Paul M. Stein Pascal, your first paragraph's argument holds no water. Currently, there are so many similar products on the market that this new acquisition itself is hyper-risky since it now comes down to a hopeful market share steal. At the time, there was zero risk and, actually, close to zero product development since the finished device was in-the-can and they already owned a hydrogel division to make the adhesive patches. It was a few-month slam dunk. The second paragraph was out of the question at the time because I was too new to the Industry, I had no network, I had to support a brand new family, and I was very happy at Medtronic in a stimulating environment coming up with dozens of novel invention disclosures. Making such a dramatic life switch then truly would have been risky.

Jim Cunningham I agree with Pascal that large (publicly traded) medical companies are so worried about covering their butts with the shareholders that innovation is almost impossible. I came from a large medical company (Covidien) that paid a lot of lip service to innovation. When it came time to pursue anything but derivative products, they were very risk averse. I believe the death of large medical companies (other than, perhaps pharma) is coming sooner rather than later because of this. The "internet of things" and wearable (or smaller) diagnostic devices will mean that many chronic illnesses will be treated far before a surgery is necessary for intervention. Big companies are too slow to keep up with the technologies, and buying everything they see will bankrupt them.

Burrell (Bo) Clawson Paul, I've seen dozens of innovations in small companies that get tossed aside, too, in companies I've helped start. CEOs have a tendency to get blinded by a goal, without realizing that some innovations, where no comparable product existed, would be very profitable with little cost. I've seen this over and over.

"Well, since no one is making it, no one must want that type of product."

'Others haven't figured out how to do it this simply, so let's try it, since it will be inexpensive.'

"No, we'll stick to what we're doing now."

These CEOs often forget the early successes that were built using exactly these techniques of doing something simpler, smaller, less complex, safer, more sanitary, etc.

Today publically traded companies are under tremendous pressure to deliver what they committed to quarter after quarter, year after year. In this context there is little room for risky, unpredictable research activities which cost would be difficult to justify is it fails to deliver the expect outcome.
In your story, maybe the better option would have been to create your own company, get founding from some VCs and develop the product yourself. Then you would have sold it to Medtronic and cashed in the $ 150M. Companies are not paying $ 150M something that is worth only $ 150K. They are rewarding the risks and investments that entrepreneurs have made for them.

Paul M. Stein Jim, I totally, completely agree with your point regarding the future demise of the large medical device companies. Trying to maintain profits with no new products will eventually become impossible when cost-cutting and simple inflation prevent that, leaving only divestitures as a last ditch means. And how long can that last before the giants become shells of their former selves. The start-ups, if they can survive, will eat the giants' lunch...and dinner...and grow up to be the next Medtronic's, Covidien's, St. Jude Medical's, Boston Scientific's, etc.

Bo, those innovation-averse dinkies will eventually simply go up in smoke when those start-ups with simple gonadal fortitude burn their asses.

Gary Abramov So, Paul, no regrets then? :) Sometimes giving away an invention for security is justifiable or at least explainable. Who's to judge? And, corporate stupidity has been and will be ever-present: there are well-known fundamental differences in behavior between corporate 'lifers' and insane entrepreneurs. At Xerox headquarters in Stamford, CT hangs a letter from IBM to the inventor of xerography, Chester Carlson, which says that IBM does not perceive a need for copying of documents and is not interested in pursuing xerography. A tiny Haloid took up the challenge, with well-known results.

Paul M. Stein Gary, no. The real entrepreneurs would have quickly blown past a rank amateur like me...and they actually did. I loved Medtronic and its people back then, and so did Wall Street, so I wanted to help push that stock share price exponential as high as possible. Regarding the "ever-present" problem, I have always said that Medtronic (and many others like IBM) succeeded despite itself.

Gary Abramov @ Paul: there's nothing wrong with 'slow but steady' wealth accumulation. 99% (maybe more) of entrepreneurs fail, so it's a huge gamble, esp. when a family is in the equation. They are just reluctant to admit of their (often spectacular) failures, so the public has a skewed view of the success rate and reward scale. So, to each - his own :). BTW, I don't think entrepreneurs can be created/taught (but it's for another thread:).

@Group: I disagree with the prophesy of an early demise of the large med co's. In a mature market, the entity that owns 'the pipe' to the customer dominates the market, whether all the technology startups (upstarts?:) like to admit it or not. That's why they want to be bought, hopefully early and dearly: they know what it takes to 'lay the pipe', and it's often not their core competency (they are techies for the most part, not sales and marketing), not counting the exorbitant resources it may require.
With all the regulations and risk-aversion on both sides (supplier and customer) in this industry there's a great reluctance/inertia for anything new, which is understandable (at least to me:). This is, btw, why Medtronic did not snap up this little co earlier: they wanted a proof of (business) concept first, to 'really' decrease their risk, IMO.

Robin Hoff, M.B.A., M.S. Interesting discussion as I am currently enrolled in an Innovation class in which we discuss the pitfalls of large companies failing to continue to innovate and what it takes for start ups to be successful. Living up to Wall Street expectations can be a hindrance for big companies, but often times their behaviors are to protect a market position, which doesn't necessary lead to growth. Bold companies can set these expectations aside if desired, to create an entrepreneurial environment in which innovative ideas can be explored, and if merited, pursued. In his book, " A Good Hard Kick in the A--" Robert Adams says big companies need to act more like startups if they want to continue to grow through innovation. Yes, there is always the option of "buying innovation" as is commonly done with big companies like Medtronic, Covidien, etc, but Adams argues it is less expensive to develop your own ideas internally, if the know-how and talent resides within the organization.

Gary Abramov @ Andrew: Why would an offshore business allegedly overpay for something? They would not get a tax benefit from it. If you meant that they are fat and happy after not paying US taxes, well, they are paying the full amount (not discounted by taxes) straight out of their profits: not exactly painless either. Whether they pay US taxes or not, they still have to make money, and hopefully profit.

Here's one little calculation, actually in Medtronic's favor. Let's suppose that they estimated (based on their past experience) that internally it would cost them $20M to develop a product, and they would have 10% of achieving success, for whatever reason: late to market, regulatory, availability of internal resources, delays, etc..
Then, to pay for the same product, fully developed, with all the IP and the developers and and regulatory and whatever else is in the development pipeline to boot, for $150M makes perfect sense, because their opportunity cost otherwise would have been $200M ($20M/0.1).

Andrew Kyle There are others. GE Medical. They moved to China.
I am sure there are many others.

Norma ray (movie) championed unions for the south. Nice story. Now they have No work. Is that smart? I think we're smart enough to reshore and supporting the financial side circumvents that we cannot neglect the changes in the world. Progressive meeting the iron plans of the Nazi. Military strength supported by a strong industrial backbone here in the USA. But I live in Texas where we are changing the stranglehold of OPEC by developing shale oil and gas

Best regards
Andrew

Andrew Kyle Because your headquarters has moved from the USA and you can avoid paying taxes here. I hate companies that move off shore to avoid paying the taxes we have to and the drug prices we subsidize for the world. So, Medtronic would not have my support except if I were a customer of their device... no stock investment from me.

Paul This is the way people in establishment conduct themselves. Similar experience I had with book publishing industry. They make big claims before their gullible audience but in fact they are very shallow people. They have inherent lack of ability to judge anything on merits. Moreover, if they are able to discover merits in you, then they will reject you only because you don't have a clout in the market. http://sciencengod.com

As an Medical OEM I see hundreds of projects each year. Even good products end up in the med device graveyard more than not.

I would not chance buying an idea at infancy since the odds would simply not be in my favor. It's the difference between gambling and a day job.

Michael Kremliovsky Unfortunately, medical device startups become more and more challenging. The cost of proving efficacy is significant, regulations are pressing, and the market is dominated by large companies who often suffocate small guys. There are success stories, but the rule of thumb today is - you need to raise about 100M+ to get to an IPO in 5-8 years. So, many have to take a "slow" approach - trying to grow organically and sustainably with a lot of bootstrapping through grants, collaboration, special deals, niche markets, and so forth.

Paul M. Stein Robin, you have been educated well. Adams is totally correct on all fronts. Still, there are so many reasons why big companies got to be the way they are in their abandonment of internal R&D. It would take a very long time to cover them all in historical context, but, needless to say, they are wholly stuck in that mode...which is great for start-ups. To Michael's point, markets are absolutely dominated by large companies, which is why start-ups must abandon the me-too sort of product development, even if they can demonstrate a price advantage. Start-ups must push their one advantage, innovation, and focus, focus, FOCUS on treating the unmet medical needs the big guys are totally incapable of touching.

Listed companies have the dumb "mental" constraints. All this creates opportunities for the non-listed ones. Develop a new product to be acquired by the listed company.
I understand the corporate constraint of the listed company.
And I understand the constraint of the employee, who instead of developing what makes real sense and creates real shareholder value, he is confined in the status quo, in fear of losing his job.

Gary Abramov It's not the swiftest who wins the race.
Also, the idea that a large co can effectively conduct a breakthrough R&D is, like, 20 years too late: it assumes entrepreneurial spirit, drive and commitment at the highest levels. In large, mature companies, entrepreneurial spirit is (by necessity!) suppressed: by its very definition, it's disruptive, and mature co's have a lot to lose from such disruptions if they don't bear fruit.
Back in the old days, enlightened companies, such as Xerox and At&T established stand-alone and often remote R&D centers, like Bell Labs and PARC. Incredible innovation flowed out of them, but even these companies, playing in un-regulated (!) sectors, had major failures commercializing most of this innovation.
Another reason why a large co is ill-advised to pursue internal R&D is the cost: the overhead rate of large cos are orders of magnitude greater than of lean startups.
So, even if a large co embarks on an R&D project, it has to be 'sanitized' not to bring an upheaval to the rest of the well-tuned business by remoting it, and to decrease overhead. This is achieved by creating a mini-co (an internal remote 'startup') which is a) cheaper to run and b) won't 'contaminate'/defocus the mother ship.
This is how smart cos , like 3M do it, btw. Or, 'cleaner' yet, they invest into startups or buy them. The proof is all around us. The big cos are not stupid, that's why they are successful, much so (orders of magnitude) than the startups around them.

Gary Abramov Capital (and business) flight can be more-or-less straightforwardly controlled through regulation and taxation. A nice fat tax slap against a co moving offshore and restriction of its access to the US markets would quickly sharpen the beancounters' and CEOs' minds.
Having a political will to do it is another matter altogether: this undermines our beliefs (delusions) in free markets, 'fair' competition, capitalism, Mom and apple pie, beside shutting down lawmakers' nice revenue stream from lobbyists (who are effectively foreign agents for offshore cos).
Cheering people like Warren Buffett for investing $100M in a Chinese electric car startup while neglecting local starving entrepreneurs in the same biz, instead of a public (at least media :) flogging says it all.
We've seen the enemy, and it's us.

Andrew Kyle We need to stop being ashamed of our leadership position and lead.

I am for the USA because we have limited our colonial ambitions to NA. We may have used military power but have not beheaded innocent journalists and destroyed the religious structures of others.

Nor are we invaded the area of an independent country.

So I favor lowering the corporate tax rate and the other actions you mentioned
Regards
Andrew

Burrell (Bo) Clawson Gary noted: "Capital (and business) flight can be more-or-less straightforwardly controlled through regulation and taxation. A nice fat tax slap against a co moving offshore and restriction of its access to the US markets would quickly sharpen the beancounters' and CEOs' minds."

Taxes do not fix problems when the government becomes the source of so many benefits that the taxation reduces the standard of living of its residents, which has been happening.

It is a trite phrase, but killing the Golden Goose, kills off the Gold. We are over 50% of all earnings taken by all forms of government in all its ways and it is still growing with no end in sight.

Politicians look at their jobs in the US as a plumb to enable them to tax and move those funds to their pet projects. Instead, they should be looking how to make the whole country work more efficiently with the government taking less and doing less and letting the private sector allocate spending.

Gary Abramov If we let the capital and biz to move offshore, we lose more than 50% due to taxes.
Also, we (still) live in a democracy where politicians are elected. So, at least theoretically, we should be able to fix things, if we wanted to. With a voter turnouts low, there's a very slim chance of that.

Michael Kremliovsky The tax story is less than straightforward. For one, it appears to be a result of nice sales pitch by one of those "Pumpkin, Pea, and Co, LLP, a law firm specializing on corporate taxation" (the exact name is Skadden, Arps, Slate, Meagher & Flom LLP). These guys made tons of money on the pitch (this year alone 1B dollars will be made by "the specialists"). Usual sales story in US: impulsive and stupid. The taxes are high in US, no questions about it. However, the services are also pretty significant. Note that the HQs are moving mostly on paper. Yet, the Congress is not rushing, because these moves underline how bad high corporate taxes are and how wrong is the President. Isn't it some type of shooting-in-your-own-leg? BTW, there are comparable taxes in several parts of the world including Norway, Netherlands, Japan, Germany, France, Belgium, Brazil, and Australia, to name a few. US is not leading in personal income taxes either. Here is the list for a fast comparison: http://en.wikipedia.org/wiki/List_of_countries_by_tax_rates. In the same time, US spent whooping 400B dollars on R&D - the highest amount per capita. US also spends more than any other country on defense and security. This is our decision as a nation. We can change that and also lower the taxes.

Now, we moved once production oversees, because labor was cheaper over there. This was a similarly stupid move. Eventually, it became more expensive to make things in developing countries, but we also lost qualifications to build things (not even mentioning the loss of corresponding R&D). Democracy is tough - we have to act like idiots, suffer, realize, and correct. It takes too long, so we kinda feel always a bit stupid.

Andrew Kyle So what do we do? If we don't act, we will be like the Keystone pipeline being studied by the Keystone Cops in Washington DC.

The democrats are for taxing us until there is no money left except to level the opportunities. That is plain stupid... who will have the money to pay the taxes.

I suggest we all vote Republican in the upcoming race. The administration has shoved all the controversial decisions until after the election. I trust President "You can keep your doctor" about as much as he deserves and the bunch who voted in the ACA are democrats... they deserve to be rewarded by retirement!

Sir,


We are manufacturers and Supplier of high quality disposable and re-useable Dental

Paul M. Stein Bo, I would totally agree with your idea if I were a bit younger. Yes, home use devices are vitally important for the aging population that wants to stay home and out of the horrid nursing home environment. Still, though, at this point in many of us codgers' careers, I personally feel, where is the fun in that? Where is the real making-a-big-difference-in-the-world that we whole-heartedly signed up for when we were younger and much more foolish...and probably never achieved?

There are still those people who are looking to the medical device industry to improve and extend their lives. For me, personally, your idea is like hitting line drives. It gets the crowd going, but then they quickly look for the next, and the next. No, I'm only going to swing for the fence in the ten years I have left, what the crowd roars for. I was a cog-in-the-great-Corporate-wheel for way too long. I've had enough of that.

Andrew Kyle The plan is to end our life at 75. Dr. Ezekiel Emanuel Explains Why Death at 75 is Right for Him. I totally agree that death at 75 is right for one of the architects of the ACA and hope he gets his wish. His statements about not getting immunized after 75 is plain stupid. Does he believe that he would not become contagious and infect younger people?

The result of our national debt Ponzi scheme will be that we will lack funds and as a physician told me, there is a simple solution to high medical costs...

Just let people die...

Is that what we have come to? I hope and think not if we act at the next election. I hope they have had enough time to read the bill to figure out what its results will be by now.

Gary Abramov Bravo, Paul! Good luck, maybe you'll find funding (I'm not being facetious).

Paul M. Stein Jim, that 90% figure is for all start-ups. My CEO told me a while ago that for medical device companies it's more like 30-40%. I think the problem with the VC's is that they never understood the technology...at all, and they rarely hired anyone to explain things to them. Then, because a few too many early start-up companies did fail miserably, again, because the VC's couldn't figure out a bad idea if it hit them in the face, the VC's all ran away, and have kept away until a company "is much more mature". And then, only if a VC absolutely knows the company team, and only if an equity deal is monstrously in the VC's favor will a start-up get money from them.

So, please don't blame those nebulous things like the FDA, the regulatory environment, or the dinky 2.3% excise tax to blame for the VC dearth of funding. Blame things that readily been observed over and over, their own stupidity and greed.

Paul M. Stein Andrew, I think your political views are way off the topic of this discussion, which is why no one has responded directly to any of your posts. Certainly, you may have some valid points, but just not here. May I suggest that you start a new discussion that would generate much more interest in that line of thought.

Burrell (Bo) Clawson Paul, I can understand going for home runs. A successful product is a success regardless.

Going for home runs can be costly in time and dollars. Exact Sciences latest diagnostic test for CRC took about 15 years and a quarter billion dollars to get FDA clearance. Plus the test is going to retail for about $600 per test. Are insurance plans going to pay for it? Are they going to earn their investors a great return?

Home based medical solutions of all types can be a giant money saver compared to going to a doctor once or twice a month. Early diagnosis, again, is the ONLY way to lower medical costs and do it by engaging the patient at home.

Stopping, alleviating or correcting medical problems so we don't have chronic disease consuming 75% of the healthcare budget is a giant amount of possible monetary savings plus letting people be more productive longer in life. That is a success.

Paul M. Stein Bo, totally agree.

Andrew Kyle Dear Paul,

Many people respond to my posts... you just did.

If we think we are going to solve our medical device problems without entering the politics that drives these changes is delusional.

We have to be activist not just debate endlessly among ourselves. We are suffering the slings and arrows of progressives who don't WORK for a living.

Gary Abramov And yet, you won't get funding unless you are 10 times cheaper/smaller/faster/better/sexier than anything on the market (this pretty much defines revolutionary).
The wow factor is alive and well in the VC community (as is the herd instinct), but they are the only ones betting on startups. The fat cats like Medtronic play it safe and buy proven cos/products. Smart and prudent, whether we like it or not.

In San Diego where I am, there are lots of very smart people trying to get funding, to no avail. Some of the apps are very sexy and address precisely the issues mentioned by Bo, but...nobody's interested and these ideas are withering on the vine. Why? Because, among other 'regular' issues, like unproven engineering, there are political and regulatory barriers and associated risks that scare investors away.

So, here are the dilemmas: the market needs and would pay for incremental improvements, the VCs say they want revolutionary solutions (because they presumably have the highest ROI) but are unwilling to fund their development, and entrepreneurs are starving to death and forced to re-join 'the dark side' (big corporations).

Add to that a rapacious med device tax that our own gvmt imposes and you get a picture of an industry teetering on collapse.

We're already seeing US companies launching new products overseas and not even offering them in the US later. If that's not slap in our collective American face, I don't know what is.

Paul M. Stein Gary, I'm sorry, but I'm going to have to disagree a bit with your first sentence's premise. It's all really a matter of perspective. What is difficult, painful, and risky to one is easy, simple, and let's-go-for-it to another. It all depends on the ideas and the team. Going back to Medtronic (sorry about being a broken record) in the late 1980's and 1990's, they were already number one in many sectors, yet worked extremely hard at expanding into many new and exciting areas. The income, and stock share price, went exponential. So, with great leadership, revolutionary zeal in not incompatible with ongoing enterprises. A culture of "we can do anything" becomes infectious, and the income simply follows. As stated immediately above, however, when that culture changes, when the entire company drifts into the doldrums, then the culture turns into a self-fulfilling prophesy, "Oh no, that sort of thing is way too difficult and way too risky."

Burrell (Bo) Clawson Evolution versus Revolution is in the eyes of the payer and the user!

If you can move a product into the home, it is going to take a lot of work and likely modern tech to make it right and get its human engineering & ease of use down pat.

We can debate categorizing, but there has to be more home testing and monitoring or we can't get medical costs down. There is no other way.

You can't let a growing medical condition go unnoticed & get to the point of an ambulance run to a hospital or you have the chance of lifetime maintenance of a problem versus inexpensive fix or control of a problem that doesn't progress to a chronic condition.

Jim Cunningham We've all heard the statistic that start-ups fail high 90% of the time. I wonder how many of those are companies with great ideas that starve trying to get funded. I expect if every company (subject to some minimum guidelines, of course) could somehow get funded for a year up front, the failure rate would be smaller and we'd all be better for it.

Pie in the sky, I know....

Jim Cunningham Bo is talking about "evolution" as opposed to "revolution." When I was with Valleylab/Tyco/Covidien, they did "evolution" well. The problem is there is only so much cost you can take out of something tried and true before something "revolutionary" comes along and makes the tried and true obsolete.

So far as I can see, Google is the only large company (maybe IBM) that isn't afraid to think revolutionarily right now.

The ironic thing is, as Paul says, the big companies have the money to back the revolution, but they aren't interested.

Burrell (Bo) Clawson Robin, Paul, Michael, Gary & others, may I offer a lower risk innovation secret for you to consider if you want to do a product that can make a difference. This would help in your startup, or maybe if you can get a senior management guy behind your idea.

Do NOT look to do the next Ebola vaccine or MRI machine. Instead, look to what is currently in the hospital or physician office that needs to be in the home for early warning diagnosis or maintenance. Find something that will allow quicker results at lower cost to patients. We have over 120 million people with chronic illness and over 100 million taking multiple meds.

Personal disposable incomes are down across the board in the US since the last recession and healthcare costs are up everywhere; insurance, deductibles, copays, family coverage extras, etc.

Taking an existing proven product and downsizing, improving and simplifying for home use can be a lot easier than doing cutting edge tech stuff, with a lot less risk, depending on the competition of course. Yes, Clayton Christensen wrote about some of this in his 2009 book "The Innovators Prescription", but I've been doing this for decades. It works if done right.

Paul M. Stein Robin, Michael jumped in before I could comment, but he is completely correct. It's absolutely a political and bureaucratic "culture" thing. All of these companies had that Rocky "Eye of the Tiger" culture once, lean and hungry to be better than the next guy through outrageous innovation to treat another big swath of the unmet medical needy. Living through that at Medtronic, those were really exciting times. This really wasn't too long ago, maybe just ten to fifteen years. Then, a new culture slowly snuck in, a more soft, and scared, keep-what-you-have attitude from the MBA schools. Be safe (however, totally un- or ill-defined that was)! As this became fully entrenched with more and more executive appointments of this new guard ilk, and layoffs and retirements of the old guard, there was no turning back. No internal, half-hearted, unrewarded innovation "centers" will bring things back to the good old days. So, it's fallen to the start-ups to become the next generation of lean and hungry. Unfortunately, the ones who don't innovate have all the money, and the ones who do innovate have none.

Gary Abramov Innovation is very difficult, painful and extremely risky. Some companies say they have to re-invent themselves every now and then, but that's for the most part often done too late, because it's done in a panic as a reaction to external forces, definitely not due to pro-active thinking, even if they say it is (would you admit to being scared?).

I venture to say that true (as in revolutionary) innovation is incompatible, by it very definition, with the on-going business of an enterprise. It takes revolutionary thinking (scarce in mature bureaucracies), revolutionary zeal (or entrepreneurial drive, whatever you want to call it), and availability of betting money. All these are in short supply in established businesses, esp large public companies, for many reasons.

That's why we see what we see: a bright entrepreneur starts a company, develops something new and useful, and then sells (out) to a larger fish. This scheme works and works well (so far).

At least there's self-awareness on the part of the large companies of what's good (e.g. new technologies) and not-so-good (e.g. internal R&D) for them. The cos that lack(ed) this self-awareness are either gone or are struggling: witness AT&T, Xerox, Wang, DEC.

Back to Medtronic acquisition which started this thread: I am sure Medtronic calculated very precisely what that business is worth to them and paid for it. They may or may not mis-calculated, but only time will tell.

Michael Kremliovsky Corporate venturing is better in theory than in practice. The first generation on incubators almost universally failed (back in early 2000s), at least, in healthcare. Now, based on the lessons learned, there is a second generation going on now. It is mostly unsuccessful in a classical startup sense, but they produce some outcome. They are not at all efficient though, because the decisions are often made within the same political and bureaucratic realm as the mother company lives in. The reward for the people driving these internal startups is mostly symbolic, so most people within don't take it seriously.

Robin Hoff, M.B.A., M.S. Hi Paul, you are correct about big companies getting stuck and there are many reasons for it- as you point out, too many to discuss in a short post. What do you think about big companies forming an independent organization or business to focus on innovation? I am aware of some examples where this has been done successfully, but often times the company's organizational structure makes it challenging.

Michael Kremliovsky Andrew, I would not jump to blaming progressives right away. It reveals a character of "tea partying" which is just an opposite of the spectrum. I agree that healthcare, in particular, is our public political issue (as many other issues). However, we face the enemy and the enemy is us. As public, we don't want to be responsible for our end of life management. It is pretty obvious from the way how we vote on issues related to fixing healthcare. Also, we don't care about participating in important campaigns that can help to reduce lobbying power of, say, physicians (this is to your point). So, it has nothing to do with progression or regression. We are just politically lazy and it is easy to prey on lazy.

Andrew Kyle Why not? Didn't Bush get the blame for Iraq. Oh. Where are we fighting today?

Gary Abramov Bo: what you are saying are universal truths, at least to the people in the healthcare ecosystem (I don't particularly like this cliche, but it happens to be the most appropriate here).

So, I want to reverse the argument: how come, if the solution is so obvious (and it is), there's nothing being done to implement/streamline its introduction? The policymakers are not dumb, they understand all of this too, as do reimbursement and insurance execs. Yet, nothing, nada. Actually, worse than nothing: ever-growing suffocating regulations and taxes and mandatory (non-competitive) health insurance to boot. This is the real problem.

The solution lies in following the money trail and exposing and eliminating the 'obstacles' inevitably to be uncovered 'along the way'. We all know what those obstacles are, unfortunately, and who/what feeds them. Takes a real crisis to sweep them away, and we maybe close to it.