Given that mission, it's fair to say Haven's success or failure won't be determined in 2019. But its focus on examining the business relationships that constitute the current health care delivery system positions it, by recent standards, for achievement. In today's world, health care startups that find favor among health plan sponsors—and the insurance brokers that counsel them—may well survive, if they can make it to Year Four.

Rather than curate a list of bright and shiny upstarts, with all the latest apps included, it may be more instructive to view potential disruptors by type of product or service. We reached out to an array of innovation watchers, asking them where they expected to see significant contributions this year from relatively unknown companies and their products or services. Here's what we heard back.

Pharmaceutical effectiveness

The trends evolving here have less to do with the national effort to rein in drug costs and more do to with connecting the right drug to the patient. Currently, as many as one-third of patients taking drugs for chronic conditions may be taking the wrong one. That's because physicians prescribe for the “typical” patient.

New genetic testing services can determine whether a specific drug will work for a specific patient. This kind of matching can lead to considerable savings for a plan sponsor over time as people get better because they have switched medications. Color Genomics (2013) is among those that offer the testing. But little infrastructure currently exists to connect plan member test results to physicians. Concert Genetics (2010) offers an interoperability platform that addresses this by, it says, “systematically communicat[ing] medical policies, network laboratories and prior authorization requirements to clinicians on a test-specific basis at the point of order.”

Meantime, other young companies are seeking solutions to disorders that run up health plan costs. Cricket Health (2015) says its multidisciplinary approach to managing kidney disorders is “realigning patients, clinicians, and payors” to drive down payor costs. Pear Therapeutics (2013) is currently focused on developing new therapies to treat substance abuse, with a product in the review stage it says will address opioid addiction.

Paid on performance

Plan sponsors have shelled out untold millions over the years for programs, projects, apps and equipment which promised better employee health at lower cost but did not deliver. What's emerging are companies willing to tie their compensation to specific outcomes. Color Genomics is one. An employer in Pennsylvania, Jefferson Health, added Color Genomics to its plan, which covered 30,000 individuals. The savings the company realized on the testing, by no longer paying for drugs that were not working, more than paid for the genetic testing. But Color Genomics put its entire fee at risk, agreeing to be paid only if the testing showed a return on investment in money saved through incorrect drug therapy.

Other behavioral change vendors are offering the same terms. Among them: Omada Health (2011), which helps plan members manage their weight, and Verto (2013), which offers a larger range of personal health control services, including Rightpath Flow, an administrative support platform. Another is Virta, founded in 2014 to provide support to patients with Type 2 diabetes. In 2018, it focused on building out its commercial business, in which it puts 100 percent of its fees at risk based on reversal of the disease in plan members. It sets two milestone of value to the sponsor: number of patients involved, and disease reversal. It only gets paid when both have been met.

Monitoring and adherence solutions

Patient monitoring and reminder devices have not really delivered on the promise of improving patient health for plan members. That's because there's no accountability loop. When patients are connected to a third party–even if that party is a robot–results improve. Solutions that connect the data gathered by a device to someone (or something) that can act upon it are viewed positively by plan designers and sponsors because of the known toll a lack of response takes on employee health.

Conversa Health (2013) offers a platform that reaches out to patients with a text message reminder. MediSafe (2012) is another app that loops in a third party when a patient has ignored a reminder to take a pill. Services like PillPack (2013, now owned by Amazon), and Capsule (2016) augment adherence by packaging a plan member's pills by individual dose and home delivering them.

Employer plan financing innovators

As the traditional broker-driven model of plan design comes under increasing scrutiny, companies have emerged that specialize in alternative means of funding plan member coverage. Most of these models propose to take the employer's current health care spend and refashion it to more closely meet the plan member's needs.

The promise is that cost to the employer will decrease and employee health with improve as they access upstream care. Gravie (2014) is one such company. Gravie takes a defined contribution approach, in which the plan sponsor puts up a certain amount and employees choose their benefits from Gravie's platform marketplace, with the option of spending their own dollars to enrich the plan. Gravie, which serves as its own broker, has more than 500 employer clients and more than 70,000 covered lives. It also provides administrative support.

Others offering alternative plan funding models include Hixme (2013) and Apostrophe Health (2016).

These are but a few of the players that have made it to Year Three and appear to be gaining traction. But even they must be ever wary of the perils startups face. Launching a health care business is like no other entrepreneurial venture. Not only is the field already crowded with solutions that make lofty claims, but the road to success is riddled with potholes: federal reviews, HIPAA compliance, identifying a market, creating the complex set of relationships needed to bring a new product or service in front of a plan sponsor.

Precise failure rates of health care startups don't really exist. Probably half don't make it into their fourth year. Writing for Fast Company last fall, Dr. Paul Yock , founder of the Byers Center for Biodesign at Stanford University, said most tech startup entrepreneurs aren't prepared for health care timelines.

“Consumer technology startups often push quickly to get a minimum viable product to market and then iterate to improve that product based on what most resonates with consumers,” Yock said. “… However, this strategy is ill-suited to health care, a much more complex and regulated industry.”

And yet one that, to the entrepreneur, glitters like gold.

Read more: 

• Is Uber the next health-care disruptor?
• 12 biggest names in health care disruption
• Health care leaders expect more disruptions, survey says