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00:09
Danny Levine (Producer)
You're listening to the Bioverge Podcast with Neil Littman.

00:29
Danny Levine (Producer)
Yeah, we've BV BV Vineeta Agarwala show today for people not familiar with her. Who is she?

00:36
Neil Littman (Host)
I am incredibly excited to welcome Vineeta to the show today. She is a general partner at Andreessen Horowitz, where she leads investments for the firm's Bio and Health Fund across therapeutics life sciences tools, diagnostics digital health, with a focus on companies leveraging unique data sets to improve drug development and patient care delivery. Prior to joining a 16 Z, Vineeta held many different roles in the healthcare space as a physician taking care of patients, as an operator at health tech startups including Flatiron Health, and as a venture investor on the Google Ventures Life Sciences team. Vineeta holds a BS in Biophysics from Stanford University, then MD, PhD degrees from Harvard Medical School and MIT. So I am incredibly excited to talk to Vineeta, particularly because she continues to see patients at Stanford as an adjunct clinical professor. I really am curious to get her perspective as a clinician and also a venture investor and how she views the types of technologies that they're investing in at A 16 Z through that specific lens.

01:40
Danny Levine (Producer)
There are certainly plenty of doctors turned venture capitalists, but it's unusual to see someone still practicing. How do you think that might inform her investment decisions?

01:53
Neil Littman (Host)
Well, I'm going to talk to Vanilla about that, but I would gather that it gives her a unique insight into the patient perspective and the patient journey. I think oftentimes a lot of investors and entrepreneurs in our industry get so caught up in the technology, you tend to forget there's a patient at the end of the journey. So I have to imagine Vineeta continuing to see patients. Reminds her consistently that there is a patient at the end of the journey which I'm sure must inform the types of technologies and therapies that they're investing in at. A 16 and the way that she views how technologies can integrate in care delivery and how they can actually impact the patient at the end of the day.

02:36
Danny Levine (Producer)
One of the recurring themes on this show is the interplay between information technology and biotechnology. Andrewson Horowitz has deep grounding in both these areas and investing in this interplay, how does that type of expansive team help inform their investment decisions?

02:55
Neil Littman (Host)
Yeah, I think when they launched the Bio and Health Fund a number of years ago, the first fund, it was pretty novel within the industry and they have a nice cross section of folks with various expertise. As you said, the firm started with technology specific investment, with a technology specific investment thesis, and now they've brought into Bio and Health. I think it's really interesting because we have seen this increasing convergence of the two fields coming together. I think it's definitely a really interesting intersection these days and there's ton of innovation between these two sectors of biology and technology and software and thinking about biology as an engineering discipline. There's just really fertile ground for investments in this space and obviously what they've done at the Bio and Health Fund, they've been leaders in this intersection for some time now. So I'm excited to get Vineeta's perspective on some of the companies they've invested in their investment thesis in general and then also what she's most excited about for the future and the types of technology themes and trends that they're really excited about.

04:05
Danny Levine (Producer)
Well, if you're all set, let's do it.

04:07
Neil Littman (Host)
Danny Vineeta, I am incredibly excited to welcome you to the show today. Thank you for joining us.

04:15
Vineeta Agarwala (Guest)
Thank you for having me.

04:17
Neil Littman (Host)
We are going to talk about your work as general partner at Andreessen Horowitz, also known as a 16 Z in the firm's Bio and Health Fund. I'm excited to dive into your investment thesis and talk about the various technologies and themes you're most excited about, as well as the importance of improving care delivery. I'd first like to start with your own journey from practicing medicine to the world of venture capital. Vineeta, you continue to see patients at Stanford as an adjunct clinical professor in the Division of Primary Care and Population Health. What led you from spending all of your time in clinical practicing patients to the world of venture capital?

04:55
Vineeta Agarwala (Guest)
Yeah, great question and it's a real privilege to continue to have a small clinical practice at Stanford now. Really I grew up industry concomitant to growing up as a clinician and so I think I just encountered a series of opportunities and always had a very sustained interest in translating work out of academia into industry. That for me it was a mutually winding path in both the clinical world and in the startup and venture world. Even when I was in college and worked in a national lab and worked in other academic labs, I was always curious and asking, how does this get to patients? Ended up working in banking and working at McKinsey in the consulting practice for healthcare, biotech and pharma companies for some time and then ultimately went to a couple of different startups including Flatiron Health, before ending up in venture, which for me, happens to just be a completely remarkable way to combine so many of my interests and enthusiasm for new technology all in one role.

06:14
Vineeta Agarwala (Guest)
Really kind of my clinical path was a winding one that intersected with that industry path.

06:23
Neil Littman (Host)
Vineeta we probably shared some similar scars from our banking days. We can save that for another discussion. One of the things that I personally get frustrated with is that it often feels like a lot of investors and entrepreneurs for that matter, get so caught up in the technology, whether it's synthetic biology or artificial intelligence or machine learning, that they often forget there is a patient at the end of the journey. How does your experience as a practicing physician impact your investment perspective and the types of tools and technologies you're most interested in?

06:56
Vineeta Agarwala (Guest)
Yeah, great question. Maybe I'll try to actually answer your prior question too as to why a clinician is wearing a Venture hat in the first place. I think you nailed it on the head, which is that at the end of the day, great technologies will have great impact and also create great value when they serve patients and offer something that just wasn't possible before. You have to know what's possible and what's not possible in order to characterize and bucket technologies into those two basic categories. Right? There are lots of technologies that we actually already have or that patients don't actually need or that there are really kind of alternative ways to solve. And so I agree with you. Technologies that are kind of looking for a problem are typically not the ones we get most excited about. At Stanford, for example, I have a very unique clinical lens, which is that I focus on the growing cohort of oncology survivors, that is, cancer patients who actually have now made it through some of the most intense and acute phases of their treatment journeys and have a unique set of needs related to long term side effects or related to prior surgery and radiation and have a unique set of surveillance and ongoing screening needs and so on.

08:30
Vineeta Agarwala (Guest)
Survivorship care actually does start the day you receive a cancer diagnosis. In general, my patient population is this very unique set of patients who require kind of a unique care model after the completion of their original cancer treatment. I often think about that because in a sense, our entire industry is focused on getting patients to survivorship, right? The whole purpose of a new therapy or a new diagnostic or even a lot of the digital health tools that I get most excited about, I view as helping us have more patients ten years from now who can call themselves survivors of any given disease state, whether that's cancer or heart disease or diabetes or autoimmune disease or whatever it may be. For me, my clinical lens is at this unique intersection where even our best therapies still leave something to be desired. Even patients who become survivors still have ongoing needs and a lot of patients don't make it there.

09:41
Vineeta Agarwala (Guest)
I am constantly asking the question, what is it that patients deserve but don't have? What is it that patients, what are the scenarios where we have a technology but patients can't access it because of a variety of constraints in our system? What are the things that I wish I could offer that just haven't been invented yet? When a founder pitches something that scratches those needs, I get very excited.

10:11
Neil Littman (Host)
So Vineeta, let's dive into that a little more. One of the things you talk a lot about is care delivery and ongoing care. You had a recent quote which sums up, shall I say, the unfortunate state of affairs perfectly. I'm going to quote, as a physician in 2022, I often lament that I have more real time insight into the status of my sandwich delivery than I do into the daily health of my patients. Wow. So, on the one hand, the advances we're seeing in novel therapeutic modalities, computational biology, synthetic biology are truly incredible. On the other hand, the patient experience navigating our healthcare system. Real time feedback seems anything but advanced. Vineeta, how do you think about this discrepancy and what can we do to fix it?

11:00
Vineeta Agarwala (Guest)
Yeah, I am incredibly optimistic that some of the technologies that have completely changed consumer lived experiences in every aspect of our lives, right? Ranging from food delivery all the way to how we shop, how we process bills, every part of consumer life has changed in a way that hasn't yet trickled to patient life. We are incredibly optimistic at Andreessen Horowitz that software and technology can really transform a large part of that not only patient journey, but importantly, also provider journey. My own bias in this space, and I acknowledge it's a bias, is that the provider just plays such a key role in healthcare in a way that's different from other elements of consumer life. Patients really do care and want and desire better access to the expertise and resources of a provider. Much of even our therapeutic and diagnostic arsenal is just simply gated by what?

12:08
Vineeta Agarwala (Guest)
A provider by a decision that a provider has to make. I am particularly focused on the provider because I think that actually translates to better patient experiences if we can make providers function as superhumans and do a lot more than they would be able to do in a technology free or less technology enabled world. My most core thesis in the healthcare investing world is to look for technologies, tools, infrastructure that enables providers to do more, that enables providers who are already out there in the community to do more on behalf of the patients who need them most. I can give you a couple of examples of that. I think the real time kind of example you mentioned related to how we are constantly being texted as providers sorry, as consumers kind of in every aspect of our life, from every service provider in our lives, is in stark contrast to our ability to have that type of rapid engagement with the healthcare system as patients.

13:20
Vineeta Agarwala (Guest)
In that context, we invested in a company called Memora Health that sets up automated smart AI enabled infrastructure to allow a provider to put a patient on a care journey in which they can be in touch all the time. Hey, did you fill that medication I prescribed? Are you having any side effects in the morning, in the evening, maybe certain care journeys require checking in multiple times. Hey, you had a baby and now you're going home. Wouldn't it be great if your provider actually checked in on you and knew when to escalate certain complaints and certain symptoms and so on? That's something that, in principle, a provider could do if they had infinite time. Every doctor wishes they could do that, but they just can't in our current ecosystem. That's a great example, I think, of a technology that enables doctors, nurses, care teams to do a better job and gives them superpowers.

14:23
Neil Littman (Host)
I love that example because it really hits the nail on the head in terms of our ability today to capture and analyze real world data sets in a changing healthcare environment that's having a direct impact on patients. And that's all happening today. If we dig into that just a little more and focus around the area of digital therapeutics where software itself may be the best way to treat a condition, where do you think the opportunities lay in that realm? Where are we on the adoption curve within the sphere of digital therapeutics?

14:58
Vineeta Agarwala (Guest)
Yeah, perhaps a controversial view. I think there will be a role for digital therapeutics, but I don't see pure software as replacing the bedrock of modern medicine's therapeutic arsenal really at all. I don't think software alone is going to cut it for a cancer patient. I don't think software alone is going to cut it for a heart disease or a kidney disease patient. All the places where we spend a lot of money in our healthcare system, in other words, all the patients who have significant illness in our healthcare system are not going to be therapeutically treated by software alone. Now, I think where the digital therapeutic field can play a huge role is in behavior change. In the subset of diseases where we know that patients do need to undergo lifestyle change or need to couple a pharmaceutical product with some other type of lifestyle change or behavior change, there have been really great strides there.

16:14
Vineeta Agarwala (Guest)
I think continuous engagement, smart engagement, kind of cutting edge consumer tech can absolutely play a huge role there. There's a lot of subtlety there. I think the first wave where these kind of very creative companies, one in our portfolio is Omada, that started this trend in some ways based on data coming out of the diabetes community that said, hey, really good lifestyle change can actually rival our best therapies in terms of their utility in that disease. Now, I don't think that applies to kind of all diseases, but we know that for heart disease, for metabolic disease, for hypertension, lifestyle change is a big part of the equation. Smart tools like that can play a huge role. I think now we're getting into the next wave of really subtle distinctions. I was just talking, actually, yesterday to a great entrepreneur in the cancer survivorship space, and she gave me this interesting insight that cognitive behavioral therapy and other types of approaches designed to help patients with more traditional forms of anxiety actually don't work as naturally in the context of a cancer survivor's anxiety because some of that anxiety is fundamentally much more rational than another patient's might be.

17:49
Vineeta Agarwala (Guest)
There's a certain rationality in the genuine anxiety about cancer recurrence because it's real, that is a real physical possibility, and so you have to treat it in actually very different ways. There's a whole emerging field now of psychoancology and maybe some of the digital tools that help with this very unique patient context where a patient's anxious because they have reason to be, and yet we still need to help them manage that anxiety in a rational way. Maybe problems like that can now merit new technologies, but I think you can hear in that example, it's become where we've reached this next level of nuance, right, this next level of precision and patient stratification that I think is extremely exciting for the field that we've earned that privilege.

18:39
Neil Littman (Host)
Vineeta you mentioned the entrepreneur that you were recently chatting with. I want to take a step back and ask if you have any advice for founders and entrepreneurs specifically within this realm, because we've seen this idea of these types of digital therapeutics or digital health products in general be piloted to death almost, or pilotitis or whatever you want to call it. How can an entrepreneur avoid getting stuck in that rabbit hole?

19:07
Vineeta Agarwala (Guest)
Yeah, it's a great question. It's been a a trope in the digital health and healthcare sector that maybe our incumbents, that is large health systems, otherwise known as provider systems or payers insurance companies can often keep startups stuck in that pilotitis. Phase where you're kind of doing hypercustom work with one customer and it lasts three months, and you have to, turn your whole team towards servicing that one customer, and then three months later, their priorities might change. Those are the underlying sentiments and risks that people often refer to when they talk about pilotitis. You can start to hear some of the solutions in the articulation of the problem, right, which is that it is really important to build generalizable infrastructure that's not extremely custom to a single health system's needs or a single health insurance company's needs. I think it's really important to understand what is the fundamental challenge that extends across an entire sector, across an entire patient population and kind of power through, to some extent, every incumbent's belief that their own ecosystem is so unique that it merits a completely unique technology solution that's just simply not always true.

20:33
Vineeta Agarwala (Guest)
Or even if it is true, the right technology infrastructure can actually be customized really easily rather than in an extremely bespoke fashion. At andreessen Horowitz in general, we love very nimble software teams. We love teams that can spin up products, demos, pilots even, right, but do it without rotating their entire team towards the pilot. Do it in a very nimble way, do it in a way that can be updated tomorrow, and then do it in a way that can be customized from one customer to the next month. That's what we think real software enables is it gives you that right to be nimble.

21:19
Neil Littman (Host)
Vineeta I want to continue down the sort of healthcare continuum. A 16 Z has a vision of drug development, becoming more and more like software development, moving from a bespoke to an Iterative process where platforms can take a modular approach to building medicine. What are some of the challenges you see in reducing biology to an engineering problem?

21:43
Vineeta Agarwala (Guest)
Biology is hard, and I think that's why sometimes I think about this in the frame of just like we need combination therapies for certain diseases, for HIV, for cancer, we're going to need multiple technologies and methods to solve really complicated biology and complicated human disease challenges. We don't think there's one software fits all or serves all or solves all paradigm. What we mean when we say that we think parts of biology and biotech can become more programmable, what we mean by that is similar to what I described on the healthcare side in terms of a nimbleness that is enabled by software. That doesn't mean you don't have to conduct potentially very large experimental screens across a wide space of chemistry or a wide space of protein sequences to find a great small molecule drug or a great biologic or a great nucleic acid therapy. Ideally, when you survey that whole space, every time you survey that whole space, you learn something about the properties of that underlying space, the topology of the terrain that you just had an opportunity to traverse, right?

23:14
Vineeta Agarwala (Guest)
The traditional regime in biotech was often to run very large screens, take the top hits, optimize them further, nominate your development candidate, conduct a rigorous set of indabing studies to further advance that into a drug product. And that can work. It obviously has worked, and our sector has been more productive than ever in terms of the pace of new drug approvals over the last decade. What we're looking for are opportunities to increase that efficiency even more by saying, what if, at that very beginning step, you learn something about the underlying topology of the space such that you could predict? Hey, if I take a step to the right in the following way, here's where I'm likely to end up. Because I have a map, so now I can go places with some intention. If I decide I need to hyperdensely sample a certain part of that map, I can do that because I recognize that the topology is particularly up and down and I need more data points.

24:21
Vineeta Agarwala (Guest)
Or in another place, I can be more sparse. All that kind of thinking we think is enabled by software will ultimately make the design of a large number of therapeutics and a large number of modalities much more programmable. That is really what we mean by the analogy to software. It's not so much that software really replaces the core drug development or discovery process, but it really augments it and makes it much more intelligent.

24:51
Neil Littman (Host)
Vineeta that's a great segue into talking about the role of artificial intelligence in healthcare. One of the key investment themes at the Bio and Health Fund is this idea of the mergence of artificial intelligence and the ability to apply this to really all aspects of health care. I want to break it down into two buckets. One is the development of therapies, and the second is delivering care. Let's stay on the topic of developing novel therapies. What's your viewpoint around how AI can deliver on the promise of, let's say, reducing the cost and timelines of the drug development process? How do you see AI integrating into that and this whole thing playing out?

25:33
Vineeta Agarwala (Guest)
Yeah, it's a great question, and I like to preface with a quote from one of our portfolio company founders. In Citro is a portfolio company in the small molecule drug discovery space that we're incredibly excited about, founded by Daphne Kohler, a leading AI scientist and veteran entrepreneur. She always says, let's think about AI like we thought about computers 20 years ago, right? The best companies 20 years ago or 30 years ago were not saying, hey, we've got really smart people. We've got experts. We're really smart. We don't need computers. That's not what they were saying, right? They were saying, how can our experts learn to use the computers and be even better? That's kind of the same stance that I think we have on AI today in 2023, which is to say, wouldn't it be crazy to say, no, that's okay, we don't need AI.

26:38
Vineeta Agarwala (Guest)
We're smart enough. We've got really good experts. Of course there could be a role for AI. We'd rather all day long back the founders and the teams who say, yes, I have experts in every part of the drug development and biotech kind of value chain, but, oh, boy, would I love for them to be enabled and armed with this technology. I often think about the role of AI as living on the spectrum of human expertise. If one side of the spectrum, you have tasks that don't require a lot of human expertise, so let's call them low skill tasks that do need to get done, ultimately in order to achieve your end goal of developing a drug, let's say. On the other side of the spectrum, you have things that even a human could never do you have a certain set of tasks that no expert is capable of doing, the things you might dream about, but that a human could never do?

27:43
Vineeta Agarwala (Guest)
In the middle, you have the tasks that really require human expertise and the training that humans have gone through, that could be chemistry, biology, pharmacology, whatnot in this center bucket? Some of the places where I think AI can play a role. I think AI can play a role in all three of those buckets. I think it's particularly compelling to leverage AI in that first bucket. Right? Let's make sure we're not inappropriately deploying expert talent in tasks that actually don't require expertise. Maybe that's a whole slew of data analysis, maybe that's a whole set of activities related to kind of automation in the lab. Maybe we don't need really super skilled biologists transferring liquids from one tube to another. We're very excited about kind of smarter and more automated lab technologies. We're very excited about better ways to document, record, leverage, query all the knowledge that exists inside a company.

28:49
Vineeta Agarwala (Guest)
We're investors in Benchling and a whole suite of companies that are providing really great software services to avoid humans from doing what are otherwise low skilled tasks. We have another company that we invested in called biodoc, for example, that helps automate the analysis of microscopy images. It turns out you have a very large number of scientists counting various features of randomly sampled subsets of a microscopy of an image, right, of cells under a microscope, for example, and annotating them manually. That's a great task for a computer to take off their plate, because it's ultimately actually a lower skilled task and something that a computer might even do better than the expert. Understanding what the results of that experiment mean in the second bucket, right, the tasks that require the skilled expert, you might let the skilled expert continue doing. Again, on the other side of the spectrum, I get incredibly excited where there are things that just no expert, no matter how great they are ever going to be capable of doing on their own.

29:59
Vineeta Agarwala (Guest)
That could be creating the underlying ML model to predict structure activity relationships for a large space of potential drug candidates. That could be finding a novel ML based signature on a pathology slide that predicts whether or not a patient is going to respond to a certain therapy. We just know that's not something an expert can do on their own, because you need to look at and integrate an extraordinary amount of data to do that. We invested in a company called Valar Labs doing exactly that for cancer patients and saying, hey, what are the hidden features in a pathology slide that could help us select which patients might actually respond to certain therapies? Right? Just to give you a flavor, I really think AI can help across the spectrum, but in different ways depending on the nature of the task at hand.

31:03
Neil Littman (Host)
What about applying AI in the realm of care delivery? How do you see that playing out?

31:11
Vineeta Agarwala (Guest)
So I think a similar framework applies. There is a host of AI tools that we're very excited about that should just automate low skill tasks which are abundant in care delivery, right? That could be documentation, that could be collecting the right billing codes on behalf of a patient, that could be processing a prior auth claim, that could be generating the evidence in support of a certain treatment decision that a payer needs to understand why a certain therapeutic choice is a good one. That could mean even as I mentioned, simply communicating with patients on a day to day basis, hour to hour basis, need not require the most skilled. All such messages and all such communications need not require the full expertise of our healthcare system. Maybe only a subset do, right once a patient is reporting something that requires further triage. There's a lot of kind of administrative tasks that we are very excited about automating, ranging from the patient experience, the provider experience, the financial experience, the whole underpinnings of our healthcare system.

32:23
Vineeta Agarwala (Guest)
On the other side, again, there are a whole bunch of things that we just don't think humans can ever do really well. There I'll give you another example of where we think an AI or some type of advanced computational tooling can start to achieve what no human can. An example is actually population health and panel health management. Physicians are fundamentally wired to see one patient at a time. You walk into a clinic and you march through your clinic schedule. You might see a patient at nine, a patient at ten, a patient at eleven, a patient at 20. You march through your schedule. If a patient cancels, you might actually breathe a sigh of relief, right, that you actually, well, I have of extra time to finish charting and do other kind of administrative follow ups for some of my prior patients and so on and so forth.

33:26
Vineeta Agarwala (Guest)
What's really difficult for an individual physician to execute on is to have a view of the health of an entire panel of patients that they're managing. That's obviously a key component of value based reimbursement frameworks and kind of a value based trend that payers are getting more excited about including physicians in. We backed a company called Pearl Health kind of in that vein on the bet that technology might be able to help a primary care doctor actually look at the health of their whole panel. Maybe that patient who canceled, maybe an algorithm could tell you, hey, this is actually a patient who you need to call. They have the following characteristics that predict an otherwise significant risk of future complications or hospitalization or all kinds of things that maybe. There are preventive strategies that could avoid such an outcome. Again, the provider needs some input, right?

34:33
Vineeta Agarwala (Guest)
Otherwise there's just across 2000 patients. It's very difficult for any human, no matter how much expertise they have in clinical medicine, to do that. Again, on both sides of the spectrum, extremely high skill, such high skill that I don't think any individual could kind of do on their own, and a large flow of low skill tasks, we think technology and artificial intelligence in particular could be transformative.

35:01
Neil Littman (Host)
Vineeta there's so many great topics in there that you dug into. One of the things that I get really excited about in terms of the care delivery model is utilizing AI in such a way, as you said, to do some of the more menial tasks that could free up the clinician to do what humans do best and that's create empathy and have that relationship with the patient instead of spending so much time doing the more menial tasks. That's something I'm particularly excited about for the future. Let's talk now about where we are at the macro level. I mean, there's a lot of economic headwinds and difficulties that we're facing, yet the pace of innovation seems to continue to accelerate. What excites you the most today in terms of the ability for technology to transform medicine and health care? Let's take this in two buckets over the relatively near term, let's say the next three to five years and then we can look out even further.

35:58
Neil Littman (Host)
Let's start in the relatively near term.

36:01
Vineeta Agarwala (Guest)
I think you're absolutely right, there are macro tailwinds. I will say, I mean, it would blow your mind to see the level of innovation that we are seeing startup founders develop day to day. We're taking more meetings with startup founders than I think in some sense we ever have in the history of our fund. And so I think you're absolutely right. There is this kind of divergence wherein the technology tailwinds are very strong, but they encounter a unique set of economic headwinds. To us that does not change the fundamental value that these technologies are going to create on behalf of patients. I would say our overall stance is actually largely at the highest level, unchanged. We are still extremely excited about backing promising big swings, and we think that there are going to be creative ways for investors, for management teams, for other players in the ecosystem to kind of lock arms and probably fund to fruition a smaller total number of companies than seemed like might be the case over the last two years.

37:28
Vineeta Agarwala (Guest)
And so that's actually a good thing. We think in a sense the markets are in a challenging position. It's important to remember that the private capital raised to deploy into biotech and healthcare was actually raised before the market downturn and it's parked right now poised to invest, including our own fund in the most, in the best and most innovative technology companies. The difference might be that not 20, but five or some other ratio shift of companies get to receive those investment dollars. We view this as a healthy consolidation welcome in some ways for our industry.

38:08
Neil Littman (Host)
And Vineeta, if we think about the super long term, maybe I'll ask you to take out your crystal ball or put on your Star Trek suit and think about innovation over the next, say, 50 to 100 years. What type of future do you envision? What gets you the most excited today?

38:27
Vineeta Agarwala (Guest)
Let's see. I've got my suit scrapped on, but the world looks very different, right? That's why we're venture investors. We're betting that the world looks kind of unrecognizable in 50 years. I think both in the bio world, frankly, and in the synthetic biology world and in the care delivery world, we hope it would be hard to recognize the way we do things today just as it would have been 50 years ago as well. I think maybe the common thread is that we think technology is going to fundamentally lower the probability of success and the total capital required to achieve better health outcomes. That could be through a drug, that could be through a care delivery paradigm, that could be through behavior change, as you referenced, through software interventions and tools. Either way, I think one of the things that's really challenging in our field, both in the biotech space and in the healthcare space, is actually the dollar of investment required to get to an improvement in patient clinical outcomes is high.

39:49
Vineeta Agarwala (Guest)
We are a capital intensive industry. We're arguably working on the problems that matter most to all of us. We're working in an industry that already spends a lot, and so that represents a huge fraction of our GDP. For all these reasons, this space has continued and will continue to attract enormous capital. Fundamentally, 50 years from now, I hope we get a lot more for each dollar that we've invested in clinical needle moving outcomes.

40:25
Neil Littman (Host)
Vineeta we've talked a lot today about technology, but when you make an investment, you're not only backing at technology, but the people. What do you look for in founders and their teams when you decide whether to invest in a company or not?

40:41
Vineeta Agarwala (Guest)
I think it's a couple of traits that are particularly attractive. The first is trust. It might sound kind of basic or not particularly technically tethered, but trust really matters. We enter kind of decade long journeys with founders in our business, and so I have to feel that I can trust what someone is telling me, that they're being transparent, that they're telling me the complete story, that they're open minded to feedback. When they say they are open minded, they actually are. All these things are fundamentally about trust in the care delivery space. We have to trust that people are going to put patients interests really first at the forefront of their business decisions. All of that's probably one of the most important. The second is I would characterize as iteration speed and iteration velocity being high is really important to us. That's again, maybe counterintuitive because you'd think I would say that the most important is that we like their ideas and that's important.

42:07
Vineeta Agarwala (Guest)
It's rare that we invest in a founder with whom we just don't see eye to eye on anything. Again, startups over this decade long journey will have to stop doing something they thought they were going to do or start doing something they didn't think they would do. The versatility, the iteration speed, the ability to say, hey, that project is not working. But guess what? We got to the answer in three months and really chased it to the ground and did so in a capital efficient way is so rare and hard to find. We start seeing signs of that, we get incredibly excited. Sometimes this happens for us even in the investment process. We'll say, hey, this is an investment for us at this time because we're not yet convinced about X. If a founder comes back months later and says, hey, I got this deal, or hey I actually ran this experiment, or hey my AI actually helped me design something in record speed that actually does have that property you wanted or that you had said would help satisfy the investment thesis you had.

43:14
Vineeta Agarwala (Guest)
Those are all meaningful iteration speed signals. Not necessarily that property or that drug or that care model is the one that the company needs to pursue, but I think it's very telling when they can move quickly and iterate rapidly.

43:29
Neil Littman (Host)
Yeah, I totally agree. And Vineeta, we could probably talk for the next three days about these topics. I find them endlessly fascinating. I want to be cognizant of your time and wrap up with one additional question, and that's any advice that you have for all the founders out there who are listening to the show.

43:49
Vineeta Agarwala (Guest)
General advice? Let's see, I think actually my advice is I know I just said that I value founders who are receptive to feedback and that I can trust. The very best founders, I would say, are not particularly molded by the investors they work with. It's a core part of our investment thesis given that most of our investments are not companies or founders that we kind of incubate within our four walls, but rather founders who really kind of take form in the wild, so to speak. That's a very core thesis at Andreessen Horowitz it has been for the 15 years of our firm's history, is that we love backing founders who have gotten obsessed with an idea on their own it's not an idea we gave them. We know that we're humble about that. That's why it's a better idea than something we would ever have.

44:48
Vineeta Agarwala (Guest)
That's why we have such enormous respect for the startup founders kind of intellect, traversal of the maze of ideas that they could have possibly pursued and then landing on the first idea that they'd like to pursue. My advice is actually typically to stick to your guns because you're way smarter than any investor you talk to. You're smarter than most of the customers you're talking to with respect to your own capabilities. Listen when appropriate, listen, hear as much as you possibly can from everybody, from your customer stakeholders, from patients, from your investors, from prospective investors. Ultimately, you have to do what you have most conviction in that's.

45:36
Neil Littman (Host)
Great advice, Vineeta, and a great way to wrap the show. Just one final question. How can people get in touch or learn more about all the exciting opportunities that you're working on?

45:46
Vineeta Agarwala (Guest)
We are available on all of the requisite social media channels, so please feel free to reach out to any member of the A 16 Z BioHealth team on LinkedIn, Twitter, email. We love hearing through other folks we're already connected to lots of different ways to get in touch and we look forward to hearing from you.

46:10
Neil Littman (Host)
That sounds great. Well, thank you so much for your time today and a really great conversation.

46:13
Vineeta Agarwala (Guest)
Vineeta, thanks so much.

46:18
Danny Levine (Producer)
Bonnie, what did you think?

46:19
Neil Littman (Host)
I thought that was a really great and wide ranging discussion with Vineeta. You heard her talk about everything ranging from digital health and digital therapeutics and the fact that she didn't think software would be a replacement for drugs for a whole variety of diseases, which makes sense. There are applicable areas where they need to modify behavior and obviously that's what they're being used for today. It's interesting to hear how she bucketed the realm of digital therapeutics within their investment thesis at A 16 Z. Then, of course, we talked a lot about the notion of care delivery. She had lots of thoughts around the integration of AI, both within the care delivery setting, but also within the realm of developing novel therapeutics. And so, as Vineeta said, there are a whole wide variety of applications for AI to help increase the reduce the cost, to reduce the timelines of drug development, to free up the time of, let's say, clinician or someone in the drug development world from some of the more menial tasks so they can focus on more high value tasks.

47:26
Neil Littman (Host)
I really enjoyed that perspective that she brought to the table.

47:31
Danny Levine (Producer)
People often get carried away with the potential for technology and she seemed to have a well grounded view. How do you think that shapes their investment thesis?

47:44
Neil Littman (Host)
Yeah, well, I think it must. From my perspective, it seems like her continuing to practice as a clinician probably helps her keep that grounded view, but no doubt it informs their investment thesis and their perspective. And you heard Vineeta talk about lots of the different types of technologies that they're interested in and areas that they're excited about. You heard her talk about some of the portfolio companies where they've already made investments and how they're doing things differently and really pushing healthcare forward, whether that's on the care delivery side or whether that's within the realm of drug discovery and drug development. There's no doubt that her unique perspective helps inform the investment thesis. Not only are they looking over the short term horizon, but they're really looking for transformational types of technologies over the much longer term. I really appreciated Benita's viewpoint on the last question I asked about the advice for founders and what makes for that type of special founder out there.

48:41
Neil Littman (Host)
So that was really interesting as well.

48:44
Danny Levine (Producer)
You also asked her about this contradiction we're in between the pace of innovation and the current economic environment. It was encouraging to hear her say that not only are they seeing unprecedented innovation, but sitting down and meeting with more founders than ever before. Do you think though, given this environment, that's going to change their commitment to these companies? Are they going to have to be prepared to go deeper in terms of backing them?

49:17
Neil Littman (Host)
Well, I can't speak to that on their behalf. But you did hear Vineeta say that it may change the number of investments that they make. Obviously there are significant economic headwinds at this point, but you heard Vineeta talk about the pace of innovation is continuing to accelerate. Those headwinds are not impacting a lot of the developments we're seeing in terms of the technologies and the scientific advances. Yes, it's harder for companies to secure funding, but as Vineeta mentioned, a lot of the large funds have already been raised right. They were raised in the good times. There is cash to be deployed into the ecosystem, maybe now more selectively than it would have been over the last five years. No question, the pace of innovation is continuing to accelerate. And as Vineeta said, looks like they're actively making investments out of their new fund and supporting a lot of this innovation and pushing things forward.

50:15
Neil Littman (Host)
Just because there are economic headwinds doesn't mean the pace of scientific advance is going to slow down.

50:21
Danny Levine (Producer)
Well, until next time.

50:22
Danny Levine (Producer)
Okay?

50:23
Vineeta Agarwala (Guest)
Thank you Danny.

50:26
Danny Levine (Producer)
Thanks for listening.

50:28
Danny Levine (Producer)
The Bioverge podcast is a product of Bioverge, Inc. An investment platform that funds visionary entrepreneurs with the aim of transforming healthcare. Bioverge provides access and enables everyone to invest in highly vetted healthcare startups on the cutting edge of innovation, from family offices and registered investment advisors to accredited and nonaccredited individuals. To learn more, go to bioverge.com. This podcast is produced for Bioverge by the Levine Media Group. Music for this podcast is provided courtesy of Joan Levine collective. All opinions expressed in this podcast by participants are solely their opinions do not reflect the opinion of Bioverging or its affiliates. The participants opinions are based upon information they consider reliable, but neither Bioverge or its affiliates warrants its completeness or accuracy and it should not be relied on itself. Nothing contained in accompanying this podcast shall be construed as an offer to sell, a solicitation of an offer to buy, or a recommendation to purchase any security by Bioverge, its portfolio companies, or any third party.

51:40
Danny Levine (Producer)
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