3 Founders on the Real Cost of Health Access | Live @ Civic Health Forum

0:03It sounds cliche and maybe Elina has also shared some of it, but where the patients are and reaching them in a way that they feel, I mean, we all know that care is about trust, and without trust you cannot actually build a patient app or a healthcare system. Welcome back to Startup Health Now, the podcast where we celebrate the entrepreneurs and innovators who are transforming health. We're going to talk about catalyzing change through founder-led innovation, something that's very near and dear to my heart, having worked with Startup Health for many years, supporting hundreds of founders. We have a short amount of time to talk about why Agile founders and Agile startups are mission critical to really changing the system and opening up access.

0:53We have an awesome panel here. We have Alina Onyskansky from Elant, who is a former payer exec turned system disruptor, who is now really changing metabolic health and helping folks who are struggling with obesity. We have Rafael Lopez, who is using AI at Diagnostic Care to radically open up access to care in Latin America. And we have Dr. Terry Huang, who has a really interesting combination of public health and private sector entrepreneurial know-how that he's leveraging at the Firefly Innovation Center, which is located at CUNY. I wanted to jump right in there with those quick bios so we could spend most of our time just talking.

1:37So I want to start, instead of doing bios, I want you to give us a sense of what you're working on and what you're building through the lens of a single patient. I know that you guys just raised$15 million in a Series A, and I congratulate you for that. But I want to pull back from that kind of press release and say, what is Illent Health? Tell us what you're working on through the story of a single patient. Absolutely. So we treat obesity, and I think one of the challenges is that we haven't considered an obesity a disease until about 10 years ago. And everyone and their mother, their grandmother, their uncle, aunt, dog, water, sister-in-law feels that they know how to address obesity, right?

2:19And that's why you've actually seen this renaming into kidney, cardio, diabetes, because everyone's trying to say, no, no, it's important. It's not just excess weight. It's like real conditions, right? And our thing is, if you actually wanted to rename it, you'd have to call it like kidney, liver, you know, cardio, diabetes, obstructive sleep apnea, osteoarthritis, mental health, and about 20 other conditions. What do we do? So we really focus on personalizing care. And we do that through a combination of technology and clinical care. And one of our real focus is really understanding how to meet people where they are, both in terms of their personal needs, but also in terms of the acuity of their condition.

3:01And one of our focus areas is on high acuity individuals. So I think everyone is aware that about 43 % of the U.S. today has what is deemed obesity based on BMI. 10 % has what is called class three obesity, which is over 40 BMI. Just to give you a sense, someone with class three obesity has about eight times the likelihood of developing diabetes as someone at optimal weight. That is actually our fastest growing segment in the U.S. today. And if you sub-segment it further, it's people over 60 BMI. So I want to give you a flavor of a member of ours who was in this class three obesity realm. She was 28 years old and 80 BMI.

3:42and because of her obesity, she literally hadn't left her house since she was about 25 years old because she couldn't stand for more than 30 seconds at a time. And if you can't stand for more than 30 seconds at a time, you can't walk out the door. And so when she came to us, you can imagine even though that she was 28 years old, she had just about every condition I just named for you associated with obesity. And she certainly had, as you would expect, anxiety, depression, and a whole host of other mental health issues. I would say sort of ironically or incredibly, she was actually doing phenomenally well at work, but she was so high acuity that you literally couldn't do surgery, right?

4:22So the evidence-based treatment for her was bariatric surgery. The surgeons refused to operate. She was too high risk for surgery. So what we did with her is helped her lose 100 pounds through medication, got her into surgery, and she's now down close to 300 pounds. But what I wanna talk about is a power of hope for someone like that. So about three months in, she was only down 30 pounds. So that's not a material amount of weight. But at that point in time, we got her stand time to two minutes. And so she could literally walk out the door for the first time in years and went to dinner with friends.

4:56Something so small, but so impactful for her. And that sort of set her off for the rest of the journey, which she capped with a Taylor Swift concert. Very nice. Raphael, same question to you. bring diagnostic care to life for us through the lens of a patient? Sure. Thank you. Let me start with a bit of context first. I mean, we're in the biggest city in North America. Mexico City is slightly bigger by a few million. And with bigger population comes bigger problems, of course. I was checking some stats. I think it's roughly 8 % of the population here in America that lacks private healthcare insurance.

5:36In Mexico is the complete opposite. It's only 8 % of the population having a healthcare private insurance. So that leaves millions of people out of the possibility to get care. Since we started the business a few years ago, we always thought about that 1%, that 1 % in the sense of reaching people that otherwise would be left out of care, out of the system, especially in a country where public healthcare system, people actually doesn't trust it because it's inefficient, it's collapsing. It's very hard to get an appointment. It's very hard to get care when you need it. So we consider ourselves an AI native company.

6:15We started using AI from the very beginning to triage patients and to triage symptoms. And obviously now with all this new AI era and tools, that has allowed us to actually be where the patient is. We typically work with blue-collar workers. Let's imagine someone working at a McDonald's, for instance, in Mexico, earning minimal wage, not being able to skip a day out of work, to go to the public system. If they do that, they don't get paid that day. And sometimes it's a decision between paying for care or paying for rent. Take into consideration, people make in a position like that,$400 a month.

6:58And statistically, nearly 90 % of our users have never had a mental health coaching or visit before, nor a virtual care consultation. So that's what we're building. We are reaching this 1%, which is the majority of the people in Mexico outside of the system, mainly through WhatsApp, which 100 million people in Mexico use WhatsApp daily. So WhatsApp has become our front door. We don't triage and we don't provide any healthcare guidance through WhatsApp. It's only the triggering message that then starts the whole process. And that's the way we are reaching that population, where they are and with a tool that they use.

7:42Awesome. Thanks, Rafael. And Terry, tell us about a founder or startup that really embodies the ethos of what you're building at Firefly. So let me just quickly say that Firefly Innovations is a unique public health entrepreneurship platform housed within a school of public health. We're the only school among 200 plus schools and programs of public health across the U.S. that has such a platform. And it was really founded to make public health more agile in both fostering and scaling innovation. Very little public health R &D coming out of academic public health ever gets scaled up. And so we wanted to do this by converging academic public health with private sector innovators and bring these different stakeholders from different sectors together to problem solve, to tackle persistent public health challenges, of which there are many, as all of you know.

8:36Some of our companies that we work with are actually here. Pons presented earlier. We have a pilot that's about to start with another company called Elle. They're on the next panel coming up. But one founder who actually participated very early on in our original accelerator six years ago is Candlelit Therapy. And the founder is Lauren Elliott. I always think of Lauren and Candlelit very fondly because in so many ways, both the founder and the startup itself really embody the mission of Firefly, which is really about expanding access to both social and clinical care, better yet the integration of the two.

9:16It's about reducing the cost of care. And then also it's about building trust, enhancing trust in the system. Those are the three pillars that are really part of our mission. And I think Lauren and Candelate Therapy really embody all of those. So Candelate Therapy is basically a platform aimed at helping women during and after pregnancy to deal with depression and mental health issues. And this is something that Lauren herself, as a woman of color, really experienced during her own childbirth experiences. And because she experienced that, she lived through that, and she realized that, wow, there was actually very little out there to help her address her problems.

9:57So she created Ketel-Lit therapy specifically for that purpose. And it's really culturally tailored and sensitive to women from diverse backgrounds in particular. And so as a founder, she's adaptive. She's persistent. After she went through our accelerator, she went on to join Techstars and continue to pivot and grow her company. And so I think it's just a really wonderful story to showcase why Firefly exists. It is to bring founders like Lauren into the mix so that we can have people with lived experience who really understand the problems that they're trying to solve at the forefront of generating these innovative solutions.

10:37Okay. So we've talked about patience. We're going to move more towards business models from the what to the how. Alina, before this panel, you told me, and I quote, you cannot say that you want to improve health in the U.S. if you do not plan to support socioeconomically challenged populations. So I want you to share what are some ways that startups need to think differently, like beyond the D2C playbook, if they want to take civic health seriously. Yeah, absolutely. I think we've sometimes gotten confused in the way that technology democratizes versus services, right? So I consider when people tell me that they're starting a D2C company so that they can eventually, you know, sell into Medicaid, a lot like basically trickle down health care, which is you're basically building for, you know, someone said, no, no, we definitely support people.

11:24Our average member makes$200 ,000 a year. And I was like, we have very different definitions of poor. The average member I supported at a Medicaid plan couldn't pay$5, right, for medication. We had honest discussions for hours on end on the difference between as the bird flies and as the bus goes in L.A. It is a very, very, very big difference. And so if you want to build for a population, right, that includes folks that have to use the bus, that may not have a smartphone, right, with unlimited data, you have to build there. If you design basically a D2C solution, right, that is built for folks that are technology innovative, that are connected, that have resources because they're able to pay for your D2C solution, then you're not actually addressing the whole host of other sort of issues that can accompany the needs that someone has that is socioeconomically diverse.

12:21So one of the things that we really focus on in our approach is like we do not have bad foods, right? I'm not saying that we love Snickers bars and Coca-Cola, but the reality is if you have someone who's working 12, 14-hour shifts in their role, it is deeply unproductive to tell them to only eat home-cooked meals and get their food from Whole Foods. That's like, Alina, you should go to the moon. I'm like, that's a wonderful idea. I'm going to get started on that today. Thank you for that suggestion, that person's crazy. And so for us, like really thinking about addressing health, right, and addressing sort of metabolic health, you really have to understand the context of someone's life.

13:05And I think a lot of times that doesn't happen if you built in a D2C system. I love that note of the pragmatism of understanding the context. And that's a good segue to you, Rafael. You're addressing the needs of a region. And in Mexico, tens of millions of people who have serious access issues. And so I want to know, how did you bake the idea of mass access to your platform into the DNA of the company in a way that would still make diagnostic care investable and scalable? Yeah. Yeah, obviously, we're an asset light business, mostly digital, a mix of obviously technology, now agents and algorithms with a core team of healthcare professionals.

13:47since the beginning we realized that partnering with employers was a good way to go in the sense that quite a few million people are employed but still lack access because by law in Mexico you're obliged to provide them with public health care access as part of a tax you pay that doesn't mean, I mean people are enrolled on paper they never use that system, they go out of pocket Mexico I believe is one of the highest countries in terms of the OECD in out-of-pocket spend. It's like five times higher than the US in that sense. So we needed to make a scalable business by finding the right partners that would allow us to reach that population and then building this kind of like network effect because once you enroll with the employee, then the family is eligible as well.

14:37And that kind of like helped us scale through relatives and the relative of the relative by building a network in which thousands of people could actually get care through us. And now we are somehow expanding that access through other type of partnerships. We recently got investment from one big pharma company based out of Europe, which is also looking for ways to reach some of the, let's say, low segment or base of the pyramid segments in Mexico through a solution like ours. So Terry, we just heard two examples, but you sit in the enviable position of being at the center of an ecosystem of public health folks who are innovating around access and other public health issues.

15:22So what are some of the exciting trends that you're seeing founders take in this area? It is exciting to kind of be in the front row, having this ability to witness the emerging things that are happening. So I would say probably three buckets of work that I'm really seeing. The first is really companies leveraging the capabilities of telehealth to extend and fine-tune services in ever smarter and more tailored ways, whether it's dentistry, we saw one example earlier, or mental health for different population groups. We have previously accelerated a company called Senera. You might know them. They're actually providing mental health services to Latino population.

16:04They're venture-backed and growing rapidly. And also specialty care. So there's a plethora of telehealth driven companies that I think are all emerging and competing in the marketplace. The second bucket is really companies leveraging AI to improve diagnostics. You saw Pons a little bit earlier, but there are lots of applications in this arena. Also using AI to improve or enhance the delivery of care more at the system level or with providers. And all of this is feeding into more tailored, more kind of precision medicine, broadly defined, oriented approaches. that in the long run will provide a more customized and tailored prevention and treatment for individuals.

16:53And so that space, I think, is really, really exciting, right? So it's leveraging data and big data from lots of different places and really finessing the ability to address people's deep, deep, deep-seated health problems. And then I would say the third bucket for me is a number of solutions that are emerging around engaging different population groups, engaging and mobilizing people, different stakeholder groups. One company that we work with is called Breakthrough, which has a really interesting platform, and they're very successful at engaging young adults for a variety of issues, whether it's social or health.

17:34And they're so good at it, that we're actually incorporating them into our own NIH-funded research as a way to pull more of the young people in the community into our work. And so there are lots of different solutions in that bucket, but we all know that engagement is one of the biggest unsolved problems in public health and in healthcare. And so if we can really crack that nut, then we can really go a long way in helping us actually deliver on what some of these new technologies are geared towards. Okay. We talked about patience. We talked about some business models. We're going to end with one quick lightning round.

18:12Before we walked up here, I asked each of you to come up with a hot take, something that describes a piece of your philosophy that might be a little bit of an unconventional wisdom to share. So I'm going to give each of you about a minute. Alina, starting with you, you said that unmanaged AI will drive an acceleration in health inequity. So tell us what you mean. you have to actually be able to access AI, right? So you need the technology. In some cases, you need to pay for it. But I think there's an even deeper piece, which is what we'd actually love for AI to do is essentially triage, right?

18:44So we'd actually love to say like, great, you know, honestly, health is wealth, right? So if you're wealthier, you use AI, you sort of triage some of the like, is, you know, X a major concern? No, sleep more, right? But I think in many cases, what you're actually going to see is folks use AI and then they want to access more care. And that will, I think, crowd out, right? You're going to have then folks at lower incomes, right? Not only not able to access AI, but now getting crowded out, right? As we have more and more concierge style practices, in some sense, catering to the additional needs.

19:18And so I think if we want to use AI to basically support high needs individuals that are lower income, we have to design around that, right? We have to design to make sure it's accessible to them, right? Which actually may mean more sort of SMS or text or using AI and then packaging it in places that people have access, addressing their needs, which often are, you know, first SDOH and then clinical and making sure that we're still sort of have real sort of clinical capacity for those individuals. Rafael, you said that in emerging markets, smartphones are replacing clinics and if in those environments you're still building for the clinic you're only building for the one percent so explain yeah i mean we see a lot of examples maybe here in the u.s or even in europe where tech systems are wanting to become the front door for a health system or for a set of clinics or hospitals the reality at least in mexico is quite different because again people decide not to go to the public hospital due to the lack of capacity and time that you spend and even like low-cost clinics like walk-in clinics we see them as a band-aid like something very transactional that doesn't allow patients to actually follow on the treatment i think what we've learned is build our solution where the patients are and reaching them in a way that they feel we all know that care is about trust you know and without trust you cannot actually build a patient app or a healthcare system.

20:49So we've made a lot of effort in making sure that patients trust our solution. We have world-class NPS, world-class satisfaction metrics, and that has been literally like a thorough effort along the way to make sure that patients that have middle-tier smartphones, they can't afford the latest iPhone or the latest Google phone or whatever, can know that they can reach and get access to a doctor or a mental health specialist the way they would almost text a friend. So that's what we've been doing and trying to nail it to reach more people. All right, Terry, you get the last word. You told me that not every startup needs to raise venture capital.

21:31So talk to us about how your partnerships shape how you grow your business. Yeah, so we're a public goods platform. We don't take any equity in the companies that we work with. It makes sense. We're a public school. But doing this work also has made us realize that there are a lot of problems that different communities are faced with. And not all of those problems are necessarily big enough for VCs, right? And so it doesn't mean that we don't need solutions for those problems. So I love the fact that earlier today we had folks from different health systems sitting on stage and talking about their perspectives.

22:08Because one, I think we need to really shorten the distance between the innovators and the end users. Imagine if we can actually create an infrastructure where there are listening sessions, where we can really learn about the pain points that different provider groups and hospital systems are experiencing, right? And then having the innovators basically helps come up with solutions to solve those problems. And then the solutions can then get trialed and then adopted by the very health systems that are actually sharing what problems that they're having. If we can really create that infrastructure and reduce the friction, then we can be so much faster at creating the solutions and getting the solutions adopted.

22:48Same is true with communities. And so not all of the companies are going to be venture backable in our kind of current system. But that also means then that other payers have to come to the table. The public sector needs to be a lot more agile in funding innovation and in investing in innovation. Health systems and other payers also need to be at the table. And I'm so happy to see that they are today. And philanthropy also has a big role, right? Not only through the provision of grants, because that I think is still important, but it's kind of like an old model. I'm a big fan of venture philanthropy.

23:25It's this idea that philanthropy can invest in startups, and then any potential gains coming from those investments are then reinvested into future work. And so you just keep recycling and allow that pie to grow. And so I just think that we need to rethink the entire system. VCs are still very important in the ecosystem, but they shouldn't really be the only actors that are supporting innovation because that really limits the kinds of innovations and the number of companies that we can ultimately support. I have so many more questions, but that's our time. Thank you, Alina, Raphael, Terry, for sharing what you're working on.

24:04Thank you. Thank you.

24:10And finally, an invitation to all of the extraordinary health transformers, whether you are a startup, someone building the future of health, or whether you are an investor, funder, or buyer of the solutions out there in the marketplace, this is an invitation to you to join the Startup Health member community. Learn more at StartupHealth.com. Look forward to hopefully seeing you soon. Thank you.