Hey is 9am...Wake up healthy with 9am Health!

Brian Urban:

Yes, this is the Healthcare Rethink Podcast. I'm your host, Brian Urban, and today we hope everybody wakes up healthy. What better way to do that than having the chief medical officer of 9am Health join us, Avantika Waring, thank you so much for joining our little show here today.

Avantika Waring:

Thanks for having me.

Brian Urban:

This is going to be a lot of fun. You are a natural without maybe even realizing, or maybe you do, for podcasting. I think I've gotten the sense of that before we started recording. It's fantastic to be able to talk a little bit more about yourself, the impact that 9am Health is making across the ecosystem. And we love to start with you as the leader. So you didn't just wake up and become a chief medical officer. Take us back really where your love or interest in medical science or health began before your endocrinology days at Kaiser, like way before. Go as far back as you want and bring us up to speed here.

Avantika Waring:

Here. No, I think it's a good question because I often people ask, "Why did you go into this field?" And it's kind of nice to reflect back and think about what brought me here. So I will say that I never intended to be a physician, although my father is a physician and stereotypically you've got a parent in the industry, it can kind of impact you. But when I went to college, I actually studied French. That was what I wanted to do. I was really into the humanities, I like the arts. And then I realized that there was just no way that I could survive a career at academics because I'm a really social person and I just loved interacting with people. I also liked science, I loved chemistry, and so I thought, "Okay, well how can I do this without ending up either in a lab or in a library Carroll doing research all day long?"

So I decided to apply to medical school and got into med school. And then going through, I still didn't really know what I wanted to do with that. I thought about doing infectious disease because I was interested in global health but I also knew I wanted to have a family and be close to my own family. So the thought of traveling abroad a lot didn't really seem like it was a great set. So in the end I ended up picking endocrinology for a couple of reasons. One, I am very interested in nutrition and exercise and how people can get motivated to make those changes. It seemed like a really good fit to be able to bring my personal passion for those topics into my work. 

And secondly, actually, I come from a South Asian community and there's a lot of folks who are impacted by diabetes and high blood pressure and heart disease, including a lot of my family members, so extended family. So I was kind of exposed to that from a pretty young age, seeing them using insulin and having to make choices about foods and things like that. So it was kind of a good fit of things that I already knew about and ways that I could make things better for people. That was kind of how I picked the field of endo.

Brian Urban:

Well, it's a good theme. One we hear often on our show here, there's some family lineage, so maybe a subliminal effect of father being a physician and now yourself, but the family story, seeing individuals struggle with being able to take care of daily needs. And I love the kind of overplay into where your career has gone now, which is 9am Health, which you clearly state on a lot of your external visible brand that you're an everyday help for diabetes, weight loss and heart health. And that daily view that you probably had, did you ever think it would come to fruition that you'd be working for an organization that says and focuses on just that?

Avantika Waring:

No, I mean honestly, no. But I think about... So I have kids, school age kids, and we talk a lot about like, "What do you want to be when you grow up?" The options have changed so much. So I don't think when I was growing up or even in college or medical school, I didn't have an idea that jobs like this could really exist. We're so removed from it. And now when we talk about this with our kids, they have all these random things they tell me that they want to be, and I'm like, "I didn't even know that was a job when I was 15 or 17 or 25." So I definitely didn't imagine it would be what it is today.

I will say that the other thing that I really love about our message is just sort of seeing my family members deal with these diseases, just how important it is to be able to culturally connect on topics that involve lifestyle change. And so having my cousin, for example, being told, "Oh, you shouldn't eat rice, or you really need to eat more protein and less carbs," But then thinking about the actual things that make up our daily diet are so in conflict with those messages, that that's something that also has really carried forward me because I think this is true for a lot of people, not just people from my background. So that's been kind of a fun bridge to walk and think about, "Okay, would this work for my family member?" If it wouldn't, then maybe it's not going to work for yours either.

Brian Urban:

I'm excited to get your perspectives, Avantika, on really the societal norms that we have as consumers, the behaviors, and maybe even the predatory models that exist with a lot of as food vendors and food chains today that have completely exacerbated and many, many health conditions across the whole United States. But before we get into all that crazy stuff, we got to start with 9am Health. Well backed in terms of investment, young in terms of an organization having impact and being around, out of San Diego, California, there's a beacon of health, a lot of good healthy things happening in different parts of California. So tell us who 9am Health is underneath all of the surface things.

Avantika Waring:

Yeah. So we are a complete end-to-end virtual cardiometabolic clinic. And so that means that we take all of the elements of what you might imagine in a center of excellence or a comprehensive clinic model that you might, for example, travel hours to go to at a academic center. And we've brought that all into a virtual space. So we have dieticians, we have health coaches, clinical pharmacists, physicians including specialty physicians, so endocrinology, obesity management, lipidologists. Lipidology is a thing, it turns out. And prescribing as well as labs that you can do in home, all wrapped into one virtual experience for patients who live with any of those conditions that we treat.

Brian Urban:

I love how you described end-to-end. I think that is becoming more of a, you better be end-to-end in any kind of digital therapeutic or digital virtual model that goes to market these days. And even if you're covering a niche condition, it's still better be end-to-end for the individual that you're serving on the other end there. So I'm curious of the focus in terms of metabolic, the different cardiovascular related conditions that you're treating here. A lot of it is around weight loss and behavior as well. So is the focus simply because of the sheer volume of lives that are impacted by these chronic conditions or early diagnoses? Or is it really the specialists that have started the organization, like yourself and others from the clinical perspective? How did this focus become a part of your core therapeutic digital design?

Avantika Waring:

Yeah, so it is actually a more personal story. Several of our founders live with diabetes and themselves, and so I think they had a very firsthand experience of what it's like to navigate the healthcare system. These are people who have plenty of education, plenty of needs, no insurance barriers. And even for them the hassle of doing all these separate components and then not being able to have support kind of on demand when you need it, that sort of revealed the gap for them. And so that's kind of how the company started in the diabetes space. 

I came obviously because this is my clinical passion. Before I came to 9am Health, I ran the population health diabetes program for Kaiser Permanente in Washington. And so that was clearly something that I was very passionate about. And then we have other folks on our team too who are either very interested in the fitness and nutrition space or live with diabetes themselves or have a family member who lives with diabetes themselves. So we have sort cultivated a group of people who are really interested in the topic and [inaudible 00:09:02] in the area.

That being said, I think there's also this strong push to bring people in who just want to help across demographics. They want to help at a company that's very energetic and young. We like to connect with people in a variety of different ways, and I think that draws in a certain kind of crew, so to speak, when you're hiring, which I really enjoy. But I think we've also noticed that the timing is really right, especially with all the talk about weight loss and weight management. It's kind of a perfect fit because with weight and diabetes, that you can't really treat one in a silo without the other. The same with high blood pressure, same with a lot of these other kind of metabolic conditions. And so we felt sort of uniquely set up to take on the weight loss challenge because we're already experiencing using those medication. We already know what nutrition interventions work. And we also already know how to manage all the conditions that go along with the condition of obesity. So that's kind of how it all came together.

Brian Urban:

That's beautiful to know. I think sometimes a lot of founders can be so tech-minded, balance sheet, growth-focused that they may not share a common thread with the individuals they're wanting to serve or outreach. So that's beautiful to hear. And it's also great to hear a few more tidbits on your background in terms of what you had stood up before relative to population health. And the challenge is you probably saw. I mean, it's very different in the tech world here where obviously your model seems to be very high touch, high frequency and everyday kind of connection to individual users. So I just love to hear that.

You mentioned a couple things there a moment ago regarding demographics. So I'm curious, you have a lot of things in play here. You have the home test kits, health literacy in terms of educating a lot of the lives you serve, but also a prescription support too to ensure understanding of medications and how it affects your condition, your daily schedules, how can you stay on track. With all that considered, are you seeing certain, I'd say trends or attributes in different geographies, whether it's age, race, socioeconomic status? Are you seeing some different trends there, relative to social determinants of health, that are being addressed with your model? Or are you starting to see insights that you're going to address maybe as part of your model in the future? I'm curious of what you're seeing.

Avantika Waring:

Yeah, so I love this question. I feel like especially when you're at a small organization and you're growing, you have so many opportunities to learn from what your patients are asking for or what their individual barriers are. And then you can actually revamp, improve and develop solutions for them, right?

So when we started the company, we started as a direct to consumer low cost diabetes management service. And so the variety of folks who were coming in, it was really interesting. We had a very dedicated large group of truck drivers who worked with us. They had insurance, but they were on the road all the time. Nutrition choices were sometimes challenging. And getting into appointment's really, really tough when you're in a different place every other week and you have to fill out these forms to drive. So we noticed we're getting a lot of traction from truck drivers. So then we sat down and talked to some of our members to find out, "Okay, so what could we do to support you better?" And they said, "Well, we can't go and follow these meal plans because we're not eating at home." So we developed a whole kind of playbook for how to eat healthy on the road, literally choosing things that you can buy at like, what do you call it, a gas station market or something.

So I think that's kind of an example of how we would meet the needs of a population. I think with the more rural geographies, the at-home test kits are so helpful. Oftentimes people can go to a lab and they're expected to go to a lab when they seek care from a traditional setting, but it's like a two-hour drive. I mean, if we can just get them to do it at home rather than have them put it off again and again and again. I mean, I put these things off and it's like five minutes from my house. So I can only imagine how hard it would be if I had to actually trust somewhere to do it.

So I think we're seeing a lot of variety in particular with race and ethnicity when we talk about that. There's the dietary preferences, things that are important in your culture. I think I mentioned rice and that's just a simple example. You have to think about what is the base of the meal, and are you telling someone to remove that? Or just work schedules. I mean, if you're working two or three different jobs and then telling someone, "Well, you have to walk 10,000 steps every day," that may just not be practical. So we need to work with you to come up with something else.

So I would say that the way that we help people is by cultivating this. We basically have a crowdsource from all of our members over the time we've been working across a really variety diverse demographics and then cultivating our resources to respond to that so that we can, "Oh, you're telling me about this issue that you're having. We actually have dealt with this before. Here's some things that we can offer to help you with that."

Brian Urban:

I think it's so interesting that you are able to pull back insights. And I think a lot of your work obviously is helping those in a frontline position, the health plan become more informed as well. I want to get into just how you do that with health plans, employer groups that we started to cover, and also pharmacy benefit managers too, the PBM side of the world. A little bit different end of our ecosystem.

But before I dive into that, I got to pull back where we were for a second, which was kind of almost like a social construct, societal norm conversation. I wanted to play this out with you. And this just struck me today. It bothered me a little bit. There's a very large fast food chain that said they're going to be offering a new sugar-filled treat out of every store with another partnership of a brand. So it's McDonald's and Krispy Kreme. And I cringe at that in a lot of ways because don't we already flooded enough in the marketplace with food options that are negatively impacting our behavior and thus healthcare system in a very complex way in terms of treatment, access, trust? What's your take on these types of partnerships or I guess consumer behavior overall? Are we just so inundated? I know 9am Health helps with that, so I'm just curious of what you're seeing in terms of that societal view and then the role of 9am Health is playing on a daily basis.

Avantika Waring:

Yeah, I mean I think, are you alluding to the idea that things that are so unhealthy for you are also so cheap and easy to access and that kind of what you're getting at?

Brian Urban:

[inaudible 00:16:04] saying like that. Yeah.

Avantika Waring:

No, I mean it is-

Brian Urban:

It drives me nuts.

Avantika Waring:

It's a very complicated problem. I mean, I definitely don't have the answer for how to improve this. I do wish that the foods that we wanted people to eat that we knew were good for their health were affordable, easy to access, easy to prepare. People knew how to prepare them. I mean, that's the other thing, is I can give you a bunch of free kohlrabi, but if you don't know what to do with it, you're not going to eat it, right?

So one of the things that we are working with is trying to incorporate not just meal planning, but sort of grocery planning, working with employers to launch programs around grocery benefits where we can essentially prescribe a diet that is in line with your macronutrient needs and your glycemic control needs. And then helping. Our dieticians can help explain what the meals could be with these ingredients. And also, I know there have been services, and there are services that are really valuable where they provide you with the stuff for a meal, right? But that's not going to be sustainable for an individual. I know when I make dinner for my kids, I have to go in the fridge and see what's left and then figure out how to use it up, right? So that's very different than saying, "Tonight we're having this specific meal. I need these 10 ingredients for. And if I don't have those 10 ingredients, I'm out of luck."

So the idea that we can train people, not train them, educate them on how to shop affordably for a family with healthy items and then be able to allot those ingredients throughout the week to create a meal plan. Probably the way a lot of us may have been raised by our parents, or 50 years ago, the way people shopped and ate. But modern life has just gotten really... It's very busy, it's very hard. Frankly, many of us don't live near our parents, so we've lost that connection to our cultural habits around food. So that's something we're trying to sort of reteach in a modern way, which hopefully can help. I mean, it's tempting if you will run by Krispy Kreme and it's free. It's going to be very hard to say no to that, but if you know that you've got a bunch of [inaudible 00:18:13] sitting in the fridge that you have to consume, maybe that would help people make a different decision.

Brian Urban:

You said that in such a loving way. Truly good bedside manner in the virtual setting here now as well. But it's so fascinating how the US operates and the rest of the world and how they maybe look at US behavior. But cultural competency, a big thing that 9am Health focuses on relatives to understanding culture related to habits and food and how that's related to managing a condition on a chronic basis. So a lot of insights that you gather, and as a daily touchpoint in terms of individual users, I would imagine there's a lot that you feed over to care managers. So getting back into the health plan purview for a moment here, tell me about the interaction and the feed of insights to care managers or anyone else that's interacting with your members that you share. I'm curious how that clinical workflow works.

Avantika Waring:

Yeah, so one of the things when we started that's super important to me, I, at my previous job, would see patients who had access to some of these other digital health tools maybe through their employer. I only ever knew about it because they may have mentioned it to me, but that was pretty much it. I never saw reports, I never saw records. Maybe they were there somewhere and I just didn't know to look for them.

So when I started 9am Health, this was very top of mind for me, that physicians should know what's going on. We're actually prescribing and doing labs, so not only is it important for safety for the other care team members to know whether it's care managers or the doctor, the specialist, but it's also really important for just data sharing for things like quality measures, for HITAS, for keeping their scores up. If we're getting a lab that was required to close the care gap, it would be such a waste if that information did get back to them. So the health system or the health plan can't mark that off as done, right?

So we decided to partner with an interoperability exchange. I don't know what you would call the company, companies are the right word. They essentially help us take our data out of our EHR and share it to a common space. It's called Care Quality. There's a couple of other ones. And then that is accessible by health organizations that use things like Epic, Cerner, these bigger the main big players in the EHR space and vice versa. So now when we get a new member, the first thing that we do is query this database and then we get all of their labs. It goes back. I was shocked. It goes back as far as you want. So fascinating. "Oh yeah, there's lab done in 1992, I was in the 7th grade. That's so interesting." And then medications. You can see the notes. You can see the chart notes. You can actually read what conversation they had with their provider. So just a ton of insights that helps our team be able to really better care for a member. And vice versa, we're able to ship that back over.

In addition to that, because we see ourselves as a specialty clinic, just like if you want to go see, I don't know, let's see, you went to go see the orthopedist and they did whatever they did and they write their note up, they'll typically send a copy of that back to your primary care doctor. So even if the primary care doctor doesn't go onto the chart and try to hunt for this, they'll get an alert or look at a letter. And so we also do that. So we share back at Cares like a consult report to the BCP. Pretty much anytime a change is made or we make lab data or anything like that. So we really want the traditional healthcare community to see us as trustworthy, competent, and practicing in line with the way that they would practice with their brick and mortar partners.

Brian Urban:

I think it's great because your work has already demonstrated a lot of value. And what you were describing there, I see you as a direct bridge player. So many health plans now I think are under scrutiny, rightfully so, but also wrongfully so. We need to have a village and a bigger support system around health plans, especially Blue Cross Blue Shield entities that are more rooted in community health. They have more of a trusted brand than maybe a large private payer or one that's become maybe a M&A engine over the years. So it's really important that bridge players and tech that goes on top of the member experience exists. And I see that so clearly with 9am Health.

So I got to jump into where we were talking about earlier is the PBM space.

Avantika Waring:

Oh yeah.

Brian Urban:

Pharmacy benefit managers. So this is unique. I think this is really unique. Is it just like data insights that you're sharing back for formulary adjustments, risk analytics? Or how do you work with these very well-known and growing middle players in the pharmaceutical and then maybe clinical space as well?

Avantika Waring: Yeah, so I think there's a couple ways. I would say it's kind of all of the above. Definitely there's a lot of opportunity to kind of help with formulary adjustments. But formulary adjustments don't work super well if you just make the adjustment and then step away, right? So there's usually transition that needs to happen. And obviously, I worked for an HMO previous to this. And so we did... Everything had to be aligned, our formulary. And so there was a lot of education around the conversions. "Why is this other drug actually just as good if not better for you?" And then follow up. Making sure that it's effective, making sure that any dose adjustments that need to happen can happen.

So I would say it can be not a very quick interaction, but it can be sort of a time limited interaction around formulary adjustments that drives value. But I think there's also a lot of opportunity around medication spend. So if you can get somebody early on, get them on the right low cost, affordable, generic medications and help them manage their diet, help them increase physical activity, help them to be adherent with the drugs that they already have, you can often prevent escalation to additional more expensive therapies. And so that's another area where the longitudinal coaching can help with drug costs.

And then I think on the third, I mean that's probably the biggest one that people want to talk about, is on the spend for obesity drugs. Really passing people through step therapy that's sensible and that really makes sure that they understand what goes into successful weight loss and where do we start, what do we start with first, what are our goals, what are our targets. And then setting expectations around, "Okay, maybe you do qualify for one of these medications. This is what it's going to mean to start it and this is what your path is going to look like." And actually, that can help reduce uptake or starting of a lot of those drugs or delay for sometimes months to years, which can also help a lot with drug spend there.

Brian Urban:

That is extremely helpful because I was thinking top level economics that would help support guaranteed cost models that are working through a health plan, but there's so much more to that when you think about the cost shift, doing step therapy and being able to be more preventative in nature. So you went far beyond what I thought that you might be doing with PBMs, pharmacy benefit managers. I love that.

I love where 9am Health is going. I'm so happy that you are a core part of that. You're a leader, you're a voice, and you're doing lots of external visible speaking events and conferences, and I'm just so happy for you. The one thing I'm curious about, you're a young company here and I want you to kind of take a look-out in the future for us to close up our conversation. What does 9am Health turn into five years from now? You're way past traction, you're maturing, you're helping a lot of people, what do you turn into?

Avantika Waring:

Yeah, so I thought about this question and I was like, "How do I answer this?" versus, "I don't actually know what my founders would say." But I think that we all sort of share alignment on the vision that this will become... Once we've kind of broken through and we've got a lot of traction, we want everyone to have access to this kind of technology. So maybe that means that it can be given or sold or however you want to say, partnered with, with other models or care delivery models because I think our technology and care, the way that we deliver care and managed care in this team-based fashion is really unique and special and a lot of folks can benefit from that.

And me personally, like my goal, I was just telling someone this earlier this morning since the theme of the day is like, "What does Ivanka want to do in 10 years?" I would love to be able to leverage this technology outside of the US. So in the developing world, in tons of places where people have constant access to mobile phones and mobile technology, but maybe not access to traditional healthcare systems where they can go in and get specialty level care, but we can do this. And that, to me, that's what I'd like to be doing in 10 years. But we'll see if that happens. But now I've said it on this podcast, so it'll be memorialized.

Brian Urban:

It will be. It'll be a little time capsule for you to look back on in 2034 or something like that.

Avantika Waring:

Yeah.

Brian Urban:

I love that outward vision because there are so many lives in developing countries that don't have the access that might have the technology and the connectivity, but just don't have the programmatic level influence or help on a daily basis. So I'm looking forward to that. We'll definitely follow up. I feel a follow up come on anyway.

Avantika Waring:

Okay.

Brian Urban:

But chief medical officer of 9am Health, Avantika Waring, thank you so much for joining our show here today. I love what you're doing.

Avantika Waring:

Thanks so much. Nice to see you.

Brian Urban:

For more exciting excerpts and insights, please visit us at finthrive.com.