This week, 100 of the Fortune 500 will report earnings for 2022 and heightened attention will be on four tech giants–Apple Inc., (AAPL); Amazon (AMZN) Meta Platforms Inc.(META) and Alphabet Inc.(GOOG). Comparatively, reports this week by Pfizer, Merck and Eli Lilly will get industry attention but news about these technology-giants will extend to a much wider audience. Why?
The impact of technology companies is ubiquitous: innovations from these companies have changed how every business operates and every consumer lives life.
The same should be said of healthcare, but aside from occasional coverage about new drugs and digital toys like smart watches, wider public attention to healthcare is usually a steady stream of case studies featuring fraudulent operations, eye-popping executive compensation or price-gauging. It has taken its toll.
Polls (Gallup, Jarrard) show declining trust and confidence in the “system” as majorities think it puts profits above purpose. Despite huge investments in facilities and clinical research, inequities and affordability stain the industry’s value proposition. It impacts every sector– some more than others. And the trend of negative coverage about healthcare lends to erosion of its public support.
2023 will be pivotal to U.S. healthcare’s future: it’s the transition year from pandemic adaptation buoyed by emergency-relief funds and opportunistic private equity plays in capital-starved sectors to a normalcy that’s unprecedented. Four trends will intensify:
- More attention to public health and increased funding for programs that address inequities and social determinants (in blue and purple states).
- More regulatory scrutiny of consolidation including retrospective review of deals that failed to deliver projected savings to consumers. (hospitals, PBMs, specialty medical practices)
- More investments by disruptors in delivery and financing alternatives attractive to employers and consumers. (reference pricing, direct primary care)
- More transparency—prices, costs, governance, compensation.
The tech companies reporting earnings this week, and others like Microsoft that reported last week operate high profile businesses with healthcare a major target of opportunity. They’re global, consumer-focused and geared to systemic solutions aka “platforms” like ChatGPT et al that displace sector boundaries.
The fragmentation in U.S. healthcare is recognized inside the industry’s board rooms and C suites, but short-term strategies to avoid risk supersede long-term actions toward systemness. Scenario plans by healthcare’s insiders reflect incremental changes in the industry while outsiders like Big Tech see transformational changes. They develop system platform solutions applicable apply to many industries while healthcare develops solutions specific to sectors wanting protection from outsiders and infidels who dare challenge their status quo.
Tech companies see healthcare as a flawed system. Healthcare companies see the same but hesitate to respond aggressively due to near-term competitive fear.
“Today, the U.S. dental market is $162.1 billion. Yet, 77 million American adults lack dental insurance, three times the number that lack health insurance. That percentage is higher for the elderly, poor, disabled, unemployed, veterans and racial minorities. 93% of people living in poverty have unmet dental needs; they spend 10 times more on dental services than higher income populations. The immense gap between service level and demand is a black mark on the country but also spells opportunity for first movers and innovators.“ David Johnson, Jenny Watson Overlooked and Underfunded: Dental Care’s Massive Potential to Serve Disadvantaged Populations 4Sight Health January 26, 2023 www.4sighthealth.com/overlooked-and-underfunded-dental-cares-massive-potential-to-serve-disadvantaged-populations
“Rankings create perverse incentives for institutions to report misleading or inaccurate data, set policies to boost rankings rather than nobler objectives, or divert financial aid from students with financial need to high-scoring students with means in order to maximize ranking criteria. “Our decision, along with those of a growing number of peer institutions, is necessary to lead a long-overdue examination of how medical education quality is evaluated and presented to aspiring students,” Lloyd Minor, Stanford School of Medicine Top medical schools reject rankings as measure of success, quality Modern Healthcare January 27, 2023 www.modernhealthcare.com/rankings/medical-schools-us-news-rankings-harvard-stanford-perelman-vagelos-mount-sinai
“Diagnostic errors are especially prone to raise concern among clinicians because they are associated with physicians’ self-identity and are often viewed as personal failings resulting in feelings of shame rather than as a signal to investigate the systems issues behind the problem. Because the underlying data are often imperfect, physicians often challenge their accuracy rather than interpret them as a call for improvement.” Jonathan A. Edlow, Peter J. Pronovost, Misdiagnosis in the Emergency Department Time for a System Solution JAMA. January 27, 2023. doi:10.1001/jama.2023.0577
“These corporate deals are bad for patients: prices for drugs sold by acquired companies increase at a faster rate than those sold by their non-acquired counterparts…Given these companies’ records of anti-competitive business practices, these acquisitions could cause further price increases on lifesaving drugs and prevent affordable alternatives from entering the market,” Warren wrote in the letter. “The Federal Trade Commission (FTC) should carefully scrutinize these deals and oppose any Big Pharma acquisition that will threaten competition, reduce innovation, or increase costs for American families.”
Letter to FTC Commissioners Khan, Slaughter, and Bedoya from Senator Elizabeth Warren January 25, 2023 www.warren.senate.gov/imo/media/doc/2023.01.25 Letter to FTC re Big Pharma Deals.
Sen. Elizabeth Warren urges FTC to ‘scrutinize’ two pharma buyouts Endpoints January 25, 2023 https://endpts.com/sen-elizabeth-warren-urges-ftc-to-scrutinize-two-pharma-buyouts
“Our modeling includes a base case, a good case, and a bad case for each asset
class, providing a range of growth forecasts given different economic and fund-
return environments. Our top-end estimate is for AUM to reach $16.1 trillion after
five years, and our low end projects muted growth to only $11.2 trillion. Our forecasts indicate a base case of $5.3 trillion in AUM by 2027, representing a cumulative growth of 15.8% from 2021.
This is a marked slowdown from the last decade, when AUM more than doubled. “What the Future H olds for Private Capital Pitchbook January 23, 2023 https://files.pitchbook.com
“A majority of people say they now believe hospitals are more focused on making money than caring for their patients. We asked 1,000 US adults this question a few weeks ago; 53 percent say hospitals put profits over patients and two thirds would easily believe a health system is not doing enough to earn its tax exemption Money, in all its various and inconsistent definitions, is shaping every healthcare conversation today and is deep in the heart of this growing tension. As an industry, we’re clumsy at this, left flat-footed in almost every payer negotiation, labor contract dispute and legislative reimbursement hearing.”
David Jarrard Hospital Finances: Ominous Waves for Healthcare Providers Jarrard January 28, 2023 https://jarrardinc.com/jarrard-insights/quick-think/2023/01/hospital-finances-ominous-waves-for-healthcare-providers
“As with any technology so vast and all-encompassing (it’s similar to AI in its scope), the potential is enormous. We estimate that the metaverse could generate $4 trillion to $5 trillion in value by 2030our research strongly suggests that in a downturn, companies that tune up their balance sheet and invest in growth capture dominant positions throughout the next cycle.“ McKinsey www.mckinsey.com/capabilities/growth-marketing-and-sales/our-insights/a-ceos-guide-to-the-taverse
Kaufman Hall: 2022 health system financials: Per the January 30, 2023 KF report:
- Last year was the worst financial year for hospitals and health systems since the start of the COVID-19 pandemic. Negative margins persisted for most of the year as the healthcare sector faced rapidly increasing labor expenses. The new data show modest margin improvements for hospitals at the end of 2022 and increased provider productivity within physician groups due to increased patient volumes.
- The median year-to-date (YTD) operating margin index for hospitals was 0.2% in December, the only month in 2022 where hospitals realized positive YTD margins, according to findings in the latest National Hospital Flash Report. Approximately half of U.S. hospitals finished the year with a negative margin as growth in expenses outpaced revenue increases.
- According to the latest Physician Flash Report, the median investment/subsidy per provider full-time equivalent (FTE) fell to $187,801 in the fourth quarter of 2022, down 5% compared to the fourth quarter of 2021.
Study: health system affiliated produces higher costs and marginal improvement in quality: Harvard researchers analyzed 580 health systems accounting for 40% of physicians and 84% of general acute care hospital beds and delivered primary care to 41% of traditional Medicare beneficiaries. Academic and large nonprofit systems accounted for a majority of system physicians (80%) and system hospital beds (64%). System hospitals were larger than non-system hospitals (67% vs 23% with >100 beds), as were system physician practices (74% vs 12% with >100 physicians).
- Performance on measures of preventive care, clinical quality, and patient experience was modestly higher for health system physicians and hospitals than for non-system physicians and hospitals.
- Prices paid to health system physicians and hospitals were significantly higher than prices paid to non-system physicians and hospitals (12%-26% higher for physician services, 31% for hospital services). Adjusting for practice size attenuated health systems differences on quality measures, but price differences for small and medium practices remained large.
“Performance on clinical quality and patient experience measures was marginally better in systems but spending and prices were substantially higher. This was especially true for small practices. Small quality differentials combined with large price differentials suggests that health systems have not, on average, realized their potential for better care at equal or lower cost.”
Beaulieu et al Organization and Performance of US Health Systems JAMA. January 24/31, 2023;329(4):325-335. doi:10.1001/jama.2022.24032
HMA survey of health system CEOs: Per the Health Management Academy (HMA) survey of the 150 largest health systems:
- 24 new appointees take up the chief executive mantle at one of the nation’s 150 largest vs. 25 in 2019, 9 in 2020 nine new appointments and 12 in 2021. Among the 24, 23 have a graduate degree, 11 have an MBA and 2 have an M.D.
- In 2022, 3 in 5 of the new CEOs were internal hires with an average of 14 years of service at their organization. Two-thirds of these came from a president or chief operating officer role. The remaining third came in from another CEO role.
The Academy Trends and Profiles of New Leading Health System CEOs https://hmacademy.com/resource/2023-new-leading-health-system-ceo-report
HCA reports strong earnings for 2022: HCA operated 182 hospitals, 126 freestanding outpatient surgery centers and 21 freestanding endoscopy centers as of Dec. 31.. According to its Jan. 27 earnings call:
“Revenues for the year ended December 31, 2022 totaled $60.233 billion, compared to $58.752 billion in the same period of 2021. Net income attributable to HCA Healthcare, Inc. was $5.643 billion, or $19.15 per diluted share, for the year ended December 31, 2022 compared to $6.956 billion, or $21.16 per diluted share, for the year ended December 31, 2021. Results for the year ended December 31, 2022 include gains on sales of facilities of $1.301 billion, or $2.46 per diluted share, and losses on retirement of debt of $78 million, or $0.20 per diluted share.
- 2023 guidance: Revenues: $61.5 to $63.5 billion, Net Income: $4.525 to $4.895 billion, Adjusted EBITDA: $11.8 to $12.4 billion EPS: $16.40 to $17.60 per diluted share
- Capital expenditures for 2023, excluding acquisitions, are estimated to be approximately $4.3 billion.
- The company announced its board authorized up to $4.5 billion in share repurchases this year, including approximately $1.5 billion that had already been authorized. Shares were trading at $248 each when markets opened on Friday, down from HCA’s current 52-week high at $275.16 per share.
- Short-term priorities include capital investments at outpatient facilities, clinical equipment for physicians and expanding its service lines. Long-term: advancing clinical systems and digital capabilities; transforming care models with innovative solutions; strengthening workforce development programs; and investing capital in its networks to expand offerings.
HCA Healthcare Reports Fourth Quarter 2022 Results and Provides 2023 Guidance HCA Healthcare January 27, 2023 https://investor.hcahealthcare.com/news/news-details/2023/HCA-Healthcare-Reports-Fourth-Quarter-2022-Results-and-Provides-2023-Guidance
Prescription Drugs, Clinical Research
VCs launch clinical trials start-up: Paradigm, a clinical trial technology company, has launched with $203 million in Series A funding through ARCH Venture Partners and General Catalyst, F-Prime Capital, GV, LUX Capital and Mubadala Capital (the state-owned investment firm for United Arab Emirates).
“Clinical trials have become a popular target for disruption both by technology and retail players. There were 17 deals for digital health companies developing clinical trial technology, collectively valued at nearly $300 million, last year, according to Digital Health Business & Technology’s database. This potential has drawn interest from drugmakers such as GSK, the British pharmaceutical giant, which signed a four-year deal in September with Medable, a clinical trial software unicorn.”
Retailers such as Walgreens Boots Alliance, CVS Health and The Kroger Co. have also entered the fray. Walgreens launched a clinical trial business in June to build a decentralized platform and offer in-person locations for recruiting and conducting clinical trials. CVS Health started a clinical trial division in 2021 and teamed with Medable for a virtual component last year. On Wednesday, Kroger announced its own clinical trial initiative in partnership with Persephone Biosciences
Gabriel Perna Venture capital firms launch clinical trial tech company with $203M in funding Modern Healthcare
Caroline Hudson Kroger is latest retailer looking to disrupt clinical trials Modern Healthcare January 25, 2023 www.modernhealthcare.com
FDA approves first marijuana-plant drug: Last week,
The U.S. Food and Drug Administration approved the first prescription drug derived from the marijuana plant, as a treatment for rare forms of epilepsy that primarily afflict children. The FDA cleared GW Pharmaceuticals PLC’s Epidiolex, also known as cannabidiol, to reduce seizures associated with forms of epilepsy known as Lennox-Gastaut syndrome and Dravet syndrome, in patients 2 years of age and older.
The LGS Foundation estimates there are between 30,000 and 50,000 Americans with Lennox-Gastaut Syndrome. GW Pharma says about 6,000 to 10,000 have Dravet Syndrome. GW Pharmaceuticals Chief Executive Officer Justin Gover said the company hasn’t set a price yet and is deploying 70 sales representatives to promote the drug to doctors specializing in severe epilepsy.
EPIDIOLEX® (cannabidiol) is the only treatment indicated for seizures associated with TSC, LGS, and Dravet syndrome in patients 1 year and older www.epidiolexhcp.com
Amazon creating generic drug subscription service: The medication delivery service, RxPass, costs $5 per month for Amazon Prime members. Amazon Prime costs either $14.99 per month or $139 annually.
Amazon Pharmacy Introduces RxPass: Unlimited Prescription Medications for Only $5 a Month, Delivered Free to your Door—Available Exclusively for Prime Members January 24, 2023 www.amazon.com
NBER report: Prior authorization reduce healthcare spending: The working paper concluded that prior authorization requirements reduced drug spending by 25% ($96 in per-beneficiary-per-year savings) which the authors estimate to be around 10 times greater than the administrative costs incurred.
RATIONING MEDICINE THROUGH BUREAUCRACY: AUTHORIZATION RESTRICTIONS IN MEDICARE NATIONAL BUREAU OF ECONOMIC RESEARCH January 2023 www.nber.org/system/files/working_papers/w30878
FDA Proposes Annual Covid-19 Vaccinations: Most people would get one Covid-19 shot annually—as they do with the flu shot—under Food and Drug Administration proposals for simplifying the nation’s Covid-19 vaccine procedures. The proposals, outlined in materials the FDA released Monday, would mark the biggest changes to Covid-19 vaccinations since boosters rolled out and are a sign of the nation’s shift to a more endemic-like approach to the coronavirus.
The Food and Drug Administration of the United States has recently changed its recommendation for COVID vaccines. As per the latest recommendations, everyone above the age of 6 months is eligible to receive all shots of the COVID vaccine.
Previously, the Food and Drug Administration did not suggest anyone below the age of 12 get their self-vaccinated with the updated booster shot. Now, the FDA has changed its stance and everyone above the age of 6 months is eligible to receive all Shots of the vaccine.
What are the Latest CDC COVID Guidelines? www.nufo.org
Long Term Care
Status of Senior Health: Per a new report from the Administration on Aging:
- In 2020, 55.7 million individuals aged 65 years or older lived in the US, representing 17% of the country’s population. Almost a quarter of this age group identified as members of historically marginalized racial or ethnic populations.
- Between January and June of 2021, 58% of individuals aged 65 years or older reported having diagnosed hypertension within the past 12 months. Vaccination rates among this age group were high: 95% received at least 1 dose of a COVID-19 vaccine, and 75% were vaccinated against influenza within the past 12 months.
- Arthritis was the leading chronic condition in 2020 for those aged 65 years or older, with 47% reporting the illness followed by Cancer (26%), diabetes (21%), difficulty seeing or hearing (21%, 29%) trouble walking or climbing stairs (38%), and cognitive issues related to concentration and memory (28%).
- This age group spent 14% of their total expenditures on health, and Medicare covered 94% of noninstitutionalized individuals in 2020. Half of the age group was covered by private insurance; only 1% had no medical coverage at all. Whereas 2% couldn’t obtain required medical care within the past 12 months because of the costs, 97% had a usual place where they could receive care when needed. Additionally, 22% reported visiting a hospital emergency department within the past year.
Suran Updated Demographics and Health Stats for Older Adults Released JAMA. 2023;329(4):277. doi:10.1001/jama.2022.23557
AHCA Report: Nursing homes workforce shortage highest of all sectors: Nursing homes have 210,000 fewer workers than before the pandemic, bringing workforce levels to the lowest they have been since 1994, according to the American Health Care Association and National Center for Assisted Living,
While nursing homes have filled a monthly average of 3,700 jobs over the last nine months, at that rate it would take nursing homes until 2027 to return to pre-pandemic staffing levels. To increase staffing minimums to the recommended ratio of 4.1 hours of nursing care per resident per day, nursing homes will require around $11.3 billion in additional funding annually, according to a report by accounting and consulting firm CliftonLarsonAllen.
The average nursing home employee turnover rate is 53.3% within a year, according to a 2022 study by the Long Term Care Community Coalition, a New-York based nonprofit organization focused on quality care.
Data Show Nursing Homes Continue to Experience Worst Job Loss Of Any Health Care Sector January 19, 2023 www.ahcancal.org/News-and-Communications/Press-Releases/Pages/Data-Show-Nursing-Homes-Continue-to-Experience-Worst-Job-Loss-Of-Any-Health-Care-Sector.aspx
Study: nursing home facilities owned by REIT have decreased RN staffing levels: In 2021 real estate investment trusts (REITs) held investments in 1,806 (11.6%) of 15,600 US nursing homes. REITs are for-profit public or private corporations. Findings:
During the post-investment period, registered nurse (RN) staffing was unchanged, but event study results showed a 6.25% decrease in years 2 and 3 after REIT investment. After the three largest REIT deals were excluded, REIT investments were associated with an overall 6.25% relative decrease in RN staffing and no changes in LPN and CNA staffing. Larger deals resulted in increases in LPN and CNA staffing, with no changes in RN staffing; smaller deals appeared to replace more expensive and skilled RN staffing with less expensive and skilled staff.
Braun et al The Role Of Real Estate Investment Trusts In Staffing US Nursing Homes Health Affairs January 25, 2023 https://doi.org/10.1377/hlthaff.2022.00278
Dollar General announces mobile clinics: Dollar General is partnering with DocGo, to provide urgent care and lab services vans in store parking lots.
Operated as part of Dollar General’s DG Wellbeing brand, on-site clinicians can perform physicals and routine checkups, vaccinations, lab testing, diagnostics like EKGs, wound care and urgent care services along with chronic condition management for patients with hypertension, diabetes, asthma and chronic obstructive pulmonary disease, according to the website. Dollar General operates 19,000 stores in 47 states.
Mobile clinics could make Dollar General a medical destination point January 26, 2023 ttps://retailwire.com/discussion/mobile-clinics-could-make-dollar-general-a-medical-destination-point/
CDC: 107, 000 deaths from a drug overdose in 2021: continuing a 2-decade-long trend of increasing overdose deaths that accelerated during the pandemic, according to a National Center for Health Statistics report. Highlights:
- The age-adjusted rate of overdoses per 100 000 people in the US was 6.8 in 2001. It jumped to 11.5 per 100 000 in 2006 and remained steady until 2013, when it increased to 13.8 per 100 000. During the COVID-19 pandemic’s first 2 years, the overdose rate increased to 28.3 in 2020 and then 32.4 per 100 000 in 2021.
- All adults aged 25 years or older saw an increase in overdoses in 2021, with individuals aged 35 to 44 years having the highest rate of overdoses at 62 per 100 000. The lowest rate of overdoses was among adults aged 65 years or older, at 12 per 100 000. However, this oldest age group experienced a 28% increase in overdoses between 2020 and 2021—the largest of any group.
- Males and females saw about a 14% to 15% increase in overdose deaths in the second year of the pandemic. However, the rate per 100 000 among males remained more than twice as high—45.1 compared with 19.6 for females.
Kuehn Fentanyl Drives Startling Increases in Adolescent Overdose Deaths JAMA. 2023;329(4):280-281. doi:10.1001/jama.2022.23563
CMS proposes standardization of e-signatures: The Centers for Medicare & Medicaid Services (CMS) proposed a rule to standardize electronic signatures and health care attachment transactions, such as medical charts and x-rays. If finalized, the rule would also standardize notes documenting physician referrals and office and telehealth visits. Finalizing the rule is estimated to save $454 million in annual administrative costs.
CMS Recommends Standardizing “Health Care Attachments” JAMA. 2023;329(4):277. doi:10.1001/jama.2022.23558
GAO Review: Political influence in government health agencies has increased: The agencies selected for GAO review were the Administration for Strategic Preparedness and Response (ASPR), the Centers for Disease Control and Prevention (CDC), the Food and Drug Administration (FDA), and the National Institutes of Health (NIH).
The report found that the ASPR, CDC, FDA, and NIH all have advisory committees to offer guidance for science-based decisions. Excluding the CDC, these agencies have leaders selected by the president and confirmed by the senate. This protects against political interference because “it may be more politically difficult to remove Senate-confirmed agency heads, particularly those confirmed with bipartisan support…. the number of political appointees at the ASPR, CDC, and FDA has increased at least twofold from 2016 through 2020,” the report highlighted.
Suran Government Accountability Office Examines Political Interference Among US Health Agencies JAMA. 2023;329(4):277. doi:10.1001/jama.2022.23556
Study: substance abuse costs employers $35 billion in 2018: In this economic evaluation of 162 million non–Medicare eligible enrollees with employer-sponsored health insurance in 2018, 2.3 million had an SUD diagnosis. The annual attributable medical expenditure was $15 640 per affected enrollee and $35.3 billion in the population; alcohol-related disorders ($10.2 billion) and opioid-related disorders ($7.3 billion) were the most costly.
Li et al Medical Costs of Substance Use Disorders in the US Employer-Sponsored Insurance Population JAMA Netw Open. 2023;6(1):e2252378. doi:10.1001/jamanetworkopen.2022.52378
Medscape: Physicians finances improved since 2018: Per Medscape’s annual “Physician Wealth and Debt Report”, changes in physician financial status 2018-2022:
- Physicians with a net worth of $1 million to $5 million: 36% in 2018 vs. 46% in 2022
- Physicians still paying off student loan debt: 32% in 2018 vs. 24% in 2022
- Physicians who experienced a significant financial loss in the last year: 75% in 2018 vs. 72% in 2022
Physician Wealth and Debt Report Medscape www.medscape.org
Census Bureau: Population shifting to South: Last year, the South outgrew other U.S. regions by well over 1 million people through births outpacing deaths and domestic and international migration, according to population estimates from the U.S. Census Bureau. The Northeast and Midwest lost residents, and the West grew by an anemic 153,000 people. In contrast, the South grew by 1.3 million new residents, and six of the 10 U.S. states with the biggest growth last year were in the South. The departures from the West started in 2021, during the first full year of the pandemic, when 145,000 residents moved to another U.S. region. Up until then, domestic migration to the West had increased each year since 2010.
US Census Bureau www.census.gov
NCHS: Life expectancy dropped in 2021: Life expectancy in the US decreased by about a half year between 2020 and 2021, from 77 years to 76.4 years, according to final 2021 mortality data from the National Center for Health Statistics. Life expectancy in 2021 was at its lowest level since 1996. The report attributed the drop mainly to increased deaths from COVID-19 and drug overdoses. The 0.6-year drop between 2020 and 2021 followed a 1.8-year decrease in life expectancy between 2019 and 2020. The overall death rate from 2020 to 2021 in the US increased by 5.3%, from 835.4 to 879.7 deaths per 100 000 people. Life expectancy in the US decreased for every age group starting at age 1 year or older, but there was not a statistically significant change in infant mortality during this period.
The leading causes of death in 2021 were heart disease, cancer, and COVID-19. Deaths attributed to COVID-19 increased from 2020 to 2021 by 18.8%, from 350 831 to 416 893 deaths. Influenza and pneumonia dropped out of the top 10 causes of death in 2021, likely because of pandemic-related infection prevention precautions
Kuehn US Life Expectancy in 2021 Lowest Since 1996 JAMA. January 24/31, 2023;329(4):280. doi:10.1001/jama.2022.23562
CB Insights: 2022 Private capital down from 2021: “Funding, the lifeblood of startups, dropped dramatically in 2022, leaving private companies strapped for cash and more prone to collapse. Global funding hit $415.1B in 2022, marking a 35% drop from 2021. And in Silicon Valley, the cradle of startup innovation, funding fell by 40% year-over-year.”
442 startup failure post-mortems CB Insights January 23, 2023 www.cbinsights.com/research/startup-failure-post-mortem