[Podcast] Genetics and the Future of Patient-Centric Care

I'm excited to share this podcast featuring Mia Nease who, at the time of recording, was Head of Healthcare and Life Science Partnerships at Arivale. She is now the founder and CEO of Multiomic Advisory Services.

This is the second podcast in a series of prep for our panel discussion at this year's EyeforPharma Conference in Philadelphia titled Patient-Centric Care: Does the Doctor Know Best?

My colleague, Lynn Nye, CEO of Medical Minds, also moderated this podcast.

“Genetics and the future of patient-centric care”

The consumer health market is undergoing a big transformation with the advent of genetic and health data technologies like FitBit and 23&me. Ms. Nease says data-driven tools like these are emerging as a result of consumer interest, “What we're seeing is an emergence of market offerings, that lean into the personalized wellness space and focus more on preventive health.”

“I think what we're seeing in the market is a trend to move upstream,” continued Ms. Nease. “Our current medical system isn’t really a healthcare system, it's more of a sick care system. You tend to only see your doctor when something is wrong—when you're symptomatic.”

She goes on to say something we’ve been talking a lot these days, which is, “[Healthcare] still all about billable codes, and there's little incentive to keep patients healthy upfront.” As the pendulum begins to swing in the other direction however, more companies are emerging, like Arivale, FitBit and 23&me that are more incented to focus on wellness and preventive health.

“As we move towards consumerization, the trend is for the individual to own their health journey. I think that's why Viome bought Habit,” continued Ms. Nease. “That's a classic play in that personalized participatory predictive space.” Viome is a microbiome-based personalized food start-up and Habit is a personalized nutrition company. According to Viome’s founder, their partnership is the perfect articulation of personalized health.

As we continue to see the market move in this more personalized direction, Ms. Nye asked whether Ms. Nease believed physicians were ready for this shift toward highly personalized wellness, particularly in primary care. “I think it's a classic technology adoption curve where you have visionaries, earlier adopters, mainstream and then the laggards,” Ms. Nease said. She went on to say that, in any technology curve, you rely on the visionaries and early adopters to convert and mainstream will eventually follow.

“Very engaged physicians who believe in personalized participatory preventative health are loving the idea of using genetics and genetic predispositions to tailor clinical recommendations.” She continued, “It doesn't necessarily map to a particular demographic, although I would say the more engaged and interested parties tend to skew toward younger, primary care physicians.”

“They tend to be part of organizations that are already thinking quite progressively and physicians tend to be more engaged when there's a very clear top-down message.” Some of the areas she’s seen more engagement is in the treatment of complex diseases like Alzheimer’s because there is an unmet medical need and physicians are eager to find ways to slow down deterioration and help improve their patient’s quality of life.

Complete transcript

Stewart Gandolf:
Hi everybody. Stewart Gandolf here with Aria Agency and Healthcare Success. I'm pleased to be doing another podcast and very excited today to be working with my colleague Lynn Nye, who's moderating our discussion today. Mia Nease, who is head of healthcare and life science partnerships at Arivale. We're going to be doing a panel together at this year's Eyeforpharma conference in Philadelphia. Lynn, take it away.

Lynn Nye:
Mia, would you just give a synopsis of your company?

Mia Nease:
Arivale originates from the Institute for Systems Biology, which is Dr. Leroy Hood's institute out of Seattle. And Dr. Lee Hood is probably best known as being the father of systems biology, systems of medicine. And his team at Caltech invented the first automated gene sequencer.

Stewart Gandolf:
Wow.

Mia Nease:
Yeah. He's a scientific co-founder of Amgen, applied bio sciences Rosetta, and many other. He's now 80 years old and still very active and engaged. He serves as the Chief Scientific Officer for the Providence St. Joseph Health network-

Stewart Gandolf:
Wow.

Mia Nease:
... which is the third largest not for profit in the country. And about three years ago he decided that timing was right to do a study on healthy individuals to see whether the deep pheno-typing and genotyping matched with coaching behavior change could help people optimize their wellness and avoid disease. So the institute did a study. And from that study Arivale was born. And Arivale is essentially now a three year old company that has two key assets. One is this wellness program that came out of the institute, which is sort of deep scientific, genetic, big data type thing with personal coaches. So that's very much a wellness offering. Although frankly two thirds of people that come into Arivale are not well. They have usually some kind of issues, which is what drives them our way.

Stewart Gandolf:
Right.

Mia Nease:
And so that's asset number one. And we've been running that program for three and a half years and have had tremendous clinical success. Really superior to what you'd see in practice, certainly far more engagement than you would see in your regular corporate annual physical. So that's sort of asset number one. If you go to Arivale's website, that's what you will see. And then the second asset that we have is the data itself. We have a very high consent rate. People have their de-identified data consent in use for research.

Mia Nease:
94% of people consent to have the data used for research. So when you think about the kind of data that we're collecting, we're collecting genetics, we're also collecting clinical labs over a period of time. We've got a six months blood draw. We've got microbiome every six months. We've got salivary cortisol every six months. Fitbit devices, scales, and sleep devices synchronizing every night. And then a ton of coach notes. So we really develop a very deep view of an individual as well as we collect a tremendous amount of longitudinal data. And people stay in the program because they build this relationship with their coach.

Mia Nease:
Anyway, so what we do on kind of asset number two, which is not as visible on the web, but GenomeWeb just wrote about us last week. And that's where we take the dataset to market. We've partnered with bio pharmaceutical companies, consumer goods companies, academic researchers who are using this de-identified multiomic dataset to further scientific research in a whole number of disease areas. And they're also using it on the provider side to conduct observational trials in certain disease states. Because we're a nice and neat ready made set platform that they can simply plug into.

Mia Nease:
And so we have trials going on in Alzheimer's disease, and IBD, and breast cancer, and wellness, and all sorts of stuff. So that's Arivale, the two assets, the kind of consumer asset as well as the back end, the data. And we're learning as we go and the consumer side has got some really good engagement metrics. Where we've struggled a little bit is to try and find the right price point and time commitment that would appeal to a consumer who's trying to solve a pain point. And then on the research side, where we've definitely got several pilot projects going on and a lot of interest in actually licensing the whole dataset. So commercially we've been pretty, pretty good. Yeah. And we're in the process of talking big scale partnerships with a number of fairly well known players, which should be announced by end of Q2.

Stewart Gandolf:
This morning my wife bought me this 23andMe kit for Christmas. And I finally got around to the whole saliva thing. I went to the signup process and it said, "Do you want to know if you have a genetic predisposition for Parkinson's or Alzheimer's?" And I thought, I don't know. I don't think so, unless there's something to do about it, right? But it's genetics. And so what can you do right? And is there something you can do to prevent it? So it's kind of funny and topical that that happened this morning.

Mia Nease:
Yeah. There's more and more interest, right? And I think 23andMe, and some of Ancestry in the driving and an interest in consumer genetics. But you're right, there's limited action-ability, which is why we focused on the stuff that is actionable. Like so when you speak to your coach, they'll talk to you much more about the polygenic risk for diabetes or polygenic risk for obesity and whatnot. And those are things that you can make a difference in. And we have partnerships too with like some of the big IDN's. So we have a partnership with Spectrum.

Stewart Gandolf:
Yeah okay.

Mia Nease:
Where they offer Arivale through their strive clinic.

Stewart Gandolf:
It totally makes sense, because if you're doing it through an employer you've got access to lots of consumers really quickly, right? And like a mix in scales versus one at a time sales which it's harder to sell. And then there's also like cardiologists, and internal medicine, and things like that, which would be really interesting in case all that fits with what they're doing.
Lynn Nye: I wanted to ask you how you felt about a few things. So you know what the topic is, patient centric care, does the doctor know best? So my question to you is, what does the doctor know best? And what are some of the things that you think the doctors don't know?

Mia Nease:
I think what we're seeing in the market, right, is a trend to move upstream, right? Because our current medical system, our healthcare system is not really a healthcare system, it's more of a sick care system, right? And so aside from people that partake in annual physicals and even those, you have sort of very limited access to the physician themselves, and very limited follow up, right? You tend to only see your doctor when something is wrong, right? When you're symptomatic. And so to me, what we're seeing is kind of an emergence of offerings, market offerings that lean into what I would call the personalized wellness space, with personalized to you based on your genetics in a unique omics. Preventative, right?

Mia Nease:
Where it's much more focused on preventative treatments as opposed to diagnose prescribed, right? And participatory, right? As we're moving towards consumerization, the trend is for the individual to really own their health journey. And so I think that's why you're seeing Viome bought Habit last week and that's a classic play in that sort of personalized participatory predictive space, right? So to me, the physician, much of the physician community continues to operate in kind of a landscape where the incentives are a little perverse, right? It's still all about billable codes. And there's little incentive to kind of keep patients healthy upfront. And so you're seeing these companies emerge that are more incented to do so.

Lynn Nye:
Do you think the doctors, do they know about that? What's their level of understanding?

Mia Nease:
So I can speak from experience because we speak to a lot of physicians, right? I have a sales rep that's just dedicated to this channel and she's a PharmD. She spends all her time speaking to physicians. Three buckets, the, "I don't care about this hocus pocus genetic stuff go away. I want to keep doing what I've been doing forever." The second bucket is, "Oh okay this is kind of interesting. I'm not necessarily opposed to it, but I wouldn't necessarily make any decisions based on it. And if you show me data that's fine, but whatever." And then you've got the third bucket, and I would say they split roughly a third, a third, a third. The third bucket is the very engaged physicians who do believe in personalized participatory preventative health and are loving the idea of using genetics, and genetic predispositions to tailor clinical recommendations. You see this for example in the Strive Clinic for sure. And so yeah I'd say we're seeing kind of a mix. And it doesn't necessarily map to a particular demographic, although I would say that the more engaged and interested parties tend to skew younger.

Lynn Nye:
Is it in a particular specialty? Like cardiology or diabetes or primary care? Or wheres-

Mia Nease:
It tends to be primary care. Yeah. It's primary care and in particular concierge, right? So the concierge community is more and more interested in this kind of approach. And then as we are getting more and more data coming through with respect to clinical outcomes, preventative critical outcomes, we are starting to see interest from oncology. Tremendous interest, funny enough from neuroscience, in particular geriatricians. So we have a cohort of people in a clinical trial right now with the Hope Hospital who have been diagnosed with early cognitive decline. And they're going through this program of sort of lifestyle and behavior change with absolutely tremendous results.

Lynn Nye:
All these buckets, like equal buckets? Or is the engaged bucket a smaller bucket of people?

Mia Nease:
No. I'd say it's roughly equal. They tend to be part of organizations that are already thinking quite progressively. There's a very clear top-down message. So Rod Hoffman, right, the CEO of Providence, is very vocal about it being a strategic agenda to keep customers. And he calls his staff caregivers and his patients and not patients, they're customers. An experience that is about keeping you healthy as well as treating you when you need it. But very much resourcing around keeping people healthy. So I think where we have really strong leadership messages coming from the top down, you see more of that sort of engaged physician. And then interestingly, Washington State University has actually just put their first cohort of med students through a program like this. And traditionally physicians get very, very little education around diet and exercise and such, right? Very, very small nutritional component as part of their entire educational process. Well, Washington State is changing that and they've actually put their first cohort of 60 med students through one of these programs.

Stewart Gandolf:
I'm not surprised at all number one, that like the sick patients are the ones that are most interested, or the younger patients tend to be interested. I would expect also there's probably a financial, the more educated upper scale are probably more interested.

Mia Nease:
Of course.

Stewart Gandolf:
That cohort about the doctors being split into thirds. That's exactly what I see when we're working with them to market their business. Like one third thinks it should be illegal. One third is in the middle and sway-able, and maybe in our case 10 to 20% are a little bit more visionary. And I bet you would see that as well. The idea of some of these partnerships, like you mentioned a minute ago for Hope. Like are you finding that doctors, the ones that are embracing this, it seems like it would have like a tremendous potential. Like they must be really excited about this, right? The ones that are in that third, do you find they tend to be more patient centric in general?

Mia Nease:
Yes, for sure. They tend to be more patient centric, but they also in many cases are struggling to find solutions for patients. Because there is sort of a huge unmet medical need, right? In that there is no cure for disease X, Y, Z. Like IBD, right, is a classic example, Crohn's, colitis, right? So this whole metabolic auto immune space where it's really about trying to keep the patient comfortable. And keeping them kind of adjusting their lifestyle because there's no pill they can prescribe.

Stewart Gandolf:
Right.

Mia Nease:
And it's a very similar situation in Alzheimer's, right? So we find the physicians are more motivated there because the pharmaceutical industry is not giving them answers yet, right? There's a lot of research going on, and it's tremendous research and some incredibly smart minds. But Alzheimer's an extremely complex disease. And so in the meantime, physicians are utilizing programs like this to see whether they can sort of bend the curve, certainly slow down deterioration, and help these patients at least with quality of life as opposed to giving them a straight up cure.

Stewart Gandolf:
And Lynn, one of the questions you were going to ask about is, as it relates to pharma, going back to the panel questions. Do you believe there's a communication gap between doctors and patients? And why?

Mia Nease:
It depends, right? It depends on what therapeutic area, what disease state. If you're talking primary care. Yeah, for sure. Because the biggest challenge with, for example, just if you look at the annual physical, right? The hallmark of preventative health, right? You go there, reality is you get a workup. If you've got good insurance, blah, blah, blah, you spend a couple of hours, right? But we all know what we need to do. Eat right, exercise, right, lose weight. We all know the basics. But behavior change is really hard. And so the physician is focused on kind of getting a baseline reading and then, "Okay. I'll see you again next year." But the reality is a lot of times people need a partner in helping them change behavior, helping them modify the behavior so that when they turn up to their annual physical, the year after the results will be positive.

Mia Nease:
That's where the physician is not stepping in, right? They're not stepping in to help. And frankly, it's not just the physicians, the system as a whole is not stepping into help. Unless you're diagnosed with something like Type 2 diabetes, in which case you can get prescribed, the Omada platform or whatever. But if you're kind of just borderline, and you have opportunities to improve your wellness, but you're not necessarily diagnosed with anything, then you're left until, okay, sooner or later you'll have a symptom and at that point we'll care.

Stewart Gandolf:
You mentioned earlier the reimbursement model is playing against it because they're not incented.

Mia Nease:
Oh totally.

Stewart Gandolf:
Because if they spend time on something they're not getting incentives for it it means they're not getting paid on something else. So from their standpoint, I could see why a sales person talks to the doctors. It's like a way of doing the right thing without being a conflict of interest, right? If your coaches can supplement this, the patient is getting better care until they can figure out how to get paid basically.

Lynn Nye:
And IBD too, it's really interesting, we're doing a program right now with the American Gastroenterological Association. And the goal of the program is to tell doctors how to talk with patients. And when we're talking with these people it's clear they do not know how to use the right kind of language to talk to their patients.

Mia Nease:
It's very, very tricky for sure. And I think here's too, the opportunity, with a market opportunity, right? We're seeing a tremendous amount of consolidation, right? In the provider space. And so particularly as we get to the true integrated delivery networks like the Kaisers where they're both payer and provider, right? Suddenly the incentives do change a little. And as we get more and more health economic data, and as we are able to have a more fact based conversation about return on investment, of keeping people healthy versus treating them once they're symptomatic. My hope is that equipped with that data as well as story, right, we will be able to kind of influence the... if not so much the reimbursement model, but kind of the attitudes within the system.

Lynn Nye:
Yeah. So do you think that improving communication, I think you're going to say yes to this, will improve outcomes or does improve outcomes?

Mia Nease:
We've definitely seen in our program that relationship based accountability combined with a personalized approach yields, one superior clinical results, and two far, far superior engagement over time. And so-

Lynn Nye:
Right.

Mia Nease:
... communication is one thing, but it's also feeling like there's an actual relationship there between the patient or the consumer, and the clinician. And whether that's a physician, or an RN, or a PA or whatever. But that's kind of, I think people don't feel accountable to a boss, right, or app, right? But they do feel accountable to a human being. And we've seen this tons and tons of times in our data.

Lynn Nye:
So do you have actual published data on that that you could point to?

Mia Nease:
So yes. I have two things. We've published in Nature Biotech, 2017.

Lynn Nye:
Right.

Mia Nease:
That was the actual P100 study that was done at the Institute Resistance Biology. And that one has all the data associated with it. Now that was only 108 people. But they did have a health coach and they didn't measure engagement and adherence and things like that. So and that includes obviously the ongoing communication with the coach via phone or app or whatever. So that is peer reviewed, it's published, it's done. And then also have just straight up data that we pull based on surveying our participant community, particularly our employers as self funded employers are interested in how the program is performing because it is a little bit more expensive than what they would usually pay for a wellness program. So for them it's about justifying that it's worth it longer term from a comp and ben standpoint.

Lynn Nye:
Let's change the topic a little bit. So how can we help time pressure doctors to be more effective? Here we are saying what they should do but what are we going to do to help them to be more effective? So tell us about what we can do with primary care.

Mia Nease:
I think the incentives need to change. I think the incentives of keeping people healthy, and really using cutting edge science. And we have the science, right, we can do polygenic scoring, we can do polygenic risk evaluations. We know how to track people longitudinally over time. We have some tremendous research showing behavior change, but we haven't connected all the dots. And so to me, making the clinic more effective is about bringing cutting edge science into the clinic preventative-ly and in a personalized way. And then helping individuals optimize their wellness and avoid disease over a period of time through holding their hand through the change, right, through making behavior modification. Now in order for that to really work in real time, we work in a full profit health world. We need to be looking at the incentives to do so. And I think more health in economics, more studies related to what's the impact of someone transitioning to disease and the cost are a good thing.

Lynn Nye:
It seems to me that nurses and PAs are a very important part of this. Would you agree?

Mia Nease:
Oh totally. RN's, dietitians, nutritionists, for sure, absolutely. They're a huge part of the ecosystem. Yeah.

Lynn Nye:
Yeah so how-

Mia Nease:
To me, it's an ecosystem thing. It's a multifaceted approach to constructing an ecosystem of care.

Stewart Gandolf:
Are you guys getting much into population health or accountable care organizations? Because it seems like that would be, the problem is of course paying for it. The consumer price here at $99 a month is not bad for an individual when you have thousands. But it seems like if you're really serious about population health, applying this model-

Mia Nease:
I think the people that need programs like Arivale the most are actually the people that can least afford them. And I personally, I've been a huge proponent of actually securing funding from our industry partners to help onboard people from either certain populations or pull from the accountable care world into a program like this, so that we can study them better. And so that we can generate data around that particular cohort. We're not there yet.

Stewart Gandolf:
One thing I thought was really powerful that people respond to people not to machines, not to like automated techs. Which we'd like to all, being a digital marketer, we love this automated stuff. But that totally resonates with me that people would be, that human element is enormous, right? It's all the difference in the world. For example, we talk about, when we're asking for reputation management at a doctor's office for compliance. Very, very low compliance or very, very little response from a patient, if you email them for requests for a review. If you text them, it goes up a lot. So like I joke that emailing them is worth a penny. Texting them is worth a dime.

Stewart Gandolf:
Asking them personally is a dollar. The compliance skyrockets. So that's not what we want to hear, right? Because the automation is cheaper. But the reality is... And I'm guessing that maybe people would be triaging, like with you guys and it's like, "Okay, I'd love to give everybody but I can't. But these patients over here are at the highest risk genetically or income wise and therefore we can pay you for this subset of my overall." And talking from an affordable care act perspective of these patients really need help. And we need to help them.

Mia Nease:
You're right. There is only a finite number of problems, particularly when you're just focused on wellness, when you're coaching to wellness as opposed to coaching to disease. And so over three and a half year, four year period now, we have seen definitely patterns. And we have optimized our coaching model such that it takes advantage of some of these patterns that you're talking about, which are kind of the high needs consumer. The demographic that requires more interaction versus the demographic that is happy to interact on the app. So yeah, we're seeing patterns and we're definitely applying tools and strategies to leverage that. And that's kind of where the human aspect is the challenge from a business model standpoint because it's expensive. And it's tough to scale, right? And so which is why I think, having some more health economics and ROI data to justify it is a good thing. But then also too, looking at how we leverage new technologies to make the investment as optimized as it can possibly be.

Stewart Gandolf:
The current environment is all about scale and letting machines do it. And then you look at something like Weight Watchers where, I know they're changing their model as we speak, but the idea of humans talking together. Even though it's not like professional coaching, they still made gains when they have some accountability to a real person. But it's like the climate today is all about scale, and cutting people out of the equation. So it'll be interesting to see how that works.

Lynn Nye:
What you were talking about was from the consumer point of view, but where you started this conversation, Mia, was you said the physicians fall into three buckets. I don't care, it's all hocus pocus. I'm interested and not opposed, but I'm not learning anything about it. And I'm engaged. So then how do you move the positions in the first two categories into the third category? What would we do that will be some kind of scalable strategy that would move that?

Mia Nease:
I think it's a classic technology adoption curve, right? Where you have these visionaries, and then the earlier adopters, and the mainstream, and the laggards. And to some extent in marketing strategy, you ignore the laggards because they're so expensive to convert. It doesn't make sense. You just take for granted that there's going to be laggards in any bell curve. And we ignore them. And frankly, it's probably not the most politically correct thing to say, but these tend to be physicians who over 50, who are over 55 who are not digital natives. They just don't get the technology, they don't feel comfortable in it, they've not been trained in it, it's not their native world. And they've been doing things like they've been doing for 30 plus years. So some of that issue is just they're going to gradually retire out of the system, right? So to me it's you tackle it like you would tackle any technology adoption curve, in that you rely on the visionaries to convert.

Stewart Gandolf:
To build on that Lynn, I've worked with somebody in the anorexia field who actually had a program written up in Langset, and the National Academy of Proceedings and Sciences, or whatever, the National Proceedings Academy of Sciences. And their argument was that doctors don't change their mind, they just die or retire. I totally agree with what Mia just said based on my experience.

Lynn Nye:
Yeah, I don't believe that though. Because I think that, where Mia was sort of going, it's classic in pharma that use the opinion leaders to educate the prescribers, right? Yeah. Then you take the data... That's why the data is so important. This is actual data. And so this is why you need to be doing this, right?

Mia Nease:
So here's the difference between what I would call the old power world and the new power, right? And I use this term by son Jeremy Heimans' book, right? And the old power is the KOL. It's the paternalistic medicine, authoritative God voice that comes down and says, "This is the right thing to do." And everyone else follows, right? What was seeing, I think in kind of the world of new power is more of a collective voice with the clinical results and the patients are so networked that the adoption is being driven a lot by that and less so by the authoritative KOL. And that's particularly in primary care. And KOL is obviously still very, very relevant in the specialty space. But in the primary care space we're definitely seeing a lot of that patient centric conversation, right?

Stewart Gandolf:
Is your company involved with groups like A 4M, for integrative medicine because that's an area these doctors love this kind of stuff. Is that anything that you... Because I'm just curious because those doctors are all about wellness and health. And I just don't know if you see them much or not?

Mia Nease:
We see them, we definitely have conversations with them. And like I said, I have one staff member that's dedicated to this space. We've had moderate success with them, right? I'm going to say moderate because we don't white label our offering. It's almost like they sometimes see us as a little bit of a competitor, right? Because we're in this sort of P4 medicine, personalized, predictive, participatory. And so that's been our experience and of course there's the cost, there's the out-of-pocket aspect that gives some people kind of heartburn.

Mia Nease:
But yeah, for sure. Attitudinal alignment is absolutely there with the integrative practitioner for sure. Some of them still are a little shy of genetics though. And they actually don't like it because it sort of disrupts some of their stuff. They tend to prescribe a lot of vitamin B, and then we start talking about people who have a receptor that you shouldn't be consuming so much of it because you can't process toxins. And then suddenly they don't know what to do with that.

Mia Nease:
My assessment is that Arivale is probably five years ahead of its market. And that we're at this sort of gradually, gradually, gradually, suddenly. And if you look at some of the other players in the market, even like 23andMe, when they started their health stuff, right, it was gradually, gradually, and then the hockey stick kind of went up. And I think we're going to see the same thing. Particularly once we start publishing some of this financial data around ROI. And there's some studies going on in that space, which I think is going to be really interesting. And it looks very specifically at claims costs, et cetera.

Stewart Gandolf:
Thanks, Lynn for helping out with this podcast today. And thank you Mia, that was really insightful. Take care.

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