Navigating the US Healthcare System for UK Founders with Demi Radeva, CEO of Across

Speaker A: Hi, this is Steve Roost and you're listening to HealthTech Hour on, um, UK Health Radio. Each week we give you the best news, views and interviews from the health technology world. From CEOs and founders to entrepreneurs and clinicians, the companies and people that are shaping the future face of healthcare,

Speaker B: all

Speaker A: on the world's number one talk, Health Radio. Hello and welcome to this week's Health Tech Hour with me, Steve Roost. Each week we bring you the best news, views and interviews with the leaders, CEOs, clinicians, doctors, founders, investors and journalists that are changing the face of health tech in the UK and beyond. As regular listeners know, I am, um, a founder and CEO of a health tech venture myself, which is called PopDoc. PocDoc is now the number one. Uh, the number. Our Healthy Heart Check, rather, is the number one product used outside of a GP surgery to screen for cardiovascular risk in the UK. Um, we work with over 30 to 40% of all NHS regions and it's the number one diagnostic test on the high street, apart from COVID and pregnancy, which are quite big categories. But if you would like to find out more, please go to POCDOC Co, that's P O C D O C Co to find out about our Healthy Heart check out, which is the equivalent of your annual health check, including blood test results, in just eight minutes using your phone. Um, thank you as always to Pop Doc for supporting the show. Thank you. Also, if you're listening live on UK Health Radio. We love UK Health Radio. We love Johan Rafaela and their team. Um, they've got some incredible shows on the platform. Um, it reaches a huge, huge audience, um, across the world. Um, and we're super grateful to be on. Thank you as well. If you're listening live or, sorry, listening on demand on any of the podcast channels, we get downloads now in over 50 countries every month. Um, which is incredible. Thank you so much to everyone for showing up. Um, you know, we, from Saudi Arabia to South Africa to Venezuela, um, you know, we, we love having you here. It's really appreciated. We wouldn't be doing this if it wasn't for you guys. Um, and thank you. If you're watching this on our YouTube channel, the Health Tech Hour YouTube channel, or, or on my Instagram, which is Eeveroost, where we put out some of the best clips. So onto today's show. Today's show is a very special show, actually, because I think this is one of the first times we've had a specialist on the show who specializes in how to translate the UK healthcare system into the US healthcare system, which, for those of you who don't know, and it's a broad church, I know that we've got listening. The UK is a fantastic market to build a health technology business in, but the US is an enormous market to go and be in. And so it's sort of in effect, the holy grail for any UK based health tech business, health technology business, to not just get to the US but to actually make it stick, to be successful in the us. Now, uh, in a previous venture, I've made that journey. It wasn't in health, but it's very rocky, it's very difficult. And health has its own special things around regulatory and all kinds of other things you have to get through. But I love this idea of the transatlantic relationship and I think that it cuts both ways as well. And actually US businesses coming to the uk, um, is also considered to be slightly controversial, which we can get into. But, um, we're very lucky on today's show to have Demi Radova, uh, who is the CEO and co founder of Akros, which is a consultancy that specializes in helping UK health technology businesses get into and be successful in the United States. Uh, Demi, how are you? Welcome to the show.

Speaker B: I'm lovely. Thanks, Steve, for having me. I really appreciate it. I'm so excited to be a part of your platform and just share this incredible experience I've had over the last almost 20 years now.

Speaker A: So how did you get into this gig?

Speaker B: Um, let's see. Well, so let me start at the beginning because honestly, my perspective and how I approach my work is shaped by all of my life experiences. So, um, like you said, my name is Demiradova. I was born and raised in Bulgaria. I grew up in Eastern Europe. And then my family and I went through the immigration journey and moved to the U.S. um, over 20 years ago now. And in that journey itself I learned a lot about health care. Right. I grew up and experienced one health system and then we moved into another health system, um, and I ended up deciding to study finance. So when I did my undergraduate degree in finance, I always thought to always follow the money. Um, and from that experience, um, I ended up landing in a space, working, uh, inside of the largest payer in the US and the world and learned a lot about, um, economics and decision making. And how do you actually, um, purchase technology inside, um, of a private payer. And then as I was working in the us, um, I fell in love with healthcare and fell out of love, um, with US healthcare, decided that I really wanted to um, understand how other health system financed themselves and so embarked on a journey to study at the London School of Economics. And um, really focused on financing health care, structuring incentives. So how do we build the right incentives? Because incentives at the end of the day drives everything. All of the decisions, whether a physician prescribes a certain medication, whether they prescribe and recommend certain technology. A lot of it has to do with um, how they get paid and what they get paid for. Right. Um, and so what I learned um, and a key takeaway for me um, at ah, lse was that there's really no perfect health system and there's no right health system or wrong health system. But there's a series of trade offs that we have to make um, as a society, as a community, um, in terms of what's okay and what's not okay. Right. Is healthcare bankruptcy acceptable or not? Um, in a lot of places around the world it's not. And so therefore they have the, they have built the safety and the protection so that never ever happens to anybody. Um, and I was so energized by what I learned. I ended up um, becoming an adjunct at the University of Minnesota and really motivated to teach the next kind of set of leaders in health care here in the U.S. um, about what it takes to build a system that is more equitable, um, that helps advance technologies that can better the lives of everybody. And um, yeah, so those are all components and experiences that I've had that brought me to where I'm today. I've also been a founder, a co founder of a couple of different digital health tech um, companies. And so I myself have been on the journey and everything that I do at Acros today is based on these experiences that I've had and what I wish I knew and what I wish I had as a founder myself. So I'm really excited to dive in and talk about even your, your journey, um, as a health tech founder today.

Speaker A: Yeah. So I actually recently came back from a trip to the United States States. Um, and I think that we can get into that as, as we go because it is, it is different. I, I'm, I'm very lucky. In previous ventures I've worked that UK US kind of corridor. Um, so I kind of had a suspicion about what, what was going to come. But it was certainly, even for me it was sort of eye opening in a good way actually, not in a bad way, just in a, in it is what it is kind of a way. But just to go back a couple of steps because the, the vocab is so different to anything that we have in the UK and, and even in Europe. So when you talk about a payer. A payer, right, like I think you mean United. I think you work for United. Is that correct?

Speaker B: I did, that's right.

Speaker A: So, so how. Yeah, exactly. Because this is such an alien concept to people in the United Kingdom and, and in Europe maybe more generally as well. But it, it's still kind of weird.

Speaker B: So. All right. The way that I like to compare and contrast this is that in the UK you have nice. And I actually was lucky enough to work uh, with NICE for my master's thesis and dissertation and I got to experience the organization um, inside and out and really understand how in the UK decisions are made about whether or not you reimburse for certain technologies. In the US think of having over 1100 decision making bodies. So we have super high fragmentation and also the decision making responsibility is really distributed across not only these payer entities which are responsible for managing population health risk and really assigning different benefits, um, but we also have very large self funded employers like Walmart, like Apple, like Disney. Right. That uh, decide what type of technologies to make available to their employee populations or not make available. Um, and so the level of complexity is just um, you know, thousand fold compared to um, the uk. And yes, the, there is more complexity than just one organization in the uk. Um, you've got clinical commissioning groups, you've got other decision making bodies, but we're still talking about a fraction of what we experience here in the US and so that is one of the most beautiful and hardest things, um, when talking to founders that want to expand into the US Is for every no that you hear, you could hear 10 yeses and for um, every no you could hear hundreds of. Or for every yes you could hear hundreds of no's as well. Because every single decision, um, organization can have a very, very different decision making process. And to be completely transparent and honest, I think going through what I did and my research that I did with nice, I was um, so deep into kind of understanding the very complicated economic research that goes into making a yes or no, whether to reimburse and pay for a technology. And then when I myself was responsible for analyzing different um, technologies and whether or not to reimburse for them, it seemed to be all over the place. There was really no one methodology, there was really no one set of parameters, um, that everybody would follow. And so therefore you get very different decisions as to whether to pay for a technology. And how much to pay for it. Um, so that was, that's been probably one of the most surprising things for,

Speaker A: for me, I think that I would agree. I think one of the things that took me a while to get my head around for the US is in the UK and um, to a large extent across Europe there the payer and the provider are often the same people. So in the sense of the person that pays the bills is also the person that provides you with the treatment. Uh, you go to the hospital and the hospital is the one that's paying for your care, but they're also the one delivering your care. Whereas in the United States that, that's completely not the case. There's some instances where that is the case, but the most majority is actually it's not. And it's a much more financially driven

Speaker B: system, I would say, increasingly. So we're getting into a very interesting, innovative new models where we, we even have entities that we call pay vitors, where it's a payer and a provider in one. Um, but you were exactly right. There is a reason to have that fracture between providers and payers. Um, and that is to make sure that we're keeping everyone in check. Right. When you have checks and balances, I mean some of that can, can be seen even in how the US Government is structured is having checks and balances so that no one party ever has all the power in the equation. But that's when you run into prior authorization, that's when you run into uh, the mechanisms with which these entities keep each other in check, creating tension. Um, and so in some aspects it can be important. It's a way to keep costs down. Um, but where it gets tricky is when you are starting to minimize and you're disallowing preventative health care, um, when you are, which ultimately then creates more cost down the, down the Runway. And so um, it's important to keep in mind exactly like how do you structure the incentives? How do you build a system that um, yes, there's some checks and balances, but yet you are um, promoting and allowing access when it's most needed.

Speaker A: Yeah, I think the prevention conceptually isn't the easiest for any healthcare system to get their head around. At scale, I don't think so. I don't think it's necessarily just a U.S. problem. I think it's always going to be easier to treat acute MHM than it is to make investments to take cost out of the future. Just particularly in anything that's resource constrained, cash constrained, and particularly in Europe, obviously, with the system so heavily subsidized by governments. But obviously if you don't do that, then you're just storing out problems for the long term and you never get on top of this stuff.

Speaker B: In the US I was going to mention we have something, um, it's an economic terminology of the wrong pocket problem because we have so many payers. No one payer wants to pay for preventative care because they don't know, well, okay, if in six months you switch your employer because a lot of health care is tied to employment here in the US if you go from one employer to another, all of a sudden it's a different payer that you're being managed by. And so if one just spent thousands of dollars on preventative care for you, now it's this next payer that would potentially reap the benefits. And in our five 15 years down the road is when you're going to see the benefits of that preventative care. And so, um, when it comes to the economics of it and really figuring out how do you build the business case for better nutrition, how do you build the business case for, um, some of these preventative services and are what a lot of folks here label a soft benefit services, um, that's the hard part is because there is membership turnover, is how do we measure, um, and how quickly do we need to show benefit in ROI? Um, I just made a post on my LinkedIn not too long ago where I specifically kind of mapped out roi. Um, so many founders think of return on investment as a point in time metric. In reality, we oftentimes look at it, um, over a timeline. So especially if you require as a founder an initial investment or buy into your product by the payer, that's immediately negative roi. And then the question is how quickly can we cross that threshold and get into positive ROI? And for some technologies it can take 3 months, for others it can take 12 depending on how you structure the intervention. And so when I work with founders, um, one of the biggest things I tell them is you need to be able to show positive ROI and really quickly. Um, and I would say three to six months is what we're aiming for typically. Um, and then if you can't do that, then you're probably structuring the intervention in the wrong way. Um, and. Or you have to figure out a different financing mechanism that allows you for that longer turnaround.

Speaker A: Yeah, and I think that's consistent with what we've sort of encountered and heard in the US which is the commercial insurers if you want to call them that way. Private insurers, non government insurers, in effect, will always view prevention as a bit like the wrong pocket problem, I. E. It's very, very difficult to get them to invest in anything where it might be someone else's problem in two years. Sorry, it might be someone else's benefit in two years time or three years time or whatever. So how do you kind of close that loop though, just conceptually? Or do you not and prevention is just the government's problem, for example?

Speaker B: Oh, absolutely not. I think everybody has to, uh, play a role in prevention. Um, and so one of the biggest things that I've done is we work really closely with actuaries and medical economists and we think really carefully about how to deploy the technology, the founders that we work with, um, and the technologies that they build. Every single one, whether it's in maternal health, whether it's in orthopedics, et cetera, there are certain populations that you can identify, um, and stratify in such a way that they produce an ROI much quicker. And so one important factor is what population are you deploying the solution to? If you're just deploying it to the general population, it might not show much effectiveness at all. Um, and the ROI could remain negative. The other thing again is the how acute. So the more acute um, the need is, typically the higher the ROI would be. And so that's why it's so important to work with professionals who have that expertise is because they can guide you to what part of the workflow should you fit in, what population should you be focused on and deployed in, um, and really how to deploy the solution so that you could create that positive roi. One, one thing I wanted to mention because, um, I think that's a m. Misconception and I'm curious what your thoughts are on this. You mentioned for profit and nonprofit. Um, and I want to unpack that for a little bit because in the US we have the federal government and then we have state governments and we have something called Medicare and Medicare fee for service, where the government pays and covers certain individuals. And then we have Medicare advant. That's where the federal government pays private and, or it could be for profit or non for profit, um, entities to manage the Medicare population, which are individuals typically over 65 in or that may have certain disabilities. Um, and then we have Medicaid where the state governments are paying because a lot of them would say, hey, I'm a state, I know nothing about managing healthcare. Right? And so they can often hire these managed care organizations to manage the population health for that given state. And so I just, I think it's worth spending a minute to dissect public versus private and for profit versus nonprofit because it is so different here in

Speaker A: the US let's do that after this first commercial break. So we will be right back after, uh, this short commercial break with this week's Health Tech Hour with Demi Radiver, uh, who is the CEO and co founder of Akros Consultancy, one of the leading consultancies helping UK businesses enter the US market. We'll be right back.

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Speaker B: Good.

Speaker A: Hello and welcome back to this week's HealthTech Hour with me, Steve Ro and my guest this week, Demi Radiver. So just before the break, we were going to go into this concept of private versus public, um, for profit versus not for profit. Because it's not very clear. It's not as clear as it might be in the the U.S. right, that's right.

Speaker B: It's interesting. I recently saw a study that basically showed that the US taxpayer is paying three times over for their health benefit. Health care, basically health benefits. Um, it's fascinating because at one time you pay taxes which then get distributed and fund state health care. They fund, uh, Medicare and, or federal care. Um, and then you pay through your employer. So then you're getting that again. And then there's, you know, you could be paying out of pocket. So like for example, I have an OURA ring. I paid for this out of pocket, but I could use my insurance or my, um, health savings dollars to pay for it as well. And so it was just fascinating to see all the ways in which we Pay for health care here in the US Um, again and again and again. And those costs are only continuing to um, ris. Um, it's, it's pretty insane. I mean, I think in um, 2024 we reached 5 over $5 trillion in spending or 18% of our GDP. Um, I think to compare that to the UK in 2025, you guys spend only about 345 billion. It's funny to say only, but it is only.

Speaker A: And as a percentage, is that, is that less as a percentage?

Speaker B: Yes. It's about 11% of your GDP. Yes.

Speaker A: Ahead, do you think?

Speaker B: Because I mean a big part of it is this double taxation. Triple taxation, um, and paying for health care in so many different ways. I would say that so many, um, so many, uh, customers or patients or even you know, citizens depending on how you want to look at them. Right. Um, they're saying they don't like the system. They're going out of the traditional ways to get the care that they want. And so we're seeing a lot of models that are direct to consumer, um, that are making a lot of money. Hey, I want a GLP one. I know that would work for me. And so therefore they go out of the traditional system and pay for it themselves, um, or they want an aura ring. And so again they go out of the traditional system and pay for it themselves. I would say that more and more we are seeing ability to use m. HSA accounts. These accounts basically allow you to use pre tax dollars. So there's some ability to manage the double taxation or triple taxation through these HSA dollars. But not everybody has access to that. You have to have a certain type of account, um, that allows you to access and have this type of savings, um, pool of money that then you can use and pay for different technologies out of pocket.

Speaker A: And how does, how do you. I've heard about this, but the different retailers will have like a way that you can use that card to buy stuff. Right? How do they sign up to it?

Speaker B: Yeah, so there's, there's regulation, very um, heavy regulation in the space. Like what is allowed and what's not allowed, what technologies kind of can get paid for or not get paid for. And so you have to follow the rules. Um, and I would say that I'm seeing more and more of these HSA stores where you can go in and literally buy tampons, um, using your hsa where you can buy uh, you know, an Apple Watch or some kind of tracker that then you can use to track your, your health and biometrics um, but yes, that's largely kind of governed by, by the government in terms of what's allowed, um, versus not allowed.

Speaker A: And do you think that that's a good thing, bad thing? It's neither good nor bad. It just is a thing.

Speaker B: Well, I do. I would say that allowing folks to use pre tax money to invest in their health care is a good thing. Um, a lot of those dollars are going to preventative. Preventative type technologies and healthcare. So I, I'm a supporter of it.

Speaker A: Um, one of the. One of the. M. Sorry, go.

Speaker B: Go ahead.

Speaker A: I was gonna say one of the things that. That. That what? The thing that struck me. There were two things that struck me the most in my most recent trip to the U.S. one was that the first question anyone asked me when I explained why we're there was, oh, Corey, how you bill for that? How do I build that? How do I build for that? So it was almost like the assumption was that your thing, whatever it is, works how you say it works and it delivers what you say it does. And actually the most important thing to get done at the beginning of a meeting is to establish what the billing pathway is, which is completely different from the uk. It might be. There's some crossover a little bit, maybe in Germany and some of these other places where they have a bit more of an insurance model. But even there it's not the same thing. So I thought that was super interesting. It's like, how do I build for that?

Speaker B: Follow the money. Going back to kicking off our conversation, right. Is I was always taught to follow the money. And we specialize in reimbursement, um, for that exact reason. So one of the core components is we always have to rule out, with the technology company that we're working with, are there billing codes that exist? If there are no billing codes that exist, do we need to apply for a billing code to, um, figure out and create a new path to reimburse for this technology? The reality is the coding system in the US is very outdated. It is very archaic. Um, and sometimes you could spend thousands of dollars and 3, 4 years applying for a code, and then you have to prove utilization of that code. And so let's say you get the code approved, you go through that whole process, but then you are not getting that uptake from the health system, um, to use that code. And so therefore the code goes away. And so one of the biggest things that we've been able to do for our, uh, founders is what we call programmatic spend. So for technologies that we work with, and I would say 90 plus percent of the founders that we work with, there's no existing code for their technology in the system because what they're creating is so disruptive and are just so new, um, that it's not yet accounted for in the coding language. And so we've been able to plug into what we call programmatic spend, which is a lot of these payers will have budgets to dedicate to innovation and technology and creative benefits that they want to make of available to their UM members. And so we're able to really help them figure out how do I access that programmatic spend and budget in order to be able to sell into the US and often what that entails is you have to have an idea of what your ROI is. You have to have an idea of where in the workflow does your technology get deployed, who uses it, how they use it, um, and you have to know who are the main decision makers within that payer that would be your champions. So if you're, if you, if you have a maternal health solution, for example, um, in a lot of these entities there's whole teams dedicated to maternal health. You need to know how to be able to access them and talk to them, um, and be able to articulate the, not only the clinical benefit of your solution but also the economic benefit of your solution. And oftentimes what happens is the way that the process works is that they would do a pilot with you so they would want to test the technology within a smaller population, really validate that what you're saying is correct and translates into their own population and then potentially expand it through additional markets in our states that they're serving in.

Speaker A: And what is it that they're looking for? Is it really that three to six month ROI that's the key sort of holy grail for them?

Speaker B: Uh, oftentimes the quicker the better. Obviously I would say that um, ROI is not the only metric that they're looking for. One of the big metrics that they're looking for is actually differentiation. So when you uh, if we take a step back again to what I was saying earlier about different states can hire managed care organizations to manage uh, the population health of their state. And what often happens is the state would release a request for proposal where they would say, okay, managed care organizations bid, let me see what you've got. And then I as a state will decide where I want to give my money and which of you I want to dedicate this population to, to manage. And so oftentimes the Payers will be scanning the market for innovative solutions that will solve an acute problem for the state. So let's say um, we'll just use a few hypothetical examples but let's say that I have a, um, highly diabetic population and so there in, I don't know, let's pick the state of Texas, right? Lots of um, folks uh, with diabetes there. And so the state says okay, how are you going to manage that population? The various managed care organizations have to come up with creative ways in our solutions partnerships that they would say you pick me because I have a partnership with this health tech company that's going to help reduce the A1C for your population. Um, another example could be, and again I'm just making these up hypothetically, um, let's say we're in the state of um, California and I have a lot of moms and babies to take care of. And so therefore when the state of California says all right, I'm releasing this request for a proposal, all these companies bid they better have a solution that says here's how I'm going to improve and manage the mom and baby health in the state. Um, and that could be through med tech solutions, um, that help monitor mom and baby heartbeat. That could be for like high risk pregnancies or that could be through better postpartum solutions. Um, so it could be you know, health tech, medtech.

Speaker A: So there is a pull factor from these payers, yes for new technology but the amount of inertia that you have to get over, uh, in order to be able to not just get into a pilot but stay in and become business as usual is very high.

Speaker B: Once you're in, you better prove the results and, or even exceed them. Yes. So you better show that you're worth it and that you can create that savings or that you can create that better experience. So another big metric that the payers would measure beyond ROI is nps. So net promoter score. Um, so are you actually improving the experience of the mom and the baby? Um, how are they feeling? Are you reducing the anxiety? Are you reducing the depression? Are you, you know, um, beyond, beyond just your typical ROI metrics? Absolutely.

Speaker A: That's super interesting. So they genuinely care about nps?

Speaker B: Yes.

Speaker A: That's awesome.

Speaker B: Yes, that's great.

Speaker A: So we at pocdock, at the Healthy Heart Check we put um, we built, this is an app based product. We put in a bunch of NPS questions from the, from day one. We put it inside the app and I still to this day believe we're the only diagnostics company definitely in Europe that actually understands what NPS actually stands for. Like no, no, like no one else. Most diagnostics businesses think that they build boxes, right? Whereas we, we believe that we deliver outcomes or we help our partners or NHS partners and other partners to deliver health outcomes. So we provide technology that we help them to use in order to deliver, uh, impact. The test itself is just a tool. It's part of a pathway, it's part of uh, a funnel of prevention that goes from the top of funnel screening through to connecting high risk individuals into treatment through the platform. So for us, nps, um, was always a critical piece because if the people at the top of the funnel are having a really bad experience, then that's going to make it really hard to convert them as you go into the triage component in the middle of the funnel risk assessment and then onto inter treatment. So for us it was always in there. But again, most, the vast majority, even the big diagnostics providers like Roche and Abbott and these type of people, they just won't even, they don't even think about how the user uses it.

Speaker B: I would love to double click here because one, beautiful perspective. I love what you're saying. And then two, you said this earlier when you said the user and the buyer. Not the same thing in the U.S. no, not anywhere.

Speaker A: They're not the same thing anywhere.

Speaker B: Uh, anyway, that's right. Well, I love my founders who are so passionate about the tech and designing the tech in a way that the users will use it. But that is table stakes. You have to do that as table stakes. Where things get tripped up is you could have a beautiful technology that is designed with the user in mind and yet no one wants to pay for it. It because the incentives are not structured the right way, the coding does not exist, we can't plug into programmatic spend for whatever reason. And so it's very important in the founder journey to think about commercialization very early on and to think about how will I get this paid for and how do I reach the people with the budgets that will actually spend the money on this.

Speaker A: And I don't know about you, but I feel like uh, I feel like the uk, we talked about this before. The show has a. There's an element of expectancy in, in I believe, UK health technology where really clever people build really, really clever innovative products that are um, really smart and innovative and thought through and backed by really, really deep levels of research, but they don't solve a big enough customer need that and therefore they aren't successful. And there might be lots of reasons why they're not successful, but ultimately there's not a lot of commercial success. And then, at least in the uk, at least it's the healthcare system that gets, quote, unquote, blamed for not adopting innovation fast enough, which creates such a negative cycle. Right. Whereas, uh, I'm a big believer that ultimately the customer is. I think if you have to believe that the customer is right, because otherwise you go insane. Because if you keep blaming the customer, I think that that way madness kind

Speaker B: of lies, you're not going to get anywhere.

Speaker A: No, you have to make it work for the customer.

Speaker B: One of the first things. So I teach, um, another course at the university called Customer Discovery and Value Proposition Design. And one of the first things that we require, this, this whole course, everybody participating in it, they have to go out there and talk to a hundred customers. And that is literally the battlefield that you learn in, like, what are they, how much are they going to pay? What are they actually paying for? What's the problem that you're solving that they have? And you, you really need to get out there as a founder and understand who's going to pay for it, when are they going to pay for it, why are they going to pay for it, how much are they going to pay for it? Um, I do want to, uh, emphasize, though, why I love working with companies from the UK is because when it comes to evidence, when it comes to being able to test your or coming with evidence, where you've tested the technology, with university partners, with private public partnerships, etcetera, you guys are incredible at, uh, making that happen. And so a lot of the time when I work with our domestic companies, they're so far behind in the level of evidence that they bring to the table as compared to my companies that I work with in the uk.

Speaker A: Why is that? Is that because it's harder to get the evidence or what?

Speaker B: I would say that, um, there's just a beautiful structure in the UK that does allow you for these partnerships with universities and helps facilitate this testing. So I have a deep appreciation for that. Um, you know, when I think about it at the macro level, um, the other component, why all of this works and makes sense, right, is that even though in the UK and the US we have very different systems, from a health funding perspective, we're sharing the same pressures. We all have an aging population, we all have workforce shortages, we all have rising costs, um, and most folks want to be able to get care at home. And so, so we're all solving for the Same problems. And then the beauty comes in, um, for my work is that I get to take that technology that works for solving a workforce shortage from the UK and really help then apply it here in the US and. Or I get to take that technology that helps solve for managing an aging population at home in the UK and then be able to take it here to the US and solve the same problem. The payment's going to be very different. The pathway to actually making money is going to be very different. But that's, that's where I come in, um, and help companies with that.

Speaker A: Well, I think it's a critical role, um, critical part of the ecosystem. One of the, one of the stories that I like to tell and I publish stuff on customer discovery all the time. It's one of my big. It's my most recent sort of theme that I'm focused on a little bit of that, which is, is before you blame your customer, just go and talk to them. Because 99 times out of 100, they're going to be able to tell you if you're really listening, you'll be able to hear in 99 times out of 100 why they're not buying. Like, like most of the time it's in there. Might they m. They might not say it explicitly, but if you're right, you know, if you do it the right way, you will, you will. And if you're open to listening, you'll be able to find out. So when we've. Before we started, we did about, before we started development, we did about three or 400 hours of, um, customer discovery before we started developing and, um, across a wide range of potential customer groups. And, um, one of them was gps. So we went and talked to a bunch of gps and we were like, look, just tell us about how do you order blood tests and what do you do and how do you think about cholesterol? And it became real obvious real fast that no GP in the UK pays for lab testing. So, so they. That bill for the path stuff is all picked up by the central ICB basically. So when you go to a GP and you're like, buy my thing to.

Speaker B: Yeah.

Speaker A: And they're like, why would I pay. That comes off my bottom line. I get path lab testing for free. Why would I? And you're like, oh, okay, well, that's sort of an obvious complete M. A complete. And, um, what's the word? Unsolvable. Misalignment of incentives. You can't bid against. Right. Actually, weirdly now it turns out that there is A model that we have with gps. But that's purely because we are able to help them achieve certain milestones that they're incentivized to achieve. And the way that they can do that is to add us on top of what they're already doing through patlab. Right. So it kind of ended up we managed to solve it, but I only solved it because you have to get that along. Alignment of incentives, like you were saying.

Speaker B: I'll give you an equivalent example here in the U.S. um, there is a concept called stars and hedis. And the way that I would sum this up is it's quality measurement of the performance of the health plan. And if the health plan performs above four stars, so there's five stars total, they get access to additional budget and dollars from the government. And, you know, it's just an another way for you to create more money for this buyer. Right. So when I talk to my founders, what I recommend is if you can figure out a way how to make your customer more money, you immediately have an in. If your technology is only about cost savings, it's always going to be second to whatever technology is actually helping them money. So anyone that helps these health plans retain members, anyone that that's making them more money, because the health plan gets paid for the members that they have and for the members that they manage. And so anytime you're able to affect the top line with your technology, you're going to be a priority. And from there on, anything that has to do with administrative savings, efficiency, et cetera, is secondary to that. Um, so what you described is just a beautiful example of how do you structure the incentives? You have to understand your customers, process and budgeting in order to be able to access, um, that budget yourself and get your technology paid for.

Speaker A: I completely agree. We are going to go for our last commercial break now. Um, we'll be back for the last part of today's show with Demi Radiver, CEO, uh, of Across Consultancy. We'll be right back.

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Speaker A: Hello and welcome back to the last part of today's Health Tech Hour with me, Steve Roost and my guest, Demi Radiver. So, Demi, one of the. The other thing that struck me when I was in the us, um, and this actually happened because I was in a tattoo parlor getting a tattoo and I was talking to the tattooist.

Speaker B: How exciting.

Speaker A: Yeah, yeah. And I was, um, and he was like, oh, ah, why are you here? And you know, blah, blah. And I sort of said, oh, I work in, I'm working health technology. I'm, you know, doing this thing in the UK and coming over. And his instant reaction was, oh my God, healthcare. What a grift. You're in that grift, are you? And I was like, what are you? That's an interesting. Because in the, in, in Europe you don't get people saying like, oh, that's a con, right? A grift is sort of like a con, you know, for those of you that aren't familiar with the words. And then he sort of went off on a kind of a rant about like how Medicare and Medicaid was like the wrong thing to do, right? So for Europeans, the idea of universal access to healthcare that's quote unquote free, although you can debate because of the taxation thing, but free at the point of care is sort of like table stakes, to use your language. So for me, it was kind of an interesting baptism of fire to be speaking to someone who was like, vociferously against the idea of providing healthcare for all.

Speaker B: Mhm. I can go in so many directions with this, but one thing I would say is actually the idea of health care as a right is a purely American thing. It started here with President Roosevelt. And so he came up with the concept of health as a right, which then got adopted in the United Nations. And so so many countries around the globe today have like, like health care is a right. However, he was not able to pass a bunch of his other policies with that included. And so therefore he had to cut it out. And so we never adopted that here in the US of health care as a right. And you have to think about culture. Um, I would say that. And I studied international business, um, in my undergrad, and so I spent a long time studying kind of culture. And in the US we have a very individualistic society where it's like every man for himself, right. In other cultures and growing up in Bulgaria, um, they're very collectivistic societies where it's like, no, we, the group as a whole have to survive and make it and thrive together. And so I would say that our governments, our political structures, our healthcare structures. And again, what's allowable, right. Is a healthcare bankruptcy okay or not okay? And acceptable or not acceptable stems from that cultural perception, the way the cultural norms and what you think is acceptable or not. And so coming from a collective, uh, society, oftentimes you see having those safety nets and everyone's protected and healthcare bankruptcy is not okay. And then going into an individualistic society of every man for himself and um, that translates into having, and manifests into having institutions, organizations and structures that do allow for things like healthcare bankruptcy. So that, that's my two cents.

Speaker A: That's a great two cents. So if you were, uh, you know, for all of the founders listening to this, you know, UK founders and stuff, um, what would your advice be if they're looking at the us? Because sometimes I feel like people get put off because it's so huge, you know, like, how do you eat an elephant? You know, how do you take that first bite?

Speaker B: I would say it's even more exciting because you have 1100 decision makers again, for every no that you hear. Could hear. And yes. And so I would encourage them to go for it. I would also encourage them to partner, uh, with someone that has that boots on the ground experience, that has those relationships, that can go to bat for them and find those introductions and those buyers so they can have the conversations. And um, yeah, the world is your oyster. I mean, again, so many decision makers and not only do you have the payers, again, you can go to very large employers and say, hey, Walmart, I have this incredible technology that can help your diabetic employees. Or um, you know, hey, Apple, I have this incredible maternal health innovation that, that can help, um, you know, reduce postpartum symptoms and get your employees back to work faster. Um, and so we would love to be a part of that journey and help, uh, all these health tech innovators really expand into the US more intelligently and find that product market fit here in the us so you wouldn't, you

Speaker A: would just go for it? You wouldn't be scared?

Speaker B: Uh, not at all, no, absolutely. You do have to have some resources, right? So that's the big thing is I would encourage you get that validation done early, get that evidence as, um, best as you can. Because you do have that access to universities and clinicians and more streamlined system in the uk. So use the resources that you have in the UK locally to build out the critical components that then you would need for expansion in the us.

Speaker A: Okay. And you think you said earlier that actually the evidence that UK startups can get is actually really good.

Speaker B: It's such high quality, um, and it's just so much more robust than, um, anything I've been able to see here domestically.

Speaker A: So, um, we're coming to the end of the show and I ask all my guests this, which is if you. What kind of self talk or motto or words do you go to that have gotten you through all of the various difficult, hard things that you've done that you want to pass on to people listening?

Speaker B: Oh, boy. It goes back to a cartoon. Um, I love Dori from Nemo and she just says, just keep swimming. Um, I feel like every day we wake up to a new challenge. Right? We went through a pandemic. We've gone through so much as a society, uh, both locally and globally, and, um, we don't know what's coming down the corner. But if we just keep swimming, I think collectively we will be all better for it.

Speaker A: That's great. I love that. Demi, thank you so much for coming on the show.

Speaker B: Thanks for having me, Steve.

Speaker A: And thanks to everyone listening. We'll be back again next week with another show.

Speaker B: Cheers.