--:-- Olivia: Hello and welcome to Raising Health, where we explore the real challenges and enormous opportunities facing entrepreneurs who are building the future of health. I'm Olivia.
--:-- Chris: And I'm Chris. You're joining us for the second episode in our deep dive series on the science and supply of GLP-1s. Last week, we heard from Carolyn Jasik, Chief Medical Officer at Omada Health. If you haven't listened to that one, it's a great primer on GLP-1s from a clinical experience.
--:-- Olivia: Today, we'll hear from Brooke Boyarsky-Pratt, the founder and CEO of knownwell. Next week's episode will be with Cronus Manolis of UPMC Health Plan on the pharmacy implications of GLP-1s. Brooke talks with Vineeta Agarwala, general partner of a16z Bio and Health, about the value of obesity-specific practitioners, patient-centric medical homes, and how she thinks the metabolic health space will evolve over time.
--:-- Chris: If a patient is given a choice, they prefer a medical home. And that's what we've seen with our patients. We've seen a lot of patients leave point solutions because they say, "Wow, you can also do my primary care. I can occasionally see you in person. You are a real doctor who I talk to and who I have a care team I know and respect." So I think that's really important, particularly as it relates to symptom management.
--:-- Olivia: You're listening to Raising Health from a16z Bio and Health.
--:-- Vineeta Agarwala: I am incredibly excited to welcome to the Raising Health pod today, Brooke Boyarsky-Pratt, founder and CEO of an incredible company called knownwell that we've had the real privilege of partnering with recently. Brooke's here to join us to share a little bit about how she's looking at the obesity medicine space as a whole, the role that she hopes knownwell will play there, and a little bit about why she's building the company at a personal level. Brooke, I'd love for you to just introduce yourself and share the story behind this company.
--:-- Brooke Boyarsky-Pratt: Yes, such a pleasure to be here. Thank you so much, Vineeta, for having me on. I am a patient. That's really what brought me to knownwell and ultimately led me to founding it. I'm someone who's been in a larger body my whole life. One of my earliest experiences in healthcare was my pediatrician telling my mom that I should go to fat camp. That unfortunately started the process of how I viewed interacting with the healthcare system when it came to my body size.
--:-- As I got older and had different educational and work opportunities, it led me to move a lot. Every time I moved and reestablished primary care, I felt like I was needing to reestablish the idea that I was a thoughtful person who took my health care seriously. Not for any fault of the primary care doctors I met with. They just have a lot of patients every day, and I'm sure it's frustrating for them to see so many patients struggling with the same disease state. So I was dreading going to the doctor. It was even harder when I was actually looking for treatment for my metabolic health to find something that was accessible to me.
--:-- In my very last move, when I was walking to my new PCP for the first time, I started getting curious about if other people feel that same dread. Other people who were like me. I was overwhelmed by the research. That was kind of the nights and weekends I started pursuing this passion of could we really create a patient-centered home for people with overweight and obesity?
--:-- Vineeta Agarwala: In the venture world, investors talk about founder market fit. I cannot imagine a more compelling and more deeply connected founder to build a company that's going after tackling not only the bias and access and comfort issues that patients face, but also the care quality. Let's talk for just a second about your professional background, though, because it's also really interesting that while you've had that patient journey and patient connection to the obesity medicine space, you didn't come from healthcare. You look a little different than some of our other healthcare portfolio CEOs and leaders in the healthcare space. But you're remarkably proficient and picked it up so fast and are so compelling now. What made you jump?
--:-- Brooke Boyarsky-Pratt: I had a background in finance and consulting. Very traditional kind of business background of Penn and Harvard Business School and McKinsey, and worked at a commercial real estate company. Certainly not in healthcare. I joke that I'm sort of glad I didn't know what I was getting myself into when I jumped into knownwell and creating the company. But ultimately, I had always hoped that I would one day find something to work on that I felt was my life's work.
--:-- Before knownwell, what I was always drawn to was doing a good job delivering for clients and being the best colleague and boss I could be. But if I'm being honest, there wasn't a day that I woke up and thought, "I am so passionate about commercial real estate today." It was just something that was important to do well and to deliver for people. I had always been drawn to healthcare because I always felt like, how could you have a more direct impact on people than in healthcare? I'd always joke with my physician friend that they made the right decision going into healthcare. So it almost sort of came together naturally that as I started to feel like there was an opportunity here to really touch a group that had been underserved, even though it's been a steep learning process, it felt natural that I found my way to healthcare.
--:-- Vineeta Agarwala: Consider me one of your physician friends who is very happy to have you join the forces in healthcare. Let's talk a little bit about what obesity and overweight management and medicine actually is. We've already used the term a few times, so let's backtrack for our listeners for a second and just make sure we're all on the same page. What is obesity medicine? Is that a specialty?
--:-- Brooke Boyarsky-Pratt: It is a specialty. If we take a step back, overweight and obesity is defined by BMI. We could have a whole podcast about how that's not the best measure to use, but it's the best and easiest measure we have today to diagnose the disease. This is really about living in a body where your weight is higher than your height would suggest on a bell curve, and that puts you into overweight and obesity.
--:-- It was not long ago that everyone viewed overweight and obesity as a cosmetic disease. The reason Medicare, for example, doesn't cover obesity treatment is they see it as a cosmetic disease. In 2012 was the first ever board certification in obesity. That's how recently this disease state has been viewed as something in the medical community. Obesity medicine is really about comprehensive treatment of the state of obesity and overweight. If a person is interested in intentional weight loss, really helping them on that path, both to address the obesity and also potentially other metabolic health conditions, such as diabetes, hyperlipidemia, that can sometimes go with these diseases.
--:-- Typically a clinician who practices obesity medicine is a primary care doctor from their medical school and residency days, though not always. You can see cardiologists and OBGYNs who have a board certification in obesity. Nowadays we have fellowships, so some folks go and do an obesity medicine fellowship. We also have a board certification. It's actually the fastest growing specialty in the U.S. There's something called the Obesity Medicine Association, which is the largest association of clinicians who practice obesity. We're really fortunate that my co-founder and our CMO, Angela Fitch, is the president of it.
--:-- Vineeta Agarwala: What about a primary care doctor like me who has an overweight or obese patient who I'm really trying to figure out how to serve? Help us understand the bridge between all primary care physicians in America and the subset of physicians who are trained to deliver obesity medicine care and certified to do so, given that we have a situation where over 40% of all Americans actually fit that definition.
--:-- Brooke Boyarsky-Pratt: Everyone is doing their best. The difference between a primary care doctor who practices obesity medicine and one who doesn't is how much they wish to help the patient. A PCP who doesn't have specialist obesity training is typically missing a few things. The average one will have four hours of training in obesity in medical school. This is an unbelievably complicated disease. Very little formal education on obesity, typically very little continuing education on the innovations that are coming onto the market.
--:-- In addition to the education issue, they're also typically lacking the resources where they practice. To practice really great obesity medicine, we also want things like dieticians, health coaches, a movement program, ideally behavioral health, and even a good prior authorization process if you incorporate anti-obesity medications. Most primary care doctors are practicing without any of those additional services. They'll say to us all the time, "Look, I suppose I can prescribe something. I don't even really understand the meds. I don't understand how to get them approved. The truth is I know the patient needs more help and I don't have the services to help them." Whereas someone who's obesity specialized not only has the formal education and the continuing medical education, but they are typically part of weight centers or other groups that have the wraparound services.
--:-- Vineeta Agarwala: You mentioned Dr. Fitch. That's exactly her background. She's set up weight centers in multiple places in the country, both health system affiliated and now at knownwell. She's president of the Obesity Medicine Association. If you could sort of channel her thinking, your thinking, knownwell's thinking on this topic, what are the key pillars of comprehensive evidence-based care for patients with overweight and obesity?
--:-- Brooke Boyarsky-Pratt: There's something called weight normative medicine and weight inclusive. Weight normative is "You should be 150 pounds, and every time you come to the office, I'm going to tell you you should be 150 pounds." It turns out patients actually gain more weight when they have experiences like that. The other approach is called weight inclusive, which is, "Hey, Brooke, I recognize you're not 150 pounds today. Let's work on the wellness goals and actions you can take inclusive of your current body size." The research suggests that actually leads to much better health outcomes. At its core is the approach around how do we work with patients.
--:-- Then there are multiple pillars of the actual actions we take. Typically, though not always, an anti-obesity medication will be used. Typically a nutrition program is used, either one-on-one coaching with a dietician or group classes. You want to address sleep and stress management. That could go as far as someone's undiagnosed sleep apnea and could be as light of an intervention as meditation. Ideally, you would include a movement program, which we do, health coaching, and remote patient monitoring. Allowing that connectedness to the clinic of having a scale at home, if you have heart disease, having a blood pressure cuff at home, a connected glucometer, and working with a health coach. Lastly, really a behavioral health component. To the extent that a patient is interested in working on their behavioral health in addition to the other medical components, those taken together are really considered the core comprehensive program for obesity management.
--:-- Vineeta Agarwala: Amazing. And referrals to surgeries and other interventions as needed that wrap around the medical care. The right interventions have to be matched to the right patients, as with all of medicine. One of the things I've learned from you all is just a better awareness of how much of an adolescent problem we have as well in this country and around the world. We've got 14 million American children and teens also living with obesity. This isn't just an adult medicine or an adult primary care challenge. It's really one that affects the pediatric community. That's a community that's even less trained on the whole in managing conditions and comorbidities associated with obesity and overweight. We have a really important opportunity ahead of us in our healthcare system to get this right, to get obesity and overweight evidence-based care right and to do it at scale. So incredibly excited about what you're building.
--:-- Let's double click on one of the pillars that you mentioned, which are obesity medicines. Not a day goes by at this point where GLP-1s are not headlining news stories, whether it's around cost, access, new drugs, new therapies, oral versions of the therapies. Anyone reading healthcare news at this point is basically inundated with GLP-1 headlines. What are GLP-1s?
--:-- Brooke Boyarsky-Pratt: We're actually all users of GLP-1s. GLP-1 is a hormone that we all have. It has a lot of different functions, but primarily it helps with insulin regulation as we eat and consume food. It affects the speed of digestion after we eat. It also affects the feeling of fullness, the signals that go to our brain. What a GLP-1 therapy typically does is mimic the hormone that we have naturally occurring in our body. Then you'll hear about things like dual and triagonists, which is as these drugs get more advanced, they're mimicking additional hormone pathways. Simply stacking on top of each other more of the pathways that we believe impacts obesity as well as diabetes.
--:-- What I'll mention with GLP-1s and what Angela would say if she were on the phone with us, Dr. Fitch, is they've been around a really long time. The first GLP-1 was approved by the FDA in 2005. We often talk about it as if these came out of thin air, but the truth is, especially endocrinologists and physicians who have been in the obesity space for a long time have been using these medications.
--:-- Vineeta Agarwala: When did you first learn about these medications and their potential? What role did they play in your conception of impact at knownwell?
--:-- Brooke Boyarsky-Pratt: 2018 was a big year for me because it was the first time I had ever heard about obesity medicine. I had never heard of it as a subspecialty. I had seen a primary care doctor in Philadelphia and she knew I was struggling with my weight. She said, "You should see Dr. Janine Krellos. She's a leader in the field in Philadelphia and she practices obesity medicine." I was like, "There are people who could just help me." I saw her and she was the first person who talked about Ozempic with me. I thought it was absolutely wild. I was like, "There's an injectable and it helps with weight." Of course, at the time it was being used just to treat diabetes. Obesity medicine physicians were using it off-label at that point to treat obesity.
--:-- It's really interesting that I ended up hearing about it much earlier than it came onto the mainstream. It's not a surprise that people who knew what they were doing knew how big of a deal it was. When I first started talking to Dr. Fitch in 2020, when it was a little bit more getting into the public eye, she was just like, "People have no idea what's coming and how big of an innovation this is going to be as these get more obesity indications approved by the FDA." She was certainly a fortune teller.
--:-- Vineeta Agarwala: The weight loss data was staring us in the face in the diabetes trials. The dates you just mentioned, 2018, 2020, are well in advance of the current moment in time when GLP-1 receptor agonists have reached peak public awareness. It is interesting to reflect on that data was sort of staring us in the eyes. What maybe wasn't as obvious just because the studies hadn't been done specifically in patients who do not have diabetes but have obesity was just the role that they would play outside of diabetes specifically for the indication of weight loss. But at this point in time, they're in the arsenal. What are some of the biggest myths about GLP-1 drugs?
--:-- Brooke Boyarsky-Pratt: One is that they're a miracle that works for everyone. They are our most effective treatment right now, no question. But when you look at the data on semaglutide, Ozempic, 40% of patients will lose 20% of their body weight. That means 60% of patients won't lose at least 20% of their body weight. That's a lot of folks. The data gets better with newer medications. Tirzepatide is 60% of patients lose 20% of their body weight, which still means you have 40% who don't. The reason that's so important to call out is one, it's important you get the right medication with the right patient, which is not always a GLP-1. They may not be a responder. The second is, for the patients who fall in that 60% or that 40%, unfortunately they can feel like a failure. Folks who have already felt like failures this whole time with their weight oftentimes, and then when they don't turn out to be a responder, that's where we need to improve the education so that there isn't this shame and stigma around the disease state and the person.
--:-- The second thing I would say is that there's a myth around the tolerability of these drugs. You see a lot of PBM data and other data sets that show after one year, only 40% of people are still on the drug. That's often used to show there's a lot of waste, a lot of issues with the medication. Sometimes this data, though not always, is confounded by the fact that people lose access to the medication from their insurance or they move jobs or whatever. But even for the people who stay on, what we have found in our clinic with our own research is well over 90% of our patients stay on the medication. We think the difference is really twofold. One, it's better understanding the patient before you put them on the medication. Full health history, family history. Are you putting the right person on the right medication? The second is actively managing the symptoms of those patients. We know exactly what to expect for certain archetypes of patients when they start a medication, whether it's phentermine or Mounjaro. We are able to say, "Hey, we expect in three days you could start to experience nausea. Actually eating small meals and making sure you start in the morning, even if you're not hungry, will help curve that nausea." Things you can do to really better educate the patient and actually reduce those side effects over time. Those are two important myths.
--:-- I would say there is one last one that doesn't come up quite as often, which is around food quality. A lot of times people say the food quality no longer matters. Patients can really eat whatever they want if they're on these medications because they're so effective at reducing and curbing appetite. Actually, we have pretty good research to show that maintaining or increasing protein intake is unbelievably more important on these medications. It's actually more like having had bariatric surgery. When we work with our patients, we have such a keen focus on things like protein intake, even if that means having to supplement occasionally with a protein bar or shake, because it can be really dangerous to the patient's long-term health to have them losing a lot of muscle mass.
--:-- Vineeta Agarwala: Especially their muscle mass. I think sometimes that detail gets lost in the headlines. Let's come back to that 40% of patients who even on tirzepatide do not hit the weight loss goal that they might have set jointly with their doctor. Can you just educate us on what some of the both medical and non-medical interventions that we might be able to offer that subset of less responsive patients are?
--:-- Brooke Boyarsky-Pratt: As I first mentioned, there actually could be a medication that's better for that patient. Interestingly, you'll find sometimes that patients who are high responders to phentermine — a drug that's like $10 a month if you get a generic — are better or higher responders than that patient would be for a GLP-1. Part of that, we think, is the biological process around what's driving the obesity, that they actually respond better to different medications. First is making sure that we're trying different medical therapies and combination therapies to see if there is a more effective medication for them. Ideally, you're starting with that therapy and moving up to GLP-1s.
--:-- The second, of course, is bariatric surgery. There's a big belief in the market that bariatric surgery is going to tank. We actually have a little bit of a contrarian view there. We feel so many more people are finally seeking treatment that for a period of time, we actually could see an increase in bariatric surgery because people are finally having these conversations with physicians. Bariatric surgery, particularly for a higher BMI individual, especially if they have a comorbidity, in today's world is a really effective treatment.
--:-- Then there are things like nutrition therapy, behavioral health. This is such a complicated disease state. What we found with all of our patients is there's generally not a silver bullet. How do you work across these different modalities and really problem solve with the patient to understand what's going on?
--:-- Vineeta Agarwala: What do we know about the long-term impact of these drugs, especially in a world where so many patients are just getting on these drugs, but there exists, as you pointed out, an evidence base of patients who have been on this drug class since 2005? What do we learn from that body of data?
--:-- Brooke Boyarsky-Pratt: From that earlier data, which of course is going to be limited because it's certain types of patients who were being tested back then, they seem pretty darn safe. There are a few things like potential risk of thyroid cancer that have been called out from animal studies, but have never actually been replicated in human studies. When you look at real world and clinical trial data, you are not seeing an increased risk of thyroid cancer for patients who have been on the medication for a long time. Generally speaking, obviously there are certain things that are coming out that are still being investigated like suicidal thoughts and other potential side effects that they'll certainly keep following up on. But for the best data, peer-reviewed, double-blinded studies that we have today, there really aren't large concerning pieces of evidence that we've seen in terms of longitudinal data.
--:-- In fact, it looks like cautious optimism, but it looks like some of the long-term benefits of the drug class over the longer-term horizon for patients could be quite interesting with respect to cardiovascular disease risk, with respect to treatment, potentially even reversal of fatty liver disease and steatosis, potentially even an impact on addiction states and other behavioral health conditions.
--:-- Vineeta Agarwala: What do you make of that? How does Dr. Fitch have those conversations with patients who come to knownwell and are curious about this range of impact?
--:-- Brooke Boyarsky-Pratt: It's really exciting. The earlier the data, the more we want to be thoughtful about our excitement around it. But the SELECT trial around cardiovascular risk was pretty darn compelling. Was it one large trial? Yes. We're going to see more data. The study that came out around patients who are HIV positive a couple of days ago with their reduction in fatty liver was extremely exciting. We're doing actually a clinical trial in fatty liver. To your point, things like addiction, while it's early in the data, we see it in spades in our patients. If you talk to a doctor in clinical practice, they will say, "I would be shocked if the data doesn't end up proving out what we're seeing in our clinical practice."
--:-- The way Dr. Fitch generally talks about this is we always want to be cautiously optimistic when the data is early, but it's really compelling.
--:-- Vineeta Agarwala: In my clinic, even I see cancer survivors. Obesity and overweight is not the most common complication in cancer survivors who've been through pretty aggressive therapy. But sometimes these other states, whether it's unexplained cardiometabolic profiles after a bone marrow transplant or fatty liver disease associated with prior steroid therapy and things like that. There are all these indications that are popping up in places that I wouldn't necessarily have expected, but are really encouraging and make me optimistic about the drug class and the role it will play in improving health outcomes.
--:-- Let's talk about access. Clinics like knownwell are playing an important role in figuring out how to scale access to these medications in a safe way and in a way that's evidence-based and consistent with where we want these drugs to go based on the evidence that you outlined. What is the best practice for prescribing these drugs? How does a provider determine if a patient is eligible?
--:-- Brooke Boyarsky-Pratt: We think the best practice includes a few things. Patient medical records. I know that sounds silly, but it's actually pretty rare in the GLP-1 space right now. Understanding the longitudinal health history of a patient: what are their comorbidities, when did those comorbidities start? We get medical records on all of our patients, for example. As we talked about earlier, thorough social and family history. While the data on things like thyroid cancer today aren't terribly compelling in terms of being nervous about it, if you have an aunt or a mom who has had a specific type of thyroid cancer, we're going to have a much longer conversation about if a GLP-1 is the right answer for you just given the data we have today.
--:-- Thoroughly understanding the patient from those medical perspectives, understanding the emotional and behavioral elements of the obesity for the patient. We always talk about what was the age at which you started struggling with your weight, what's been your highest weight. Someone who may eat emotionally could actually need a different kind of intervention from someone who actually just eats in excess at different times. There are different elements of how a patient's relationship with food has evolved that may impact what their treatment should be. I think that's extremely important and something we spend a lot of time on.
--:-- Third, of course, is what does the patient actually have access to?
--:-- Brooke Boyarsky-Pratt: The worst thing you could do is tell a patient after all of this evaluation, spending an hour with you live synchronously, "I think you'd be an amazing candidate for Mounjaro, for Zepbound." And then you find out their insurance doesn't cover it and it's a formulary exclusion. So for us, we try to have that information on the patient before they even walk in the door.
--:-- And then the last element is really that synchronous interaction. We think it's helpful to occasionally see a patient in person, but we don't always. But whether it's live or via video, again, it sounds a little bit silly, but being able to see the patient, understanding their emotional response when you're talking about different interventions, we think is really important.
--:-- Vineeta Agarwala: Couldn't agree more. It's not necessarily how all GLP-1 receptor agonist access is happening, though, today. And you're seeing it, we're seeing it, patients are seeing it. There are emerging different channels through which medication access may become possible. There are still supply shortages and expense hurdles that make those channels not totally a turnkey solution. But going back to comprehensive obesity medicine, how do you think about where that goes in a world where there are other avenues by which patients are understandably looking to access medication that they think could really help them?
--:-- Brooke Boyarsky-Pratt: If a patient is given a choice, they prefer a medical home. And that's what we've seen with our patients. We've seen a lot of patients leave point solutions because they say, "Wow, you can also do my primary care. I can occasionally see you in person. You are a real doctor who I talk to and who I have a care team I know and respect." So I think that's really important, particularly as it relates to symptom management and comorbidities. By the way, I have comorbidities that are real medical conditions. Like, we can also manage your diabetes and everything else.
--:-- And we had patients who say to us, "Look, I was throwing up for four days. I ended up in the ER. I couldn't get anyone in the app to respond to me." So I think there's a real patient safety and patient comfort in going to something that's more clinically oriented. But I think to your point, patients are so desperate for access that there will always be a role to play, whether good or bad in some instances, of this more direct prescribing with less interaction with the patient.
--:-- But I think at their core, most patients—and I'll speak for myself—want to feel known well. If they can find that locally who takes their insurance, that is their preferred method. So I think both models will exist in the long term.
--:-- The one thing I would add, though, is I do wonder if we'll see more scrutiny around that prescribing. We have a physician who's joining us from another company who had said, "Look, the big reason I'm leaving is a year ago we stopped having any synchronous visits with patients. I get a survey filled out by the patient and I'm meant to prescribe and I've never even seen or talked to that patient synchronously." I'm going to go out on a limb—I'm not a doctor—and say I don't know that that's the best medical practice. I could claim to be a 75-year-old man and if you've never seen my medical record and you've never seen me. So I do think we'll probably, at the most extreme end, see some curbing of that kind of behavior.
--:-- Vineeta Agarwala: What else will change with access going forward?
--:-- Brooke Boyarsky-Pratt: It's really important to note that obesity is one of the only disease states that's not a standard benefit on insurance. I bet you've never been a part of a conversation that says, "Is an employer or an insurer going to cover breast cancer?" It's expensive, but we cover it. "Are we going to cover diabetes?" It's expensive, but we cover it. Obesity is more akin to what you've seen with fertility, where it was considered this carve-out rider. And that puts employers in the really tough position of, when they're self-insuring or when they're going to payers and buying something off the shelf, it's not typically within the standard benefit. That means they need to make a decision about if they're going to include it or not, and are they going to raise their costs.
--:-- So we think ultimately the most important thing for access—and Dr. Fitch was on the Hill on Monday advocating for the TROA Act—is getting TROA passed, which would have Medicare cover obesity. That would really be the first step in establishing obesity as a standard part of any insurance benefit. Until then, we're left to each insurance company and each employer trying to navigate what's a really difficult situation.
--:-- We do think over time, access in terms of insurance is going to continue to improve. We see more Medicaid states approving obesity treatment. We have never seen the momentum we currently see behind TROA as it relates to Medicare. And you are seeing employees and patients use their voice and get their insurance package to cover it. So we think it's actually going to be a good news story, particularly as more disease states seem to be treated by GLP-1s.
--:-- The argument around treating obesity effectively, having such a wide-ranging impact on overall health, on concomitant conditions—whether that's diabetes, cardiovascular conditions, hypertension, the list goes on—is enormous. That argument puts obesity in a special category of something that patients want care for, something that providers want to deliver care for, and something that I think ultimately will lower overall medical expenditures in the quest to achieve great health outcomes, which is what we all want.
--:-- Vineeta Agarwala: The fertility analogy is very interesting. I'm also a big proponent of access to great fertility care. The behavioral health analogy is also interesting. It took some time for our collective communities to understand that those are medical conditions. They have implications for other medical conditions and for overall patient well-being, patient cost, patient access, patient return to work.
--:-- I don't want to lose sight of something you slipped in there, which I just thought was so beautiful and important. This idea of building a medical home where patients feel known well or well-known to their care team is just really beautiful. It's something that I think every patient wants, every parent wants for their child. Everybody wants their doctor to know them well, no matter how much technology is coming into healthcare. You want your doctor to feel like they know you well enough to make the right choices when they have many choices, which is kind of the incredible realm we're entering in obesity medicine. Your doctor is going to have many choices. Choosing between those choices presumably requires knowing you well. So I just love that mission, that name.
--:-- We could end this amazing conversation on the topic of building a company to execute on that mission. How do you scale that? How do you blow it out to everybody who wants it?
--:-- Brooke Boyarsky-Pratt: A lot of things have to go right. And they are. One is, while obesity medicine is the fastest growing subspecialty in the U.S., we still have like 6,500 clinicians, most of whom don't practice obesity. 115 million Americans need treatment. So that certainly can't be we just hire every obesity medicine certified physician in the country.
--:-- So the first thing we're doing is hiring APP and physician PCPs who have not had the training in obesity but are really excited to get it. Something we do is we train them in depth in the best practices of delivering obesity medicine. This is actually something Dr. Fitch does across the country today with PCPs. We do that not only for our own PCPs, but frankly others in the community because we think it's so important for people to expand access for patients. So first is hiring non-specialized in addition to specialized physicians so that we can treat more patients and deliver that care at scale.
--:-- The second is investing in the technology to help automate the stuff that doesn't matter. As you well know, so much of practicing medicine, especially on the primary care side, is administratively burdensome but not something that really deepens the relationship between the patient and the physician. It's things like getting referrals done, getting the imaging in, getting the prior authorizations out. Things that are just necessary for care. So we're investing a lot in making sure that those pieces of our process are more automated so that we can scale and leave physicians the time to spend with their patients.
--:-- And that's the last thing I would say: really around physician clinical decision support and productivity. We are big believers that to serve the patient, you also have to serve the clinician. We know there is a huge burnout problem in the country. So how do we help clinicians work to the top of their licensure? We're working on a lot of systems, processes, and tools to really reduce that burden for clinicians so that they are able to see more patients and spend time with those patients.
--:-- Vineeta Agarwala: What's something that you've learned as a founder about standing up a business to do all those things and move closer to your vision around scale? What's something you've learned that they just don't teach in business school?
--:-- Brooke Boyarsky-Pratt: You have to be the one who jumps. I'll share a little story with you. I was in Hawaii and it was 8 a.m. I had finally worked up the courage that I scheduled a meeting with my CFO and CEO at 5 p.m. that day, which was a big deal. I was on the executive team to let them know I was going to step down as CEO—this is at my prior company—because I'm going to start knownwell. And I was dreading that conversation because I love the company so much and love them.
--:-- At 8 a.m., right before I was going to head out to a farm, I got a text from Dr. Fitch that said, "I know you're going to quit today. Don't quit. What if we can't do it?" This is many years ago now. I looked to my husband and I said, "You know what? I'm always going to have to be the one who jumps. Some founder has to be the one who just says, 'I'm going off the cliff,' because someone has got to be the first one to do it."
--:-- And I called Dr. Fitch—she does not mind me sharing this story—and I said, "We're going to do it. And I'm going to be the first person who jumps. And I know you'll end up following me." And she did. She jumped.
--:-- So I think I underestimated—and I don't mean to, I'm not a military vet or anything else—but I underestimated the amount of courage it takes as a founder. You focus so much on the day-to-day stuff and the long hours and building the team. But every day you really need to be the person who says, "I'm all in. And I'm going to set the cultural tone that we are going to get there." I just didn't realize how important that would be on the path.
--:-- Vineeta Agarwala: I love that. That's a great note to end on. It is incredible what you're building in such an important space on behalf of patients who want to access amazing, comprehensive obesity medicine. Thank you for joining us on the Raising Health podcast, and thank you for being all in.
--:-- Brooke Boyarsky-Pratt: Thanks for having me.
--:-- Olivia Webb: Thank you for listening to Raising Health.
--:-- Chris: Raising Health is hosted and produced by me, Chris Tatiosian.
--:-- Olivia Webb: And me, Olivia Webb.
--:-- Chris: With the help of the Bio + Health team at a16z.
--:-- Olivia Webb: The show is edited by Phil Hegseth.
--:-- Chris: If you want to suggest topics for future shows, you can reach us at
[email protected].
--:-- Olivia Webb: Finally, please rate and subscribe to our show.
--:-- Chris: The content here is for informational purposes only, should not be taken as legal, business, tax, or investment advice, or be used to evaluate any investment or security, and is not directed at any investors or potential investors in any a16z fund. Please note that a16z and its affiliates may maintain investments in the companies discussed in this podcast. For more details, including a link to our investments, please see a16z.com/disclosures.
