This past week, while applying for the InSITE Fellows program, I had to prepare a quick analysis of CareCloud (a healthcare IT company) based on a venture beat article that can be found here. Now that the application cycle is over, I thought I’d share my response and some general thoughts on the company. Admittedly, I know very little about healthcare companies but the industry is intriguing and very much ripe for disruption. Here is a first attempt at evaluating the company from an investment perspective.
In assessing CareCloud as a potential investment, I examined three core areas: the market, the technology and the team. While the technology is very sound and the team is promising, I would likely not invest in the company due to several significant issues in the electronic medical record (EMR) market.
CareCloud’s medical practice management software is a great solution to a clear pain point in the market—namely that legacy vendor’s provide systems that are too bulky, inefficient and costly. Built on a nimble Ruby on Rails platform, CareCloud’s elegant design and user-friendly interface has been well received by physicians and other users. The product is completely cloud based making it easy for physicians to update and stay on top of complex regulations and compliance mandates. It also focuses on providing users with the flexibility to pick and choose components of the software rather than being forced to adopt an entire platform and abandon existing software. All these features result in a lowered cost to the physician and a better way to manage their practices.
The management team at CareCloud is also very strong—comprised of industry veterans and individuals who are experts at the given function they lead. This of course starts at the top with Albert Santalo—the founder and CEO of the company. Santalo has spent the last 12 years working in healthcare. He is a successful serial entrepreneur having co-founded and grown Avisena into one of the largest providers of revenue cycle management software and services for physician practices in the world. The rest of the team is likewise very strong and experienced. This is a team that has experienced a lot of success prior to starting CareCloud and in the first 4 years of the company have continued to be successful.
The biggest challenge with CareCloud is the market. At a high level, things look pretty good. Healthcare is the largest sector in the U.S. economy and set to grow from a $2 trillion dollar market to a $4 trillion dollar market in the next 10 years. In particular there are mounting cost pressures stemming from an aging U.S. population that will grow from 12% who are 65+ to 17% who are 65+ in the next 10 years. Those over the age of 65 tend to spend 4X as much on healthcare as the rest of the population. Against this backdrop, the EMR market is estimated to be a $6-10 billion dollar market—which would appear to be large enough to invest in.
However, the big problems with the market are the regulatory environment in the industry and the plethora of competition CareCloud faces. Regulations and mandates imposed by the federal government could easily destroy the industry and put CareCloud out of business—particularly since so much data is stored in the cloud where it is more susceptible to compromise. In terms of the competition, legacy vendors like Allscripts, Epic, GE and Siemens already control at least 75% of the market and almost all large hospitals use them because of the subsidies from the government—CareCloud is unlikely to take any of this market share away. The remaining niche of 25% or $1.5-2.5 billion of the original market is comprised of pysichians operating in small clinics with over 300 electronic vendors, including well established companies like Practice Fusion and AthenaHealth, competing for their business. Even if we assumed that CareCloud could capture 25% of that market (which it almost assuredly won’t), that would only be a total share of $375-$625m, which is too small to invest in especially since the company has already taken in $54 million in total venture funding and we are only at the Series B level. There is a lot of pressure to have a very high exit in situations like this. Because of these challenges in the market, I would be very hesitant to invest in CareCloud.
Some additional questions I have that would be useful to know when investing include:
- What was the pre-money valuation before the Series B round of financing?
- What do the actual revenue and customer acquisition numbers look like?
- What are the terms of the deal—what sort of exit size do we need to make a good return?