TDOC Bear Thesis + My Reponse

Investment Analysis Clubs Saul’s Investing Discussions
#38

What’s the one thing TDOC does really well? ZM does videoconferencing really well. CRWD does endpoint security really well. FSLY and NET do edge networks really well (notice I didn’t say “edge computing” because that is still nascent). TDOC does…now a jumbled mess of video visits and software to monitor glucose levels and give feedback…and some other things they’re trying to get into. Healthcare is too big. One upstart isn’t going to do it all.

Bear,

I may be wrong but it seems to me that the one thing TelaDoc (TLDC) does really well is low cost distance health care. Distance health care barely existed before the internet and reliable high quality video conferencing. Problem is, people in general seem to be very wary of talking to nurses and doctors over the internet in spite of the savings in time and money. Understandable as a person’s health is a very intimate topic.

To be honest, I never saw any potential in TDOC as an investment when compared to my other stocks. I estimated growth would be far too slow.

Then along comes covid-19 forcing many people to accept video chat, remote work, online shopping, and many other internet & cloud solutions. Talking to a doctor over the internet must have become a lot more palatable to many people these past few months. And by the way, save a bit money at a time when everyone is particularly aware of the high cost of health care and how tight finances have becoome.

Livongo (LVGO) certainly complicates the company yet I can see the potential synergy in providing low cost (cost saving) remote health care solutions.

The big wrinkle, as others have pointed out, is that the health care establishment won’t easily give up its patients to a new operating model. Only time will tell if people’s desire for these new solutions will offset the established health care giants. Before covid-19 I would have said not a chance. Now … It may be possible.

As a health care consumer, I see the merger as a good thing.
As an investor I see a lot of potential in this company for steady growth.
As an investor of hyper-growth stocks I don’t have enough information.

I have been in and out of both of these companies more than once. At the moment I have a small position while I watch and learn and wait for more information on what the future will bring.

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#39

“Don’t just place a bet because of grand dreams. We can do better than that.

Bear

I’m not betting on grand dreams but on a company with proven growth and increasing opportunities ahead. But I do think it’s important to dream big. A vision or dream of the future may be the most critical element in investing, especially growth investing. That may be one thing I’ve learned here on Saul’s board.

I appreciate your bearish viewpoint. I share all your concerns and limit my bets accordingly. And I invest in multiple other companies here with wonderful growth prospects as well.

Dave“

Interesting discussion. While grand dreams have kept me in names like AAPL since 2003, great analysis has moved me out of stocks like SHOP at 150, NVDA at 250/300.

TSLA is a great example of a company and a CEO I finally decided to take a chance on last year. I entered to stock at 375 with a 50k investment. I love investing in leaders like Bezos and Hastings, so I finally decided that even with Musks crazy quirkiness, he had something very special and I’d take the chance, even if it felt more like a dream investment. Two weeks later I read a scathing and well presented post On the MF TSLA board that scared the bejesus out of me and moved me out of the stock at 425. I gave up on my dream of taking a chance on Musk and let well thought our fundamental analysis be my guide. Oh what a mistake that has turned out to be.

As for AAPL, on a historic day like today when AAPL becomes the first company to ever cross into the two trillion dollar market cap area, I remember the dozens of times I could have sold out of the stock because of fundamental analysis. It’s overvalued, it’s growth is slowing, the competition, no new products. So many reasons to sell.

What’s even more interesting to me is that back when I first bought AAPL in 2003 the market cap was 7.8 billion, which is lower then just about every cloud name that’s discussed on this board today. In 17 years AAPL grew from a 7.8 billion market cap to over two trillion dollars. Amazing. No really amazing.

Which I have to wonder, is there another company that will be the next AAPL, that will have that kind of mind blowing phenomenal growth, and will anyone have the patience to hold that stock for a decade or longer?

TMB
Still holding my original positions in AAPL, AMZN, NFLX. Wish I held my SHOP, TSLA, and a large handful of others.

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#40

In teledentistry, I now have different codes that I can bill out for different reimbursements. One code that utilizes video and one code for without video.

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#41

First off, let me say again how much I appreciate the makeup of this board. I have no other source of information like this where people are going into deep discussions about these stocks and where there is input from people who have expertise working in these fields. I also really enjoy seeing both sides of the argument - bull and bear.

A few thoughts regarding the thread on TDOC/LVGO. I will compare TDOC with AMZN (I am not saying that TDOC = AMZN, I am just using it as a point of reference)

  • Amazon started very small and focused on a specific area of a much larger TAM. TDOC = same.

  • At first people were nervous about buying things online with AMZN and giving their financial information to companies online. From my own personal experience, I only bought a few things the first year I ever started using Amazon and that slowly increased over time as I developed comfort and familiarity. I have not yet personally used TDOC, but I can definitely envision myself starting to use it for certain things in the future. I think as people use it they will become more comfortable with it and it could become the “go-to” name in the same way that Amazon is the “go-to” name for Internet purchases.

  • Amazon expanded into more and more areas over the years once they had a solid base established. We do not know if TDOC will be successful in this, but we can envision lots of different ways in which it can be expanded in the future.

  • With regard to “fighting the establishment” - Amazon destroyed the establishment. The retail establishment was gigantic and powerful and wealthy - and much of it was obliterated. Did Amazon destroy all of the establishment - no. Walmart and target and SHOP are all doing pretty well. However, Amazon destroyed enough of it to become one of the largest companies on the planet. TDOC does not need to displace the entire establishment - there is plenty of room for them to grow for many years at a high rate. Can they accomplish that? Only time will tell - but they are the clear leader at the moment.

  • One of the things that MF stresses is “optionality”. AMZN had that. TDOC and LVGO have that. There are lots of different things they can potentially expand into.

  • A lot of the comments I have read center around American healthcare. One of the things I have read in other sources is that there is a lot more need for health care efficiency in some other countries. Specifically related to Canada and England, I have read things stating that the wait time for getting into a doctor can be extraordinarily long. TDOC has the potential to have a big impact in something like that.

For me personally, I have decided to stay in LVGO for now and see how it plays out.
However, as I mentioned elsewhere I previously sold calls that expire this week and I will be forced to sell a portion of my holdings in LVGO. I will still have a very large position after the sale, so I’m going to re-deploy the proceeds into others that I have less of (CRWD, FSLY, NET, GH specifically).

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#42

I was speaking to a healthcare professional and his take is that normally patients wait for doctors in clinic but with tele-medicine its the other way round and patients join in late or have issues with technology or basic data that normally a nurse would collect . As an average a doctor takes 7 minutes for a patient and with tele-med its a lot more and that means doctors who are the biggest stakeholders are not seeing that benefit - unless this gap is bridged this could be just a short term tailwind until the COVID vaccine is approved.

The other issues is that the payment for tele-med is below the physical visit where the doc controls the pricing

food for thought

Rajesh

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#43

Funny thing is that my wife, who’s an NP, is the Bull on TDOC and I remain a bit more Bear. The question I ask her and would put forth to the group is: What does TDOC do that her Health Care System (HCS) doesn’t currently do or couldn’t do at the push of a button?

Her HCS runs a 24 hour telemedicine system through video or audio and it works well. A staff nurse, NP or Dr. picks up every time. Her HCS has specialists in oncology, cardiac, etc. Her HCS also has physical locations with testing and labs. Where is TDOC’s advantage? What is the revolutionary technology TDOC has that will disrupt medical delivery? Can they coexist, yes. But what is the disruption?

Eventually patients will return to physical locations for more complex cases (ICU, ONC, OT, CCU, NICU) while both TDOC and the HCS will continue Video/Audio for lower/routine level visits. At that point, what’s the differentiator?

To be transparent, I opened a small position in TDOC at her insistence back in November 2018 and it’s performed very well (as I’m constantly reminded of at home) but neither she nor I can determine an advantage beyond brand awareness or potential scale. Open to your thoughts.

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#44

At that point, what’s the differentiator?

IMHO by acquiring LVGO TDOC is seeking to enhance its differentiation . Unlike the usual teledoc services TDOC be able to offer services whose success is based on AI methods shown to save considerable sums and achieve success in controlling (at least) T2D. There seems to be great interest in replicating this achievement for other illnesses. A number of posters here have questioned whether the success with diabetes can in fact be replicated for other conditions. I certainly don’t know, but TDOC
management and TDOC investors seem to be betting on exactly that.

#45

As an average a doctor takes 7 minutes for a patient and with tele-med its a lot more and that means doctors who are the biggest stakeholders are not seeing that benefit - unless this gap is bridged this could be just a short term tailwind until the COVID vaccine is approved.

Any doctor whose prime worry is getting my money in seven minutes is a doctor I don’t want to see.

Denny Schlesinger

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#46

who’s an NP

non-professional?

Denny Schlesinger
hates alphabet soup

#47

From the context, I would say Nurse Practioner.

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#48

who’s an NP

non-professional?

Funny. Be sure to use that one on your next visit.
No, Nurse Practitioner. Graduate or Doctorate Degree. All of the same duties as a General Practitioner (diagnosis, referrals, prescriptions.) Basically between a Dr. and Registered Nurse.

#49

the last 2 telehealth visits I made were with Zoom. Both had problems, apparently at their end. The nurses are phoning me 15 or 20 minutes before the appointments to see if I am connected. Both times the problems were fixed before the appointment. I think nurses have become experts.

#50

What does TDOC do that her Health Care System (HCS) doesn’t currently do or couldn’t do at the push of a button?

TDOC sees LVGO addition as helping build differentiation from other HCS offerings. Similar to the Intouch acquisition.
They particularly like LVGO’s high engagement (150 Million data points added just last Q!), high net promoter scores, and the fact that customers love it. Customers are constantly engaging with Livongo. Tullman always says we meet the customer in their life flow. This is a very important factor. So this will increases platform stickiness and that will be TDOC’s moat.

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#51

Agree, LVGO enhances differentiation (and margins) for TDOC… while TDOC can super charge LVGO new patient acquisition…

On HCS vs TDOC, big differentiation to consider is potential for TDOC as low cost leader… e.g. becoming defacto first choice for self buyer with high deductible (gig workers) / under-insured / non-insured population… (number of which unfortunately will grow with current pandemic driven job losses)…

Today large portion of this population have to pay much higher price per visit to traditional HCS… TDOC can (not sure if it does already or not) offer a lower cost direct subscription or just fee per visit type of tele-health option… potential here is enormous…

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#52

I was speaking to a healthcare professional and his take is that normally patients wait for doctors in clinic but with tele-medicine its the other way round and patients join in late or have issues with technology or basic data that normally a nurse would collect. As an average a doctor takes 7 minutes for a patient and with tele-med its a lot more and that means doctors who are the biggest stakeholders are not seeing that benefit - unless this gap is bridged this could be just a short term tailwind until the COVID vaccine is approved.

The other issues is that the payment for tele-med is below the physical visit where the doc controls the pricing

These are two good points. The first is fixable, the second is tolerable, if the first gets fixed.

MOTIVATION FOR IMPROVEMENT:
Patients: An online doctor visit is fast and convenient. There is a risk to all people, but especially aging people, just going into a hospital, where there are communicable diseases and nasty bacteria and viruses outside of COVID. Also, but less so, with a doctor’s office visit (where they aren’t the same place). Any chance to get seen and treated without that risk is a good thing, if you can trust the answers you get from the visit. The first meeting may have all the answers that make the in-person meeting unnecessary.
Doctors: Many things can be handled via telemedicine, if it is done right. Smaller waiting rooms. You can also spot what needs in-person treatment.
Insurers: Risks of secondary infections picked up at the hospital are lower, and in-person visits can be reserved for those really necessary.

WHAT IS NEEDED TO DEVELOP RELIABLE TELE-MEDICINE VISITS? IT CAN’T BECOME “NORMAL” UNTIL YOU HAVE THESE CONDITIONS MET:

  • High enough resolution video and/or photography. Doc wants to see the face of the person talking with them, get the micro-expressions and nuances. Facial coloring: Is the patient’s face too red, indicating an infection under the skin? Is there an paleness/palor that compares poorly to the photo the doc has in the office? Doc wants an image of a wound or patch of skin to decide if an in-person visit is needed. Cameras are pretty good these days. They can only get better. A high-resolution camera with broad spectrum (good color down to infra-red) is required. Maybe modern cellphones have that good a camera. Some research is needed to tell you if it is good enough at the right price.

  • Good audio: Standard cell phone audio is not good enough to hear the voice correctly. Even landline telephones trim too much of the voice sound to get the full voice experience, but it is still so much better than a cell phone. The doctor wants to hear if you sound “weak” or strong. If you want to “hear” the tone of your patient’s voice, and relative strength or weakness, the audio (and video) needs to as good as in person, and integrated with the image. That is NOT HARD. You need a good microphone and good speakers on the other side. As an aside: The only reason cell phones sound so bad is that they wanted more customers in the radio bands they already paid for. Digital cellular puts three times as many in the same band as the original analog phones that sounded so much better.

  • Reliable broadband internet or radio connection. The video and audio, done right, will probably take 25-50 million bits per second. In cities now, carriers are competitively offering billion bits/second connections. You need to define the medical protocol connection, such that the data packets are guaranteed to arrive and be reconstructed correctly. That quality isn’t guaranteed with the statistical multiplexers used to pack cable TV entertainment and internet now, but it can be carved out of the carrier’s bandwidth with a few regulations and some good engineering.

  • Low cost, infrequent-use medical measurement kits: You can buy devices to do electro-cardiograms for $100-$200. You can buy blood pressure measurement devices for $50-$100. Blood analysis can be cheap as well. As telemedicine evolves, the providers will develop “kits” for home use and send to clients to keep on hand to prepare for and participate in online visits. They will smoothly integrate with cellphone or laptop software. My wild guess: That is already in development, along with the software to collect data from the kits.

  • Preparation procedures and “process”. The weak link is usually humans. The human must follow a simple process, and the nurse or administrative person setting up before the doctor comes on line must ensure they got it right. Else let the doc go on to the next client and let the patient re-read the instructions and reschedule the visit.

All this is possible given just the technology we have today. Will TDOC do it? Maybe. Someone will.

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#53

My oldest son has a telehealth doctor appointment with our children’s hospital surgery group coming up. They are going to look at an indentation in his chest for something called pectus excavatum. (I am hoping they decide this does not need surgery, and all three of our boys have this kind of indent. We can’t find an indent on myself or my husband, but perhaps it’s because of, er, extra padding.)

But anyway, they are going to examine his chest, in consideration for surgery, on ZOOM.
That’s ZM.

I have asked my husband to use his nicer laptop so that we can get the best camera for this important virtual visit.

Why do we need TDOC?

Regarding having people show up on time, it seems that this is an easy thing to have them check-in with their technology in advance before the doctor shows up.

Karen
long ZM

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#54

ibuildthings says ‘Reliable broadband internet or radio connection. The video and audio, done right, will probably take 25-50 million bits per second.’

HDTV with 5.1 stereo requires 3-5 Mbps.
4K requires 15-25 Mbps.

I posit that HDTV provides sufficiently color, spatial resolution and audio quality for medical appointment.

So there is a barrier…but it’s not a very high one.

Larry

#55

I posit that HDTV provides sufficiently color, spatial resolution and audio quality for medical appointment.

HDTV is fine for watching TV and movies. I am projecting forward a few years to see where telemedicine can go. Examining a skin lesion or eyeball iris may require finer detail. Zoom in and scan the surface of the skin while having a conversation. It is worth having the extra bandwidth to support higher resolution for medical exams. Seeing that weakness and slight grey in someone’s face when they are really ill may not come through well with 1040 HDTV. That’s why I bumped it to 4k. Also, you need a reliable low or no-compression connection, such that your image doesn’t come and go because it was compressed and multiplexed with a football game to save a few bits of bandwidth. The artifacts of image compression algorithms are magnified when blocks are lost.

As telemedicine grows in popularity, someone will define a proper telemed channel - bandwidth and protocols.

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#56

No… they will develop algorithms to search the video feed for exactly the characteristics you are discussing, and relay measurements to the doctor.

A doctor sees patients in his offices all day under the same light, week in week out. He/she develops skills at assessing under that “one” set of lighting conditions.

On a video feed, the lighting will be different for each caller, and the doctor’s skill will be considerably less reliable no matter the quality of the video. All the values that the doctor controls for, normally, have become variable.

Now, a lighting analysis algorithm will need to back out the ambient light and adjust for the color of the light…

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#57

Let’s not exaggerate the utility of TDOC. There is generally an inverse relationship between validity and feasibility, such that the more valid a test or procedure is the more expensive, time-consuming, and invasive it is. TDOC represents the feasibility option, and its main utility will be to 1) screen for serious conditions that may require immediate attention, 2) deliver a prescription for a very obvious medical condition, and 3) modify or refill an existing prescription. These are things that can be readily addressed via phone or video, which is likely to result in a savings of both time and money.

Example of appropriate use of TDOC: a person with Type II Diabetes relays to their physician that they have been taking their blood sugar regulation medication as prescribed, but their blood sugar has been consistently low. The doc asks about any recent changes in diet or physical activity or weight, and the patient responds that they have started a daily walking routine and have lost 10 pounds. Since the medication and exercise have overlapping effects on blood sugar regulation, the doc praises the patient and lowers the dosage of the medication. The patient was seen sooner and din’t have to take sick leave.

TDOC will NEVER replace the necessity for in-person office visits, but it will absolutely be a feasible AND valid substitute for many of them!

I’ll close with a thank you to everyone who has contributed to this thread, as each of you has helped me become a more informed investor!

Sincerely,
Nate

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