

Sharing & The Next Generation of Enterprise Software

Salesforce.com runs the CRM system (Customer Relationship Management) for a huge number of companies — at last check more than 150,000. It’s interesting to think of the number of duplicate records that must exist in Salesforce. As an example, there are probably hundreds of vendors that, as we speak, are trying to sell their product into Microsoft. Each of these vendors has a record (or opportunity) titled, “Microsoft” in their instance of Salesforce. In many situations, such as sales to a large software company like Microsoft, this redundancy makes sense. Most of the vendors selling to Microsoft are selling very different products to very different stakeholders within the company. So it's logical to have a different record in Salesforce for each sales opportunity.

But for narrow industries like real estate, this redundancy makes no sense at all. As we speak, there are at least ten brokers trying to rent space on the 11th floor of 600 Park Avenue in New York. If all of these brokers use Salesforce.com as their CRM that means there are ten records for only one sales opportunity. Ten brokers would be entering information on the same opportunity in ten different places. This is silly. But this is the way traditional, silo'ed CRM works.

Real estate brokers would benefit immensely from shared records in Salesforce where they all could view the same profile for the same sales opportunity. The opportunity would include the most up to date information on availability, square footage, price per square foot, etc. This would bring 10x more value to Salesforce's customers.

Now consider what's happening in healthcare. The average Medicare patient sees seven providers per year; if the patient has a chronic condition it can be many more than that. These seven providers don’t work together. They’re employed by different organizations, work in different locations and likely use different medical record software. This means that there are seven separate records in seven different places containing seven separate sets of information for only one patient. This isn't just wasteful, it makes it impossible for providers to work together to optimize patient care.

Real estate, healthcare and many other industries need software that doesn't simply get the same job done seven or ten times across disparate organizations but instead brings all of the stakeholders together to use a single, shared record.

Of course there are a number of challenges associated with building this type of networked software -- not the least of which is getting disparate stakeholders to agree to share important information with one another. But I'd guess that a big segment of the next generation of multi-billion enterprise startups will build software around sharing and networks as opposed to silos and features.

How To Sell An Innovative Product To A Large Enterprise

Selling an innovative product into a large organization is extremely difficult. The average enterprise sale requires sign off from 5.4 individuals. And when selling something that is novel that the buyer hasn't bought before it can be two or three times that number. In addition, there's no set budget or buying process in place for a buyer to buy. As a result, it falls on the seller to create a process for the buyer to purchase the innovation.  I designed the process below to help address this challenge. The idea is to take the buyer through a set of meetings that generates support for the idea and get an gets them comfortable that they're checking all the boxes they need to check to get a contract signed.

The process requires three meetings (though the second and third meetings could be grouped together for smaller, less complex deals).

1. The Concept Meeting. This meeting is where the seller introduces the concept, gets support from the buyer that the product solves an important problem and that the seller's product might be a good solution to that problem. The goal for this meeting is to ask for the buyer's permission to start a process around examining the potential ROI of a partnership. If the buyer isn't supportive of the concept, both parties shake hands and part ways.
2. The Financial Meeting. If the concept meeting is successful, prior to the financial meeting, the seller should ask the buyer to provide them with some financial inputs that will help determine the return on investment that would come from a partnership. The purpose of the financial meeting is to walk through the financial inputs and an ROI model and allow the buyer to poke holes in the model and to get to agreement on what a realistic ROI might be. If the ROI is compelling and the project is worth prioritizing, move to the next meeting. If it's not, shake hands and part ways. The ROI is going to be the thing that drives the rest of the process so it's crucial to have agreement in this area. It's also crucial that, when possible, the seller is using the buyer's own numbers in the model, rather than industry averages. 
3. The Implementation Meeting. The purpose of this meeting is to determine whether or not it makes sense for the buyer to buy the product now. With a compelling ROI, it will most likely make sense, but there are lots other considerations. Technology resources, leadership changes, budget cycles, competing priorities, etc. The idea is to get the prospect so excited about the importance of the problem and the concept and the ROI that all of these concerns will be overcome. But this meeting should be used to put everything on the table. The meeting should include the appropriate stakeholders from both sides to determine if the project can be implemented and, if it can, what kind of work will need to be done and which resources will be required. A timeline with tasks and assigned owners should also be discussed and (ideally) agreed upon. If successful, the next step is to move to contract and setup a weekly meeting between both organizations to track the deal to contract close and product delivery. If that can't be done, both parties should shake hands and part ways. In this meeting the seller should inventory all of the elements of the customer's procurement process and get all of them down on paper. Those elements should be incorporated into a project management document that will be tracked in the weekly meeting.

One other note: when moving the deal to contract, the seller should setup a short meeting with the attorney on the buyer side. Because the product is innovative, the contract terms may be confusing and non-standard. Walking the attorney through the product and the purpose of the partnership should dramatically reduce back and forth on the contract.

Being disciplined about taking the buyer through these three meetings and understanding exactly what they'll need to do be able to write a check will help sellers accelerate sales cycles and avoid many of the pitfalls that come when selling into a large organization.

So often "selling" innovation is the easy part. The bigger challenge, in many cases, is helping the buyer "buy."

Enterprise Network Effects & User Retention

A16z had a good podcast the other day talking about startups with network effects and it got me thinking about network effects in enterprise businesses. A product has network effects when the product becomes more valuable as more people use it. Your fax machine was more valuable when more people bought fax machines — you could fax more people. Facebook is more valuable when more of your friends use it -- you can view more photos of your friends.

Businesses with network effects scale exponentially. The reason is that their users effectively become extensions of their sales and marketing team. A Facebook user has an inherent incentive to get other people to use the product. This is a beautiful way to grow and scale a business.

In order to maintain growth, though, these businesses need to ensure that they're retaining the users they acquire -- which is an entirely different challenge. This is relatively easy in B2C because, in theory, the user can be part of the network forever. This is much harder in B2B because users — employees — turnover at the rate of ~20% per year (people get terminated and quit). So in theory, the entire network turns over every five years. And while it's true that often an employee that leaves is replaced by another this kind of churn is not a great way to scale.

That said, some B2B network effect businesses have found ways to retain some users after they change jobs. LinkedIn, Evernote, Wunderlist, Dropbox are a few that come to mind. Not only do these businesses retain their users as they move from job to job, these users also drive new customer acquisition by promoting the product within their new companies (what I refer to as B2E2B). These businesses are seeing network effects drive new users, retention of those users when they move to a new job, and new sales driven by those employees that evangelize the product in their new companies. This how an enterprise business can grow like WhatsApp.

But this isn't easy. Enterprises are concerned about their employees using the same software as they move from company to company -- e.g. they don't want an employee taking their Evernote notes on to their next company. And the product customizations and switching costs may be so high in some cases that the value of the product doesn't translate from one company to another.

The challenges are significant; but the businesses that build an enterprise product with 1.) inherent network effects to drive new users and 2.) the ability for those users to stay engaged with the product as they move from job to job will be the networks that win. 

10 Things B2B Startups Need To Know Before They Start Selling

Below is an updated version of a presentation I show to B2B startup teams that are beginning their sales efforts. It's presented here without the context surrounding each of the points but the insights should still be helpful.

10 Things B2B Startups Need To Know Before They Start Selling from Brian Manning

The Attributes Of A Great Strategic Salesperson

Defining the attributes to look for in any new hire is really challenging.

People are complex and every situation and every environment is different. So it's extremely difficult to apply a blanket set of attributes that will lead to success in any job.

I’ve found that this is particularly difficult with “strategic sales” roles in a startup. By strategic sales I mean a role where a salesperson is selling a highly innovative product into a large organization that requires a large investment of time and/or money from that organization.

It’s important to define strategic sales because the skill set required to be able to close strategic deals is very different from the skill set required to close smaller, more defined, "transactional" deals. Often, success in transactional selling comes down to simple hard work and effort. If you analyze a transactional sales funnel you'll see that there actually isn’t a huge difference between conversions for high performing salespeople and conversions for low performing salespeople (by conversions I mean things like 'phone call to meeting set' and 'meeting held to verbal commitment'). Success in that world often comes down to volume. More calls = more sales.

While there’s certainly nothing wrong with good old-fashioned hard work -- in fact, it's a requirement -- strategic sales is almost exactly the opposite of transactional sales. Conversions really matter and lead qualification is even more crucial because strategic deals require a huge time commitment from the salesperson. And there are massive differences between the conversion rates of high-performing salespeople versus low-performing salespeople. A high-performing strategic salesperson can convert 100% of their meetings into an active sales cycle; a low performing strategic salesperson may convert none. Literally zero. Strategic sales is not a numbers game.

Ben Horowitz likes to say that closing a deal with a large organization is like passing a law in congress. And it’s even harder than that when selling innovation — there's no set process for the buyer to buy within their organization or budget to buy the product. And in a startup, you’re small and nobody knows you and you don’t have a clearly defined sales process and you don't have perfectly polished sales materials. It’s really difficult.

I've thought a lot about the attributes that are most closely correlated with success in strategic sales. I've seen a lot of successful strategic salespeople and a lot of unsuccessful strategic salespeople. It's a problem I've been trying to understand for years.

Recently I’ve spoken to a number of people I trust on this topic and here’s where I think I’ve landed. Here are the four key attributes of a successful strategic salesperson.

Insatiable curiosity

In order to solve a complex problem you need to fully understand it. How does the buyer buy? Who has influence in the organization? What value do customers see in the product? What does the customer do during the day? How is the buyer bonused or promoted? What other options does the buyer have?

I could literally write 100 more questions like this. A strategic salesperson must always be wondering about the answers to these questions. They should constantly be learning from their customers, their leadership, their colleagues, the media, their competitors and anyone else that will talk to them. They need to be obsessing about the problem and trying to build a story and a solution and constantly iterating their approach.

A person that doesn’t have this level of insatiable curiosity simply won’t figure it out. They'll get stuck.

Optimistic grit

I’m fusing two attributes together with this one but I think it’s necessary. Any type of sale will inevitably lead to lots of rejection of the salesperson, the product and the company. This sucks. It’s painful. It’s even worse when selling innovation because there will be prospects that think the idea is crazy and will never work and the buyer has no process or defined way to buy the product. In order to get through this the salesperson must be a winner and must have a winning attitude and know that they can overcome. And they must have the grit and determination to keep getting up after they get knocked down. It may sound cliché but it's true. I've never met a pessimist that was good at strategic sales. There will be an endless number of reasons why it won’t work and the only people I’ve seen that will push through have a high level of optimistic grit.

Extreme humility

I used to joke that there are two types of salespeople:

1.) The type of salesperson that flies home from a bad meeting with a prospect and sits on the plane mentally blaming the product, the marketing team, the legal team, their boss or the prospect that just doesn’t “get it."

2.) The salesperson that sits on the plane thinking: How could I have answered that one question better? What else should I add to the presentation? What should I take out? What’s the context of the person that didn’t like the product? Where are they coming from? Does the product I’m selling threaten some of the people in the room? What went well in that meeting and what didn’t go well in that meeting? Who can help me get better?

The second approach requires an immense, almost unnatural level of humility. It’s human nature to point fingers when things don’t go well. It’s also often perfectly reasonable -- because it might actually may be someone else’s fault! But placing energy into #1 is a losing approach. Obsessing about the things that we can control is the way to win. So much energy can be soaked up by complaining and blaming others. Great strategic salespeople transform the energy that most put into complaining and blaming and point it toward improvement.

Ability to educate and inspire

I’ve written before that people buy with their heart and justify it with their mind. This is why I advocate not showing a lot of numbers in an initial sales presentation — the prospect doesn’t know or trust the salesperson yet and they’re generally not buying for ROI anyway. They’re buying because of the way the product makes them feel.

As a result, when selling innovation it’s crucial that the buyer be on board with the salespersons's mission and buy in to their perspective on both the problem they have and the way that the salespersons's company is going about solving that problem. The sale has to be somewhat fun and interesting and educational and insightful. It can’t be boring. I don’t mean that the salesperson has to personally be super charismatic or an amazing  presenter (though that helps), I mean that they have to be intelligent and interesting and insightful. The buyer has to want to get behind the company and the product -- they have to become a true advocate.

It's a lot of work for a company to buy something. It requires security reviews, legal reviews, budget reviews, consensus building and many other activities. It also creates a lot of risk for the champion. If they're going to go on the line and buy an innovative product they have to be excited and inspired.

Great strategic salespeople continuously inspire, excite and educate their prospects.

Some Thoughts On Non-Competes

It was nice to see the news a few weeks ago that Massachusetts House Speaker Robert DeLeo vowed to put new limits on contracts that prevent employees from working for competitors. "Non-competes" that restrict the free movement of talent from one company to another can do real damage to an individual's livelihood and the economy at large. Many people believe that the reason that the explosion of successful tech companies happened in Silicon Valley is because of California's effective ban on employee non-competes. Allowing talent to flow to the best organizations without friction is good for a local economy.

Unfortunately, over the past several months I've seen lots of startups going in the opposite direction by including aggressive non-compete terms in employee agreements.

Many companies take it a step farther and require 'no-poaching' terms in their vendor contracts and even try to collude with other local startups and agree to not steal one another's employees.

I don't think companies fully understand the damage that's being done with these types of arrangements. Let me explain.

Imagine that you're working for a startup in Buffalo, New York (Buffalo actually has a pretty hot startup community by the way). And imagine that there are another 20 tech companies in Buffalo that, at some point, you could go work for -- you have the talent they need and you'd potentially like working for some of these companies. Then imagine that the startup you currently work for requires you to sign a non-compete as part of your employment contract. Then you learn that your company requires all of their vendors and customers and partners to sign an agreement that precludes them from poaching your company's employees.

As your company grows, the number of other companies that can demand your services around your home has dropped from 20 to, say, 12. Suddenly 40% of the companies that would potentially demand your services now can no longer demand your services. So the demand for your services has decreased 40%. You're now 40% less valuable than you used to be.

At a minimum, a company doing this to their employees is unethical. At its worst, it's illegal (Apple, Google, Intel and Adobe recently paid a $415 million fine for colluding on no-poaching efforts to suppress employee wages).

When a company creates an agreement where another company cannot poach its employees, they are artificially reducing the value of those employees and their ability to make a living.

Again, the spirt of this is understandable. Hiring and training employees is expensive and companies want to fight to keep their best people. But addressing employee churn through contracts is a backwards way of handling the problem.

The better (and harder) way of dealing with the problem is to create an environment where good employees feel valued and are being challenged and are working on difficult problems and are developing professionally and personally and are being compensated fairly. Writing contracts to compensate for shortcomings in these areas is cruel and likely very ineffective in the long term. And it's nice to see that the state of Massachusetts is catching on and pushing for legislation that will protect employees and the local economy.

The best way to keep employees loyal is to act in a way that deserves loyalty.

Productivity Hacks

I've added some productivity hacks over the last several months. Here are 5 that have been working well for me lately:

1. File, Do, Defer. I've started using the "file, do, defer" system. I look at a task (in Wunderlist, a great to-do list manager) or an email in my inbox and decide if it needs action or not.  If it doesn’t need action I either delegate it or file it. If it does need action and takes less than 3 minutes, I do it. If it will take more than 3 minutes I’ll defer to a time when I have more bandwidth and focus. To keep me focused on the 3 minute rule I’ve begun using the Pomodoro app for Mac that tracks the time I spend on a task.  This isn’t to make me rush through the task it’s to make sure I stay focused on it and get it done quickly and don’t get distracted.
2. Working Offline. I’ve been doing this for years and can’t recommend it enough. I put my email in offline mode, close Slack and focus on initiating rather than responding.
3. Virtual Assistant. I’ve hired a virtual assistant for personal tasks. There are lots of great services out there but I use FancyHands which has been great. My virtual assistant does everything for me that I don't want to do -- they have have coordinated my move, found me a couch, helped plan a vacation, changed my cable service, researched health insurance plans and booked a New Year's Eve dinner reservation. I’m constantly scanning my to do list and looking for low-value tasks that I can outsource. It's low cost and a massive time saver.
4. Soylent. I’ve begun drinking Soylent, a meal replacement drink that supposedly contains every nutrient needed by the human body. It’s fantastic. It allows me to have breakfast on the go and sometimes lunch on the go so I can maintain energy with zero time commitment. It’s incredibly helpful on hectic days.
5. Make projects seem small. We all have those projects or tasks that need to get done but seem hard and time consuming and stressful and keep getting put off. I read about a productivity trick in the book Getting Things Done to help deal with this problem. The trick is that you think about the thing you need to do that you keep putting off and on the bottom of a piece of paper you write down the outcome that you want with regard to the project  -- e.g. what is success? Then break it up until small tasks and write those as a list on the rest of the page. Going through the process of breaking the project into small tasks makes it seem so much easier and actually gets you somewhat excited to go do it.

Hope some of these are helpful.

5 Questions To Ask Yourself Before Joining A Startup

I had a good conversation the other day with a former colleague who’s considering making a move to very early-stage startup. I shared with him the list of questions I ask myself before I make a commitment to working with a startup and thought I’d share them here as well.

A quick disclaimer: startups are inherently risky and these five questions aren’t designed to help you avoid a high level of risk. That’s not the point. These questions are designed to help ensure that you understand the risk and make you a bit more comfortable that you’re making a good decision.

Here they are:

1. Do you have confidence in the people, particularly the leadership team? There’s a great quote from Peter Drucker that I can’t seem to find where he points out that, when a company finally succeeds, more often than not, it will find that it will end up selling a different product at a different price to a totally different set of customers than it initially had planned. The point is that the startup doesn’t have to have the perfect idea or the perfect product to be successful. What they have now probably isn’t right. And that’s ok. What’s important is that you’re working with an ultra-talented team that can iterate and execute like crazy. I’ve written before that the most critical traits for people working in startups are grit, humility, curiosity and adaptability. If you find that the team you’re working with has these traits you’re off to a good start.
2. Has the founder(s) earned the right to know a secret? If what this startup is doing is so valuable, why isn’t someone else doing it? More often than not the reason is that the founder knows something that other people don’t. Or at least knows how to execute in a way that others don’t. It’s important to be able to understand the secret that the startup knows and to understand why they know it and others don't.
3. Can the investors/board articulate how the business could be massive and why it’s defensible? Prior to making a jump, when possible, it’s important to talk with some of the investors and board members. This is a good way to test their engagement and confidence in the company and alignment with leadership. Really push them on why they invested. Ask them what they think the core of the business will be and what they think will come after the core. If they can’t confidently articulate this in a way that makes sense it’s a clear red flag.
4. Can you see yourself being truly passionate about the work you'll be doing? Startups are tough. You’re fighting an uphill battle most of the time and there are lots of highs and even more lows (at least at the beginning). If it's easy then it's not valuable. I’ve found that dealing with the pain of working at a startup is a lot easier when I truly believe and care about the mission of the company. If you don't care about the impact you'll have beyond your own personal benefit then you'll find that the tough days are a lot tougher.
5. What are 3 reasons it could fail? Again, most startups are long shots. And it’s important to be humble enough to know that you can fail. If you can’t articulate 3 reasons that it could fail, then you either don’t understand the business well enough or you aren’t taking the risk very seriously. Do your diligence such that you understand as many risks as possible and the reasons it might not work out. If after truly understanding the risks and potential pitfalls ahead you really feel like you still want to make the move then you've probably found a good fit.

The Convergence Of Private & Public Valuations Is Good For Employees

There’s been a lot of talk in the tech blogosphere over the last couple of weeks about the convergence of private and public valuations. One of the things that hasn’t been talked about all that much is how important this convergence is for employees at early-stage companies. I was talking to a founder recently and he was telling me that he really struggles with the tradeoff between the importance of showing the world that his company has a unicorn-like valuation versus the importance of keeping his valuation low so that new employees can see lots of value in a follow-on round or an IPO.

On one hand, being a unicorn gets you lots of good press and attention and is for good sales and good for recruiting. On the other hand, a huge valuation makes it hard to deliver value to employees in the form of stock options — if you’re already a unicorn, it’s likely that future employees have missed the big uptick and equity becomes a lot less valuable from a compensation perspective. When you have a potential bubble in the private market and normalcy in the public market, lots of employees are going to find their options are deep underwater. Castlight Health learned this the hard way following their IPO last year (see image below).

Because of the emergence of crowdfunding, angel syndicates, private exchanges, and a lower regulatory bar to invest in early-stage startups, it’s likely that we’ll start to see much more consistency between private valuations and subsequent public valuations. Also, don’t underestimate tools like eShares that help founders manage complex cap tables. I can vividly remember being at a startup where we didn’t want to give out stock options to consultants for no other reason than it would’ve added too much complexity to our cap table. It's a lot easier for a private company to manage thousands of investors than it used to be.

A founder’s desire to push for a massive valuation is perfectly understandable. It creates a buzz that helps recruit employees and close big deals. But when founders push too hard for a private valuation that won't hold up when employees find liquidity, it's bad for the team that built the company in the early years. It's great to see private and public valuations beginning to converge.

Managing The Enterprise Deal (Panel Notes)

Earlier this year I participated in a panel for the NYC Enterprise Sales Meetup. The topic of the panel was Managing the Enterprise Deal. It was a great discussion and I thank Mike and Mark for inviting me to participate. Prior to the panel, the moderator provided us with a list of questions that we should be prepared for. In preparation for the discussion I wrote down some rough answers to each of the questions and I thought I'd post my notes here. It's great to see that Enterprise Sales Meetup has expanded to other cities over the last few months. I highly recommend attending one if they're in your area.

Questions:

How many deals do you think a high level business to business professional can manage?

This depends on the salesperson's goal and the average deal size. Generally, salespeople should have a pipeline that is 3x their goal. So if your goal is $1MM and your average deal size is $250k, then you need to be working 12 deals.

What are the best tactics you find to manage a pipeline effectively?

To me it comes down to good stages and good tipping points. I recommend using 4 or 5 stages of a deal, and then for each stage assign actions or things you need to get done before you can move them to the next stage (tipping points). This ensures that there's consistency across deals and ensures the salesperson isn't kidding themselves when they say they have 3 deals 'in contract'. The stages I use are generally something like, Lead, Decision Maker Engaged, Project Design, In Contract, Closed Won. The tipping points for each stage depend on what you're selling, but it could be things like contract sent, legal work completed, technical review completed, etc.

Do you believe in mapping out a process for your company to manage deals?

Absolutely. You need consistency across stages and tipping points. And you need a funnel so you can determine where you're getting stuck.

How do you qualify deals?

Typically I would come up with 3 or 4 elements that I'm looking for from a prospect. Size, revenue, technical setup, management structure, etc. Over time you can iterate on these as you discover what makes a good prospect that leads to good revenue.

How do you find your deal sponsor?

You have to nail down the one or two business metrics that your product impacts and then find the people who are responsible for those metrics.  If X metric goes up at the company you're selling to, who is going to get a bonus at that company? That's the person that should drive the deal for you.

Who else do you need besides a sponsor, what other personas do you see?

Project Managers. You want to push for a strong Project Manager that is totally sold on your product and can get it launched and can help you get the deal done. After the executives are sold, so much of enterprise sales is about simple project management and driving the deal through the prospect's buying process. It's really hard for big company's to buy things. You need a partner at the company that can help you get it done.

How do you build a relationship with your sponsor?

One thing is frequency of communication. I always try to set up a weekly check-in. Those consistent check-ins force you to get to know one another. The other thing is I try to make their job really easy. Keep communications really short and simple and show them how to buy your product. Map out their own buying process and track them on it.

How do you determine the buying cycle and process?

You try to identify trends across organizations on how they buy. Who needs to be involved? Who needs to approve? What kinds of meetings need to happen to get to that approval? And then you start to map out the ideal buying process that works for you. If you don't have one, make one up based on what you do know. And map to that.

How do you map out the decision-making team?

Again, another useful way of mapping out a decision-making team is to show one from another client and get them to react to it. Make sure you show legal, technical, compliance, procurement, business people, etc. so nothing gets missed.

How prevalent do you think consensus decision-making is?

It's huge. I've never seen a large company buy without consensus. You have to tell everyone that is involved in the decision-making process your story. Everyone has to support the concept.

How do you use or overcome the startup stigma?

Use it as an advantage. By definition you're disrupting the old way of doing things.. You're doing something much bigger. Inspire them. I find most people want to get better and recognize that the status quo isn't working. Tap into that. Challenge them. The way they are doing things now is not acceptable anymore. Get them to see that and get them on your side. The size and stage of your company is irrelevant compared to the problem you're solving.

How do you establish an ROI, is it even that important?

It's important, but it's often not as important as you think. I think most businesses buy primarily for emotional reasons, rather than rational reasons (prospects buy with their heart and justify it with their mind). So when you come up with your story, it's important that you focus on how your story makes people feel. Most buyers aren't going to believe your ROI anyway.  It's about emotion. And most big companies aren't as metrics driven as salespeople would like them to be. Your focus should be on getting the team you're selling to a bonus at the end of the year. And you need to understand what are the levers that will drive that bonus.

If you have a brand new offering how do you overcome the need for an ROI? 

The easy answer is a pilot. But the bigger answer is that you have to sell them on your vision and the thing you're trying to disrupt. They have to believe in you, in your company, in your priorities and in your team. That's the hard part. Then you can provide them with a rough ROI that gets them comfortable they're going to make their money back. Use the "what you would have to believe" approach where they only have to believe that you will move the numbers a small amount and they'll still make their money back. Be conservative.

How do you add value in your interactions dealing with other executives?

I like to use what I refer to as "insight selling". Be interesting. Your pitch should be exciting and provocative and short. Like Peter Thiel says, "say things that others aren't". Be exciting. But also use the approach of not "always be closing" but "always be leaving". Have one foot out the door. Look to disqualify opportunities. The prospect is looking to disqualify you and you should do the same thing. You're both trying to figure out if there's an opportunity to help one another. You're total equals in that sense. Act like it. Also, I try to drip prospects quarterly with tidbits of information that might be interesting to them with absolutely no ask.  You're not allowed to ask for something in these drips.  It could be an article, an insight you picked up from another prospect, etc. Stay on the radar but do not ask for anything. You need to preserve that level of trust and the power dynamic you've built.

A List Of Health Tech Startups

For a while now I've been keeping a running list of the health technology startups I come across sorted by the category they compete in. There are about 100 companies on the list.  I've moved the list over to an open Hackpad that you can find here. Hopefully this list will help people better understand what's happening in the industry, research competitors and even discover new investment and job opportunities.

I've left the Hackpad open so that anyone can add a company or category. Please add any that I've missed (I'm sure there are a lot).

As we move to the "Post-EHR" world where innovation is led by patient and provider needs as opposed to government mandates, I'm sure we'll see even more startups and categories emerge -- so I expect this list to get a lot longer.