AI transcript
People have no idea what’s coming and how big of an innovation this is going to be.
One of my earliest experiences in healthcare was my pediatrician telling my mom that I should
go to fat camp. Specialist obesity training. They’re typically missing a few things. The
average one will have four hours of training in obesity in medical school. We’re actually all
users of GLP-1s. There we go. In the sense of GLP-1 is a hormone that we all have.
Obesity. A choice or a condition. Well, regardless of what you believe, this chronic
disorder continues to impact millions of Americans, with nearly 70% of Americans fitting the description
of overweight or affected by obesity. And moreover, 55% have cancelled appointments due to the
anxiety of being weighed, at least according to Noanwell. Noanwell is a company trying to rethink
obesity medicine and its founder and CEO, Brooke Boyersky-Platt, joins a 16c general partner,
Vanita Agarwala. Together they discuss what it’ll really take to change some of these statistics
and how new technologies like GLP-1s fit into this mix. Brooke herself has personal experience in this
domain as a former patient with obesity, having even been told by her pediatrician that she has to
go to a fat camp. Now she’s using that fuel to rethink obesity care herself. Now this episode
was also part of our sister podcast, Raising Health’s GLP-1 series. And if you’ve been
paying attention over the last year, GLP-1s went from being an unassuming acronym to a familiar
class of drugs that some recent studies have even pegged as many as one in eight Americans trying.
The recent adoption of these drugs has also springboarded companies like Novo Nordisk,
the manufacturer of Ozempic, to the largest company in Denmark. So if you, like many others,
are interested in learning more about GLP-1s, make sure to tune into the rest of the series
on Raising Health. You can find a link to the show or the full series in our show notes. Let’s get started.
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. 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 Jasek, 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. Today, we’ll hear from Brooke Boyarski Pratt, the founder and CEO of Knownwell.
Next week’s episode will be with Cronus Minolas of UPMC Health Plan on the Pharmacy Implications
of GLP-1s. Brooke talks with Vanita Agrawala, general partner of A-16Z 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.
If a patient is given a choice, they prefer a medical home. And that’s what we’ve seen with
our patients. So 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.
You’re listening to Raising Health from A-16Z Bio and Health.
I am incredibly excited to welcome to the Raising Health pod today Brooke Boyarski 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.
So Brooke, I’d love for you to just introduce yourself and share the story behind this company.
Yes, such a pleasure to be here. Thank you so much, Venita, for having me on.
I am a patient. I mean, 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,
and that really unfortunately started the process of how I viewed interacting with the
healthcare system when it came to my body size. And as I got older and sort of had different
educational and work opportunities, it led me to move a lot. And every time I moved and re-established
primary care, I felt like I was needing to re-establish the idea that I was a thoughtful
person who took my healthcare 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,
and it was even harder when I was actually looking for treatment for my metabolic health
to find something that was accessible to me. And 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, and I was overwhelmed by the research,
and I’ll just say briefly, 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?
Well, in the venture world, investors talk about founder market fit, and 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. So 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. But what made
you jump? You had a background in finance and consulting. Yeah, very traditional kind of business
background of Penn and Herbert Business School in McKinsey and worked at a commercial real estate
company. So 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 known well 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. And before known well, what I was always drawn to was doing a good job delivering for clients
and being the best colleague and boss I could be in terms of the people I worked with. 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, right? I mean, it was just something that was important to do well and to
deliver for people. But as I started, I had always been drawn to healthcare, like just to the healthcare
industry, because I always felt like, how could you have a more direct impact on people than in
healthcare? And 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 sort of felt natural that I found my way to healthcare.
Consider me one of your physician friends. It’s 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 actually, 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?
Like, is that a specialty? What is it? It is a specialty. So 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 sort of easiest measure we have today to diagnose the
disease. So 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. And it was not long ago.
I mean, the reason Medicare, for example, doesn’t cover obesity treatment is they see it as a
cosmetic disease. And it wasn’t long ago that that’s how everyone viewed overweight and obesity.
In 2012 was the first ever board certification in obesity. So that’s how recently this disease
state has been really viewed as something in the medical community. And obesity medicine is really
about comprehensive treatment of the state of obesity and overweight. And 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. So 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 do have a board certification in obesity. And nowadays we have fellowships. So
some folks go and do an obesity medicine fellowship. And then we also have a board
certification. And I’ll note it’s actually the fastest growing specialty in the US. And there’s
something called the Obesity Medicine Association, which is the largest association of clinic
clinicians who practice obesity. And we’re really fortunate that my co-founder and our CMO,
Angela Finch, is the president of it. So 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. Totally. And as we mentioned earlier,
everyone’s doing their best. So what I don’t think the differences between a primary care
doctor who practices and doesn’t is how much they wish to help the patient. So a PCP who doesn’t have
specialist obesity training, they’re 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,
right? So very little formal education on obesity, typically very little continuing education on the
innovations that are coming on to the market. So in addition to the education issue, though,
they’re also typically lacking the resources where they practice. So to practice really great
obesity medicine, we also want things like dietitians, health coaches, a movement program,
ideally behavioral health, and even like a good prior authorization process if you incorporate
anti obesity medications. So most primary care doctors are practicing without any of those
additional services. And what they’ll say to us all the time is, look, I suppose I can prescribe
something. I don’t even really understand the meds. I don’t understand how to get them approved.
And the truth is, I know the patient needs more help, and I don’t have the services to help them.
Whereas someone who’s been in obesity, 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. 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. You mentioned she’s president of the Obesity Medicine Association.
But 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? So there’s something called weight normative medicine and weight inclusive. And
it’s a way we practice using the broad way here. Weight normative is you should be, you know,
I’m 5’4″, 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.” And what’s really interesting is the research suggests that that
actually leads to much better health outcomes, right? So at its core is the approach around how
do we work with patients. Then there are multiple pillars of the actual actions we take. So typically,
though not always an anti-obesity medication will be used and we’ll talk more about those,
typically a nutrition program is used, either one-on-one coaching with the dietitian 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, right? And other
things that we work on with patients. Ideally, you would include a movement program, which we do,
health coaching and remote patient monitoring. So 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. And lastly, really a behavioral health, right? So
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. 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. And I’ll also note that one of the
things I’ve learned from you all is just kind of a better awareness of how much of an adolescent
problem we have as well in this country and around the world. But we’ve got 14 million
American children and teens also living with obesity. And so this isn’t just an adult medicine
or an adult primary care challenge in front of us. 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. So I think it’s just 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. And not a day goes by at this point where GLP ones are not headlining news stories,
whether it’s around cost, access, new new drugs, new therapies, oral versions of the therapies,
you know, anyone reading healthcare news at this point is basically inundated with GLP
one headlines. What are GLP ones? Yeah, you know, we’re actually all users of GLP ones.
There we go. So GLP one 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, and it also affects the feeling of fullness. So kind of the signals
that go to our brain. So what a GLP one therapy is going typically is going to do is mimic the
hormone that we have naturally occurring in our body. And then you’ll hear about things like
dual and triagonists, which is, you know, as these drugs get more advanced, they’re mimicking
additional hormone pathways. So, you know, simply just kind of stacking on top of each other more
of the pathways that we believe impacts obesity as well as, of course, diabetes. And, you know,
what I’ll mention with GLP ones and what Angela would say if she were on the phone with us,
Dr. Fitch, is they’ve been around a really long time, right? The first GLP one was approved by
the FDA in 2005. So 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. When did you first learn about these medications and their
potential and what role did they play in your conception of impact at known well?
2018 was a big year for me, because first it was the first time I had ever heard about obesity
medicine, had never heard of it as a subspecialty. And I had seen a primary care doctor in Philadelphia.
And she knew I was struggling with my weight. And she said, well, you should see Dr. Jeanine
Crullos. She’s a leader in the field in Philadelphia. And she practices obesity medicine. And I was
like, there are people who could just help me. So I saw her and she was the first person who
talked about ozempic with me. And I thought it was just absolutely wild. I was like, there’s an
injectable and it helps with weight, of course, at the time was being used just to treat diabetes.
So that was the first time I had heard of it. Obesity medicine physicians were using it off
label at that point to treat obesity. But it’s really interesting that I feel like I actually
ended up hearing about it much earlier than it sort of came on to the mainstream. But it’s not
a surprise that people who knew what they were doing knew how big of a deal it was. And I’ll say
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. So she was
certainly a fortune teller. Yeah, the way last data was staring us in the face in the diabetes
trials. So it is all the dates you just mentioned, 2018, 2020 are well in advance of kind of the
current moment in time when when GLP one receptor agonists have reached peak public awareness.
But it is interesting to reflect on that 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. What was not maybe as obvious 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 one drugs? Yeah, one is that they’re a miracle that works for everyone.
They are our most effective treatment, right? That is that is no no question. But when you
look at the date on semagletide slash ozempic, right, 40% of patients will lose 20% of their
body weight. So that means 60% of patients won’t lose 20% of their body weight. So that’s a lot
of folks. And the data gets better as you get with newer medication. So trezepotide is 60% of
patients lose 20% of their body weight, which still need to do a 40% who don’t. And the reason
I think 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 one. They may not be a responder. And the second is,
boy, for the patients who fall in that 60% or that 40%, unfortunately, they can feel like a
failure. You know, folks who have already felt like failures of this whole time with their weight
oftentimes. And then when they don’t turn out to be a responder, I think 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.
So you see a lot of PBM data and other data sets that show, you know, after one year, only 40%
of people are still on the drug. And that’s often used to show there’s a lot of waste, you know,
there’s a lot of issues with the medication. First, sometimes this data, they’re not always
as confounded by the fact that people lose access to the medication, right, 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. And 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, right, are you putting the right person on the
right medication. And then the second is actively managing the symptoms of those patients. So we
know exactly what to expect for certain archetypes of patients when they start a medication,
whether it’s Fentermen or, you know, Manjaro. So we are able to say like, 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, we’ll help curve that nausea, right. So things you can do to
really better educate the patient and actually reduce those side effects over time. So I think
those are kind of 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. The last thing I’d say about that is
actually we have pretty good research to show that maintaining or increasing protein intake is
unbelievably, it’s more important on these medications. It’s actually more like having had
bariatric surgery. So 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, you know,
losing a lot of muscle mass. Especially their muscle mass. Yeah, exactly. I think sometimes
that detail gets lost in the headlines. So let’s come back to that 40% of patients who even enter
his appetite do not sort of 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? Absolutely. So as
I first mentioned, there actually could be a medication that’s better for that patient. You
know, interestingly, you’ll find sometimes that patients who are higher responders to
fentermine, by the way, 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. So 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. You know, ideally, actually,
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,
we 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. So, you know,
bariatric surgery, particularly for a higher BMI individual, especially if they have a comorbidity,
in today’s world, maybe not with innovations 10 years down the line, but in today’s world
is a really effective treatment. And then there’s like the thing is like the nutrition therapy,
the behavioral health. This is such a complicated disease state. And what we found with all of our
patients is there’s generally not a silver bullet. So how do you work across these different
modalities and really problem solve with the patient to understand what’s going on?
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, you know, this drug class since 2005.
So what do we learn from that body of data? Yeah. So from that earlier data, which of course,
as we talked about, it’s going to be limited because it’s certain types of patients who were,
who were being tested back then, they seem pretty darn safe, right? I mean, 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, right? Like 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. So 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,
you know, peer-reviewed, double-minded studies that we have today, there really aren’t large,
concerning kind of 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. What do you make of that? How does Dr. Fitch have those conversations
with patients who come to know and well and are curious about this range of impact?
It’s really exciting, right? I mean, like you said, the earlier the data, the more we want
to be thoughtful about our excitement around it. But look, this select trial around cardiovascular
risk was pretty darn compelling. Was it one large trial? Yes, right? So we’re going to see more
data. Obviously, the study that came out around patients who were 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, right? So 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.” So the way Dr. Fitch generally talks about this is, again, we always
want to be cautiously optimistic when the data is early, but it’s really compelling. I mean,
in my clinic, even I see cancer survivors and 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.
So 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. So what is the best practice for prescribing these drugs? How
does a provider determine if a patient is eligible? Yeah, so we think the best practice includes a
few things. So patient medical records. I know that sounds silly, but really, I mean, it’s actually
pretty rare in the GLP-1 space right now. So understanding the longitudinal health history
of a patient, what are their comorbidities? When did those comorbidities start? So we get medical
records on all of our patients, for example. As we talked about earlier, thorough kind of social
and family history. Because 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. So thoroughly understanding the patient
from those kind of medical perspectives, understanding to have 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. Because for example,
someone who may eat emotionally could actually need different kind of intervention
from someone who actually just eats in excess at different times. So there are different elements
of how a patient’s relationship with food has evolved that may impact what their treatment
should be. So 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? 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 Manjaro, for ZEP bound, 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 like being able
to see the patient understanding their emotional response when you’re talking about different
interventions, we think is really important. 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? If a patient is given a choice, they prefer a medical home. And that’s what we’ve seen with
our patients. So 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. We have comorbidities.
By the way, I have comorbidities that are real medical conditions.
We can also manage your diabetes and everything else. And we’ve had patients who say to us like,
“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, look, 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 like, “Look, the big reason I’m relieving is a year ago
we stopped having any synchronous visits with patients. I get a survey and I’m 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
we’ll see some curbing of that kind of behavior.” What else will change with access going forward?
So 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.” So I think 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,
and 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 TroA, it’s getting TroA passed,
which would have Medicare cover obesity, which 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 solution. 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
getting their 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 ones.
And 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. So 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. So the fertility analogy is very interesting and
also 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. But 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’s going to have many choices. And so choosing between those
choices presumably requires knowing you well. So I just love that mission, that name. We could end
this just 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?
A lot of things have to go right. And they are. One is, look, while obesity medicine is the fastest
growing subspecialty in the US, we still have like 6,500 clinicians, most of whom don’t practice
obesity, 115 million Americans who 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,
you know, APP and physician, PCPs, right, who have not had the training in obesity, but are really
excited to get it. And 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 specialists, physicians, so that we can treat more patients and deliver that care
at scale. The second is investing in the technology to help automate this stuff that doesn’t matter.
As you well know, so much of practicing medicine, and especially on the primary care side,
so much of that is administratively burdensome, but not something that really deepens the
relationship between the patient and the physician, right. It’s things like getting referrals done,
getting the imaging in, getting the prior offs out. So 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 is really around physician clinical decision support and productivity.
We are big believers in to treat, 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. What’s something that you’ve learned as a founder about standing up a business to do
all those things and kind of move closer to your vision around scale? What’s something you’ve learned
that they just don’t teach in business school? You have to be the one who jumps.
So I’ll share a little story with you. I was in Hawaii and it was 8 a.m. and 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 your prior company.
This is at my prior company because I’m going to start knowing well and 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. Fett that said, “I know you’re going to quit today.
Don’t quit. What if we can’t do it?” This was many years ago now. It was funny. I looked to my husband
and I said, “You know what? I’m always going to have to be the one who jumps.” Like someone,
some founder has to be the one who just says, “I’m going off the cliff because someone’s got to be
the first one to do it.” And I called Dr. Fritz. 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 too. And she jumped. I underestimated, and I don’t mean that I’m not
a military vet or anything else, but I underestimated the amount of courage it takes as a founder,
that you focus so much on what’s all the day-to-day stuff in the long hours and the building the team.
But it’s like 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.” And I just, I didn’t realize how important that
would be on the path. 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. Thanks for having me.
Thank you for listening to Raising Health. Raising Health is hosted and produced by me,
Chris Tatiosian, and me, Olivia Webb, with the help of the Bio and Health team at A16Z.
The show is edited by Phil Hegseth. If you want to suggest topics for future shows,
you can reach us at raisinghealth@a16z.com. Finally, please rate and subscribe to our show.
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.
[BLANK_AUDIO]
One of my earliest experiences in healthcare was my pediatrician telling my mom that I should
go to fat camp. Specialist obesity training. They’re typically missing a few things. The
average one will have four hours of training in obesity in medical school. We’re actually all
users of GLP-1s. There we go. In the sense of GLP-1 is a hormone that we all have.
Obesity. A choice or a condition. Well, regardless of what you believe, this chronic
disorder continues to impact millions of Americans, with nearly 70% of Americans fitting the description
of overweight or affected by obesity. And moreover, 55% have cancelled appointments due to the
anxiety of being weighed, at least according to Noanwell. Noanwell is a company trying to rethink
obesity medicine and its founder and CEO, Brooke Boyersky-Platt, joins a 16c general partner,
Vanita Agarwala. Together they discuss what it’ll really take to change some of these statistics
and how new technologies like GLP-1s fit into this mix. Brooke herself has personal experience in this
domain as a former patient with obesity, having even been told by her pediatrician that she has to
go to a fat camp. Now she’s using that fuel to rethink obesity care herself. Now this episode
was also part of our sister podcast, Raising Health’s GLP-1 series. And if you’ve been
paying attention over the last year, GLP-1s went from being an unassuming acronym to a familiar
class of drugs that some recent studies have even pegged as many as one in eight Americans trying.
The recent adoption of these drugs has also springboarded companies like Novo Nordisk,
the manufacturer of Ozempic, to the largest company in Denmark. So if you, like many others,
are interested in learning more about GLP-1s, make sure to tune into the rest of the series
on Raising Health. You can find a link to the show or the full series in our show notes. Let’s get started.
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. 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 Jasek, 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. Today, we’ll hear from Brooke Boyarski Pratt, the founder and CEO of Knownwell.
Next week’s episode will be with Cronus Minolas of UPMC Health Plan on the Pharmacy Implications
of GLP-1s. Brooke talks with Vanita Agrawala, general partner of A-16Z 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.
If a patient is given a choice, they prefer a medical home. And that’s what we’ve seen with
our patients. So 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.
You’re listening to Raising Health from A-16Z Bio and Health.
I am incredibly excited to welcome to the Raising Health pod today Brooke Boyarski 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.
So Brooke, I’d love for you to just introduce yourself and share the story behind this company.
Yes, such a pleasure to be here. Thank you so much, Venita, for having me on.
I am a patient. I mean, 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,
and that really unfortunately started the process of how I viewed interacting with the
healthcare system when it came to my body size. And as I got older and sort of had different
educational and work opportunities, it led me to move a lot. And every time I moved and re-established
primary care, I felt like I was needing to re-establish the idea that I was a thoughtful
person who took my healthcare 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,
and it was even harder when I was actually looking for treatment for my metabolic health
to find something that was accessible to me. And 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, and I was overwhelmed by the research,
and I’ll just say briefly, 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?
Well, in the venture world, investors talk about founder market fit, and 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. So 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. But what made
you jump? You had a background in finance and consulting. Yeah, very traditional kind of business
background of Penn and Herbert Business School in McKinsey and worked at a commercial real estate
company. So 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 known well 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. And before known well, what I was always drawn to was doing a good job delivering for clients
and being the best colleague and boss I could be in terms of the people I worked with. 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, right? I mean, it was just something that was important to do well and to
deliver for people. But as I started, I had always been drawn to healthcare, like just to the healthcare
industry, because I always felt like, how could you have a more direct impact on people than in
healthcare? And 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 sort of felt natural that I found my way to healthcare.
Consider me one of your physician friends. It’s 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 actually, 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?
Like, is that a specialty? What is it? It is a specialty. So 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 sort of easiest measure we have today to diagnose the
disease. So 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. And it was not long ago.
I mean, the reason Medicare, for example, doesn’t cover obesity treatment is they see it as a
cosmetic disease. And it wasn’t long ago that that’s how everyone viewed overweight and obesity.
In 2012 was the first ever board certification in obesity. So that’s how recently this disease
state has been really viewed as something in the medical community. And obesity medicine is really
about comprehensive treatment of the state of obesity and overweight. And 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. So 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 do have a board certification in obesity. And nowadays we have fellowships. So
some folks go and do an obesity medicine fellowship. And then we also have a board
certification. And I’ll note it’s actually the fastest growing specialty in the US. And there’s
something called the Obesity Medicine Association, which is the largest association of clinic
clinicians who practice obesity. And we’re really fortunate that my co-founder and our CMO,
Angela Finch, is the president of it. So 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. Totally. And as we mentioned earlier,
everyone’s doing their best. So what I don’t think the differences between a primary care
doctor who practices and doesn’t is how much they wish to help the patient. So a PCP who doesn’t have
specialist obesity training, they’re 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,
right? So very little formal education on obesity, typically very little continuing education on the
innovations that are coming on to the market. So in addition to the education issue, though,
they’re also typically lacking the resources where they practice. So to practice really great
obesity medicine, we also want things like dietitians, health coaches, a movement program,
ideally behavioral health, and even like a good prior authorization process if you incorporate
anti obesity medications. So most primary care doctors are practicing without any of those
additional services. And what they’ll say to us all the time is, look, I suppose I can prescribe
something. I don’t even really understand the meds. I don’t understand how to get them approved.
And the truth is, I know the patient needs more help, and I don’t have the services to help them.
Whereas someone who’s been in obesity, 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. 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. You mentioned she’s president of the Obesity Medicine Association.
But 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? So there’s something called weight normative medicine and weight inclusive. And
it’s a way we practice using the broad way here. Weight normative is you should be, you know,
I’m 5’4″, 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.” And what’s really interesting is the research suggests that that
actually leads to much better health outcomes, right? So at its core is the approach around how
do we work with patients. Then there are multiple pillars of the actual actions we take. So typically,
though not always an anti-obesity medication will be used and we’ll talk more about those,
typically a nutrition program is used, either one-on-one coaching with the dietitian 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, right? And other
things that we work on with patients. Ideally, you would include a movement program, which we do,
health coaching and remote patient monitoring. So 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. And lastly, really a behavioral health, right? So
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. 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. And I’ll also note that one of the
things I’ve learned from you all is just kind of a better awareness of how much of an adolescent
problem we have as well in this country and around the world. But we’ve got 14 million
American children and teens also living with obesity. And so this isn’t just an adult medicine
or an adult primary care challenge in front of us. 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. So I think it’s just 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. And not a day goes by at this point where GLP ones are not headlining news stories,
whether it’s around cost, access, new new drugs, new therapies, oral versions of the therapies,
you know, anyone reading healthcare news at this point is basically inundated with GLP
one headlines. What are GLP ones? Yeah, you know, we’re actually all users of GLP ones.
There we go. So GLP one 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, and it also affects the feeling of fullness. So kind of the signals
that go to our brain. So what a GLP one therapy is going typically is going to do is mimic the
hormone that we have naturally occurring in our body. And then you’ll hear about things like
dual and triagonists, which is, you know, as these drugs get more advanced, they’re mimicking
additional hormone pathways. So, you know, simply just kind of stacking on top of each other more
of the pathways that we believe impacts obesity as well as, of course, diabetes. And, you know,
what I’ll mention with GLP ones and what Angela would say if she were on the phone with us,
Dr. Fitch, is they’ve been around a really long time, right? The first GLP one was approved by
the FDA in 2005. So 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. When did you first learn about these medications and their
potential and what role did they play in your conception of impact at known well?
2018 was a big year for me, because first it was the first time I had ever heard about obesity
medicine, had never heard of it as a subspecialty. And I had seen a primary care doctor in Philadelphia.
And she knew I was struggling with my weight. And she said, well, you should see Dr. Jeanine
Crullos. She’s a leader in the field in Philadelphia. And she practices obesity medicine. And I was
like, there are people who could just help me. So I saw her and she was the first person who
talked about ozempic with me. And I thought it was just absolutely wild. I was like, there’s an
injectable and it helps with weight, of course, at the time was being used just to treat diabetes.
So that was the first time I had heard of it. Obesity medicine physicians were using it off
label at that point to treat obesity. But it’s really interesting that I feel like I actually
ended up hearing about it much earlier than it sort of came on to the mainstream. But it’s not
a surprise that people who knew what they were doing knew how big of a deal it was. And I’ll say
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. So she was
certainly a fortune teller. Yeah, the way last data was staring us in the face in the diabetes
trials. So it is all the dates you just mentioned, 2018, 2020 are well in advance of kind of the
current moment in time when when GLP one receptor agonists have reached peak public awareness.
But it is interesting to reflect on that 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. What was not maybe as obvious 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 one drugs? Yeah, one is that they’re a miracle that works for everyone.
They are our most effective treatment, right? That is that is no no question. But when you
look at the date on semagletide slash ozempic, right, 40% of patients will lose 20% of their
body weight. So that means 60% of patients won’t lose 20% of their body weight. So that’s a lot
of folks. And the data gets better as you get with newer medication. So trezepotide is 60% of
patients lose 20% of their body weight, which still need to do a 40% who don’t. And the reason
I think 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 one. They may not be a responder. And the second is,
boy, for the patients who fall in that 60% or that 40%, unfortunately, they can feel like a
failure. You know, folks who have already felt like failures of this whole time with their weight
oftentimes. And then when they don’t turn out to be a responder, I think 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.
So you see a lot of PBM data and other data sets that show, you know, after one year, only 40%
of people are still on the drug. And that’s often used to show there’s a lot of waste, you know,
there’s a lot of issues with the medication. First, sometimes this data, they’re not always
as confounded by the fact that people lose access to the medication, right, 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. And 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, right, are you putting the right person on the
right medication. And then the second is actively managing the symptoms of those patients. So we
know exactly what to expect for certain archetypes of patients when they start a medication,
whether it’s Fentermen or, you know, Manjaro. So we are able to say like, 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, we’ll help curve that nausea, right. So things you can do to
really better educate the patient and actually reduce those side effects over time. So I think
those are kind of 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. The last thing I’d say about that is
actually we have pretty good research to show that maintaining or increasing protein intake is
unbelievably, it’s more important on these medications. It’s actually more like having had
bariatric surgery. So 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, you know,
losing a lot of muscle mass. Especially their muscle mass. Yeah, exactly. I think sometimes
that detail gets lost in the headlines. So let’s come back to that 40% of patients who even enter
his appetite do not sort of 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? Absolutely. So as
I first mentioned, there actually could be a medication that’s better for that patient. You
know, interestingly, you’ll find sometimes that patients who are higher responders to
fentermine, by the way, 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. So 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. You know, ideally, actually,
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,
we 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. So, you know,
bariatric surgery, particularly for a higher BMI individual, especially if they have a comorbidity,
in today’s world, maybe not with innovations 10 years down the line, but in today’s world
is a really effective treatment. And then there’s like the thing is like the nutrition therapy,
the behavioral health. This is such a complicated disease state. And what we found with all of our
patients is there’s generally not a silver bullet. So how do you work across these different
modalities and really problem solve with the patient to understand what’s going on?
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, you know, this drug class since 2005.
So what do we learn from that body of data? Yeah. So from that earlier data, which of course,
as we talked about, it’s going to be limited because it’s certain types of patients who were,
who were being tested back then, they seem pretty darn safe, right? I mean, 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, right? Like 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. So 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,
you know, peer-reviewed, double-minded studies that we have today, there really aren’t large,
concerning kind of 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. What do you make of that? How does Dr. Fitch have those conversations
with patients who come to know and well and are curious about this range of impact?
It’s really exciting, right? I mean, like you said, the earlier the data, the more we want
to be thoughtful about our excitement around it. But look, this select trial around cardiovascular
risk was pretty darn compelling. Was it one large trial? Yes, right? So we’re going to see more
data. Obviously, the study that came out around patients who were 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, right? So 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.” So the way Dr. Fitch generally talks about this is, again, we always
want to be cautiously optimistic when the data is early, but it’s really compelling. I mean,
in my clinic, even I see cancer survivors and 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.
So 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. So what is the best practice for prescribing these drugs? How
does a provider determine if a patient is eligible? Yeah, so we think the best practice includes a
few things. So patient medical records. I know that sounds silly, but really, I mean, it’s actually
pretty rare in the GLP-1 space right now. So understanding the longitudinal health history
of a patient, what are their comorbidities? When did those comorbidities start? So we get medical
records on all of our patients, for example. As we talked about earlier, thorough kind of social
and family history. Because 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. So thoroughly understanding the patient
from those kind of medical perspectives, understanding to have 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. Because for example,
someone who may eat emotionally could actually need different kind of intervention
from someone who actually just eats in excess at different times. So there are different elements
of how a patient’s relationship with food has evolved that may impact what their treatment
should be. So 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? 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 Manjaro, for ZEP bound, 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 like being able
to see the patient understanding their emotional response when you’re talking about different
interventions, we think is really important. 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? If a patient is given a choice, they prefer a medical home. And that’s what we’ve seen with
our patients. So 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. We have comorbidities.
By the way, I have comorbidities that are real medical conditions.
We can also manage your diabetes and everything else. And we’ve had patients who say to us like,
“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, look, 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 like, “Look, the big reason I’m relieving is a year ago
we stopped having any synchronous visits with patients. I get a survey and I’m 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
we’ll see some curbing of that kind of behavior.” What else will change with access going forward?
So 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.” So I think 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,
and 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 TroA, it’s getting TroA passed,
which would have Medicare cover obesity, which 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 solution. 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
getting their 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 ones.
And 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. So 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. So the fertility analogy is very interesting and
also 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. But 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’s going to have many choices. And so choosing between those
choices presumably requires knowing you well. So I just love that mission, that name. We could end
this just 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?
A lot of things have to go right. And they are. One is, look, while obesity medicine is the fastest
growing subspecialty in the US, we still have like 6,500 clinicians, most of whom don’t practice
obesity, 115 million Americans who 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,
you know, APP and physician, PCPs, right, who have not had the training in obesity, but are really
excited to get it. And 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 specialists, physicians, so that we can treat more patients and deliver that care
at scale. The second is investing in the technology to help automate this stuff that doesn’t matter.
As you well know, so much of practicing medicine, and especially on the primary care side,
so much of that is administratively burdensome, but not something that really deepens the
relationship between the patient and the physician, right. It’s things like getting referrals done,
getting the imaging in, getting the prior offs out. So 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 is really around physician clinical decision support and productivity.
We are big believers in to treat, 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. What’s something that you’ve learned as a founder about standing up a business to do
all those things and kind of move closer to your vision around scale? What’s something you’ve learned
that they just don’t teach in business school? You have to be the one who jumps.
So I’ll share a little story with you. I was in Hawaii and it was 8 a.m. and 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 your prior company.
This is at my prior company because I’m going to start knowing well and 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. Fett that said, “I know you’re going to quit today.
Don’t quit. What if we can’t do it?” This was many years ago now. It was funny. I looked to my husband
and I said, “You know what? I’m always going to have to be the one who jumps.” Like someone,
some founder has to be the one who just says, “I’m going off the cliff because someone’s got to be
the first one to do it.” And I called Dr. Fritz. 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 too. And she jumped. I underestimated, and I don’t mean that I’m not
a military vet or anything else, but I underestimated the amount of courage it takes as a founder,
that you focus so much on what’s all the day-to-day stuff in the long hours and the building the team.
But it’s like 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.” And I just, I didn’t realize how important that
would be on the path. 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. Thanks for having me.
Thank you for listening to Raising Health. Raising Health is hosted and produced by me,
Chris Tatiosian, and me, Olivia Webb, with the help of the Bio and Health team at A16Z.
The show is edited by Phil Hegseth. If you want to suggest topics for future shows,
you can reach us at raisinghealth@a16z.com. Finally, please rate and subscribe to our show.
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.
[BLANK_AUDIO]
Brooke Boyarsky Pratt, founder and CEO of knownwell, joins Vineeta Agarwala, general partner at a16z Bio + Health.
Together, they talk about the value of obesity medicine practitioners, patient-centric medical homes, and how Brooke believes the metabolic health space will evolve over time.
This is the second episode in Raising Health’s series on the science and supply of GLP-1s. Listen to last week’s episode to hear from Carolyn Jasik, Chief Medical Officer at Omada Health, on GLP-1s from a clinical perspective.
Listen to more from Raising Health’s series on GLP-1s:
The science of satiety: https://raisinghealth.simplecast.com/episodes/the-science-and-supply-of-glp-1s-with-carolyn-jasik
Payers, providers and pricing: https://raisinghealth.simplecast.com/episodes/the-science-and-supply-of-glp-1s-with-chronis-manolis
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Please note that 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. a16z and its affiliates may maintain investments in the companies discussed. For more details please see a16z.com/disclosures.
