Marquette Intellectual Property Law Review

Volume 22 | Issue 1 Article 6

Celebrating Wisconsin Entrepreneurs: Lessons Learned From Wisconsin Entrepreneurs and Businesses, and Future Prospects for a Healthcare Sector that is Healthcare Reform Daniel S. Sem

Si Gou

Taleb Aljabban

Follow this and additional works at: https://scholarship.law.marquette.edu/iplr Part of the Business Organizations Law Commons, Health Law and Policy Commons, Intellectual Property Law Commons, Law and Society Commons, and the Science and Technology Law Commons

Repository Citation Daniel S. Sem, Si Gou, and Taleb Aljabban, Celebrating Wisconsin Entrepreneurs: Lessons Learned From Wisconsin Entrepreneurs and Businesses, and Future Prospects for a Healthcare Sector that is Healthcare Reform, 22 Marq. Intellectual Property L. Rev. 51 (2018). Available at: https://scholarship.law.marquette.edu/iplr/vol22/iss1/6

This Article is brought to you for free and open access by the Journals at Marquette Law Scholarly Commons. It has been accepted for inclusion in Marquette Intellectual Property Law Review by an authorized editor of Marquette Law Scholarly Commons. For more information, please contact [email protected]. 40672-mqi_22-1 Sheet No. 28 Side A 05/20/2019 14:43:36 , 52 54 9/21/2018 1:50 PM * LJABBAN TM A ...... 61 ...... 57 ALEB T Remedium eXchange (Rx) Think Tank AND , ECOSYSTEM...... 61 ...... OU Entrepreneurs G I re: ...... 62 62 re: ...... REFORM grant Population: , S to Capital...... 63 ...... to Capital. EM ployment: S. S S. ENTREPRENEURS ) NTREPRENEURIAL ...... E ELETE CELEBRATING WISCONSIN WISCONSIN CELEBRATING ANIEL Innovation Cultu S D ’ D OT OT N Ranking ...... 59 1. Midwestern Culture: ...... 60 60 ...... 1. MidwesternCulture: 2. Decreasing Immi 3. Low Unem 4. More of a Manufacturing and Less of a Technology- 5. Lack of Access Ecosystem ...... 63 O (D A.54 ...... and Exports Major Beyond Beer and Cheese: Industries B. Celebrating Wisconsin C. Measuring Entrepreneurialism in Wisconsin: National D. Wisconsin Challenges Facing the Entrepreneurial Ecosystem60 E. Opportunities: Resources to Grow and Initiatives the F.in Wisconsin Law - Legislation to Encourage Investment LESSONS LEARNED FROM WISCONSIN FROM WISCONSIN LESSONS LEARNED INAL INAL ISCONSIN * Dean and Professor of Business, Professor of Pharmaceutical Sciences, Concordia of Pharmaceutical Sciences, Concordia * Dean and Professor of Business, Professor .F SECTOR THAT IS DRIVING HEALTHCARE IS DRIVING HEALTHCARE SECTOR THAT ENTREPRENEURS AND BUSINESSES, AND AND BUSINESSES, ENTREPRENEURS FUTURE PROSPECTS FOR A HEALTHTECH FOR A HEALTHTECH FUTURE PROSPECTS NTRODUCTION M K EM C Y 7. S 7. I. I University Wisconsin; Law J.D., Marquette University School, Ph.D., University of Wisconsin at Madison, MBA, Marquette University. Daniel Sem is also a co-founder of Bridge to Cures Inc., healthcare mentoring to devoted a nonprofit [https://perma.cc/F27G-X74W], www.bridgetocures.com and HealthTech entrepreneurs in Wisconsin. and Taleb Aljeban is Si Gou is an undergraduate student The a graduate student at Concordia University Wisconsin, in the Batterman School of Business. authors would like to thank members of the for strategic input on this article, as http://rxthinktank.org/our-staff/ [https://perma.cc/33FD-4TQA], Scholz. well as Colin Murdy and Professor Tom II. W 40672-mqi_22-1 Sheet No. 28 Side A 05/20/2019 14:43:36 A 05/20/2019 28 Side Sheet No. 40672-mqi_22-1 40672-mqi_22-1 Sheet No. 28 Side B 05/20/2019 14:43:36 , M K C Y 86 92 69 OR [Vol. 22:1 [Vol. F 9/21/2018 1:50 PM OADMAP ECH T in the United States for : A R EALTH H In contrast, Wisconsin ranks at EFORM 1 HE R T s ...... s ...... 76 United States ...... 89 89 ...... United States NTRODUCTION and Acces ups ...... ups ...... 66 EALTHCARE I. I H ooms? ...... 79 ooms? 79 ...... althcare ...... althcare ...... 91 PPORTUNITIES FOR PPORTUNITIES ISCONSIN ...... O ...... 69 69 ...... MARQ. INTELL. PROP. L. REV. REV. L. PROP. INTELL. MARQ. TATES ...... NABLED W (May 18, 2017, 7:00 AM), http://www.jsonline.com/story/money/2017/05/ S ) -E , For Third Straight Year, Wisconsin Ranks Last in Business Startup Activity ...... 83...... ELETE Wisconsin Start D ECH NITED ENTINEL OT OT T N U HealthTech ...... 68 Innovation 74 ...... Southeast Wisconsin United States is Cost Healthcare System in the Consumerize He via Emergency R via Emergency Solution ...... 80 Bundling ...... 81 81 Bundling ...... O J. S (D HE NDUSTRY IN NDUSTRY G. Growth Future Opportunities Healthcare – Spotlight on and T I A. Learning from Best Practices in the Rest of the World ...... 86 A...... the World Learning from BestRest Practices in the of A. Wisconsin’s History of Healthcare and HealthTech Rich B. HealthTech and the Entrepreneurial Ecosystem Startups in D. for the Poor—Universal Healthcare Access Challenges Care B.HealthTech-enabled Hybrid and Tiered Proposal for a C. The Major the Healthcare Industry in the Challenge Facing C. The Remedium eXchange (Rx) Think Tank—Helping to E. for the Poor—A Healthcare Access Challenges HealthTech F. Healthcare Solutions: Transparent Pricing, Medical Homes and H.85 ...... and Consumerization Barriers to Healthcare Reform G.Healthcare Technology: Consumerizing Enabling HealthTech EALTH INAL INAL HALLENGES AND HALLENGES ONCLUSION ...... 1. Rick Romell .F Wisconsin a rich history of entrepreneurial activity, which is often not has EM ILWAUKEE 7. S 7. M 18/third-straight-year-wisconsin-ranks-last-business-startup-activity/328803001 [https://perma.cc/S6YZ-HPUJ]. III. C the top appreciated beyond its well-recognized strength in the beer and cheese appreciated beyond its well-recognized industries. However, Wisconsin’s entrepreneurial nature has been called into question. Recently, Wisconsin was ranked fiftieth 52 startup activity by the Kauffman Foundation. V. C IV. H 40672-mqi_22-1 Sheet No. 28 Side B 05/20/2019 14:43:36 B 05/20/2019 28 Side Sheet No. 40672-mqi_22-1 40672-mqi_22-1 Sheet No. 29 Side A 05/20/2019 14:43:36 53 , 9/21/2018 1:50 PM OUNDATION F ), with lessons learned ), with lessons ), which has significant ), which has significant AUFFMAN , K Table 1 tartup-activity&indicator=se- Table 2 ) ELETE D CELEBRATING WISCONSIN ENTREPRENEURS ENTREPRENEURS WISCONSIN CELEBRATING OT OT N The first half of this article willhalf of this article The first review some and of the challenges O 2 (D Larger States Rankings: Main Street Entrepreneurship INAL INAL 2. .F The second half of the article willThe second half of deeper and forward-looking provide a M K EM C Y 7. S 7. opportunities that have faced Wisconsin entrepreneurs, and will Wisconsin that have faced opportunities an provide entrepreneurs, and of over 150 Wisconsinoverview companies ( fromtheir founders. Multiple taken by entrepreneurial journeys the industry sectors will reviewed, be manufacturing,food and beverage, including regulatory, mentoring, seed healthcare. Resources (legal, biotechnology and entrepreneurial created to improve Wisconsin’secosystem are being funds) that presented. will also be sector, HealthTech ( analysis of one industry impactgrowth positively potential, and potential to reform. healthcare However, the HealthTechand faces political, legal, regulatory, industry also that could block its growth—abusiness challenges that growth has to potential and The history of the healthcare positively impact the healthcare industry. a summaryof in Wisconsinbe reviewed, followed by will industry HealthTech for the industry. The status of healthcare the current status and a look forward in the United States, with its high cost and poor access, will be discussed in the context of the current political debate. this political debate that It will be argued is focused more than on how to constrain cost and increase on who is covered discussion of the relative value (and quality, and it does not provide a useful current implementation) of single payer versus competitive markets as a way Ato control cost and increase quality. case will be presented that Wisconsin’s HealthTech entrepreneurs could provide lower cost and higher quality of care. Still, challenges consumerization healthcare, via technology-enabled extend marketwhich may issues and barriers to entry, exist that relate to privacy monopoly-power (intended to foster beyond intellectual property-based innovation) into the realm business practices that hinder of anti-competitive market-driven improvements in healthcare delivery (e.g., consumer-driven value-based shopping; usage of medical centers of excellence; consumer- centric integrated care). The promise of HealthTech-based consumerization tools that empower front-line of healthcare to at the and educate consumers provide higher quality care at lower with cost is presented, along the legal and regulatory challenges that may to be addressed for HealthTech need goal. entrepreneurs to succeed in this of the country for startups that are local and established business with more business and established are local that for startups country of the longevity. 2018] http://www.kauffman.org/kauffman-index/rankings?report=s 2017). (last visited Sept. 26, rate&type=larger [https://perma.cc/RPY6-VQXL] 40672-mqi_22-1 Sheet No. 29 Side A 05/20/2019 14:43:36 A 05/20/2019 29 Side Sheet No. 40672-mqi_22-1 40672-mqi_22-1 Sheet No. 29 Side B 05/20/2019 14:43:36 3 7 M K C Y . (May EV . R [Vol. 22:1 [Vol. US 9/21/2018 1:50 PM . B (Oct. 18, 2016), ARV As markets started , H 8 (Sept. 26, 2017), ENTINEL , https://www.bioforward.org/ J. S NALYSIS , https://www.wisconsinhistory.org/tu . A Y ISCONSIN ’ , 186 (The State Historical Soc’y of Wis. ILWAUKEE W CON OC ); and, increasingly it is the source ); and, increasingly S E , M ISCONSIN ORWARD W F Table 1 UREAU OF IO ISTORICAL fm?fips=55000&areatype=STATE&geotype=3 . B NTREPRENEURIAL ECOSYSTEM ECOSYSTEM NTREPRENEURIAL , B . H E IS OM S C ’ ISTORY OF , W H T OF ’ 4 century, with dramatic growth in the period of time consumer co-operative techniques . . . supporting co- consumer co-operative techniques EP HORT MARQ. INTELL. PROP. L. REV. REV. L. PROP. INTELL. MARQ. What an Entrepreneurship Ecosystem Actually Is What an Actually Entrepreneurship Ecosystem Wisconsin and is home has a rich entrepreneurial history ) ISCONSIN 5 , A S , U.S. D Sem: The Wisconsin Entrepreneur ELETE ARA D II. W G OT OT N Old WorldOld O A. Exports Beer and Cheese: Major Beyond Industries and ARRY (D Wisconsin Strength of Wisconsin Biohealth 19th-Century Immigration 6 INAL INAL 4. Dan Sem, 3. Daniel Isenberg, 5. 8. L 6. 7. .F Immigrants from Europe and the Eastern United States settled in WisconsinStates settled United Immigrants Europe and the Eastern from An entrepreneurial ecosystemAn entrepreneurial element as a core can be defined of an As is well-known, Wisconsin’sAs is well-known, successes include entrepreneurial EM 7. S 7. strength-wisconsin-biohealth/ [https://perma.cc/SEP2-6DV3] (last visited Sept. 26, 2017). strength-wisconsin-biohealth/ [https://perma.cc/SEP2-6DV3] (last visited Sept. 26, economic development on fostering entrepreneurship. that focuses strategy This could include the people, the supporting institutions This could resources, and people, the supporting as well the include providing a begins by This article of a region. and values as the culture of Wisconsin’shistorical overview ecosystem entrepreneurial and of the Wisconsin entrepreneur. to flourish, many producing cheese and brewing beer. Whileproducing cheese are an important these industries aspect of its economy, Wisconsin’s finance, insurance, largest industries are to the Bureau of Economicaccording rental and leasing real estate, and (“BEA”). Analysis 1962). 12, 2014), https://hbr.org/2014/05/what-an-entrepreneurial-ecosystem-actually-is [https://perma.cc/A 12, 2014), https://hbr.org/2014/05/what-an-entrepreneurial-ecosystem-actually-is 827-LPKV]. of new and emerging companiesin growth in areas like healthcare (e.g., medical and diagnostics), biotechnology, and HealthTech (e.g., digital devices health). to many well-recognized domesticto many well-recognized companies and international that were Wisconsin entrepreneurs ( started by operative stores,” and establishing the concept of a market. a of concept the establishing operative stores,” and With was an increased demand this rapid population growth, there for merchandise. Immigrants brought crucial knowledge and experience “of successful 54 http://www.jsonline.com/story/money/business/onramp/blog/2016/10/18/sem-wisconsin- entrepreneur/92382318 [https://perma.cc/4NPN-62RW]. during the nineteenth increased 1848. population in Wisconsin’s state a becoming leading up to during the period fromfrom 1836–1850. 11,000 to over 305,000, thirty-fold, rningpoints/tp-018/?action=more_essay [https://perma.cc/5ANT-QRLD] (last visited July 31, 2017). 31, July (last visited [https://perma.cc/5ANT-QRLD] rningpoints/tp-018/?action=more_essay [https://perma.cc/9P3V-R5XM]. https://www.bea.gov/regional/bearfacts/pdf.c 40672-mqi_22-1 Sheet No. 29 Side B 05/20/2019 14:43:36 B 05/20/2019 29 Side Sheet No. 40672-mqi_22-1 40672-mqi_22-1 Sheet No. 30 Side A 05/20/2019 14:43:36 , 55 9/21/2018 1:50 PM (May 27, 2016 5:00 . ACH 12-14 (2014), GRIC A OURNALS Examples of Wisconsin . J 10 US B ). HE ENSUS OF , T Table 1 , 1 2012 C Adding to this strength in the dairy industry, the dairy industry, this strength in Adding to , https://www.revenue.wi.gov/DORReports/bt1001611.pdf 9 EVENUE R Largest Wisconsin Breweries ). ) include Miller (now MillerCoors), Leinenkugel, Minhas T OF ’ EP 11 ELETE D Table 1 CELEBRATING WISCONSIN ENTREPRENEURS ENTREPRENEURS WISCONSIN CELEBRATING . D OT OT N IS O W Wisconsin Beer Production Report Returns Posted between 11/1/2016 and 11/30/2016 (D Dairy Cattle and Milk Production INAL INAL 9. 11. Barbara Zaferos, 10. .F Besides the dairy and beer industries, businesses from different industries Besides the dairy and beer industries, Along with the dairy industry, WisconsinAlong with the dairy is a significant beer supplier. In M K EM TATE OF C Y 7. S 7. thrived in the past two construction, energy, finance, centuries, including Somehealthcare, insurance, law, and manufacturing. companies in founded Wisconsin an international presence, such as Harley- have grown to have Davidson, Northwestern Mutual, Alliant Energy, Acuity Insurance, and Brady Corporation ( AM), https://www.bizjournals.com/milwaukee/subscriber-only/2016/05/27/largest-wisconsin-brewer ies.html [https://perma.cc/G8Z6-QKPM]. beer companies ambitious immigrant entrepreneurs founded their own companies in Wisconsin. in own companies their founded entrepreneurs immigrant ambitious As time Wisconsin progressed, as a dominant itself with strength established Accordingdairy supplier. the United to States Department of Agriculture, Wisconsin was second in the Unites ranked States, with 1.3 million milk cows in sales in 2012. and $5 billion 2018] [https://perma.cc/6UH2-MYLC]. Craft Brewing, Stevens Point Brewery and moreCraft Brewing, Stevens Brewery, recently, Lakefront left that have since brands Brewing. Older Glarus Sprecher’s and New WisconsinBrewing Company include Joseph Schlitz (founded in 1848 and and Pabst Brewing Companyonce the largest producer of beer) (founded in 1844). Wisconsin is also strong morebeverage industry, and generally in the food with dairy-based companies like Sargento Cheese, Palermo’s (pizza), and Culver’s prominent(frozen custard) being brands ( one month, Wisconsin barrels of beer, and sells 622,071 produces 868,424 kegs of beer for export out of state. cases and 71,638 https://www.agcensus.usda.gov/Publications/2012/Online_Resources/Highlights/Dairy_Cattle_Milk_ Prod/Dairy_Cattle_and_Milk_Production_Highlights.pdf [https://perma.cc/C3N2-5NM9]. S 40672-mqi_22-1 Sheet No. 30 Side A 05/20/2019 14:43:36 A 05/20/2019 30 Side Sheet No. 40672-mqi_22-1 40672-mqi_22-1 Sheet No. 30 Side B 05/20/2019 14:43:36 J. M K C Y and the 12 ILWAUKEE [Vol. 22:1 [Vol. 9/21/2018 1:50 PM , M profiles over 150 over profiles TM MARQ. INTELL. PROP. L. REV. REV. L. PROP. INTELL. MARQ. Manufacturing Biggest Single Employment Sector in State ) ELETE D OT OT . The Wisconsin Entrepreneur Exhibit Entrepreneur Wisconsin The . N O (Sept. 26, 2014), http://archive.jsonline.com/business/as-us-creates-low-wage-jobs- (D Wisconsin also exports a considerable number of products. Wisconsin’s Fig. 1 Fig. INAL INAL 12. John Schmid, .F Manufacturing is the largest employment sector in Wisconsin, EM Wisconsin companies in thirteen major sectors. The profiles profiles The sectors. major in thirteen companies Wisconsin the of stories the tell (https://www.cuwbusiness.com/wi-entreprenuer) values. their and founders ENTINEL 7. S 7. 56 S wisconsin-clings-to-manufacturing-b99348747z1-277269841.html/ [https://perma.cc/5QYF-NVN2]. wisconsin-clings-to-manufacturing-b99348747z1-277269841.html/ [https://perma.cc/5QYF-NVN2]. biggest manufacturing sub-sectors include electric equipmentbiggest manufacturing manufacturing sub-sectors include (e.g., Rockwell Automation Power Systems) Inc. and Generac followed by paper and paper converting (e.g., Kimberly sectors such Clark) and then other chemicalsas food and beverage (dairy, agriculture), (plastics, consumer products) and machinery (machines, metalworking, hardware, foundries, stamping). 40672-mqi_22-1 Sheet No. 30 Side B 05/20/2019 14:43:36 B 05/20/2019 30 Side Sheet No. 40672-mqi_22-1 40672-mqi_22-1 Sheet No. 31 Side A 05/20/2019 14:43:36 ; 57 Fig. 1 Fig. in what 15 9/21/2018 1:50 PM . The compilation Manufacturing and TM 13 Historically,Wisconsin Wisconsin Manufacturers The other largest sector is 14 16 , https://milwaukeehistory.net/ [https://perma.cc/H9 Y ’ Wisconsin’s Exports: A Special Report on Wisconsin’s Wisconsin’s Exports: A Special Report on Wisconsin’s , OC S , with a synopsis of key information provided in EVENUE R ISTORICAL , http://www.fabwisconsin.com [https://perma.cc/P8G4-EJRC] (last T OF Wisconsin Exhibit Entrepreneur Fig. 1 Fig. ’ . H O EP ) C D B. Entrepreneurs Wisconsin Celebrating ISCONSIN ELETE D CELEBRATING WISCONSIN ENTREPRENEURS ENTREPRENEURS WISCONSIN CELEBRATING OT OT B W N ISCONSIN A ILWAUKEE . at 4. . at O Id (D . Wisconsin companies tend to cluster into the sectors shown in , 1 (2011) https://www.revenue.wi.gov/DORReports/10exports.pdf [https://perma.cc/X3TT- INAL INAL 15. M 14. 13. W 16. F .F Wisconsin has a rich history of entrepreneurial successes, but the stories of successes, but the stories of entrepreneurial rich history Wisconsin has a M K EM C Y 7. S 7. Economy CBZT]. ZB-FYT7] (last modified 2018). ZB-FYT7] (last modified modified 2012). but it is but noteworthynumbers that the in terms of largest sector companies is of brands like Sargento, Palermo’s,food and beverage, with recognizable Sendik’s, Johnsonville Foods, Usinger’s, MillerCoors, Pabst, Cousins Subs, Pick ‘nSentry Foods, Roundy’s (Kroger’s, Save in Wisconsin), Oscar Meyer, Penzeys Spices, Hillshire Farms, Organic Valley, Rocky Rococo, and Natural industry the food and beverage Ovens. The trade organization supporting sector in Wisconsin Wisconsin. is FaB Table 1 the formation of those companies of the people who founded them – and – are this problem, address one location. To on not available in information over 150 Wisconsin companies, values of their founders’ stories and the core including the companies, compiled is being Concordia in a partnership between University Wisconsin the Milwaukee and Society, County Historical is being called the interface is shown in exports increased to increased exports $19.8 billion in 2010, withfive the top destinations export Mexico,being Canada, Germany, China, and Japan. 2018] companies also contributed significantly during World War II. For example, companiesduring World significantly also contributed War II. effort. vessels for the U.S. Oshkosh and built eighty Corporation designed machinery one of Wisconsin’s represent comprising industries, larger export 27% total Wisconsin’s of followed by computers exports in 2010, total and and electronics, transportation equipment. manufacturing which includes Harley-Davidson, Hydrite and engineering, Chemical, Mercury Johnson Controls, Kohler, Marine Outboard (Evinrude Trek Bikes, amongstEngines), Rexnord, SC Johnson and many others. It is noteworthy that Wisconsin a large number can also boast of law firms (Foley, Michael Best, DeWitt Ross and Stevens, Godfrey Kahn,Quarles and Brady) and insurance companies American (Acuity, Family, Northwestern Mutual, Sentry, Thrivent and West Bend Mutual). The trade organization supporting the manufacturing industry sector in Wisconsin is 40672-mqi_22-1 Sheet No. 31 Side A 05/20/2019 14:43:36 A 05/20/2019 31 Side Sheet No. 40672-mqi_22-1 40672-mqi_22-1 Sheet No. 31 Side B 05/20/2019 14:43:36 M K C Y [Vol. 22:1 [Vol. 9/21/2018 1:50 PM illustrates the large illustrates TM for Sargento. for Sargento. A survey of the company , www.wmc.org [https://perma.cc/E32A-KSE6]. , www.wmc.org Fig. 2 Fig. . OMMERCE TM .& C MARQ. INTELL. PROP. L. REV. REV. L. PROP. INTELL. MARQ. FRS Wisconsin Exhibit Entrepreneur ) M Retail companies Menards, include Kohl’s, QuikTrip, Allen ELETE 17 . D . Representative profile of a company in the Wisconsin of in the a Wisconsin company profile . Representative OT OT N ISCONSIN O (D Fig. 2 Fig. INAL INAL Entrepreneur Exhibit Entrepreneur 17. W .F EM 7. S 7. Edmonds Shoes, and Florsheim sampling Shoes. This larger list of of the companies in the profiles reveals a commonprofiles reveals a theme of values amongst Wisconsin companies, integrity, hard work,including trust, honesty, and quality. Mission statements reflect these same state the centrality of the values, and on occasion also corporate culture, which religious values as drivers of founders’ faith and economics. business, and frequently blend faith, number origins in brands (companies) of recognizable have their that Wisconsinstarted by Wisconsin and were A representative entrepreneurs. is shown in a company profile of and Commerce and 58 40672-mqi_22-1 Sheet No. 31 Side B 05/20/2019 14:43:36 B 05/20/2019 31 Side Sheet No. 40672-mqi_22-1 40672-mqi_22-1 Sheet No. 32 Side A 05/20/2019 14:43:36 , 20 59 ). OMMERCE Fig. 1 Fig. C 9/21/2018 1:50 PM Thus, while and N OF ’ 19 Entrepreneurial (Nov. 20, 2007), SS 3 (Mark Casson et al. 3 (Mark Casson et al. A 21 Table 1 ROUP G In a recent conference ,” an expert panel 23 ILWAUKEE , http://www.kauffman.org/kauffma In the words of Todd Teske, Todd In the words of . M ., https://www.cuwbusiness.com/wien 22 This ranking has led manyThis ranking in TEERING US NTREPRENEURSHIP S E B ETRO 18 M A Framework for Addressing and Measuring , which focuses on local local , which focuses on small and OUNDATION F note 2. ONCORDIA C NDICATORS ANDBOOK OF I supra H , AUFFMAN , K XFORD O HE OUNDATION F , T ) NTREPRENEURSHIP ELETE ASSON D C AUFFMAN , E CELEBRATING WISCONSIN ENTREPRENEURS ENTREPRENEURS WISCONSIN CELEBRATING Celebrating the Wisconsin Entrepreneur Celebrating OT OT K N ARK O Wisconsin International Trade Conference, Wisconsin Entrepreneur Exhibit, 2016 Main Street Reports See (D C. Ranking Measuring in Wisconsin: Entrepreneurialism National INAL INAL 19. 22. Nadim Ahmad and Anders Hoffman, 18. 20. 21. M 23. .F While Wisconsin may rank at the bottom in the Kauffman Index for Startup If Wisconsin ranks low in one Kauffman If Wisconsin ranks low in Index and high in another for According to the KauffmanAccording annual Index Foundation’s of Startup Activity, M K EM C Y 7. S 7. n-index/reporting/main-street [https://perma.cc/8JGW-BUGR] (last visited Sept. 26, 2017). 2017). n-index/reporting/main-street [https://perma.cc/8JGW-BUGR] (last visited Sept. 26, trepreneur [https://perma.cc/T4MC-3RRH]. eds., 2006). entrepreneurial business activity, howentrepreneurial business activity, does one define the Wisconsin entrepreneur and what he or and who creates newa person who is viewed as an innovator industries sheand is good at? Anprecipitates major structural changes in the economy. entrepreneur can be defined as Entrepreneurship Wisconsin of entrepreneurialism about the level to feel concerned the state in discussions about It has also led to and promptedhow to improve debate on it. entrepreneur. what defines the Wisconsin Kauffman Foundation’s ranks second in the country in the Activity, it actually Index of Main Street Entrepreneurship entrepreneurialism) can (that drives innovation CEO of Briggs and Stratton, the solving.” as “customer-driven problem be defined established businesses (more than five years old and less than fifty employees), fifty years old and less than five (moreestablished businesses than business. such as survival rate of these and includes factors 2018] http://web.mmac.org/events/Wisconsin-International-Trade-Conference—1117/details 2017). [https://perma.cc/2YEL-VMQK] (last visited Sept. 29, Wisconsinactivity. last for startup ranked focused on “ activity is enterprising humanis enterprising the generation of value, in pursuit of activity action and identifying of economicthrough the creation or expansion activity, by or markets.exploiting new products, processes, Wisconsin may not have the startup churning activity that is observed in states Wisconsin activity that is observed maythe startup churning not have and does appear to excel at building like California, it growing small sustainable that stand the test businesses of time. In this regard, there are many stories of Wisconsin and companies entrepreneurs started that have small but Harley-Davidson, brands, like later grew to be widely recognized Kohl’s, Menards, Rockwell Automation, (cheese), Cousins Subs, Sargento Briggs and Miller, to namejust a few (see Stratton, SC Johnson, and http://search.oecd.org/std/business-stats/39629644.pdf [https://perma.cc/GMS2-B8LH]. 40672-mqi_22-1 Sheet No. 32 Side A 05/20/2019 14:43:36 A 05/20/2019 32 Side Sheet No. 40672-mqi_22-1 40672-mqi_22-1 Sheet No. 32 Side B 05/20/2019 14:43:36 26 M K C Y [Vol. 22:1 [Vol. Celebrating 9/21/2018 1:50 PM ). These are certainly Table 1 ; )—can be problematic in starting While the Wisconsin entrepreneur 25 note 18. Fig. 1 Fig. ( TM supra , event concluded that Wisconsin entrepreneurs TM 27 OUNDATION Wisconsin entrepreneurs were described as “innovative, “innovative, Wisconsin as were described entrepreneurs MARQ. INTELL. PROP. L. REV. REV. L. PROP. INTELL. MARQ. F 24 ) note 4. ELETE D AUFFMAN supra OT OT K N . . O Id Id See (D D.Ecosystem Challenges Facing the WisconsinEntrepreneurial Index of Main Street Entrepreneurship INAL INAL 26. 27. 24. Sem, 25. .F The Kauffman Foundation survey data make it clear that while Wisconsin the expert panel at the As discussed in the previous section, EM 7. S 7. is strong in Main Street Entrepreneurship, challenges remain for the creation of venture by that are funded the kind startups, and high-reward scalable high-risk capital. While the causes of this entrepreneurial culture dichotomy are not known, several are proposed below. 1. Midwestern Culture: capital efficient, hard-working, hard-working, capital efficient, humblevalues-driven, it was reliable,” and and that last; sustainable businesses in creating these traits are valuable noted that maybut they high-reward very high-risk and the creation of work against was noted also capital to scale. It of venture need large amounts startups that Wisconsinthat a trait of the entrepreneur is humility, which a is a virtue. But, potential down-side was agreed humility noted: “the panel and audience is another great virtue—butcuts both ways, it do selling to because you need to attract investment and then customers.” attempted Wisconsin to define differ fromhow they and entrepreneurs, their coastal counterparts. Perhaps this is why the Wisconsin leader in Main entrepreneur is a national Street Entrepreneurship. 60 admirableHowever, and in life. traits in business the panel also felt that this aversion to to an coupled Midwest,typically which exhibited in the is humility pursuit of high-cost high-risk ventures “selling,” along with an aversion for (seemingly opposed to being “reliable”)—while admirable in some situations (e.g., may be somewhatextreme, excel at sales (and, in the averse and may risk not it was observed “the Wisconsinhype and puffery), entrepreneur is more enduring and robust—often more the sprinter.” the distance-runner than typically embrace hard work, integrity, delivering on promisestypically embrace without integrity, hard work, reliable, and acting withexcessive hype or hyperbole, being humility coupled to a commitment to values. the research is further supported by This assessment 150 Wisconsin-basedthat went in to profiling the over companies in the Wisconsin Exhibit Entrepreneur Wisconsin Entrepreneur 40672-mqi_22-1 Sheet No. 32 Side B 05/20/2019 14:43:36 B 05/20/2019 32 Side Sheet No. 40672-mqi_22-1 40672-mqi_22-1 Sheet No. 33 Side A 05/20/2019 14:43:36 . IS 61 and , W Table 1 9/21/2018 1:50 PM While unemployment 31 Historically, Wisconsin’s 30 The extent of immigrant migration to (and 28 ) ELETE D CELEBRATING WISCONSIN ENTREPRENEURS ENTREPRENEURS WISCONSIN CELEBRATING OT OT The U.S. unemployment rate is 4.4%. N 29 . O Id. Id. Id Wisconsin’s a Bottom-Feeder in Startup Index. Here’s Why, and How it Can Improve Index. Here’s Why, and How Startup in Wisconsin’s a Bottom-Feeder (D ). Immigrants are importantto Wisconsin’s entrepreneurial ecosystem J. (May 19, 2017), http://host.madison.com/wsj/business/wisconsin-s-a-bottom-feeder-in- INAL INAL 29. 30. 31. 28. .F While low unemployment a good thing, means people are often (overly) Wisconsincan be seen has a rich history of immigrant entrepreneurs, as M K EM TATE C Y 7. S 7. satisfied with their current job and the status quo. Sometimessatisfied with their current job and people pursue have no other options (i.e., the risk of entrepreneurial ventures because they taking “the leap” is lower in terms of opportunity cost, in a “what do I have to lose” situation). Wisconsin’s unemployment rate recently dropped to a seventeen-year low of 3.2%, well below the 9.2% peak during the Great Recession. 3. Low Unemployment: unemployment rate is lower than the national average. startup-index-here-s/article_ec612faf-03fd-5b93-968c-730b427e8eed.html [https://perma.cc/2CYF- startup-index-here-s/article_ec612faf-03fd-5b93-968c-730b427e8eed.html 2ASU]. Fig. 1 Fig. twiceare statistically likely to as because they a smallstart business relative to non-immigrants, have by necessity overcome perhaps because they risk- the startup entrepreneurs; and immigrantsaversion challenge that plagues all ecosystemprovide a diversity which an entrepreneurial needs. As evidence of this, consider Wisconsin’s business creation successes in the early twentieth century, which came at a time roughly twenty-five percent of the state’s when population was born overseas. new companies companies new with high potential. growth This mindset the risk hinders often and a very high-risk start and finance needed to “selling” that is taking and is sometimes via a process that scalable venture, high-reward to a high coupled with associated level of uncertainty outcomes What for the venture. might be is sometimes as foolish and viewed in California bold and visionary viewed as in Wisconsin.risky puffery in Wisconsin, The approach is to bootstrap rather, a business and grow it incrementally grows, thereby justifying the as revenue expansion. 2.Population: Decreasing Immigrant its most iconic companies ( of some of founders the of after perusal 2018] retention in) Wisconsin is much lower now than a century ago and is less than retention in) Wisconsin is much lower now than a century ago and is less in the coastal United States, where immigrant entrepreneurs were often first offered by the high density of top U.S. attracted by the quality education locations. universities in those S 40672-mqi_22-1 Sheet No. 33 Side A 05/20/2019 14:43:36 A 05/20/2019 33 Side Sheet No. 40672-mqi_22-1 40672-mqi_22-1 Sheet No. 33 Side B 05/20/2019 14:43:36 J. 35 M K C Y However, However, [Vol. 22:1 [Vol. ILWAUKEE 9/21/2018 1:50 PM 36 , M The state can 33 , https://www.wisconsinhisto Y ’ Furthermore, the recent ., http://inwisconsin.com/inside- OC 37 S ORP . C EV . D ISTORICAL . H While Wisconsin’s have industries CON E IS (May 15, 2017), http://www.modernhealthcare.com 34 , W ISCONSIN EALTHCARE , W H 32 MARQ. INTELL. PROP. L. REV. REV. L. PROP. INTELL. MARQ. Wisconsin Economy Stuck in Old Growth Industries Wisconsin Economy Stuck in Old Growth ODERN note 30. ) Life After Pfizer: A Decade Later, Michigan Pharmaceutical Companies have Companies Michigan Pharmaceutical Later, Decade A Life After Pfizer: , M ELETE supra D OT OT N . O Organizational Reports The Rise of Skilled Manufacturing Id (D (June 17, 2013), http://archive.jsonline.com/business/wisconsin-economy-stuck-in-old- (June 17, 2013), http://archive.jsonline.com/business/wisconsin-economy-stuck-in-old- INAL INAL 35. 37. 34. 33. John Schmid, 32. Jay Greene, 36. Schmid, .F The major Wisconsindriving economic industries that are growth are in EM ENTINEL 7. S 7. Found Paths to Growth wedc/transparency/reports/ [https://perma.cc/9SZW-Q64T] (last visited Aug. 27, 2017). wedc/transparency/reports/ [https://perma.cc/9SZW-Q64T] (last visited Aug. 27, /article/20170515/NEWS/170519908 [https://perma.cc/4MS3-YDJZ]. growth-industries-b9934100z1-211923141.html [https://perma.cc/R3BJ-MVPD].growth-industries-b9934100z1-211923141.html attribute only 15% of its economic output to technology-innovation-driven its economicgains 18.8% output fromon average of nation industries, while the like California and industries; states technology-innovation-driven Massachusetts rank even higher. is certainly not a solution to Wisconsin’s a solution not is certainly it is worthstartups, of dearth noting that occurs whenresult of the churning that as a companies large with highly skilled workforces skilled yet unemployed have layoffs, workers often start new companies—as of Michigan’s with the downsizing has been the case pharmaceutical industry. Wisconsingrowing technology-innovation industry base. does have a Furthermore, a Wisconsin Economic Development Corporation (“WEDC”) industries are seen report notes that “Madison’s and biotechnology life-sciences industries.” showcase as being among the state’s announcement of Foxconn locating in Wisconsin is expected to grow the state’s locating announcement of Foxconn capability—as of a skilled as there is enough advanced manufacturing long Part of what attracts and retains technology-innovation startups are first class Part of what attracts and retains technology-innovation workforce.educational institutions and an educated While Wisconsin does colleges, they are not in as high a have excellent universities and technical density as in states with larger technology-innovation hubs (e.g., Massachusetts slightly lower level of post-secondary is a and California). Additionally, there education in the workforce in Wisconsin compared to the national average. Wisconsin and older with only a high school degree adults age twenty-five number 33.6%,compared to the national average of 28.4%. 62 4. Culture: More a Manufacturing of a Technology-Innovation and Less of manufacturing, some and related “old growth” industries. historically been focused on manufacturing,historically been focused it is now making to the transition advanced manufacturing—which relies more and innovation. on technology S ry.org/turningpoints/tp-044/?action=more_essay [https://perma.cc/9A82-RYEK] [https://perma.cc/9A82-RYEK] Sept. 29, (last visited ry.org/turningpoints/tp-044/?action=more_essay 2017). 40672-mqi_22-1 Sheet No. 33 Side B 05/20/2019 14:43:36 B 05/20/2019 33 Side Sheet No. 40672-mqi_22-1 40672-mqi_22-1 Sheet No. 34 Side A 05/20/2019 14:43:36 , , 39 63 (Mar. indicate 38 41 CONOMY 9/21/2018 1:50 PM , X , http://wisconsintechnologycouncil predominantly in California, 40 OUNCIL . C ECH The Tech Skills Gap Will Test Foxconn’s New The Tech Skills Gap Will Test Foxconn’s New T (July 28, 2017), http://www.jsonline.com/story/money/2017 (July 28, 2017), Madison, Wisconsin: How a City a Hub an Innovation Becomes Madison, Wisconsin: How ISCONSIN , W Alarm Sounded Over Wisconsin’s Lack of Start-ups, Venture Capital Venture Start-ups, of Lack Wisconsin’s Sounded Over Alarm ENTINEL Rockwell Automation partners with Foxconn on Wisconsin Plant Rockwell Automation partners with Foxconn J. S (July 26, 2017 6:41 PM), https://www.wired.com/story/foxconn- Investors Reboot Wisconsin Venture Capital Association Capital Reboot Wisconsin Venture Investors (June 01, 2014), http://archive.jsonline.com/business/alarm-sounded-over- While Madison may be the most hub of well-known ) (June 16, 2016), http://www.atlanticcouncil.org/blogs/futuresource/madison- 42 IRED ELETE D , W CELEBRATING WISCONSIN ENTREPRENEURS ENTREPRENEURS WISCONSIN CELEBRATING ENTINEL OT OT ILWAUKEE N O J. S OUNCIL , M C WTC 2017 Whitepapers (D E.Ecosystem Opportunities: to Grow Resources and Initiatives the INAL INAL 39. Kathleen Gallagher, 42.Peter Alex Paul Engelke, & 38. Barrett, Rick 40. Jeff Buchanan, 41. .F While Wisconsin strengths in Main has recognized Street Entrepreneurship, A serious concern for Wisconsin-based startups is a lack of venture capital is a lack of venture concern for Wisconsin-basedA serious startups M K EM ILWAUKEE TLANTIC C Y 7. S 7. Technologies 5.Capital. Lack of Access to it has weaknesses overall Startup Activity, in according to the Kauffmann is being made in building an Foundation indices. However, progress entrepreneurial ecosystem to better support Wisconsin Wisconsin’s startups. best example hub is Madison, of an entrepreneurial a city that has built a innovation and for technological national reputation as a center entrepreneurship. wisconsin-us-tech-skills-gap [http://perma.cc/QX99-NWTL]. entrepreneurial startup activity in Wisconsin,entrepreneurial startup activity in there are initiatives that are having an impact outside of Madison, Wisconsin, in southeast and across the and state. Some and organizations that are working of these initiatives to build there have recently been increasing investments,there have recently which will work to dramatically support and improve activity in Wisconsin. entrepreneurial wisconsin-how-a-city-becomes-an-innovation-hub [https://perma.cc/PMP7-2H8G]. .com/publications/wtc-white-papers [https://perma.cc/M3CC-3LMM]. A 2018] Wisconsin companies over $223 million raised slightly which in 2016, is less than 1% nationally, of the $69 billion raised wisconsins-lack-of-start-ups-venture-capital-b99279993z1-261467221.html/ [https://perma.cc/8AFP- wisconsins-lack-of-start-ups-venture-capital-b99279993z1-261467221.html/ K5ES]. 22, 2017), http://www.xconomy.com/wisconsin/2017/03/22/investors-reboot-wisconsin-venture- capital-association [https://perma.cc/X3BX-FLM6]. Massachusetts,there have been improvements and New York; but here again Wisconsinin the last few years. policy papers Technology Council’s that is needed for the more for the that is needed startups. high-reward scalable high-risk, M /07/28/rockwell-automation-partners-foxconn-wisconsin-plant-technologies/519756001 [https://perma.cc/5GL5-FTZH]; Issie Lapowsky, Wisconsin Factory workforce in Wisconsin in workforce technology-innovation. kind of this to support 40672-mqi_22-1 Sheet No. 34 Side A 05/20/2019 14:43:36 A 05/20/2019 34 Side Sheet No. 40672-mqi_22-1 40672-mqi_22-1 Sheet No. 34 Side B 05/20/2019 14:43:36 , , 44 49 M K C Y COM . Medical and it is gBETA, [Vol. 22:1 [Vol. 51 52 It is one of It is one OLLEGES 9/21/2018 1:50 PM C 43 50 Universities, of 53 EST and BioForward. , http://inwisconsin.com Lighting Your Way to a 48 , B a.cc/Z8N9-TJGC]. ISCONSIN , http://db.nelsonmandela.org/speech W N , I , http://www.medconline.com/M7_Venture_Cap , http://www.medconline.com/M7_Venture_Cap OUNDATION The Commons, F 47 ANDELA (Sept. 12, 2016), http://news.wisc.edu/uw-madison-ranked- EDCONLINE lleges-with-highest-research-and-development-expenditures/ M , https://www.bioforward.org/ [https://perma.cc/MDS8-5579] , https://www.bioforward.org/ [https://perma.cc/MDS8-5579] , M EWS , https://www.gener8tor.com/statistics [https://perma.cc/89NG- , https://www.gener8tor.com/statistics [https://perma.cc/89NG- , https://www.startupmke.org/ [https://perma.cc/94GQ-N2F8] (last , https://www.startupmke.org/ [https://perma.cc/94GQ-N2F8] N ELSON TOR 8 ISCONSIN Gener8tor Again Named as One of Nation’s Best Startup Accelerators Gener8tor Again Named as One of Nation’s Best MARQ. INTELL. PROP. L. REV. REV. L. PROP. INTELL. MARQ. , http://www.thecommonswi.com/ [https://perma.cc/Z7YC-CC64] (last , http://www.thecommonswi.com/ [https://perma.cc/Z7YC-CC64] Startup MKE,Startup UW-Madison Ranked 10th Best Public College by U.S. News & World UW-Madison Ranked 10th Best Public College W ADISON ) ENER 46 ILWAUKEE . M M , G IS ELETE OMMONS D , https://www.gbetaaccelerator.com [https://perma.cc/YYL2-CLSW] (last visited W . J. (June 6, 2017, 11:42 AM), https://www.bizjournals.com/milwaukee/news/2017/ C ORWARD OT OT F N US ETA OF Highest Research & Development in 2017 MEDC, (July 16, 2003), N HE O IO . B B TARTUP Funding G Start, Relocate or Grow Your Business M7 Venture Capital Fund (D 45 NIV INAL INAL , U 48. T 51. Kari Knutson, 45. 49. B 52. 44. 50. Melanie Lawder, 43. 47. S 46. 53. Nelson R. Mandela, Speech at the Launch of Mindset Network: .F As nucleating hubs of innovation, Wisconsin has excellent universities, one EM ILWAUKEE 7. S 7. visited Sept. 29, 2017). visited Sept. 29, 06/06/gener8tor-again-named-as-one-of-nations-best.html [https://perm 06/06/gener8tor-again-named-as-one-of-nations-best.html M ital_Fund.html [https://perma.cc/63B5-XKVH] (last visited Sept. 29, 2017). (last visited Sept. 29, ital_Fund.html [https://perma.cc/63B5-XKVH] [https://perma.cc/XF8L-MQ4N] (last visited Sept. 29, 2017). [https://perma.cc/XF8L-MQ4N] (last visited Sept. 29, College of Wisconsin, Marquette University and UW–Milwaukee also have very large and research and developmentgrowing programs integrated into the As Nelson Mandelaeducational experience. “[e]ducation is the most said, world.” which you can use to change the powerful weapon es/pub_view.asp?pg=item&ItemID=NMS909&txtstr=education%20is%20the%20most%20powerful [https://perma.cc/U858-ELJ4]. Report Sept. 29, 2017). Sept. 29, visited Sept. 29, 2017). visited Sept. 29, improve ecosystem the entrepreneurial Gener8tor, include: 10th-best-public-college-by-u-s-news-world-report [https://perma.cc/M5HU-VPWH]. ESFN] (last visited Sept. 29, ESFN] (last visited Sept. 29, 2017). 64 WEDC, in Madison, offices that has is a startup accelerator Gener8tor Milwaukee, and Minneapolis, among recently ranked and was programs the top 16 accelerator in the United Seed Accelerator States by the project. Rankings which there are many in Wisconsin, equip students with the necessary knowledgeinnovators. To and skills to succeed in industry, and to be startup start successfully and a grow company, leader and there needs to be a visionary (last visited Sept. 29, 2017). 2017). (last visited Sept. 29, only four such programs in that ranking that do not have a presence in not have a presence that do such programsonly four that ranking in California. of which is Universityof Wisconsin–Madison (UW–Madison). U.S. News & World ranked UW–Madison Report Public College, the tenth Best also ranked third highest for research and developmentalso ranked third spending. [https://perma.cc/85YN-U62R] (last visited Sept. 29, 2017). http://www.bestcolleges.com/features/co Better Future 40672-mqi_22-1 Sheet No. 34 Side B 05/20/2019 14:43:36 B 05/20/2019 34 Side Sheet No. 40672-mqi_22-1 40672-mqi_22-1 Sheet No. 35 Side A 05/20/2019 14:43:36 , 59 In 65 58 ISCONSIN and that W 54 there are a 9/21/2018 1:50 PM TAR 62 S Madison Region 63 56 RIGHT (November-December , B EVIEW , mentioned is a above, . R US , http://madisonregion.org/start-locate- , https://www.startupmke.org/funding/ . B , https://www.healthxventures.com/#about SHIP Accordingto the ARV . P’ , which had been dormant, which had been since the , H 55 CON ENTURES ILWAUKEE E M , http://siliconpastures.com/ [https://perma.cc/9L7M- X V , L.P., http://wsafund.com/ [https://perma.cc/RXG5- , L.P., http://wsafund.com/ [https://perma.cc/RXG5- Wisconsin Super Angel Fund) EGION UND the capital access problemWisconsin. in R F 61 EALTH TARTUP , http://www.goldenangelsinvestors.com/ [https://perma.cc/XD , http://www.goldenangelsinvestors.com/ [https://perma.cc/XD 57 ASTURES , H , S P RS 65 64 ’ NGEL ADISON A NV , https://ventureinvestors.com/ [https://perma.cc/397J-FUEY] (last I , at least 128 Wisconsincompanies early stage raised note 39. note 39. RS , M ILICON ’ ) UPER , S BrightStar; NV S How Venture Capital Works I supra supra NGELS 60 A ELETE D CELEBRATING WISCONSIN ENTREPRENEURS ENTREPRENEURS WISCONSIN CELEBRATING OT OT N ENTURE ISCONSIN . O OLDEN Startup Funding Guide Who We Are Wisconsin Capital Association Venture Venture Capital Id About HealthX Ventures About HealthX BrightStar Wisconsin: Job Creation through Capital Donation BrightStar Wisconsin: (D Venture Investors HealthX Ventures HealthX INAL INAL 59. 55. Buchanan, 64. V 54. Zider, Bob 60. G 62. W 63. 61. 65. 57. Buchanan, 56. 58. .F The In addition to having the right people, capital is needed to start a company. a is needed to start people, capital to having the right In addition M K EM C Y 7. S 7. addition to Angel investors and Angel networks (e.g., Silicon Pastures; Golden Angels; growing number of Wisconsin-based venture capital sources: growing number of Wisconsin-based venture capital G2-W7B7] (last visited Sept. 29, 2017). G2-W7B7] (last visited Sept. 29, consortium and corporate investors, and was recently of venture capital, angel formed to begin addressing 1998), https://hbr.org/1998/11/how-venture-capital-works [https://perma.cc/WH55-T8CM]. 1998), https://hbr.org/1998/11/how-venture-capital-works [https://perma.cc/J77B-Q7VX] (last visited Sept. 29, 2017). [https://perma.cc/J77B-Q7VX] (last visited Sept. 29, a team Wisconsin fields. the relevant in people skilled of the universities has Wisconsin. as some this talent, as long to produce of themin stay For a larger companya bolder (and with more expensive) vision, venture capital Bob Zider an essential role. often plays summarized as follows: “the the issue a company’sis to invest in venture capital] idea [of sheet and balance credibility,” it reaches a sufficient size and infrastructure until 2018] [https://perma.cc/2YB9-EBBA] (last visited Sept. 29, 2017). AVFR] (last visited Sept. 29, 2017). http://www.brightstarwi.org (last modified 2018). http://www.brightstarwi.org (last modified 4EQV] (last visited Sept. 29, 2017). 4EQV] (last visited Sept. 29, visited Sept. 29, 2017). visited Sept. 29, Economic Partnership investment and several new capital, were venture funds launched recently, Ventures. including American Family and HealthX Ventures expand/find-capital/venture-capital/ [https://perma.cc/HFU8-5PFL] (last visited Sept. 7, 2017). 7, (last visited Sept. expand/find-capital/venture-capital/ [https://perma.cc/HFU8-5PFL] recession of 2008, has been reformed, and could provide much-neededreformed, support and has been recession of 2008, capital in Wisconsin.to grow venture venture capital allows new companiesventure capital allows scale. Recently, the to grow and Wisconsin Capital Association Venture 40672-mqi_22-1 Sheet No. 35 Side A 05/20/2019 14:43:36 A 05/20/2019 35 Side Sheet No. 40672-mqi_22-1 40672-mqi_22-1 Sheet No. 35 Side B 05/20/2019 14:43:36 M K C Y [Vol. 22:1 [Vol. 9/21/2018 1:50 PM , http://4490ventures.com/ , http://amfamventures.com/ VENTURES 70 ENTURES , http://nmfutureventures.com/ V , 4490 AMILY ENTURES , https://www.ideafundvc.com/people , http://csapartners.com/ [https://perma.cc/T7AR- , http://csapartners.com/ [https://perma.cc/T7AR- V . F M While Wisconsin still ranks last for startup 71 Startups ROSSE , A 75 , http://www.37celsiuscapital.com [https://perma.cc/8JJU- C , http://www.bairdcapital.com/sector-expertise/baird- , http://www.bairdcapital.com/sector-expertise/baird- UTURE , http://www.capitalmidwest.com/ [https://perma.cc/VHM5- , http://www.capitalmidwest.com/ [https://perma.cc/VHM5- 72 69 67 A ARTNERS . §§ 16.295, 20.505(1)(fm), 25.17(72) (2013–2014). . F L Act 41 created Wisconsin Statute section 16.295, Act 41 created Wisconsin Statute section UT TAT 77 APITAL ARTNERS IDWEST C . M . S P 68 , CSA P M IS W UND OF , http://www.cmfgventures.com/ [https://perma.cc/YB4Y-6YUX] (last 66 F MARQ. INTELL. PROP. L. REV. REV. L. PROP. INTELL. MARQ. 73 , N AIRD note 40. for later stage companies. which provides a source of startup capital via creation of which provides a source of startup ) DEA , B APITAL 74 76 APITAL C , I , GCI, http://www.gcionline.com/about/ [https://perma.cc/2ZCL-FTHD] (last , GCI, http://www.gcionline.com/about/ [https://perma.cc/2ZCL-FTHD] supra ENTURES , C ELETE , D OT OT N CELSIUS O Funding Innovation About Us Future Ventures Sector Focus Fueling Entrepreneurs’ Dreams 4490 Ventures Forward Funding Funding Overview (D Northwestern Mutual Investors Future 4490 Ventures 4490 37Celsius, Baird Venture Partners Baird Venture CMFG Ventures Capital Midwest Funds American Family Ventures Gary Comer Inc. (GCI) CSA Partners Our Partners INAL INAL 69. 70. 67. 74. 37 71. 66. 73. 72. 68. CMFG V 75. 76. Wisconsin Act 41, W 77. .F F.Wisconsin Wisconsin in Law - Legislation to Encourage Investment Legislation to help foster startup formation in Wisconsin includes the 2013 Finally, Wisconsin’s nationally recognized accelerator program,recognized accelerator Wisconsin’s Gener8tor, nationally Finally, EM 7. S 7. visited Sept. 29, 2017). visited Sept. 29, visited Sept. 29, 2017). visited Sept. 29, [https://perma.cc/R7S8-4AH3] (last visited Sept. 29, 2017). 29, [https://perma.cc/R7S8-4AH3] (last visited Sept. the Badger Fund-of-Funds. HZET] (last visited Sept. 29, 2017). [https://perma.cc/LV82-B6SE ] (last visited Oct. 2, 2017); Badger Fund of Funds (Venture Capital)[https://perma.cc/LV82-B6SE ] (last visited Oct. 2, 2017); Badger Fund of Funds (Venture Wisconsin Act 41, activity, this will hopefully change as an increasing number of venture capital sources emerge for Wisconsin and startups, as the state itself enacts legislation investments. to further encourage startup [https://perma.cc/Q645-Y2SH] (last visited Sept. 29, 2017). 29, [https://perma.cc/Q645-Y2SH] (last visited Sept. FLLQ] (last visited Sept. 29, 2017). 2017). FLLQ] (last visited Sept. 29, [https://perma.cc/GSM2-X49T] (last visited Sept. 29, 2017). [https://perma.cc/GSM2-X49T] (last visited Sept. 29, 66 has already invested in fifty-four companieshas already invested that have gone on to secure over $120 million in follow-on capital. capital-sectors.aspx [https://perma.cc/2M57-CKTV] (last visited Sept. 29, 2017). capital-sectors.aspx [https://perma.cc/2M57-CKTV] (last visited Sept. 29, V225] (last modified 2017). V225] (last modified 40672-mqi_22-1 Sheet No. 35 Side B 05/20/2019 14:43:36 B 05/20/2019 35 Side Sheet No. 40672-mqi_22-1 40672-mqi_22-1 Sheet No. 36 Side A 05/20/2019 14:43:36 , , 83 67 85 ., Businesses 9/21/2018 1:50 PM 4 (2015), 84 ORP . C According to the EV OUNCIL 78 C . D CON E It is the experienced private It is the experienced ECHNOLOGY 81 T ISCONSIN , W ISCONSIN note 78. , W . § 16.295 (2015–2016). . § 16.295 supra The statute that was enacted by Act 255, The statute that , TAT 82 . S IS OUNCIL . C Winnebago Seed Fund, Part of Badger Fund of Funds, Raises $11M Winnebago Seed Fund, Part of Badger Fund ) ECH WI’s Badger Fund of Funds Unlocks State Money, Eyes First Recipients WI’s Badger Fund of Funds Unlocks State T This is therefore a public-private partnership, where the state where the state partnership, a public-private This is therefore ELETE . § 16.295. . § 238.15 (2013–2014). . § 238.15 . § 238.15 (2015–2016). D 80 CELEBRATING WISCONSIN ENTREPRENEURS ENTREPRENEURS WISCONSIN CELEBRATING OT OT TAT TAT TAT N ISCONSIN . S . S . S O Qualified New Business Venture Program Investing in Next-Generation Jobs (Mar. 3, 2015), http://www.xconomy.com/wisconsin/2015/03/03/wis-badger-fund-of- (June 2, 2017), http://www.xconomy.com/wisconsin/2017/06/02/winnebago-seed-fund- IS IS IS (D The state funds are leveraged since they are to be matched since they are funds are leveraged The state by 2:1 79 INAL INAL 78. W 84. W 85. 82. W 79. Jeff Engel, 80. 83. W 81. Jeff Buchanan, .F One final piece of legislation that Wisconsin has passed to nurture startup Other Wisconsin legislation that was created to foster Wisconsin’sOther Wisconsin startup legislation that was created M K EM CONOMY CONOMY C Y 7. S 7. X activity is Act 52, which was passed to create the state counterpart to the federal AnnualReports.aspx [https://perma.cc/7E2F-VSRK] (last visited Oct 2, 2017). AnnualReports.aspx [https://perma.cc/7E2F-VSRK] [https://perma.cc/77FM-MJ8L].funds-unlocks-state-money-eyes-first-recipients investment includes the investor tax credits that were created by Act 255 in that were created by Act investment the investor tax credits includes in 2013. 2004 and revised statute, the state provides $25 million to the Fund-of-Funds, which$25 million state provides statute, the Fund-of-Funds, the is to be to managed investment by an manager of their own $300,000 that provides funds. private funds. part-of-badger-fund-of-funds-raises-11m/ [https://perma.cc/9RWX-NPLB]. Wisconsin Stage Business called the “Early Statute Section 238.15, is Investment Program” contains within it the “angel investor tax credit.” and Annual and Quarterly Reports, https://doa.wi.gov/Pages/StateFinances/VentureCapitalQuarterlyand to “establish and administer a program for the investment of moneys of investment in venture the for administer and to “establish a program in this state.” businesses located that invest in capital funds This tax credit encourages investment in Wisconsin startups and applies only to investments in Wisconsin-based companies with less than 100 employees capital. than $10 millionless in private equity and that have raised 2018] http://wisconsintechnologycouncil.com/wp-content/uploads/2015/09/2015WhitePapers-Web.pdf [https://perma.cc/U9FW-5HAF]; W of Wisconsin (to date) the investors, including invests along-side private Winnebago Fund ($4 million), Seed of La Crosse ($8.1 million) the Idea Fund Partners ($6 million).and Rock River Capital http://inwisconsin.com/entrepreneurs/assistance/qualified-new-business-venture/ 2017). [https://perma.cc/Y9GC-VYSR] (last visited Oct. 2, X investors who are co-investing and making the investment co-investing and making investors who are rather decisions, government. than the that meet these and other criteria specified in the statute are said to have in the that meet specified these and other criteria eligible are then Venture (“QNBV”) certification, and Qualified New Business investment. is 25%for the angel investor tax credit, which of the equity 40672-mqi_22-1 Sheet No. 36 Side A 05/20/2019 14:43:36 A 05/20/2019 36 Side Sheet No. 40672-mqi_22-1 40672-mqi_22-1 Sheet No. 36 Side B 05/20/2019 14:43:36 , M K C Y . (June Panel: ORP Any such Any such [Vol. 22:1 [Vol. . C 9/21/2018 1:50 PM EV 87 (Jan. 14, 2012), . D This sector is IMES 92 CON E Generally Accepted Auditing N.Y. T N.Y. While crowdfunding is , , as defined by federal , as defined by federal 90 HE ORG , T ISCONSIN Health Care in Wisconsin, Part 1: , W ndards/AuditAttest/DownloadableDocuments/AU- accredited investor However, any single investor However, any single cannot invest more , as defined by state law. , as defined by state 88 MARQ. INTELL. PROP. L. REV. REV. L. PROP. INTELL. MARQ. ) Madison’s HealthTech Cluster: The Rise of Epic and Everybody Else are the healthcare and HealthTech sectors. are . § 551.202(26)(c)(1)(b) (2015–16); AICPA. ELETE . § 551.202(26)(d). 91 Digitizing Health Records, Before It Was Cool D TAT which crowdfunding. enabled of the selling is Crowdfunding OT OT , http://www.epic.com/ [https://perma.cc/MH8C-45JC] (last visited Sept. 29, 2017); , http://www.epic.com/ [https://perma.cc/MH8C-45JC] TAT . S N 86 IS qualified investor . S O PIC Jeff Engel, IS (Aug. 17, 2015), http://www.xconomy.com/wisconsin/2015/08/17/madisons-healthtech- (D , https://www.aicpa.org/Research/Sta or a INAL INAL 88. W 91. E 89. 17 C.F.R. § 230.501(a) (2017). 90. W 92. 87. Crowdfunding, 80 Fed. Reg. 71, 387 (Nov. 16, 2015) (to be codified in scattered sections 86. Our Business Startups Act, Pub. Jumpstart L. No. 112-106, 126 Stat. 306 (2012) (codified .F 89 Wisconsin’s entrepreneurial ecosystem is showing signs of growth on other is showing Wisconsin’s ecosystem entrepreneurial EM CONOMY G.HealthTech Future Growth Opportunities – Spotlight on Healthcare and 7. S 7. particularly promising, to the tremendous in part due success of Epic Systems (Madison, WI), fronts, beyond the traditional manufacturing and advanced manufacturing technology-based startup growth that is sectors. One high-growth area of X cluster-epic-everybody-else/# [https://perma.cc/4BG3-7M5Y]; Business Ecosystem Helps Foster Health Technology Success 8, 2016), http://inwisconsin.com/entrepreneurs/launch-blog/health-care-in-wisconsin-part-1-business- ecosystem-helps-foster-health-technology-success [https://perma.cc/2QBL-3382]; Brian Lee, as amended in scattered sections of 15 U.S.C.). as amended in scattered sections of 15 C.F.R.). of 17 Standards unregistered private securities on the internet, subject to regulatory restrictions. regulatory subject to on the internet, private securities unregistered The Securities and Exchange Commission of crowdfunding. of the process on and oversight guidance (“SEC”), a federal agency, provides 00150.pdf [https://perma.cc/WPQ5-43GD] (last visited, Apr. 14, 2018). http://www.nytimes.com/2012/01/15/business/epic-systems-digitizing-health-records-before-it-was- cool.html?mcubz=0 [https://perma.cc/F62G-SR9T]. Milt Freudenheim, transactions are typically subject to both federal and state laws. The relevant and state laws. federal to both are typically subject transactions Wisconsin from statute resulting allows to $1 to issue up a startup Act 52, million in a twelve-month in securities period via the crowdfunding exemption, and $2 million accounting principles the startup does a generally accepted if audit. (“GAAP”) compliant JOBSAct, 68 an interesting source of startup capital for Wisconsinan interesting source companies, the bigger impactto come our startup ecosystem on from is likely legislation that fosters larger and more traditional equity investments, like Act 41 and Act 255. Meanwhile, it is clear that state government it can to encourage is doing what investment in Wisconsin whether it be from startups, individuals (Act 52), or 255). from (Acts 41 and angel and venture capital investors than $10,000, unless they are an than $10,000, unless law, 40672-mqi_22-1 Sheet No. 36 Side B 05/20/2019 14:43:36 B 05/20/2019 36 Side Sheet No. 40672-mqi_22-1 40672-mqi_22-1 Sheet No. 37 Side A 05/20/2019 14:43:36 , 69 9/21/2018 1:50 PM NDUSTRY IN , CNBC (Jan. 17, I which broadly broadly which (May 13, 2017), 93 ECH T (May 19, 2015), Report: Epic, Cerner and EALTH NFORMATICS I 95 H TARTUPS S HE T ADISON EALTHCARE , M , H which sponsors the healthcare innovation the healthcare which sponsors ISCONSIN With the success of Wisconsin-based Epic note 89; Heather Landi, 94 W 96 newsem/ehr/report-epic-cerner-and-athenhealth-lead-small- , www.bioforward.org [https://perma.cc/8AHX-5HNZ] (last , www.bioforward.org [https://perma.cc/8AHX-5HNZ] supra , www.bridgetocures.com (last [https://perma.cc/VV6D-VPM3] PPORTUNITIES FOR O ISCONSIN URES Tech Set to Transform $3 Trillion Health Care Industry W C ) note 89; Lee, Bridge to Cures Eyes More Funds, Bigger Programs to Nurture Startups Bridge to Cures Eyes More Funds, Bigger ELETE D supra ORWARD CELEBRATING WISCONSIN ENTREPRENEURS ENTREPRENEURS WISCONSIN CELEBRATING OT OT F N RIDGES TO IO O (Dec. 24, 2015), http://www.xconomy.com/wisconsin/2015/12/24/bridge-to-cures-eyes- (D 97 HALLENGES AND INAL INAL 96. Gemma Acton, 95. Jeff Engel, 97. Engel, 93. B 94. B .F A.Innovation Wisconsin’s Rich History of Healthcare and HealthTech Wisconsin’s innovation in the food and beverage industry sector history of Why is HealthTech the sector to watch? Many believe it is well-positioned well-positioned Whysector to watch? Many is HealthTech the believe it is M K EM CONOMY III. C C Y 7. S 7. 2017 11:41 AM), https://www.cnbc.com/2017/01/17/tech-set-to-transform-3-trillion-health-care- 2017). industry.html [https://perma.cc/U8XF-SEAD] (last visited Sep 29, more-funds-bigger-programs-to-nurture-startups/ [https://perma.cc/6ZJJ-HMT4].more-funds-bigger-programs-to-nurture-startups/ visited Oct. 01, 2017). visited Oct. 01, X as well as in manufacturing manufacturing)now advanced (and is impressive, healthcare and HealthTech (e.g., digital but it is also strong in the areas of health). Prominent companies in this sector, now, include Epic, Aurora, Ascension, Froedtert/MCW, Covance, Promega, GE Healthcare (once in, Wisconsin),headquartered in, but not started TomoTherapy, Roche NimbleGen, Dohmen Cambridge Life Sciences, Major Labs (now Alchemy), http://www.madisonstartups.com/panel-wi-ahead-in-health-tech/ [https://perma.cc/B8W5-8NUX].http://www.madisonstartups.com/panel-wi-ahead-in-health-tech/ hossmall-hospital-ehr-adoption [https://perma.cc/F79T-PFAM]. https://www.healthcare-informatics.com/ to transform a $3 trillion healthcare industry, and it may reshape how healthcare reshape may it and industry, a $3 trillion healthcare to transform Unitedis delivered in the States. visited Oct. 01, 2017). visited Oct. 01, WI Ahead in Health Tech, Startup and Tech News supported by the industry trade organization BioForward, organization trade the industry by supported 2018] Athenahealth Lead Small Hospital EHR Adoption pitch event, that provides business, regulatory, and intellectual property and intellectual business, regulatory, that provides pitch event, mentoring while also connecting and HealthTech innovators, to healthcare funds. seed and venture capital them to sources of supports the biohealth industry, including digital health, medical devices and medical devices digital health, including the biohealth industry, supports biotech, and biopharmaceuticals.diagnostics, resource A recently developed Wisconsinin southeast and HealthTech healthcare to further assist Cures, is Bridge to entrepreneurs Systems captured 26% (which hospital marketof the U.S. for EMRs, Electronic Medicalnext generation of HealthTech the behind us as a state, Records) innovators in Wisconsin of HealthTech are working on the next generation startups. 40672-mqi_22-1 Sheet No. 37 Side A 05/20/2019 14:43:36 A 05/20/2019 37 Side Sheet No. 40672-mqi_22-1 40672-mqi_22-1 Sheet No. 37 Side B 05/20/2019 14:43:36 , 98 M K , 3 100 C Y . (May EV . R Ralph M. M. Ralph [Vol. 22:1 [Vol. US 99 9/21/2018 1:50 PM . B In addition to (May 29, 2008), 101 ARV . Y ’ , H [https://perma.cc/P4CM- OC S 286, abstract (2003), vitamins ISTORICAL . H As a result, the Wisconsin Alumni IS NESTHESIOLOGY 103 , W (2015), http://jdc.jefferson.edu/gibbonsocietyprofiles/43 (2015), http://jdc.jefferson.edu/gibbonsocietyprofiles/43 Frederic E. Mohs, M.D. (1910-2002): Physician and Innovator Frederic E. Mohs, M.D. (1910-2002): Physician , 98 A After further experimentsled to on rats, this Why Innovation Why So in Is Health Care Hard ROFILES History of the Discovery of Vitamin D and its Active Metabolites 102 P Ralph M. Waters, M.D., and Professionalism in Anesthesiology: A Ralph M. Waters, M.D., and Professionalism MARQ. INTELL. PROP. L. REV. REV. L. PROP. INTELL. MARQ. ) 1, 2 (Jan. 2014), https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3899558 ELETE ISTORICAL , D H OT OT N . EPORTS O Vitamin-Finding Feces Bucket Id R (D URGERY OCIETY S Y S INAL INAL KE 101. 100. Donald Caton, 98. E. Herzlinger, Regina 103. 99. et al., Nicholas A. Ross, 102. Hector F DeLuca, .F T OF Wisconsin companies but they face innovation, are leaders in healthcare Examples of healthcare innovators include many biomedical researchers at manyExamples biomedical innovators include of healthcare researchers ’ EM EP IBBON ONE Access HealthNet, and SmartChoice and HealthNet, Access MRI. 7. S 7. challenges. challenges. innovation, face healthcare that the difficulties analyzed Herzlinger funding limitations,including more, and restrictions, accountability policy but in spite of these challenges, Wisconsin of these challenges, but in spite and companies innovators have many achievements great healthcare and significantly to which contributed below. technological advancement. are reviewed These [https://perma.cc/KT52-6RWU]. B Celebration of 75 Years the University of Wisconsin–Madison, Mohs. such as Frederic E. Mohs, while a medical student at UW–Madison, the micrographic surgical developed used to remove skin cancer lesions. later widely technique that was D Research Foundation (“WARF”)in 1925 to commercialize was created http://anesthesiology.pubs.asahq.org/article.aspx?articleid=1943820 http://anesthesiology.pubs.asahq.org/article.aspx?articleid=1943820 PWTM]. [https://perma.cc/S6UE-8Q9G]. Additionally, researchers Hart and Humphrey, along with E.V. McCollum Hart and Humphrey,Additionally, researchers along and did animalHarry Steenbock, feeding experiments to discover essential nutrients present in corn but deficient other grains, and after years of in the nutrients as research, characterized these unknown 70 G Waters, to UW–Madison recruited training in 1927, established an anesthesia program, which improved the world. anesthesia practice throughout 2006), https://hbr.org/2006/05/why-innovation-in-health-care-is-so-hard [https://perma.cc/3ZTF- 2006), https://hbr.org/2006/05/why-innovation-in-health-care-is-so-hard 8Q4C]. https://www.wisconsinhistory.org/Records/Article/CS2635 [https://perma.cc/M3X5-7UUP]. participating in the pioneering work that led to the discovery of participating in the pioneering work vitamins, Harry levels between sunlight and calcium Steenbock also discovered the connection levels when kept lacked proper calcium in blood, based on studies of goats that indoors in the winter. Steenbock’s discovery and patenting of the process for using UV light to the process for of Steenbock’s discovery and patenting activate vitamin D—aused to treat most process subsequently of the milk sold that contributed to the eliminationin the United States, and a discovery of rickets as a major medical problem. 40672-mqi_22-1 Sheet No. 37 Side B 05/20/2019 14:43:36 B 05/20/2019 37 Side Sheet No. 40672-mqi_22-1 40672-mqi_22-1 Sheet No. 38 Side A 05/20/2019 14:43:36 At At 71 VER I LUMNI 104 AC A , M The drug , 122 (Anne 106 9/21/2018 1:50 PM ISCONSIN ISTORY H , W ICTORIAL : A P ISCONSIN W NIVERSITY OF U HE How dead cattle led to the discovery of Warfarin , T UW–Madison Foundations Assets to More than $6 Grow Billion (June 27, 2013), https://www.warf.org/news-media/news/in-the-news/how- ) OVE H ELETE D CELEBRATING WISCONSIN ENTREPRENEURS ENTREPRENEURS WISCONSIN CELEBRATING 107 OT OT N This vision grewThis vision expectations, withfar beyond initial WARF now RTHUR O OUNDATION (Mar. 20, 2015), http://www.maciverinstitute.com/2015/03/uw-madison-foundations- F (D 105 INAL INAL 106. Nick Novak, 107. Thomas Meek, 104. A 105. Id. .F M K EM ESEARCH C Y NSTITUTE 7. S 7. Biebel 1991). being one of the country’s premier university technology transfer and premier of the country’s being one technology university commercialization innovation. research and university supporting foundations In 2014, WARF gave UW–Madison a $58 million 17% grant, of its $342 millionand related activities. revenue, to support research annual grow-assets-to-more-than-6-billion [https://perma.cc/4BEM-P89N]. the time, WARFthe time, to patent and being created concept, was a pioneering commercialize money research to generate faculty to support more faculty research. dead-cattle-led-to-the-discovery-of-warfarin.cmsx [https://perma.cc/8TFF-CYBL]. Warfarin (derived fromdiscovered at UW–Madison dicoumarol), by Dr. Karl was named the door to a new class of blood anticoagulants, Link and opening after WARF. I R Steenbock’s invention of this method of this invention Steenbock’s D in milk. vitamin activating for 2018] 40672-mqi_22-1 Sheet No. 38 Side A 05/20/2019 14:43:36 A 05/20/2019 38 Side Sheet No. 40672-mqi_22-1 40672-mqi_22-1 Sheet No. 38 Side B 05/20/2019 14:43:36 M K N.Y. N.Y. C Y HE , T [Vol. 22:1 [Vol. 9/21/2018 1:50 PM Ernst and Young, LLC - August 2015. Data 2015. August - LLC Young, and Ernst More recently, Dr. Howard Jacobs, when he was recently, Dr. Howard More 108 MARQ. INTELL. PROP. L. REV. REV. L. PROP. INTELL. MARQ. W. Dudley Johnson, Heart Bypass Surgery Pioneer, Dies at 86 ) ELETE Reproduced with permission. While a majority of bioscience bioscience of majority a While permission. with Reproduced D Bioscience and Healthcare IT (HealthTech) activity in activity top 5 (HealthTech) Healthcare IT and Bioscience OT OT N O (D Fig. 3. 3. Fig. INAL INAL 108. Sam Roberts, .F Medical innovation in Wisconsin certainly not limited was to Madison. Wisconsin counties, based on revenue. Size of bubble corresponds to corresponds bubble of Size revenue. on based counties, Wisconsin in Waukesha and Dane is county, Madison ofnumber employees. relative Wisconsin’s Energizing Source: Bioscience: Milwaukee. is a of suburb by completed Economy; Year: 2013. Year: and Milwaukee the is in HealthTech of majority a in Madison, is Waukesha areas. EM 7. S 7. Milwaukee artery physician Dr. Dudley Johnson pioneered the first coronary bypass surgery in the 1960s, by removing a vein from the leg and implanting to the coronary artery, and thereby helping to make Milwaukee a leader in also the first to do the cardiovascular medicine and surgery. Dr. Johnson was multiple bypass surgery. 72 40672-mqi_22-1 Sheet No. 38 Side B 05/20/2019 14:43:36 B 05/20/2019 38 Side Sheet No. 40672-mqi_22-1 40672-mqi_22-1 Sheet No. 39 Side A 05/20/2019 14:43:36 : 73 EART H (Dec. 18, 9/21/2018 1:50 PM TATE OF THE ENTINEL , S J. S 113 (The Society of Thoracic 113 (The Society of TEPHENSON l [https://perma.cc/ZWT5-9F2D]; ILWAUKEE S , M URGERY S ARRY EART H (Jun. 06, 2016), https://www.aurorahealthcare.org/ (Jun. 06, 2016), https://www.aurorahealthcare.org/ ., [https://perma.cc/WFJ2-69UJ] (last visited Oct. 2, (Apr. 5, 2017), https://www.aurorahealthcare.org/me ARE ONF A Baffling Illness C Additionally, at Aurora St. Luke’s Medical ARE C s/health/111641209.htm C and now Promega has over 2000 products that 111 EART AND H ORLD EALTH 113 H EALTH . W H OUR . J. (May 25, 2008), http://host.madison.com/business/madison-bio- ED Y Madison Bio-Giant Promega Helped put Madison on the World’s (Apr. 20, 2016), https://www.washingtonpost.com/opinions/a-boys- T for a undiagnosed boy with an young and life-threatening M URORA . S A Boy’s Mysterious Illness, a Bold Gamble and a Breakthrough in Genetic A Boy’s Mysterious Illness, a Bold Gamble and ) OST IS URORA 109 , A . P , A ELETE , W UIDE TO D Dr. Kress commented that “[w]e’re. . reduce future able to . G ASH CELEBRATING WISCONSIN ENTREPRENEURS ENTREPRENEURS WISCONSIN CELEBRATING RECISION OT OT N W , P 110 O 112 Aurora Health Care Heart Experts Among First in Nation to Implant New Heart Valve to Heart Valve to Implant New in Nation Among First Aurora Health Care Heart Experts Aurora St. of People to Improve Luke’s Medical Lives Hybrid Pioneers Center Procedure HE (D , T INAL INAL (Oct. 30, 2016), https://www.nytimes.com/2016/10/31/health/dudley-johnson-dead-coronary- RACTICAL 111. Id. 112. 113. Judy Newman, 109. Susan Okie, country are looking at.” country are looking 110. .F P Wisconsin played an important has also role in the early days of Innovation has also occurred at hospital institutions like Aurora. occurred at hospital institutions like Innovation has also Dr. Jasbir M K EM IMES HE C Y 7. S 7. biotechnology, with companies in Madison founded like Promega, in 1978 by Bill Linton. Promega enzymes, restriction provided the primary tools needed to do genetic cloning work, Surgeons, 1999), https://www.ctsnet.org/book/soth/chapt08_rev.pdf [https://perma.cc/P6VA-JGBS]. with Atrial Fibrillation Treat Aortic Stenosis media-center/news-releases/aurora-st-lukes-medical-center-pioneers-hybrid-procedure-to-improve- lives-afib-patients [https://perma.cc/PJ7V-Q97R]. Biotechnology Stage dia-center/news-releases/aurora-health-care-heart-experts-among-first-in-nation-to-implant-new- dia-center/news-releases/aurora-health-care-heart-experts-among-first-in-nation-to-implant-new- heart-valve [https://perma.cc/FJK7-BEAD]. giant-promega-helped-put-madison-on-the-world/article_4589f664-3abe-58f9-9a7e- 4904445045d2.html [https://perma.cc/7P8K-GSPA]. Medicine Center, Drs. O’Hair and Bajwa implantedCenter, Drs. O’Hair the new Medtronic CoreValve Evolut Aurora St. 2017, makingthe FDA in PRO, by a new valve approved in Wisconsin,third hospital in the nation, and first to apply this the Luke’s new valve. instances of arrhythmias [i]t’s a model other health care systems across the instances of arrhythmias [i]t’s a model other health care systemsacross T mysterious-illness-a-bold-gamble-and-a-breakthrough-in-genetic-medicine/2016/04/20/13f20b16- e638-11e5-bc08-3e03a5b41910_story.html?utm_term=.d7069c5bab87 [https://perma.cc/TF5R-KTe638-11e5-bc08-3e03a5b41910_story.html?utm_term=.d7069c5bab87 LD]. Mark Johnson & Kathleen Gallagher, T director of the Medical Wisconsin’s of College of director Genetics Molecular Human and targeted a whole genome the first to use Center, was to guide sequencing treatment strategy, 2018] inflammatory disease. This successful gene-based diagnosis and treatment diagnosis successful gene-based disease. This inflammatory a milestonerepresents precision medicine, in the era of using genomic makeup. information to target treatments on a person’s genetic based Sra, medical director of Aurora Healthcare’s AtrialAblation Fibrillation Surgery at Aurora Kress, the chief of Cardiothoracic Center, and Dr. David St. to treat atrial technique Luke’s Medical ablation Center pioneered a new hybrid fibrillation. Howard Jacob 2010), http://archive.jsonline.com/new 2017). bypass.html?mcubz=0 [https://perma.cc/L9KC-NLA8]; L bypass.html?mcubz=0 [https://perma.cc/L9KC-NLA8]; 40672-mqi_22-1 Sheet No. 39 Side A 05/20/2019 14:43:36 A 05/20/2019 39 Side Sheet No. 40672-mqi_22-1 40672-mqi_22-1 Sheet No. 39 Side B 05/20/2019 14:43:36 , M K 115 C Y These 120 [Vol. 22:1 [Vol. The most The most 9/21/2018 1:50 PM 114 BioForward is with a net worth 119 118 , https://www.bioforward.org/strength- Forbes’ 2016 List of America’s Richest Self-Made Forbes’ 2016 List of America’s Richest Self-Made IOFORWARD Her way: Epic Systems CEO Judy Faulkner Talks Her way: Epic Systems CEO Judy Faulkner Talks giving it the largest marketgiving it of any share , B 116 Wisconsin (Jan. 11, 2016), http://archive.jsonline.com/business/ge- . J. (Apr. 12, 2017), http://host.madison.com/ct/news/local/her- . T . S IS , GE Healthcare to Move Global Headquarters from United Kingdom to United Kingdom Headquarters from Healthcare to Move Global , GE Epic Systems Soars with Transition to Electronic Health Records Epic Systems Soars with Transition to Electronic MARQ. INTELL. PROP. L. REV. REV. L. PROP. INTELL. MARQ. (Jan. 24, 2016), http://archive.jsonline.com/business/epic-systems-soars- ENTINEL note 89. , W ) J. S ELETE supra and its founder Judith Faulkner was ranked as the third Judith Faulkner was ranked as and its founder D ENTINEL (June 1, 2016), https://www.forbes.com/sites/forbespr/2016/06/01/forbes-2016-list- (June 1, 2016), https://www.forbes.com/sites/forbespr/2016/06/01/forbes-2016-list- OT OT N . 117 J. S O Id 2015 Wisconsin Bioscience Report 2015 ILWAUKEE (D ORBES , M , F INAL INAL 118. Forbes Corporate Communications, 116. Engel, 117. Guy Boulton, 120. 119. Thomas Content 114. 115. Ferral & Erik Lorenzsonn, Katelyn .F While Madison-based Epic Systems may be the largest and most prominent B. Entrepreneurial Ecosystem in Southeast HealthTech Startups and the EM ILWAUKEE 7. S 7. Women with-transition-to-electronic-health-records-b99642837z1-366328781.html [https://perma.cc/B3F8- with-transition-to-electronic-health-records-b99642837z1-366328781.html VPH5]. M healthcare-to-move-global-headquarters-from-united-kingdom-to-chicago-b99649839z1- 364927371.html [https://perma.cc/J8LK-M878]. wisconsin-biohealth/ [https://perma.cc/DAX6-983W]. of-americas-richest-self-made-women/#768320c51747 [https://perma.cc/89ZZ-EN7J]. Chicago the trade organization representing the healthcare (e.g., medical and devices the the trade organization representing (e.g., digital health) industries for diagnostics), biotechnology and HealthTech Wisconsin, and in 2015 BioForward commissioned & Ernst to do Young analysis of the economic impact of these industries in the state. it sells in thirteen countries. countries. in thirteen it sells of has the industry history This long earned serving Promega of biotechnology.” the “granddaddy the title as way-epic-systems-ceo-judy-faulkner-talks-about-trusting/article_7fafd560-d5fd-5a7f-8ef8- 59d6bd4cf452.html [https://perma.cc/GP8D-A3LA]. EMR company. over $1.8 billion in sales and In 2015, Epic had 9500 employees, industries produce $27 billion in economic impact (2013), while directly 74 record) systems the EMREpic developed in 26% used medical (electronic of in the Unitedall hospitals States, of $2.4 billion. of $2.4 about Trusting Her Vision wealthiest self-made woman in the United States in 2016, prominent HealthTech company with in Wisconsin roots Systems, is Epic a UW–Madison by Judith Faulkner, started in computer science graduate. HealthTech in Wisconsin,it is certainly in the company of other HealthTech Healthcare, companies, many southeast Wisconsin. of which are located in GE a pioneer in imaginganalytics technology, is located in and associated Waukesha there). (and previously had been headquartered 40672-mqi_22-1 Sheet No. 39 Side B 05/20/2019 14:43:36 B 05/20/2019 39 Side Sheet No. 40672-mqi_22-1 40672-mqi_22-1 Sheet No. 40 Side A 05/20/2019 14:43:36 , 125 75 The 121 DVISORS For that A 122 9/21/2018 1:50 PM ). APITAL C Fig. 3 Fig. NDERSON founded EMSystems A 124 AYNE , K , http://www.spauldingclinical.com/index.php/ecg- Another southeast Wisconsin HealthTech which is a group that supports HealthTech which is a group that supports HealthTech , http://www.xconomy.com/author/anunemaker/ [https:// , http://www.xconomy.com/author/anunemaker/ LINICAL 127 C 129 CONOMY Previously, Nunemaker note 120. , https://dynamiscorp.com/about [https://perma.cc/AA8Z-ZRXT] (last , X PAULDING , www.healthtechmke.com [https://perma.cc/9MP7-9DJS]. , www.healthtechmke.com , S 123 ) supra , ECH 5, http://www.srhwebdev.com/wp-content/uploads/2016/02/BFOR-0002_EY_ YNAMIS new company, Dynamis, produces software facilitates that T ELETE D t, D CELEBRATING WISCONSIN ENTREPRENEURS ENTREPRENEURS WISCONSIN CELEBRATING 126 OT OT N . . at 10. . at CONOMY EALTH O Energizing Wisconsin’s Economy 2015 Wisconsin Bioscience Economic Development Energizing Wisconsin’s Economy 2015 Wisconsin Intermedix Corp Acquires EMSystems, LLC Abou Another serial HealthTech entrepreneur in Milwaukee is Jay Mason, Jay entrepreneur in Milwaukee is HealthTech Another serial ECG Solution Andy Nunemaker Id Id (D IOFORWARD 128 B INAL INAL 124. 125. 122. 123. 129. H 128. 121. 126. X 127. .F Southeast Wisconsin number has a large and growing of new HealthTech M K EM C Y 7. S 7. White_Paper_W0.pdf [https://perma.cc/QW2V-TUZK]. solution [https://perma.cc/2W9G-EWE5]2016). (last modified Report, perma.cc/H99H-VQ4M] (last visited Oct. 2, 2017). reason, this article will provide a deeper analysis of the HealthTech industry in industry of the HealthTech a deeper analysis article will provide reason, this southeast Wisconsin. companies, Wisconsin founded by HealthTech (summarized entrepreneurs in Milwaukee’sTable 2). One of most prominent entrepreneurs is HealthTech Andy Nunemaker. communication insurance brokers and customers between healthcare (e.g., employers, and their human resource administrators), to enable competitive shopping for health insurance. entrepreneurs. Mason has formed six companies, his most recent being visited Oct. 2, 2017). creating 37,000 jobs (and 70,000 total jobs, due to a multiplier due total jobs, 70,000 jobs (and 37,000 creating effect). Nunemaker’s 2018] success is Spaulding Clinical, founded by Randy Spaulding and focused on success is Spaulding Clinical, founded providing quality-based ECGs (electrocardiograms) with web-based remote along to physicians, information real-time moreto give monitoring, reliable and such as in medicalwith better access to care and information for patients, homes. http://kaynecapital.com/intermedix-corp-acquires-emsystems-llc/ [https://perma.cc/32Y4-CM4G]http://kaynecapital.com/intermedix-corp-acquires-emsystems-llc/ 2017). (last visited Oct 2, (acquired by Intermedix) Dynamis is now CEO and founder of and Corporation. EMSystems (now Intermedix) solutions for provides web-based forty-five states and in over in emergency providers and is used healthcare emergency1500 hospitals for and related applications. dispatch, reporting, report established that the largest concentration of companies largest concentration that the report established on (based is in the Madisonrevenue) County), Milwaukee (Dane and Waukesha regions, with Wisconsin southeast (Milwaukee and Waukesha) having a particular general ( in in medicalstrength and HealthTech devices founder of HealthTech MKE, 40672-mqi_22-1 Sheet No. 40 Side A 05/20/2019 14:43:36 A 05/20/2019 40 Side Sheet No. 40672-mqi_22-1 40672-mqi_22-1 Sheet No. 40 Side B 05/20/2019 14:43:36 , M K 133 C Y [Vol. 22:1 [Vol. Affordable 9/21/2018 1:50 PM X-FVW3] (last visited (July 18, 2017, 12:31 PM), (July 18, 2017, 12:31 PM), ORBES , F 3VR-XGLA]. , http://www.accesshealthnet.com/about/ , http://www.accesshealthnet.com/about/ ET N EALTH and their benefit administrators. H 131 is Cost and Access CCESS (Jan. 24, 2017), https://khn.org/news/block-grants-medicaid-faq , http://intellivisit.com [https://perma.cc/C2D Intellivisit Lands New Customers, Expects New Financing in October Intellivisit Lands New Customers, Expects New EWS MARQ. INTELL. PROP. L. REV. REV. L. PROP. INTELL. MARQ. The For Medicaid Case Block Grants , A N ) NTELLIVISIT ELETE D , I EALTH H OT OT is focused on who should get insurance coverage and how muchis focused on who should get insurance Everything You Need to Know about Block Grants—’The Heart of GOP’s Medicaid Everything You Need to Know about Block Grants—’The N O Home About Us 132 (Sept. 2, 2015), http://www.xconomy.com/wisconsin/2015/09/02/intellivisit-lands-new- , (D Access HealthNet, founded by yet another southeast Wisconsin serial Wisconsin by yet another southeast founded Access HealthNet, AISER 130 INAL INAL 131. 132.3590 (111th): H.R. Patient Protection and Affordable Care Act, 42 U.S.C. § 18001 et seq. 133. Capital Flows, 130. , K .F A general theme for southeast Wisconsin’s HealthTech companies is to The current political debate over healthcare, as it pertains to the pertains to it over healthcare, as current political debate The EM CONOMY C. States The MajorFacing the Healthcare Challenge Industry in the United 7. S 7. https://www.forbes.com/sites/realspin/2017/07/18/the-case-for-medicaid-block- grants/#4042a37b3ddb [https://perma.cc/BKV2-QXQB]; provide software-based technology that gets informationprovide software-based in the hands of consumers, better access to healthcare typically patients, so they can receive and lowerthat is higher quality cost. Many of the tools also enable more (e.g., price, outcomes),transparency in healthcare whichenables competition by empowering consumers withinformation use that and the ability to information healthcare value. to shop for better [https://perma.cc/T6JB-THRX] (last visited Oct. 2, 2017). 2, [https://perma.cc/T6JB-THRX] (last visited Oct. (2012). Shefali Luthra, Plans Intellivisit, whichIntellivisit, informationdiagnostic provide to intelligence artificial uses seeking on-demand front door” for patients and a “digital to physicians doctor visits. that coverage should be. It is about insurance. This debate includes an that coverage should be. It is about important for the poor or uninsured, including discussion regarding coverage those on Medicaid. has emerged The latter debate since there is discussion of states being allocated limited funds in the form of block grants to cover the for their Medicaidexpense of providing healthcare coverage populations, [https://perma.cc/A6QT-34VA]. leaving states to figure out how to cover healthcare expenses for their leaving states to figure out how limitedvulnerable populations with increasingly funds (especially since there 76 customers-expects-new-financing-in-october [https://perma.cc/X X HealthTech entrepreneur, Eric Haberichter, uses the cloud to create a virtual uses the cloud to Eric Haberichter, entrepreneur, HealthTech marketplace,healthcare of has bundled thousands Access HealthNet where services fromhealthcare price and quality to secure the best various providers acting like They are effectively for healthcare consumers. (i.e., value) possible completea broker that provides and outcomes—as transparency in pricing a entities service for self-funded Oct 2, 2017); Jeff Buchanan, Care Act 40672-mqi_22-1 Sheet No. 40 Side B 05/20/2019 14:43:36 B 05/20/2019 40 Side Sheet No. 40672-mqi_22-1 40672-mqi_22-1 Sheet No. 41 Side A 05/20/2019 14:43:36 , 137 77 OUNDATION (Jan. 2016), , F 9/21/2018 1:50 PM (Oct. 7, 2015), FFICE O AMILY F OUNDATION F OUNDATION UDGET F B AISER AMILY F AMILY , K F AISER , K AISER , K ONGRESSIONAL As of 2015, government spending on (Sept. 19, 2017), https://www.kff.org/medicaid/fact- (Sept. 19, , C 135 5 Ways the Graham-Cassidy Proposal Puts Medicaid 5 Ways the Graham-Cassidy Proposal Puts 134 OUNDATION F State-level Medicaid 16% spending represents of note 129. Medicaid in Wisconsin 138 supra AMILY F ) ELETE AISER D CELEBRATING WISCONSIN ENTREPRENEURS ENTREPRENEURS WISCONSIN CELEBRATING , K OT OT with $539 billion spent on Medicare (administered federal by the Health Spending: Trends and Impact N The Federal Budget in 2015 O The Wisconsin Health Care Landscape 136 (D INAL INAL 134. Kaiser Family Foundation, 137. Capital Flows, 138. 135. 136. .F While important extremely coverage are these concerns about questions How healthcare in the United expensive is States? According to Kaiser, M K EM C Y 7. S 7. government) and $350 billion spent on Medicaid (administered by states), with (administeredMedicaidgovernment) by spent on and $350 billion seventy million people (one in five Americans).covering Medicaid currently https://www.kff.org/health-reform/fact-sheet/the-wisconsin-health-care-landscape [https://perma.cc/RX7T-KKN3]; healthcare (Medicaid and Medicaid) 24% represented of all mandatory federal spending, that mustmakers, by policy be addressed it misses the most important point problems—which all of these that underlies spending in the is that healthcare 20% (approaching United States is excessive of GDP) and must be contained somehow, while not sacrificing quality of, or access to, care. If healthcare costs then a tipping point willare not contained, someday be reached whereis there not enough money but not limited to pay for care for anyone, including to Medicaid populations. The cost problem the focus of in healthcare is therefore the remainderthis article, with of emphasis on how HealthTech can help address the problem, while quality and access to care is ensuring high maintained. percent of GDP have risen fromhealth expenditures per capita as a 5.2% in 1960 to 17.9% Furthermore, these numbers2010 and continue to rise. in are developed country (e.g., UK, Germany,significantly higher than in any other Switzerland, Austria, and Canada). In 2015, Wisconsin’s of Medicaid share spending was $8 billion, which provides support for 17% of Wisconsin’s 5.7 million people and 60% of those living in nursing homes. is concern that Medicaid that is concern This indefinitely). continue will not expansions causes many will populations to fear that vulnerable or to lose coverage begin receive lower quality healthcare. 2018] http://files.kff.org/attachment/fact-sheet-medicaid-state-WI [https://perma.cc/KQW6-RMEJ] (last 2018). visited Apr. 14, Coverage At Risk https://www.cbo.gov/sites/default/files/114th-congress-2015-2016/graphic/51110-budget1overall.pdf [https://perma.cc/FHZ8-M3ZH]. sheet/5-ways-the-graham-cassidy-proposal-puts-medicaid-coverage-at-risk [https://perma.cc/C6ND- sheet/5-ways-the-graham-cassidy-proposal-puts-medicaid-coverage-at-risk FRZ9]. https://www.kff.org/slideshow/health-spending-trends-and-impact/ [https://perma.cc/CB8A-KN56 ] https://www.kff.org/slideshow/health-spending-trends-and-impact/ 2017). (last visited Oct. 2, 40672-mqi_22-1 Sheet No. 41 Side A 05/20/2019 14:43:36 A 05/20/2019 41 Side Sheet No. 40672-mqi_22-1 40672-mqi_22-1 Sheet No. 41 Side B 05/20/2019 14:43:36 M K HE C Y , 7 T [Vol. 22:1 [Vol. 9/21/2018 1:50 PM 49 (2016), FFICERS O UDGET only later to discover there B 142 TATE S Physician Coding and Reimbursement N OF ’ SS A L ’ , https://www.healthcare.gov/glossary/exchange/ [https:// 7, http://www.gao.gov/financial_pdfs/citizensguide2008.p AT GOV , N . there is no competitionthe actual level of the at FFICE ARE O 141 C In addition to federal and state spending on healthcare, on healthcare, spending and state to federal In addition MARQ. INTELL. PROP. L. REV. REV. L. PROP. INTELL. MARQ. 139 Clearly, the most serious underlying problem in healthcare in healthcare Clearly, the most underlying problem serious EALTH ) , H 140 ELETE D CCOUNTABILITY OT OT N A O State Expenditure Report Exchange 2008 Financial Report of the United States Government—A Citizen’s Guide, (D J. 1, 8–15 (2007), https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3096340/pdf/i1524- INAL INAL 141. 140. 139. 142. David E. Beck & David A. Margolin, .F This level individual, employer,This level on healthcare federal spending state, and One challenge in healthcare that mayOne challenge in to cost increases is a be contributing EM OVERNMENT SCHNER 7. S 7. individual and employerindividual of pocket expenses out to rise are continuing as well, both in terms employer of ($4129 in 2011) 2011) and worker ($10,944 in premiums. to insurance contributions df [https://perma.cc/DS6H-CRFL]. G perma.cc/5K7T-8GZ5] (last visited Oct. 2, 2017). perma.cc/5K7T-8GZ5] (last visited Oct. 2, in the United States is that cost is increasing at a rate reaching a level that a level that is that in the United States at a rate reaching cannot cost is increasing be sustained. Why is it that healthcare costs more in the United States than in country? Whileany other developed is not clear the answer to this question found. of muchand is the subject debate—a political solution must be lack of true competition markets. in free and transparent While there may be competition companies at the level of insurance (i.e., the health insurance markets, or “exchange”), the total state budget. state the total 5012-7-1-8.pdf [https://perma.cc/CL3T-MEV7]. O 78 https://higherlogicdownload.s3.amazonaws.com/NASBO/9d2d2db1-c943-4f1b-b750- 0fca152d64c2/UploadedImages/SER%20Archive/State%20Expenditure%20Report%20(Fiscal%202 014-2016)%20-%20S.pdf [https://perma.cc/H48N-M89R]. cannot continue forever. At the federal level, so-called mandatoryAt the federal level, forever. cannot continue federal spending from just the three major entitlement programs, Medicare, Medicaid, and Social defense, Security (ignoring interest, etc.), will exceed revenue (20% 2080. of GDP) by are large copays or unreimbursed That would be analogous shopping services. in a grocery store of products without prices because you under the are falsely impression In this scenario, there is no “reimbursed.” everything is being as long as price, to control such as hospitals, incentive for healthcare providers, the products or services are reimbursed by insurance. Thus, there are no market consumer—who employer) purchasing the healthcare is the patient (or their “buying decisions” are madeproduct or service. In other words, at the level of the decision—withouta patient seeing a physician, where knowing price—is made a healthcare services, such as: a clinical assay (e.g., blood to purchase panel), a hip surgery, an MRI, some or other procedure. Typically, neither the much these procedures or services has any idea how patient nor the physician the back reimbursed on are on the notion or hope that they simply relying cost, end by the insurance company or government, 40672-mqi_22-1 Sheet No. 41 Side B 05/20/2019 14:43:36 B 05/20/2019 41 Side Sheet No. 40672-mqi_22-1 40672-mqi_22-1 Sheet No. 42 Side A 05/20/2019 14:43:36 . , 145 79 ERVS S (June 27, (June 27, 9/21/2018 1:50 PM would mean EDICAID ORBES (June 5, 2017), J. (Apr. 10, 2016, and effectively 144 & M ttps://perma.cc/AKJ8- 146 TREET Finds, F RUNCH S C EDICARE ALL ECH M W , T HE FOR . , T TRS ,C tion-of-healthcare/ [h Consumerizationof healthcare (Apr. 05, 2011), http://www.hhnmag.com/articles/5010-the- Emergency Rooms? 143 The Law That Changed Everything-and it Isn’t the One You Think ETWORKS Out-Of-Pocket Hospital Costs Up 37%, Study Out-Of-Pocket Hospital Costs Up 37%, Study The Consumerization of Healthcare N ) ELETE EALTH D Emergency Medical and Active Labor Act Treatment H CELEBRATING WISCONSIN ENTREPRENEURS ENTREPRENEURS WISCONSIN CELEBRATING OT OT Are Out-of-Pocket Medical Costs Too High? N O (D INAL INAL D. Healthcare Access Challenges for the Poor—Universal Care via 145. § 1395dd(b)(1) (2012); 42 U.S.C. Act, Emergency Medical Treatment & Labor 144. Sam Myers, 143. Kate Ashford, 146. Emily Friedman, .F What about access to the care itself, for those without insurance, or those In 1986, Congress passed legislation that permitsIn 1986, Congress passed legislation anyone to get medical M K EM OSPITALS AND C Y 7. S 7. who are the underinsured? What can they do, and what do they do? Emergency Medical Treatment & Labor Act (EMTALA) (Mar. 26, 2012 8:43 AM), https://www.cms.gov/Regulations-and-Guidance/Legislation/EMTALA/ [https://perma.cc/SL6U-ZJYH]. 10:03 PM), https://www.wsj.com/articles/are-out-of-pocket-medical-costs-too-high-1460340176 [https://perma.cc/TZ4S-DQ7Y]. EHKV]. EHKV]. providing the patient with access to moreproviding the patient information upfront, via HealthTech information. on that based maketo decisions them tools, and empowering They could shop for the best healthcarecare. values, care at the lowest price, and they could play a more active role in their which means access to the best quality 2016, 2:07 PM), https://www.forbes.com/sites/kateashford/2016/06/27/hospital-costs/#2097580aa42f [https://perma.cc/359F-KA6S]; Catherine Lane, provides a kind of universal healthcare. People without any healthcare provides a kind of universal healthcare. unemployed,insurance, perhaps because they are or their employer does not (“EMTALA”), was passed in the Reagan administration, forces where they need to they need where forces empowerment and no be of consumers (i.e., patients) with information ability to make and on that information. based To decisions marketsupport this teams hospitals have dysfunction, of administrative staff from reimbursement and seeking services medical coding to members devoted the government on average 25% hospitals spend payers. U.S. or third-party on administrative of their budget ($200 billion) costs (which coding includes and billing), which is more devote than other countries. Therefore, hospitals get reimbursed services by insurance to ensuring their significant resources companies Medicaid), (or and insurance companies are incentivized to find reasons not to reimburse, gets stuck in the middle while the patient often with for large copays needing to pay moreno input, and increasingly out of pocket or for uninsured procedures. 2018] law-that-changed-everything-and-it-isn-t-the-one-you-think. H care in emergencytheir ability to pay. This legislation, rooms, irrespective of termed the https://techcrunch.com/2017/06/05/the-consumeriza 40672-mqi_22-1 Sheet No. 42 Side A 05/20/2019 14:43:36 A 05/20/2019 42 Side Sheet No. 40672-mqi_22-1 40672-mqi_22-1 Sheet No. 42 Side B 05/20/2019 14:43:36 , M K 150 C Y Who ,” that 149 148 [Vol. 22:1 [Vol. 9/21/2018 1:50 PM a pioneer in Medical Home 151 , 8 PLOS ONE 2 (2013), Medical Home Network Emergency Medical Treatment & Labor Act Act Emergency Medical Treatment & Labor , http://www.medicalhomenetwork.org [https://perma.cc/ “How Much Will I Get Charged for This?” Patient Charges for Charges “How Much Will I Get Charged for This?” Patient for , http://www.texturehealth.com [https://perma.cc/46K6-DVD8]. [https://perma.cc/46K6-DVD8]. , http://www.texturehealth.com Assuring Hospital Emergency Care Without Crippling Competition ETWORK N MARQ. INTELL. PROP. L. REV. REV. L. PROP. INTELL. MARQ. EALTH (July 6, 2015), http://healthaffairs.org/blog/2015/07/06/assuring-hospital- ) H OME H LOG ELETE B D note 141. EXTURE OT OT N EDICAL O supra (D FFAIRS , , which uses HealthTech Health, created by Texture A an ED cannot turn away any patient. Thus, while there is debate in the while there is debate patient. Thus, turn away any an ED cannot INAL INAL 151. M 149. Christopher Pope, 150.129. Luthra, supra note 148. Nolan Caldwell et al., 147. 42 U.S.C. § 1395dd(b)(1) (2012); .F 147 One could argue that use of EDs by the uninsured, madethat use of EDs by the uninsured, One could argue possible by E.Solution Healthcare Challenges for the Poor—A Access HealthTech EM EALTH 7. S 7. emergency-care-without-crippling-competition/ [https://perma.cc/3TRJ-52XW]. H (EMTALA) JDR5-M8AD]; T Top Ten Diagnoses in the Emergency Department Top Ten Diagnoses in the Emergency https://doi.org/10.1371/journal.pone.0055491 [https://perma.cc/S7PF-KZF9]. United States as to whether healthcare is a right, it seems healthcare is a right, as to whether United States care is that universal in the most provided but already being expensive manner possible. is providing a HealthTech-enabled care coordination for underserved is providing a HealthTech-enabled The hospitals, which normallypopulations (and ED over-users). compete the because helping together to work are incentivized with each other, intensely improvesunderserved populations in Chicago their bottom lines—because the their EDs less often. underserved populations are using Network provide insurance, often seek care by going to an emergency going to care by seek often insurance, provide room (also as referred to an emergency department, or “ED”). to According the EMTALA law, population health management, is able to provide very effective care EMTALA, is a form this makes universal care, and given the expense, of a needed for these net is urgently universal healthcare safety strong case that a as it would provide a moreunderserved populations, alternative cost-effective to the misuse and overuse of EDs. Furthermore, that states may given soon be moving to a block grant system of reimbursement for Medicaid expenses (coupled to more limited Medicaid expansion), less funds will be available for the most vulnerable populations (e.g., on Medicaid). However, these factors for hospitals (which bear the incentives are already conspiring to create strong brunt of expenses associated with ED overuse) to find solutions that address the Indeed, the majorneeds of these vulnerable populations. healthcare providers work together in an Accountable Care in Chicago have already begun to called “ Organization (“ACO”), with a nonprofit 80 pays for this? pays for this? Hospitals do not get reimbursed uninsured when people use their emergency rooms; subsequently, this meansother healthcare consumers or 2013. whichtaxpayers end up paying, was estimated billion in to be $46 40672-mqi_22-1 Sheet No. 42 Side B 05/20/2019 14:43:36 B 05/20/2019 42 Side Sheet No. 40672-mqi_22-1 40672-mqi_22-1 Sheet No. 43 Side A 05/20/2019 14:43:36 . 81 152 OMPANIES MPROVING , I C EDICAL 9/21/2018 1:50 PM (July 28, 2017), OW HILE , M MHN Connect W : H EVIEW R OSTS C Consumerization ARE EVOLUTION C R ATIONAL , N ARE C EALTH H Millennials and the Consumerization of ), http://insights.wired.com/profiles/blogs/ HEIR EALTH T obal/home/what-we-think/consumerization [https obal/home/what-we-think/consumerization [https H Torinus argues that if such transparent Torinus argues that if such transparent The Consumerization of Healthcare 154 12:48 PM UTTING 153 How Big Data is Driving the Consumerization of Health How Big Data is Driving the Consumerization C RASSROOTS G goal was to provide cost-effective care that is high care that to provide cost-effective goal was HE (Aug. 14, 2015 7:00 AM), https://health.usnews.com/health- (Feb. 26, 2015 , T RAMATICALLY (Jan. 30, 2017), https://www.mpo-mag.com/issues/2017-01-01/view_colu ) Yes, We Should Block-Grant Medicaid D ORINUS RE NSIGHTS ELETE T I EALTHCARE A D H CELEBRATING WISCONSIN ENTREPRENEURS ENTREPRENEURS WISCONSIN CELEBRATING OT OT N IRED OHN O EWS UTSOURCING (D &, https://www.strategyand.pwc.com/gl , W MERICA O A INAL INAL (2014). 153. Steve Maylish & Nick Rakhshani, 152. Sally Pipes, 154. J .F While the average healthcare consumer not in the United States does Advocates for the consumerization trend and transparent pricing includes , U.S. N M K EM CROSS ARE TRATEGY RODUCT C Y F.Bundling Medical Solutions: Transparent Pricing, Healthcare and Homes 7. S 7. receive primary medical insurance (typically care in an ED and does have through their employer), they general have or limited,no, to shop for the ability for medical (whether for insurance or directly best healthcare value services). Rather, it is employers that (HR administrators) shop for insurance. At the level made, at the patient (consumer)-physician interface, decisions are where buying neither party knows how much a treatment or medical nor what service costs, one source from is obtained or service treatment the if relative outcomes are the competitionover another. In effect, there is no where it needs to be, so there are no market to constrain costs and increase value to the consumer. forces putting informationThe trend towards changing this, by and buying power in the hands of patient consumersusing HealthTech tools, is called the healthcare.” “consumerization of John Torinus, Wisconsin-based healthcare thought leader and author of “The Grassroots Health Care Revolution.” http://www.nationalreview.com/article/449926/medicaid-block-grants-would-put-states-budget [https://perma.cc/XE5M-UL9B]. ://perma.cc/SD7P-UEU4]; Girish Navani, Care S mns/the-consumerization-of-healthcare [https://perma.cc/7KY3-QXCR]; mns/the-consumerization-of-healthcare [https://perma.cc/7KY3-QXCR]; A C P coordination to these populations using a software tool they call they call tool a software using these populations to coordination 2018] Medical Home Network’s Medical a coordination in care technology-enabled accessible, using quality and of primarynetwork systems. and hospital care providers a period of two Over $11 million, wereyears, they able to save providers while providing care for Medicaid1,189,195 cost care at lower This was better enrollees in Chicago. and represents the kind of approach states may are need to explore if they going where Medicaidto be put in a situation dollars become more limited via block budget. states on a on expansion, effectively putting grants and constraints millennials-and-the-consumerization-of-healthcare#axzz4uSAtxfPe. news/patient-advice/articles/2015/08/14/how-big-data-is-driving-the-consumerization-of-health-care news/patient-advice/articles/2015/08/14/how-big-data-is-driving-the-consumerization-of-health-care Glannulli, [https://perma.cc/MD7X-PJDW]. Thomas Healthcare 40672-mqi_22-1 Sheet No. 43 Side A 05/20/2019 14:43:36 A 05/20/2019 43 Side Sheet No. 40672-mqi_22-1 40672-mqi_22-1 Sheet No. 43 Side B 05/20/2019 14:43:36 M K 160 C Y TREET OW S H and into ALL [Vol. 22:1 [Vol. ERIGRAPH 158 AND S W 9/21/2018 1:50 PM , If companies HE OW ARE , T 159 C : H ARE So, employers often C ETTER B 157 156 EALTH H ROVIDING P OLVED for his employees by shopping, on shopping, for his employees by S HILE 161 W HAT T OSTS C OMPANY C HE , T with no logical or transparent connection to outcomes. connection or transparent with no logical note 150, at 3. note 150, at shows the dramaticdifferent variation in price for four KYROCKETING MARQ. INTELL. PROP. L. REV. REV. L. PROP. INTELL. MARQ. How to Bring the Price of Health of Open Price Care Into the How to Bring the S 155 ) ORINUS supra T , ELETE D EDUCED OHN Table 3 J R OT OT N . . at 9. . at 24. . at ORINUS O See Id Id Id . at 116. (D Id INAL INAL 161. 160. 156. 157. T 155. Melinda Beck, 158. 159. .F Torinus views the healthcare consumer as being not just the patient seeking EM RAMATICALLY 7. S 7. self-insurance. Indeed, the trend in U.S.self-insurance. Indeed, the trend in companies is away from commercial insurance, towards direct pay by the companies, with the companies now for the best healthcare value. shopping Currently, over 40% of U.S. companies due to the increasing cost. do not offer health care insurance have the strongest incentive to find better care at lower cost (and they try to care at lower better have the strongest incentive to find on to their employees).with the associated benefits, along incentives, pass those Companiesfeel the pressure intensely since, according to Torinus (who was also former hyperinflation “has driven 40 CEO of Serigraph), healthcare percent of U.S. companies, mostly smaller firms, out of coverage” care but also the employer that pays for that person’s insurance. Employersemployer are that pays for but also the care incentivized—in the long term—for their employees to have good health, if themonly because it costs extremely chronic diseases is less since treating the importancecostly. Torinus notes sector as a healthcare payer of the private because it is companies pay for) most that provide (and people’s health insurance in the United the cost of the nation’s States, as they currently split nearly $3 trillion medical bill with the public sector. In the company Serigraph, he was able to save where Torinus served as CEO, care and provide better significant money self-insure, then they are empowered and incentivized to shop for the best cost. value—theoutcomes at the lowest best healthcare Torinus notes that price bears no variation for healthcare to the significant and procedures is connection the samewith procedure. for variations of 300%or outcomes,of care quality 1393020966 [https://perma.cc/X5NZ-DXYT]. 1393020966 [https://perma.cc/X5NZ-DXYT]. varying dramatically For example, Angeles. different hospitals in Los procedures at five pricing and marketspricing consumerswere healthcare in place, would ultimately get better care lowerat since cost what get patient-consumers (outcomes) would be to shop for value incentivized were to price, if patient-consumers better linked Yet, at present, copays). plans and associated high deductible (e.g., through there is transparency in no such pricing or outcomes, to healthcare cost leading J. (Feb. 23, 2014 5:03 PM), https://www.wsj.com/articles/what-does-health-care-really-cost- D 82 40672-mqi_22-1 Sheet No. 43 Side B 05/20/2019 14:43:36 B 05/20/2019 43 Side Sheet No. 40672-mqi_22-1 40672-mqi_22-1 Sheet No. 44 Side A 05/20/2019 14:43:36 163 83 , (Sept. 9/21/2018 1:50 PM UND F OLLABORATIVE C ARE —essentially patient- C 162 , Quad/Graphics Unit OMMONWEALTH RIMARY C P HE , T . J. (June 23, 2016 8:35 AM), US ENTERED B Medical Home Medical -C , http://www.quadmedical.com/company/history , http://www.quadmedical.com/company/history ED M ATIENT , P UAD ILWAUKEE , 14–15 (2010). , Q , M 150, at 92. 150, at AME S supra ) O THE D ELETE AN Case Study: QuadMed—Transforming Employer-Sponsored Health Care D C CELEBRATING WISCONSIN ENTREPRENEURS ENTREPRENEURS WISCONSIN CELEBRATING OT OT Company History N Likewise, for MRIs, he found bundled prices as low as $525, which Likewise, for MRIs, he found bundled prices O Defining the Medical Home (D 164 OMPANY G.Healthcare Enabling HealthTech Technology: Consumerizing C INAL INAL 162. 163. 164. John Torinus, .F Bundling of pricing to enable competition,shopping can enable and provide M K EM VERY C Y 7. S 7. telemedicine) facilitate this process? bundled prices By negotiating upfront and bundled price for his Serigraph employeesshopping, Torinus found the lowest for knee replacementsto be $27,500; whereas, in the Milwaukee market, knee $27,500 to $70,586, replacement from prices range arbitrarily a medianwith of $44,422. QuadMed in Growth Mode QuadMed in 2009), http://www.commonwealthfund.org/publications/newsletters/quality-matters/2009/september- october-2009/case-study [https://perma.cc/76X7-24LB]; Rich Kirchen comparedcommonly favorably with the $2000 or $4000 charged by some shopping in this mannerlarge healthcare providers. However, is labor intensive and outside of the scope of what most healthcare consumers (whether better care at lower cost, as Torinus did for his Serigraph employees.better care at lower cost, as Torinus Can digital medicine;HealthTech (e.g., healthcare IT; medicine; connected Through Workplace Primary Care and Wellness Programs [https://perma.cc/S4FF-2SSM]; Douglas McCarthy, https://www.bizjournals.com/milwaukee/news/2016/06/23/quad-graphics-unitquadmed-in-growth- mode.html [https://perma.cc/T6FC-W3FS]. https://www.pcpcc.org/about/medical-home [https://perma.cc/F5T8-LTZY]. https://www.pcpcc.org/about/medical-home [https://perma.cc/F5T8-LTZY]. E their behalf, for the best healthcare. However, shopping requires a bundling of bundling a requires shopping However, healthcare. the best behalf, for their which medical a healthcare procedure, prices for have not providers typically done (e.g., simplyone cannot how much ask a knee replacement costs, because as operating room expenses, such a range of undefined there are cost, surgeon, etc.). Companiesanesthesia, will Serigraph like Torinus’ negotiate bundled their employees, upfront for like knee surgery various procedures prices for routine medical services. a range of provide onsite clinics to also have and they of is considered a kind onsite clinic The obtained, Companiesthat to implement want that Serigraph of savings the kind QuadMed. contract with but need help, can companies like Milwaukee’s 2018] centered care that is implementedcentered care that by a healthcare team. and coordinated This an on-site clinic/medicalmodel home is prices and providing of using bundled in companiesbeing adopted broadly States but was actually across the United pioneered by a Milwaukee company, which formed Quad Graphics, QuadMed to address its own Now, healthcare costs. QuadMed is growing nationally and Briggs & Stratton. by companies like Kohls and has been adopted 40672-mqi_22-1 Sheet No. 44 Side A 05/20/2019 14:43:36 A 05/20/2019 44 Side Sheet No. 40672-mqi_22-1 40672-mqi_22-1 Sheet No. 44 Side B 05/20/2019 14:43:36 ). M K 173 J. C Y has now [Vol. 22:1 [Vol. Table 2 ILWAUKEE 167 9/21/2018 1:50 PM (May 10, 2016), , M 170 ALL H ttps://perma.cc/2WZQ- founded by Eric founded a.cc/9KSV-XL3Y]. 165 (Mar. 19, 2017 9:19 AM), AUFMAN are providing individuals , K 172 NSIDER I although Access HealthNet acts although Access -disruption [h 169 USINESS , B and RemedyNow A web portal has been created to allow A web portal has note 163. 171 168 supra , , http://accesshealthnet.com/ [https://perma.cc/9ZP9-HLQ4]. , http://accesshealthnet.com/ A Clear and Present Disruption ET ET N N MARQ. INTELL. PROP. L. REV. REV. L. PROP. INTELL. MARQ. A New Kind of Doctor’s A New Kind of a Monthly Fee and Office Charges Doesn’t Take MRI, https://smartchoicemri.com/[https://perm Milwaukee Start-up Makes Health Care More Efficient Milwaukee Start-up Makes Health Care More , https://remedynow.net [https://perma.cc/D2JL-QNM2]. ) This is strong evidence of how transparent pricing and of how transparent pricing This is strong evidence OW EALTH EALTH HOICE N H H 166 ELETE , https://www.guroo.com [https://perma.cc/MRP7-RA59]. , https://www.guroo.com C D MD, https://www.yourmdmequon.com [https://perma.cc/CJ4K-BK53]. MD, https://www.yourmdmequon.com OT OT N UROO CCESS OUR CCESS EMEDY MART O (D (Jan. 12, 2017, 8:09 PM), http://www.jsonline.com/story/money/business/health- INAL INAL 167. A 169. G $69,259 to $109,432). 166. Kenneth Kaufman, 172. R 165. S 171. Y 170. A 168. Guy Boulton, 173. Lydia Ramsey, .F Other southeast Wisconsin HealthTech companies working to improve EM ENTINEL 7. S 7. https://www.kaufmanhall.com/resources/clear-and-present C9LV]. care/2017/01/12/milwaukee-startup-makes-health-care-more-efficient/96268824/ [https://perma.cc/724K-WMM8]. individuals or the companies or individuals employ that them) end, To this expect. Milwaukee HealthTech Smart startup Choice MRI, Milwaukee startups YourMD healthcare delivery and to create more transparent and competitive markets include Dynamis, Intellivisit, YourMD,and RemedyNow ( 84 S competition lead to lower can cost and care high-quality a howand Milwaukee HealthTech company is addressing that problem. Another Milwaukee Access HealthNet, founded by Haberichter, HealthTech startup http://www.businessinsider.com/direct-primary-care-a-no-insurance-healthcare-model-2017-3 [https://perma.cc/37Y2-8TRA]. (rather than companies) with the information and power to make own their business a self-pay but in decisions, buyingand urgent care healthcare primary model where patient-consumerspay out of pocket for expenses. Often the this direct-pay model, which bypasses insurance, associated with expenses Haberichter, is revolutionizing the MRI the is revolutionizing Haberichter, in Wisconsin industry by bundling consumers employers, (individuals or sometimes and direct-pay prices for even offer some because they other providers) quality MRIs of the highest at $600, mostwhereas the much had been charging hospitals an average higher with price of $2600. bundled theover 1000 procedures, to expand savings that can be obtained from pricing morebundled and transparent healthcare, including broadly across vary from tunnel surgery (where prices procedures like carpal carpal tunnel from (where prices vary surgery back lower $4003 to $8936) and from surgery as a broker to shop for and negotiate the best bundled and transparent prices as a broker to shop for and negotiate for healthcare consumers (typically employers that self-insure). consumers to mine these price variations, Insurance—and it Could be the Future of Medicine 40672-mqi_22-1 Sheet No. 44 Side B 05/20/2019 14:43:36 B 05/20/2019 44 Side Sheet No. 40672-mqi_22-1 40672-mqi_22-1 Sheet No. 45 Side A 05/20/2019 14:43:36 , 85 NSIGHT I Dynamis 9/21/2018 1:50 PM ROPHIT P of 1973, this trend (Mar. 6, 2017 12:12 PM), PM), 12:12 2017 (Mar. 6, Network Leakage, IMES T IZ B ), while also increasing healthcare costs. ), while also increasing healthcare A third barrier to free markets and A third barrier to free markets 178 176 Table 3 Price Competition in Hospital Markets, The Significance of Managed note 126. 292, 320 (2002). 292, 320 which provides an insurance plan optimization resource plan optimization an insurance which provides resource Health Maintenance Organization Act ) This lack of outside referral decreases value-based This lack of outside referral AW Accurate Information Using ReferralMD Provider SmartMatch Reduces supra L 174 Section IV.A. , https://dynamiscorp.com/ (last visited Oct. 3, 2017); Molly, https://dynamiscorp.com/ (last visited Oct. 3, Dill, , MD, https://getreferralmd.com/track-patient-referral-leakage/ [https://perma.cc/ ELETE 177 D Another importantAnother consumerizing tool in HealthTech care is CELEBRATING WISCONSIN ENTREPRENEURS ENTREPRENEURS WISCONSIN CELEBRATING OT OT EALTH N H 175 H.Consumerization to Healthcare Barriers Reform and YNAMIS See e.g. O See infra EFERRAL OF (D , R INAL INAL 176. Buchanan, 177. 175. 174. D 178. William G. Kopit, .F , 35 J. In order for healthcare to be consumerized, with patients having freedom to freedom consumerized, with patients having to be In order for healthcare M K EM C Y 7. S 7. https://www.biztimes.com/2017/industries/banking-finance/dynamis-software-raises-1-3-million- https://www.biztimes.com/2017/industries/banking-finance/dynamis-software-raises-1-3-million- round [https://perma.cc/LS82-3YP3]. Software raises $1.3 million round, $1.3 million Software raises Care towards as anticompetitive hospital consolidation could be characterized and consumershealthcare who “face increased hospital prices as result of is hurting decreased price competition.” 7S6N-JUVZ] (last visited Oct. 3, 2017); telemedicine, door to primary front providing a digital along such as is care, Intellivisit. being offered by Adding to this issue is a trend towardmaking increasing consolidations, for a smaller providers with increasing levels of market pool of large healthcare power in a given community. review article by one of As was noted in a law the architects of the competition and likely contributes to the lack of correlation between cost and competition to the and likely contributes outcomes (see above and are less than the copays associated with insurance plans. For those that would that would For those plans. insurance with associated the copays than are less value, Milwaukee for the best insurance like to shop has serial entrepreneur created Dynamis, general healthcare in Switzerland to offeredwhat is reminiscent of for brokers, consumers. 2018] shop for value-based care based in transparent and competitive care based in transparent and shop for value-based markets, patients must be empowered healthcare they want. They may shop for the to want the but can they actuallyknow what they want, it? If they decide they get Smart Choice and because they feel it is better MRIthey prefer the quality $600 $2600 price tag, are they empoweredprice tag over the that choice? to make The reality is that they are not always free to do so. Hospitals often strongly in the services the MRI (e.g., to use for procedures encourage internal referrals hospital even if it is lower a quality and more there is such expensive). In fact, string concern about outside referring of the hospital, referred to as “leakage,” prevent this fromthat hospitals expend resources to happening since it costs them revenue. http://www.prophitinsight.com/network-leakage (last visited Oct. 3, 2017). http://www.prophitinsight.com/network-leakage (last visited Oct. 3, Leakage 40672-mqi_22-1 Sheet No. 45 Side A 05/20/2019 14:43:36 A 05/20/2019 45 Side Sheet No. 40672-mqi_22-1 40672-mqi_22-1 Sheet No. 45 Side B 05/20/2019 14:43:36 , M K It is C Y ONEY 179 , M Out-of- Out-of- OR F Former [Vol. 22:1 [Vol. IERCE F 9/21/2018 1:50 PM OADMAP with predominantly (Aug. 31, 2015 10:28 AM), : A R (EMRs) hospitals, in used EWS , Is Epic Stifling Health IT Innovation? IT N EFORM TATES with private-sector providers and R S Beveridge Model NITED EALTHCARE Why Epic’s Market Dominance Could Stifle and EHR U (Apr. 25, 2013), http://medicaleconomics.modernmedi , H HE EALTHCARE T former-hospital-ceo-calls-epic-antitrust-probe former-hospital-ceo-calls-epic-antitrust-probe H However, what does the rest of the world do, and However, what does the rest of the CONOMICS E What Is Single-Payer Healthcare and Why Is It So Popular? What Is Single-Payer Healthcare 180 MARQ. INTELL. PROP. L. REV. REV. L. PROP. INTELL. MARQ. NABLED Electronic MedicalElectronic Records ) -E EDICAL Paul Levy Urges Investigation of Epic for Antitrust Violations, Paul Levy Urges Investigation of Epic for Antitrust , M ELETE ECH D (rural areas of Africa and India) where consumers(rural areas of Africa and India) where pay directly , http://www.epic.com/ [https://perma.cc/Y2J9-BZGJ] (last visited Oct. 3, 2017). , http://www.epic.com/ [https://perma.cc/Y2J9-BZGJ] T OT OT N PIC (Sept. 1, 2015 12:43 PM), http://www.fiercehealthcare.com/ehr/paul-levy-urges- National Health Insurance Model A.World Learning from Best Practices in the Rest of the O (D EMR & EHR (April 30, 2013), http://www.hospitalemrandehr.com/2013/04/30/is-epic- EALTH INAL INAL 180. Alicia Adamczyk, 179. E .F The current debate about healthcare in the United States often focuses on The current debate about healthcare EM OSPITAL EALTHCARE IV. H 7. S 7. how well is it working? There are four majorhow well is it working? There are models of healthcare delivery used throughout the world: (a) the government Great Britain; Spain; most control (e.g., Scandinavian countries; Cuba), the governmentKorea, and Taiwan), the run insurance (Canada, South Pocket Model single payer (government) versus multi-payer (competition) and the benefits and downsides of each. which are provided predominantlywhich are by two companiesand and Cerner) (Epic or two major by one adopted exclusively which, when in a providers community, used as a way can also be to exclude competition, to since access limited records is patient health Some or excluded. and even have argued as anticompetitivebe characterized that this can also litigated behavior. true that under HIPAA requirementstrue that under HIPAA be shared (without patient data cannot consent), but extreme medical limiting of access to data, that arguably record to the consumerization is going to be a strong barrier belongs to the patient, of healthcare. Somehow, patients need to be empowered access to and to have healthcare data and to makecontrol of their other healthcare buying or the various providers that data. This includes data about decisions based on and insurance companiescompeting that are (or should be) for their business. for the consumerizationThis is the vision healthcare. of cine.com/medical-economics/content/tags/electronic-health-records/why-epics-market-dominance- could-stifle-ehr [https://perma.cc/L8W6-6ASJ]; Anne Ziegler H investigation-epic-for-antitrust-violations Mike [https://perma.cc/7HNJ-RS53]; Miliard, stifling-health-it-innovation/ [https://perma.cc/YY7B-G4DU]. competition the is http://www.healthcareitnews.com/news/ [https://perma.cc/9F68-XF66]; Brandon Glenn, Health IT Innovation (Apr. 13, 2017), http://time.com/money/4733018/what-is-single-payer-healthcare-system [https://per ma.cc/4TWN-B4SF]. H 86 Hospital CEO Calls for Epic Antitrust Probe Marla Durben Hirsch, 40672-mqi_22-1 Sheet No. 45 Side B 05/20/2019 14:43:36 B 05/20/2019 45 Side Sheet No. 40672-mqi_22-1 40672-mqi_22-1 Sheet No. 46 Side A 05/20/2019 14:43:36 , , 183 87 ., CH . ARE The C ROG (Apr. 29, 181 P OSPITAL About the H 9/21/2018 1:50 PM ORBES EALTH EALTH H , F H HICH L ’ 184 AT , W N , which makes decisions FFICIENCY IN E HYSICIANS FOR A , P with nonprofit insurance that covers that insurance nonprofit with Institute for Quality and Efficiency in Institute for Quality and Efficiency in Health Care: Institute for Quality and Efficiency in Health (July 2009), http://www.commonwealthfund.org/~/media/ UALITY AND UND Federal Joint Committee Q F which was created in 2004 to provide healthcare which was created 182 Bismarck ModelBismarck ) Why System Switzerland Has the World’s Best Health Care and also has the and also has the ELETE D OMMONWEALTH CELEBRATING WISCONSIN ENTREPRENEURS ENTREPRENEURS WISCONSIN CELEBRATING OT OT C (“IQWiG”), N NSTITUTE FOR O Health Care Systems—Four Basic Models HE (D , T INAL INAL 184. Avik Roy, 181. 182. I 183. Mona Nasser & Peter Sawicki, .F M K EM C Y 7. S 7. .pdf [https://perma.cc/MNQ3-SW2E]. final model model is a type of hybrid often encourages allows for and that consumers with information allowing and providing of care by consumerization them and outcomes). value (price for the best healthcare to shop though Even it as a “universal government-guidedthis can be described healthcare system,” system.is not a single payer some There is still form of competition, and consumers information are given to permit Germany shopping. has the Bismarck Model Healthcare Files/Publications/Issue%20Brief/2009/Jul/Chalkidou/1294_Nasser_CER_Germany_issue_brief_724 2011 5:27 PM), https://www.forbes.com/sites/theapothecary/2011/04/29/why-switzerland-has-the- worlds-best-health-care-system/#503b78bb7d74 [https://perma.cc/AP7X-JESX]; Independent Association Hospital Comparison Switzerland, Zurich for care, and the care, and for consumers and often allows doctors and providers but uses private everyone for the best to “shop” Japan). values (Germany, healthcare Switzerland, It is advisory to Germany’s regarding reimbursements, German based on evidence. Since under law all needed medical procedures must be covered, this information is only used to compare cost and benefits of comparable relative treatments, so that the best and also most cost-effective treatments of can be chosen. This is a kind healthcare information to foster competition. sharing, Switzerland, by many world. systemsaccounts, has one of the best healthcare in the 2018] consumers with information on cost and benefits of different health services. of health benefits different cost and information on consumers with http://www.pnhp.org/single_payer_resources/health_care_systems_four_basic_models.php 2017). [https://perma.cc/4TWN-B4SF] (last visited Oct. 3, www.iqwig.de/en/home.2724.html [https://perma.cc/NTP9-UCDV]. Germany https://which-hospital.ch/hospital-comparison-switzerland.php [https://perma.cc/CK37-U3SX] (last visited Oct. 3, 2017). 40672-mqi_22-1 Sheet No. 46 Side A 05/20/2019 14:43:36 A 05/20/2019 46 Side Sheet No. 40672-mqi_22-1 40672-mqi_22-1 Sheet No. 46 Side B 05/20/2019 14:43:36 , M K 185 C Y ONEYLAND [Vol. 22:1 [Vol. M 9/21/2018 1:50 PM ) that is maintained Fig. 4 Fig. , an independent association. This , an independent association. This MARQ. INTELL. PROP. L. REV. REV. L. PROP. INTELL. MARQ. ) ELETE D OT OT . Web-based portal in Switzerland for healthcare consumers to to consumers for healthcare in Switzerland portal Web-based . Hospital Insurance: Compare Premiums and Services, N O (D Fig. 4 Fig. INAL INAL Like Germany,for consumer-based it also provides a mechanism research 185. .F Hospital Comparison Switzerland EM research and compare providers, in terms of quality metrics and price price and metrics quality of terms in providers, compare and research (Which-hospital.ch). 7. S 7. by on the quality of medical services, via a web portal ( What is unique about the is that shop for Swiss system individuals and purchase their own limited insurance, rather than being to plans provided by their employers or the government (as in the States), and there are copays United to value by consumers.encourage shopping for the best healthcare The Swiss comparedgovernment to 7.4% spends only 2.7% in the of GDP on healthcare, United States, and Switzerland achieves this with some of the best health in the clinic, outcomesedge in the world,technology medical cutting access to 88 resource allows patients to query and compareresource allows patients to query and metrics such as: infection rate, mortality rate, number patient satisfaction, and number of patients treated, of Swiss healthcare consumers to help staff per patient. There are also resources compare coverage for procedures with and shop for hospital insurance filters that permit where procedures are fully covered. identification of hospitals https://www.moneyland.ch/en/hospital-insurance-comparison [https://perma.cc/WA5H-DL68] (last 2018). updated Apr. 40672-mqi_22-1 Sheet No. 46 Side B 05/20/2019 14:43:36 B 05/20/2019 46 Side Sheet No. 40672-mqi_22-1 40672-mqi_22-1 Sheet No. 47 Side A 05/20/2019 14:43:36 189 89 While HYSICIANS 187 Affordable , P (Aug. 9, 2016), 9/21/2018 1:50 PM (Oct. 8, 2017), OST C UORA RUE T , Q [https://perma.cc/6G6H-CRVD]; available at A Two-Tier Health Care System: The New A Two-Tier Health Care System: The New http://www.pnhp.org/news/2003/january/the_ The Swiss modelThe might makefor a The New Zealand Health Care System 186 ract_id=2627709 190 in the United States in the United (Jan. 3, 2003), ) can address those needs in whatever healthcare systemhealthcare those needs in whatever address ) can List of Countries with Universal Healthcare, ROGRAM P ) note 178. ELETE EALTH Table 2 D supra In contrast, countries like Australia and New Zealand, which like Australia and New Zealand, In contrast, countries H What are the Benefits of a Two-Tier Healthcare System CELEBRATING WISCONSIN ENTREPRENEURS ENTREPRENEURS WISCONSIN CELEBRATING Colleen M. Flood & Lorian Hardcastle, OT OT N . . (Ottawa Faculty of Law Working Paper No. 2015), 188 O See Id Id ). (D ATIONAL INAL INAL N 188. Praveenghanta, 187. 189. 190. 186. Roy, .F Whether system,insurance or hospitals in the Swiss shopping for or This article has presented arguments in favor of the consumerization of M K EM C Y B. for a HealthTech-enabled Hybrid Proposal and Tiered Healthcare System 7. S 7. could also serve as modelscould also serve have a two-tier for the United States, system, Germany have an care, they both hybrid models of have and Switzerland mandateinsurance States, under the case in the United (as is the Care Act new_zealand_heal.php [https://perma.cc/BLM7-GPVX]. politically expedient compromiseexpedient it has elements in the United politically that States, since (privately-managed both conservatives could satisfy government care; low insurance market).care; regulated and liberals (universal spending) https://truecostblog.com/2009/08/09/countries-with-universal-healthcare-by-date https://truecostblog.com/2009/08/09/countries-with-universal-healthcare-by-date 21, 2013). [https://perma.cc/XU9H-JE9C] (last updated Jan. healthcare services generally in New Zealand’s system,healthcare services consumers looking for value need informationthe best healthcare empowered and to be use that to information. The HealthTechbeing developed by Wisconsin tools HealthTech entrepreneurs ( https://www.quora.com/What-are-the-benefits-of-a-two-tier-healthcare-system [https://perma.cc/4JT4-SGXK]; Stuart Bramhall, and low wait timeslow wait and procedures. for 2018] by somewhich is considered to be a possible improvement to the Canadian system—by market providing a self-pay private layer on top of the government- net. safety funded universal care FOR A Brandon Waugh, Zealand Story https://papers.ssrn.com/sol3/papers.cfm?abst healthcare, by giving consumersaccess to transparent pricing and outcomes, and empowering them healthcare value based on that to shop for the best information. It is argued, based on lower cost and examples, that this would to care, as long as increase anticompetitivequality and access behavior of large this trend. Based on the above argumentshealthcare providers does not block and data from New Zealand and Switzerland, a other countries, especially hybrid and two-tiered as being the best modelis for the system suggested Unites is ultimatelyStates. implemented in the United 40672-mqi_22-1 Sheet No. 47 Side A 05/20/2019 14:43:36 A 05/20/2019 47 Side Sheet No. 40672-mqi_22-1 40672-mqi_22-1 Sheet No. 47 Side B 05/20/2019 14:43:36 M K C Y [Vol. 22:1 [Vol. 9/21/2018 1:50 PM ) to shop for the best ) to shop for the best 191 if a healthcare consumer if a healthcare consumer Fig. 4 Fig. Institute for Quality and , using an open EMR that sits on top of the (and analogous to what Access HealthNet offers in what Access HealthNet (and analogous to MARQ. INTELL. PROP. L. REV. REV. L. PROP. INTELL. MARQ. note 169; WISHIN, www.wishin.org [https://perma.cc/J8LB-RYV7]. note 169; WISHIN, www.wishin.org ) supra ELETE , D OT OT N UROO Medical Home Network O (D INAL INAL 191. G .F So, the first tier in this two-tier proposed healthcare is system market driven Many would argue that healthcare should be universal, and that the above be universal, and that Many would argue that healthcare should EM 7. S 7. Wisconsin, or via web portals like Guroo and WISHIN). Wisconsin, via web portals like Guroo and or Efficiency in Healthcare insurance value; or, for the best healthcare value, defined as cost and quality of of cost and quality defined as value, healthcare best the for or, insurance value; provided in Germanythe service, as is by the States. ConsumersStates. a system in such consumers direct healthcare be the could or their employer(i.e. the patient), or QuadMed). (e.g., Serigraph party Either choose to could in New Zealand, for care (as pay directly and as with YourMD or RemedyNow in Switzerlandin Wisconsin), and (as shop for insurance or to as with Dynamis in Wisconsin). Information consumer to guide decision- making these above, and tools, as discussed provided by HealthTech could be tools could resemble the portal used in Switzerland ( 90 various provider EMRs. This would require a type of HIPAA-compliant difficult. Ultimately,sharing of patient data that is currently patients need to informationbe empowered also have and should to have access to and use this not affiliated withaccess to a care coordinator that is by) any one (and biased provider that has commercial of leakage). Primary interests (e.g., avoidance and urgent care could be provided in this way, with to referrals more expensive MRIs)and specialized care (e.g., hip surgery; by shopping for the best value, systemusing the help of a broker and portal like Access HealthNet, done directly by the consumer, a consumer or by representative, such as a care coordinator. system is flawed, being unfair to especially vulnerable populations who cannot afford care. Those populations may choose to get care only when then EDs, made using possible by needed, and in the most way expensive absolutely possible because of EMTALA regulations. about meeting There is also concern the needs of the poor, especially Medicaid populations—which the includes 60% homes of people in nursing who ultimately end up on Medicaid(and therefore in poverty). any as well as of the needs of this population, To address person who needs access to basic medical care in very dire and expensive it situations, is argued that there should also be a second tier that acts as a safety with competition (as in Newdirect pay or paid via could be Zealand) and (unlike New Zealand). individual insurance However, and is getting care fromis in charge of care multiple sources (e.g., a medical home-like clinic at work, such as a QuadMed clinic, and also via direct pay options, like YourMD), it will coordination like that important be to have care offered by 40672-mqi_22-1 Sheet No. 47 Side B 05/20/2019 14:43:36 B 05/20/2019 47 Side Sheet No. 40672-mqi_22-1 40672-mqi_22-1 Sheet No. 48 Side A 05/20/2019 14:43:36 in 91 Out of this 9/21/2018 1:50 PM 193 model) or by the (July 9, 2010, 2:57 PM), 2:57 PM), (July 9, 2010, Remedium eXchange OST in Chicago does. That That does. in Chicago . P ASH W HE , T . Nor is there any reason why the state . Nor is there any reason why the state Healthcare Medical Home Network Medical Home Network , agreed there is value in having a safety net: net: , agreed there is value in having a safety , rxthinktank.org/healthcare-economics-summit-meeting- comprehensive system of social insurance Medical Home Network Network Home Medical CHANGE Hayek on Social Insurance X ) 192 ELETE D CELEBRATING WISCONSIN ENTREPRENEURS ENTREPRENEURS WISCONSIN CELEBRATING OT OT N The Road to Serfdom EMEDIUM E O sufficient to preserve health (D INAL INAL 193. R 192. Dylan Matthews, .F The poor or those confronted with medical situations or expenses which are The above article is based on and derived fromThe above article is based on and a meeting on March 21, There is no reason why, in a society which has reached the general level of reached which has There is no reason why, in a society The above proposal is two-tiered, resembling the system in New Zealand, is two-tiered, resembling the system The above proposal C. (Rx) Think The Remedium eXchange Tank—Helping to Consumerize M K EM C Y 7. S 7. summary [https://perma.cc/3VQK-Z4L4 ] (last visited Oct. 02, 2017). summary [https://perma.cc/3VQK-Z4L4 ] (last visited Oct. 02, http://voices.washingtonpost.com/ezra-klein/2010/07/hayek_on_social_insurance.html added). [https://perma.cc/M64G-LVFE] (emphasis excessive and unanticipated should have someexcessive and unanticipated should safety net but done in a way that also preserves the Americanpassion and commitment to free markets and competition. Maybe this is something Democrats and Republicans, albeit on. reluctantly, could actually agree to—or at least compromise 2017, entitled the “Healthcare Economics Summit,” attended by over 100 healthcare in Wisconsin.thought leaders and practitioners in event grew a healthcare economics think tank, called the providing for those common which few can make life against hazards of adequate provision. wealth ours be not has, the first kind should guaranteed of security to all without endangering general freedom; is: some that minimum of food, shelter and clothing, should not help to organize a system care system a unique coordinated to provide uses HealthTech that was able to improve outcomes, million and even saved $11 over 1 million for the MedicaidCanadian tier, as in the years. This second served over two patients might so it system, from eventually suffer would be universal, some of the same limitations Canadian system as the long waiting (i.e. times more and limited net for everyone that is to care), but it would provide a safety access be in the U.S. healthcare system.currently not available This second tier could financed by the major healthcare providers from the savings they enjoy (as was the case in the Chicago-based net, and functions like the like and functions net, 2018] government, in a single payer model. government, in a single payer be considered compromiseand offering elements would likely that both by the Unitedpolitical parties in States, so it may viable be the only politically and free market economist individualistic solution. Even the Friedrich Hayek, in his book 40672-mqi_22-1 Sheet No. 48 Side A 05/20/2019 14:43:36 A 05/20/2019 48 Side Sheet No. 40672-mqi_22-1 40672-mqi_22-1 Sheet No. 48 Side B 05/20/2019 14:43:36 M K C Y [Vol. 22:1 [Vol. 9/21/2018 1:50 PM ” event, an expert These traits are valuable in , even if Wisconsin ranks low 198 In short, it is focused on helping to In short, it is focused is to “to provide information,is to “to provide resources, 197 ONCLUSION note 187. V. C supra , rxthinktank.org/our-staff/ [https://perma.cc/4R4J-MASC] (last with a focus on consumerizingwith a focus This healthcare. , rxthinktank.org/about-us [https://perma.cc/G4YG-YVQ6] (last , rxthinktank.org/about-us [https://perma.cc/G4YG-YVQ6] , This may be why the Wisconsin is a entrepreneur 199 195 Rx Think Tank Rx Think MARQ. INTELL. PROP. L. REV. REV. L. PROP. INTELL. MARQ. CHANGE CHANGE CHANGE X X X where over forty members over forty where in conversations engaged have ) note 4. Main Street Entrepreneurship Celebrating the Wisconsin Entrepreneur 194 , ELETE D supra OT OT N The vision of the Tank is to “to increase Quality,Rx Access,Think . EMEDIUM E EMEDIUM E EMEDIUM E O Id Id. (D 196 INAL INAL 199. 196. R 194. R 195. R 197. 198. Sem, .F A survey of Wisconsin companies and the entrepreneurs that founded At a recent “ The mission the of EM 7. S 7. panel described Wisconsin entrepreneurs as “innovative, capital efficient, hard- entrepreneurs Wisconsin described panel humblereliable.” and working, values-driven, and Affordabilitypatient-centered and consumer- of healthcare for all, in a delivery model.”driven healthcare consumerize and reform and learning from healthcare, by partnering with Wisconsin including southeast Wisconsin’s healthcare leaders and innovators, HealthTech community. national leader in for overall startup activity. However, Wisconsin a vibrant entrepreneurial ecosystem, resources, is with associated working hard to change that latter statistic. creating sustainable businesses that last, but they may last, creating sustainable businesses that sometimes work against and high-reward startups that need large amounts high-risk the creation of very the Wisconsinof venture capital to scale. In particular, is entrepreneur sometimesmay not and risk averse excel at sales (and, in the extreme, hype and puffery), but they are “more and robust—often enduring more the distance- runner than the sprinter.” (Rx) Think Tank (Rx) 92 visited Oct. 02, 2017). visited Oct. 02, about healthcare reform,about healthcare and support to policy makers, healthcare innovators, patients, and providers, to makers,healthcare to policy patients, and providers, innovators, and support help them consumerize and to accomplish healthcare, this by incentivizing, can make so they educating, and empowering their own and providers patients healthcare decisions—so market increase can drive down cost and forces quality.” think tank exists think tank to serve a as for catalyst reform, on healthcare discussions with especially cost, United States, challenges in the address healthcare a goal to access. quality, and visited Oct. 02, 2017). visited Oct. 02, 40672-mqi_22-1 Sheet No. 48 Side B 05/20/2019 14:43:36 B 05/20/2019 48 Side Sheet No. 40672-mqi_22-1 40672-mqi_22-1 Sheet No. 49 Side A 05/20/2019 14:43:36 93 9/21/2018 1:50 PM a two-tier healthcare , reveals a , reveals “common TM 201 , Rx Think Rx Tank Mission statements reflect these values, these values, Missionreflect statements 200 , http://www.rxthinktank.org [https://perma.cc/PD77-W9Z9]. , http://www.rxthinktank.org CHANGE Wisconsin Exhibit Entrepreneur X ) ELETE D CELEBRATING WISCONSIN ENTREPRENEURS ENTREPRENEURS WISCONSIN CELEBRATING OT OT N EMEDIUM E O Id. (D INAL INAL 200. 201. R .F M K EM C Y 7. S 7. 2018] theme of values amongstof values Wisconsin companies, trust, honesty, including theme integrity, hard work, and quality.” them profiled in the in them profiled system has been proposed for the United States. This system would have have would system This States. has been proposed for the United system markettransparent pricing and competition in a driven system in one tier, coupled to a second safety net tier that is universal, and both tiers are modeled and after successes in other countries, also by Wisconsin HealthTech deliver patient-centered healthcare to ways businesses that are pioneering new more efficiently. and on occasion also state the centrality of the founders’ faith and religious faith and founders’ the the centrality of occasion also state on and faith, business and often blending culture, of corporate drivers values as economics. Over with the largest profiled, Wisconsin companies were 150 number of companies manufacturingin sectors that included: and engineering, and food and beverage, and insurance, the law, numberwith a significant in and impactfulare mostmay exciting that trends future the but sectors, retail which sectors, biotechnology and technology and the be in the healthcare, industry. Wisconsin, southeast and particularly HealthTech the includes Wisconsin, has a large number of HealthTech companies that are proposing solutions to some of the delivery, and are leading the challenges in healthcare leaders in and on their efforts, Based healthcare. consumerizing efforts at that are part of healthcare thought the 40672-mqi_22-1 Sheet No. 49 Side A 05/20/2019 14:43:36 A 05/20/2019 49 Side Sheet No. 40672-mqi_22-1 40672-mqi_22-1 Sheet No. 49 Side B 05/20/2019 14:43:36 M K C Y [Vol. 22:1 [Vol. 9/21/2018 1:50 PM cousinssubs.com culvers.com festfoods.com usventure.com wecenergygroup. com associatedbank. com bakertilly.com heartlandadvisors .com johnsonbank.com bmoharris.com rwbaird.com spectruminvestor. com belgioioso.com abcsupply.com galarson.com jschmitt.cc industries.com eatstreet.com manpowergroup. com .com construction.com richardson- .com Bill Specht and Jim Sheppard George, Ruth, Craig and Lea Culver UW-Madison Students Paul and Jane Skogen Art, Ray, and Bill Schmit Bill Nasgovitz Samuel C. Johnson Elmer Winter and Aaron Scheinfeld Robert Wison Baird James F. Marshall Otto J. Schoenleber buybulkchocolate Errico Auricchio Ken and Diane Ken and Diane Henricks Gus Larson Joseph Schmitt Patrick G. Miron Joseph and Carolyn miron- Richardson Martin Boldt theboldtcompany 1848 1896 1972 1894 1984 1899 1984 1970 1979 1948 1919 1936 1946 1889 1951 2010 1995 2000 1882 1918 1970 1982 1982 APPENDIX—TABLE 1 MARQ. INTELL. PROP. L. REV. REV. L. PROP. INTELL. MARQ. Sheboygan Falls Minnesota Menomonee Falls Prairie du Sac Madison Wisconsin Brookfield Milwaukee Chicago Milwaukee Milwaukee Chicago ) Pewaukee Sheboygan Green Bay ELETE D OT OT N O (D INAL INAL .F EM Ambrosia Chocolate Wayzata, BelGioioso Cheese Green Bay Cousins Subs Culvers Eat Street Festival Foods Associated Banc- Corp Baker Tilly Virchow Krause L.L.C. Fiserv Johnson BankManpower Racine Marshall & Ilsey (BMO Harris) Robert W. Baird Spectrum Investing Mequon PG MironRichardson Industries The Boldt Company Neenah Appleton Us Venture Inc.WEC Group Appleton ABC SupplyGustave A Larson Company Beloit Jos. Schcmitt Construction 94 7. S 7. Food and Beverage Corporate NameCorporate HQ Year Founder Trades and Building Construction Website Energy (gas, electric, transmission, pipelines, mining) Finance, Accounting and Support 40672-mqi_22-1 Sheet No. 49 Side B 05/20/2019 14:43:36 B 05/20/2019 49 Side Sheet No. 40672-mqi_22-1 40672-mqi_22-1 Sheet No. 50 Side A 05/20/2019 14:43:36 95 g s.or y 9/21/2018 1:50 PM history bcw.edu chw.org columbia- stmar gehealthcare.com omanhene.com organicvalley. coop palermospizza. rockyrococo.com roundys.com schreiberfoods. com sendiks.com pointbeer.com/abo ut/ usinger.com woodmans- food.com aurorahealthcare. org genbev.com belgioioso.com hillshirefarm.com johnsonville.com/ home.html kopps.com kwiktrip.com mabaensch.com mastersgalleryfoo ds.com millercoors.com milios.com newglarusbrewing .com com com com The Junior League of Wisconsin Daughters of Charity Steven C. Wallace George Siemon Oscar F. MayerJacob Best oscarmayer.com Gasoare and Zina Fallucca Sam Jacobsen pabstbrewingco. pdqstores.com Leonard Gentine L.D. Schreiber sargento.com Balistreri Godfrey FamilyRandal Sprecher sentryfoods.com Frank Wahle and sprecherbrewery. George Ruder Fred Usinger John Woodman William A. Breyer breyers.com Errico Auricchio Fritz Bernegger Alice Ralph F. and Stayer Elsa Kopp Don Zietlow Baensch family Leonard Butch Frederick Miller Mike Liautaud Paul A. StittDeborah Carey naturalovens.com 1953 1945 1857 1974 1947 1894 1848 1984 1956 1993 1844 1976 1945 1866 1979 1991 1964 1872 1926 1960 1880 1932 1950 1949 1965 1934 1934 1974 1920 1985 1988 1873 1933 1989 1855 Waukesha Milwaukee Milwaukee Milwaukee Janesville Milwaukee Milwaukee Milwaukee Milwaukee New Glarus Milwaukee La Farge Los Angeles Sheboygan Falls La Crosse Milwaukee ) Steven's Point Plymouth Green Bay Greenfield ELETE D CELEBRATING WISCONSIN ENTREPRENEURS ENTREPRENEURS WISCONSIN CELEBRATING OT OT N O (D INAL INAL .F M K EM C Y GE Healthcare UsingersWoodmans Milwaukee Aurora Health Care Blood Center of Wisconsin Children's Hospital of Wisconsin CSM Milwaukee Palermo's PDQ Food StoresRocky Rococo Middleton Roundy's Sargento Cheese Oconomowoc Schreiber Foods Plymouth Sendik's Food Green Bay Market Sentry Foods Sprecher Brewery Glendale Steven's Point Brewery Masters Gallery Foods MillerCoorsMilo's SandwichesNatural Ovens Madison New Glarus Brewing Chicago Manitowoc Omanhene Cocoa Bean Company Organic Valley Oscar MayerPabst Madison General BeverageGeneral Good Humor- Madison Breyers CheeseBelGioioso Hillshire Farms Green Bay Foods Johnsonville IL Peoria, Kopp's Frozen Custard Kwik Trip Ma Baensch Insurance (life, health, casualty, flood) 7. S 7. 2018] 40672-mqi_22-1 Sheet No. 50 Side A 05/20/2019 14:43:36 A 05/20/2019 50 Side Sheet No. 40672-mqi_22-1 40672-mqi_22-1 Sheet No. 50 Side B 05/20/2019 14:43:36 M K C Y [Vol. 22:1 [Vol. 9/21/2018 1:50 PM g amsoil.com appvion.com foley.com gklaw.com gruber-law.com quarles.com allischalmerslawn. com amsoil.com appvion.com allischalmerslawn. com quadmedical.com shopko.com aurorahealthcare. or bcw.edu chw.org acuity.com amfam.com m3ins.com dewittross.com ual.com aosmith.com rockwellautomati on.com aosmith.com rockwellautomati on.com com Charles Jeremiah Smith Charles Boyd Asahel Finch, Jr. and William Pitt Lynde Dudley Godfrey and Jerry Kahn David Gruber Michael F. HupyEdward G. Ryan hupy.com michaelbest.com Lynde Bradley and Stanton Allen Charles Jeremiah Smith Charles Boyd Carlyle Weinberger ashleyfurniture. Lynde Bradley and Stanton Allen Harry V. Quadracci Harry James Ruben League The Junior of Wisconsin Herman Wittwer John Johnston northwesternmut William R. Bagley 1978 1857 1925 1962 1874 1842 1957 1984 1969 1848 1903 1847 1874 1903 1847 1984 1947 1894 1907 1907 1927 1903 1978 1974 1945 1990 MARQ. INTELL. PROP. L. REV. REV. L. PROP. INTELL. MARQ. Milwaukee Superior Milwaukee Milwaukee Chicago Milwaukee Superior Milwaukee Madison Milwaukee Milwaukee Milwaukee Sussex Milwaukee Milwaukee Milwaukee Milwaukee Milwaukee ) Arcadia Madison Madison ELETE D OT OT N O (D INAL INAL .F EM anufacturing and Engineering AppvionAshley Furniture Industries Allen Bradley Appleton Allis ChalmersAmsoil Milwaukee AO Smith Appvion Appleton Hupy & Abraham, S.C. Michael Best Quarles & Brady Allen Bradley Allis ChalmersAmsoil Milwaukee AO Smith M3 Insurance Northwestern Mutual DeWitt, & Ross Stevens Foley & Lardner, LLP Godfrey & Kahn Gruber Law Offices LLC Quad Med Quad Shopko Pharmacy Care Aurora Health Green Bay of Blood Center Wisconsin Children's Hospital of Wisconsin Acuity InsuranceAmerican Family Sheboygan Insurance 7. S 7. 96 Law M 40672-mqi_22-1 Sheet No. 50 Side B 05/20/2019 14:43:36 B 05/20/2019 50 Side Sheet No. 40672-mqi_22-1 40672-mqi_22-1 Sheet No. 51 Side A 05/20/2019 14:43:36 97 m m 9/21/2018 1:50 PM us.kohler.com manitowoccranes .com mercurymarine. com newplasticscorp. com hydrite.com kapcoinc.com ki.com us.kohler.com manitowoccranes .com menashacorpor ation.co mercurymarine. com newplasticscorp. com oshkoshcorporati on.com plenco.com rexnord.com ritehite.com snapon.com trane.com trekbikes.com trombetta.com uline.com ki.com badgermeter.com bradycorp.com evcoplastics.com falk.rexnord.com gbp.com huscointl.com menashacorpor ation.co harley- davidson.com com com briggsandstratton .com John Michael Kohler Harry SorefElisha D. Smith masterlock.com Irvin Vincent Warren JohnsonTom Kacmarcik Sr johnsoncontrols. Al Krueger John Michael Kohler Harry SorefElisha D. Smith masterlock.com Irvin Vincent Frank G. Brotz Samuel C. Johnson scjohnson.com Al Krueger Carlyle WeinbergerCarlyle ashleyfurniture. BemisJudson Moss Will H. Brady bemis.com and Stephen Briggs Harold Stratton Alfred Mellowes chartermfg.com Don Evans William S. Harley, Arthur Davidson, and Walter Davidson Agustin Ramirez, Jr. 1988 1939 1939 1968 1902 1902 1934 1968 1929 1921 1941 1921 1941 1933 1885 1892 1965 1905 1905 1914 1908 1903 1985 1976 1917 1920 1948 1936 1892 1980 1945 1972 1849 1849 1858 1858 1873 1873 1886 Racine Milwaukee Chicago Luxemburg Milwaukee Milwaukee Auburn Milwaukee Milwaukee Milwaukee Neenah Milwaukee Milwaukee Mequon Deforest ) Luxemburg Arcadia Green Bay Grafton ELETE D CELEBRATING WISCONSIN ENTREPRENEURS ENTREPRENEURS WISCONSIN CELEBRATING OT OT N O (D INAL INAL .F M K EM C Y New Plastics Corp. SC Johnson Snap-onTraneTrekTrombetta Kenosha Uline KI Piscataway, NJ KohlerManitowoc Cranes Waterloo Manitowoc Master LockMenasha Corp Kohler Green Bay Oak Creek Mercury Marine Neenah Fond Du Lac Manitowoc Cranes Manitowoc Master LockMenasha Corp Oak Creek Mercury Marine Neenah Fond Du Lac New Plastics Corp. Oshkosh Corp.Plenco Oshkosh Rexnord Rite Hite Sheboygan Falk Corporation Green Bay Packaging Corp. Harley-Davidson HUSCOHydrite ChemicalJohnson Controls Brookfield KAPCO Metal Waukesha Shaping KIKohler Kohler Green Bay Ashley Furniture Furniture Ashley Industries Badger Meter Bemis Brady Corporation Briggs & Stratton Charter Manufacturing Evco Plastics 7. S 7. 2018] 40672-mqi_22-1 Sheet No. 51 Side A 05/20/2019 14:43:36 A 05/20/2019 51 Side Sheet No. 40672-mqi_22-1 40672-mqi_22-1 Sheet No. 51 Side B 05/20/2019 14:43:36 M K C Y m [Vol. 22:1 22:1 [Vol. 9/21/2018 1:50 PM boucher.com florsheim.com jockey.com corporate.kohls. com mercurymarine. com newplasticscorp. com oshkoshcorporati on.com plenco.com rexnord.com ritehite.com snapon.com trane.com trekbikes.com trombetta.com uline.com jnlcom.com qg.com allenedmonds. com ashleyfurniture. com bergstromauto. com oshkoshcorporati on.com plenco.com rexnord.com ritehite.com snapon.com trane.com trekbikes.com trombetta.com uline.com ki.com us.kohler.com manitowoccranes .com ation.co Max Kohl Irvin Vincent Frank G. Brotz Samuel C. Johnson scjohnson.com Alex Haley Frank G. Brotz JohnsonSamuel C. scjohnson.com Al Krueger John Michael Kohler Harry SorefElisha D. Smith masterlock.com menashacorpor 1917 1988 1988 1956 1962 1922 1939 1988 1968 1902 1934 1934 1941 1921 1892 1965 1892 1965 1976 1976 1892 1917 1920 1920 1920 1980 1980 1945 1974 1974 1849 1873 1886 1886 1886 1971 MARQ. INTELL. PROP. L. REV. REV. L. PROP. INTELL. MARQ. Glendale Milwaukee Milwaukee Racine Milwaukee Chicago Franklin, TN Sussex Luxemburg Milwaukee Milwaukee Racine Milwaukee Chicago ) Neenah Falls Mequon ELETE D OT OT N O (D INAL INAL .F EM Allen Edmonds Shoes Ashley Furniture Arcadia Bergstrom Automotive Boucher Automotive Florsheim Shoes Jockey International Kenosha Kohls Corporation Menomonee Rexnord Rite Hite SC Johnson Snap-onTraneTrekTrombetta Uline Kenosha NJ Piscataway, Waterloo Journal Communications Quad Graphics KIKohlerManitowoc Cranes Manitowoc Master LockMenasha Corp Kohler Green Bay Oak Creek Mercury Marine Neenah New Plastics Corp. Du Lac Fond Oshkosh Corp.Plenco Oshkosh Sheboygan Oshkosh Corp.Oshkosh Plenco Oshkosh Rexnord Rite Hite SC Johnson Snap-on Sheboygan TraneTrekTrombetta Uline Kenosha Piscataway, NJ Waterloo Retail Printing, Publishing and Communications 7. S 7. 98 40672-mqi_22-1 Sheet No. 51 Side B 05/20/2019 14:43:36 B 05/20/2019 51 Side Sheet No. 40672-mqi_22-1 40672-mqi_22-1 Sheet No. 52 Side A 05/20/2019 14:43:36 99 9/21/2018 1:50 PM schneider.com delongcompany. com alcaminow.com sigmaaldrich.com mycarmex.com covance.com cray.com epic.com nimblegen.com promega.com rockwellautomati on.com airwis.com freightrunners. com lake-express.com nmtransfer.com menards.com fleetfarm.com pacific-cycle.com shopko.com marcuscorp.com mlb.com/brewers nba.com dohmen.com Seymour Cray Friedrich W. Dohmen Gary ComerGary landsend.com James Ruben 1997 1975 2009 PA 1972 1935 1962 1858 1903 1985 2004 1935 1964 1968 1962 1963 1963 1978 1965 1955 1999 1977 1937 1964 1913 1979 Milwaukee Milwaukee Neenah Conshohocken, Milwaukee Madison Milwaukee Milwaukee Milwaukee Wilmington, NC Saint Louis, MO Dodgeville Madison ) Clinton Franklin Green Bay ELETE D CELEBRATING WISCONSIN ENTREPRENEURS ENTREPRENEURS WISCONSIN CELEBRATING OT OT N O (D INAL INAL .F M K EM C Y Air WisconsinFreight Runners Express Appleton Lake Express N&M Co., Transfer Inc. Schneider NationalThe DeLong Green Bay Company Covance CrayDohmen Epic SoftwareNimblegen/Roche Promega Verona WA Seattle, Rockwell Automation Fitchburg Marcus Corp Milwaukee Brewers Milwaukee Bucks Milwaukee Alcami (AAIPharma Services and Cambridge Major Laboratories) Aldrich Chemicals Carma Labratories, Inc. Land's End Land's MenardsMills Farm Fleet Pacific Cycle Appleton Shopko (Retail) Pharmacy (Includes Eau Claire info) Transportation (rail, trucking, air, water) Transportation (rail, trucking, air, 7. S 7. 2018] Sports, Hospitality, and EntertainmentSports, Hospitality, Technology and Biotech Technology and 40672-mqi_22-1 Sheet No. 52 Side A 05/20/2019 14:43:36 A 05/20/2019 52 Side Sheet No. 40672-mqi_22-1 40672-mqi_22-1 Sheet No. 52 Side B 05/20/2019 14:43:36 s M K C Y [Vol. 22:1 [Vol. place 9/21/2018 1:50 PM etwork ehavior- Virtual PopulationCompas market Prostate Cancer screening test MIPS Accelerator e-prescribing network ConsortiEX b ADHD Clinic Radixact- TomoTheray Fertility Finder N Consulting Scally-My Easy Weight app-The challenge to change BluDiagnostics digital healthcare- focused seed fund The Super Option The Super PopulationManager - GrandCare System Extract Systems Platform Platform Charlie m m m p.com luetreenetw ludiagnostics. ork.com com gregordiagno stics.com healthefilings. com healthxventur es.co consortiex.cco easywayto health.co envisionadhd. com extractsystem s.com forwardhealth grou grandcare. com accesshealthn et.co accuray.com CyberKnife- b b nggroup.com com datica.com IT service ensodata.io EnsoSleep Tobias Zutz Robert Hopton Jonathan Baran healthfinch. Mark Bakken Joe Reinardy centerx.com Neal Long Travis Good, MD, and Mohan Balachandran, Renato Romani Chris Fernandez Jacob Behrens Rasmussen Michael Barbouche Eric Haberichter Joshua H. Levine Sarah Katherine Brenner Jeremy Schwach Rachel Neill carexconsulti David APPENDIX—TABLE 2 2016 1990 2005 2016 2013 2014 MARQ. INTELL. PROP. L. REV. REV. L. PROP. INTELL. MARQ. 2009 2011 2015 2015 2015 2012 2016 2009 2013 2015 ) ELETE D OT OT West Bend West Madison Madison Milwaukee Madison Milwaukee Milwaukee California Madison N Madison Madison Madison Madison Madison Madison O (D H INAL INAL .F EM Name HQ Year CEO Website Product Forward Health Group GrandCare Gregor Diagnostics Health Eflings HEAL THFINC Healthx Ventures Easy Way to Health Ensodata Madison Envision ADHD Clinic Extract Systems Bluetree Network Carex Consulting Group Centerx Madison Consortiex Datica Madison Access HealthNet Accuray Blue Diagnostics 7. S 7. 100 40672-mqi_22-1 Sheet No. 52 Side B 05/20/2019 14:43:36 B 05/20/2019 52 Side Sheet No. 40672-mqi_22-1 40672-mqi_22-1 Sheet No. 53 Side A 05/20/2019 14:43:36 101 9/21/2018 1:50 PM Swallow Strong Diagnostic test CarePaths B60 VelociDoc ReadyList Remedy Technology and Technology Services Solution intellivisit app Moxe’s clinical data CareSelect Imaging MicroC3 clinical research Propeller - Reconcile - - Reconcile Persist Data services Redox Platform (healthcare data exchange solution) assistants (IVA) om pport.com om ropellerheal racticevelocit th.com y.com swallowsolution s.c taidiagnostics. com wellbe.me nobo.io oaxhealth.com p ushealthcenteri nc.c p readylist.com remedyanalyti cs.com speechtails.com SpeechTails hps.md lynxbioscienc es.com mpirik.com nationaldecisio nsu al.com com com com Mardini Spauldingspauldingclinic Frank Langley Joy Casterton valianthealth. James Dias Sanjay Mohan mynest.care healthio Erich JacobsDavid Stern onkol.net OnKöl David Van Sickle Luke Bonney redoxengine. Scott Martin Aamir Siddiqi remedynow.net Health service Randy Amy Reno Sal Braico highfiverx.com Prioritize - Predict Jay Fulkerson Norrie Daroga idavatars.com Intelligent virtual Jeff MillerDr. Chorom intellivisit.com Pak Dan Wilson moxehealth. Michael 1998 2010 2012 2013 2002 2010 2007 2015 2011 2015 2012 2016 2015 2005 2014 2016 2009 2014 2012 2014 2013 2013 2013 ) ELETE D CELEBRATING WISCONSIN ENTREPRENEURS ENTREPRENEURS WISCONSIN CELEBRATING OT OT Elm Grovesconsin Madison Eric Horler Milwaukee Park Milwaukee Madison Milwaukee Milwaukee Milwaukee Milwaukee Waukesha Madison Milwaukee Machesney Milwaukee N Delafield Madison Bend West Madison Madison O (D Inc. INAL INAL .F M K EM C Y Wellbe Madison Remedy Now Spaulding Clinical Research, LLC Speechtails Swallow Solutions TAI Diagnostics, Inc. Valiant Health Velocity Predictimed /US Health Center, Propeller Health ReadyList, Inc. Redox Madison Remedy Analytics Moxe mpirikNational Decision Milwaukee Support Company nestCARE Inc. Nobo Oax Health ONKÖL Practice Highfive Health Hps Idavatar Mequon Intellivisit Lynx Biosciences 7. S 7. 2018] 40672-mqi_22-1 Sheet No. 53 Side A 05/20/2019 14:43:36 A 05/20/2019 53 Side Sheet No. 40672-mqi_22-1 40672-mqi_22-1 Sheet No. 53 Side B 05/20/2019 14:43:36 M K C Y [Vol. 22:1 [Vol. 9/21/2018 1:50 PM APPENDIX—TABLE 3 MARQ. INTELL. PROP. L. REV. REV. L. PROP. INTELL. MARQ. ) $85,156 $57,735 $85,156 $57,735 $53,128 $15,835 $167,860 $125,036 $167,860 $125,036 $88.191 $43,715 $178,435 $146,428 $178,435 $146,428 $77,719 $52,580 $60,167 $52,110 $60,167 $52,110 $21,864 $15,356 $31,688 $39,795 $21,106 $13,133 $31,688 $39,795 $31,688 $21,106 $13,133 ELETE D Hemorrhage & Shock Pain Failure OT OT N O (D INAL INAL .F EM Harbor–UCLA Medical Center Los Angeles Community Hospital Sherman Oaks Hospital Sherman Oaks Hospital Garfield Medical Center Cedars-Sinai Medical Center 7. S 7. 102 Hospital Hospital Brain Failure Heart Chest Kidney 40672-mqi_22-1 Sheet No. 53 Side B 05/20/2019 14:43:36 B 05/20/2019 53 Side Sheet No. 40672-mqi_22-1