Reimagining care of chronic conditions

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In this episode you’ll discover:

• How Dr. Manejwala got to DarioHealth and why

• What the arc of digital health adoption and re-imagining of care looks like

• What will emerge as novel in the digital health space and why

Learn more from Carrie and Rebecca: 

Healthcare insights (monthly email) | Telehealth/Virtual Care Mgmt Update (biweekly LinkedIn update)

Website | Carrie on LinkedIn | Rebecca on LinkedIn | NGL on LinkedIn

Learn More

• Connect with Dr. Manejwala on LinkedIn

• Learn more about DarioHealth

• If you want to know more about virtual care business models, be sure to download our new guide

Read the transcript:

Carrie Nixon (00:18):

Hello everyone, and welcome back to this episode of Decoding Healthcare Innovation. Today I am so pleased to be joined by Dr. Omar Manejwala, who is the Chief Medical Officer of DarioHealth where he focuses on the impact of behavior on chronic disease at scale. He's also one of the nation's leading experts on addiction medicine and substance use disorder, behavioral health, mental illness and for anyone who listens to this podcast those topics are near and dear to my heart. I'm probably going to get a note from someone that says, do you ever talk to digital health companies that aren't into mental health space? I'll take that note, but nonetheless, I'm so excited to have you here Dr. Manejwala. Welcome.

Dr. Omar Manejwala (01:02):

No, it's really great to be here with you today. I, I've been enjoying the series so far.

Carrie Nixon (01:08):

Thank you. Thank you. So today I definitely want to learn a little bit about how digital health is being used to address chronic conditions but I also would like to have with you as we've had before in the past, some big brain discussions about the arc of digital health adoption and re-imagining care. But before we go ahead and do that, I would love to start out as I start out all of these by doing a little bit of a backwards look into your journey toward from devoting your career to the provision of clinical services, to really being pivotal in helping a company innovate in the mental health space and maybe a little bit about Dario Health.

Dr. Omar Manejwala (01:56):

Sure. No, absolutely. There's a lot there, and I think it'll be great to cover off on that, and I appreciate the opportunity to be with you. Yeah. So, and you have spoken with a lot of people in this kind of space, and as you know, there's just no path from there to here. I mean, maybe in the future there will be but my path was, as you said, providing clinical care, taking care of patients and their families, and really though the best teachers and learning from them. And then appreciating, as I kind of went to positions of varying responsibility, I was at Duke, and then I was the chief resident at Duke, and then I went on into practice, and along the way, I just discovered that well, I think what everybody knows, which is the whole thing is just broken seemingly beyond repair, and that there's just no way to fix it from the inside.

(02:45):

So I thought, well, if there's really no way to fix this from the inside, then I'm going to go figure out how other people look at these kinds of problems. So I had the choice of getting a healthcare MBA or just a general management MBA, and I went and got a general management MBA from University of Virginia Darden with the philosophy, with the thought. And with the thought that how do non-healthcare industries approach problems like this to solve them? And that was really exciting. So then I went and got a position as the medical director of one of the oldest and largest rehabs in the country. I wrote a paper and a throwaway journal of a new way of thinking about ROI in behavioral healthcare at scale. Some investors read it. I went out to have lunch with them. I left with a job.

(03:34):

I'm fast forwarding this. I grew that. We grew that company from zero to half billion dollar company publicly traded. And then I left that with many of the same members of that leadership team to come over to Dario two years ago to try to solve this fundamental question of how do we use digital and human in combination at scale to help people do the things that doctors have been trying to help people do all along, change their behavior and do things differently, and what unique opportunities are there in this space? And Dario was I think, a very, doing really well as a direct to consumer diabetes solution. And the question was, if you build something that people love in the retail direct to consumer space and you've had to evolve it in a way that people actually like using it and they see value and they'll use it, even if their health plan gives them something else for free, they'll pay for it. Is there a way to use those kinds of direct-to-consumer retail insights to expand to other conditions where behaviors involved and to expand to health plans and employers and other aggregators? We call it B2B2C in our company, and access those populations, basically give more people access to the support they need. So that's kind of my career evolution and a little on Dario.

Carrie Nixon (04:52):

Yeah. I want to go back to something you said, which I think is I have found to be very true, which is some of the folks that are making the most significant impact in healthcare today at some point, were outside of healthcare looking in. I think your perspective is pretty unique given you came from inside of medicine, popped out, learned about how businesses done elsewhere and came back. But I have found that people who are willing to look at the system and say, but why though? No, I get that. That's how it is. But why? And try to build something different have been really, I think we've talked about this before, how there's a lot of incremental improvement in digital healthcare but not a lot of true innovation. And I think the true innovation stuff does tend to come from an outside in perspective.

Dr. Omar Manejwala (05:48):

Yeah, I really agree with that. I think there's also a caveat there, which is if you don't do what you said, which is also learned about healthcare then you end up with this problem of it works in Berlingame and Mountain View, but will it work in Peoria and rural West Virginia? Or this idea that you're solving problems for Peloton users and wealthy folks, but are you really solving problems for rural folks for low socioeconomic status folks and others? So there's a kind of an arrogance that can come out of digital out of the tech approach of looking at it from the outside in that that tends to overly simplify the problems in healthcare. So I think it's important to appreciate what has been tried, how the systems are complex and operate now, and then bring in that fresh perspective. And we saw with Haven and other things where just an attempt to just go in and change it all didn't quite work. But if you can marry those things, I think that's the sweet sauce.

Carrie Nixon (06:53):

Yeah. Yeah. That's actually great insight. And I also should add the caveat that I don't think any of these direct to patient care companies should be doing so without someone who is inside of healthcare, specifically a licensed clinician who is helping develop the patient experience, and of course the care protocols, et cetera. Okay. So now currently it's the end of March. We're currently at the tail end of a month that contained some of the industry's largest conferences where everybody comes together and talks about the new things and sometimes recycles some buzzwords and sometimes comes up with new items. And so we're all a buzz. I don't know if all of you have seen all the bingo cards, all the bingo cards of the buzzwords and in digital health. So we're all trying to suss out what's real and what's marketing. There's a ton of themes that are emerging, personalization of care, bringing the care into the home omnichannel, telemedicine, access decentralized clinical trials, a lot of focus on equity starting to see more conversations about integration and aggregation of a lot of solutions. I could go on and on and on. I'm interested in high level where your head is at both as a person who's sitting inside of a company that's innovating, and also someone who really keeps tabs on what's happening in the industry at large.

Dr. Omar Manejwala (08:23):

Sure. No, that's great. Actually, that was a great survey of some of the stuff that came out in the last month. That was nice. I just sort of should have been jotting it down because it's nice to have it all in one place. Yeah. So I think it's important to be a very discerning consumer of these innovations in care, because some of it is meet the new boss, same as the old boss, and you got to watch out for that. It's something really just being repackaged in some ways is, as you noted, there's for just taking personalization as an example there is this view that digital health offers an opportunity around personalization, but when you look under the hood at a lot of solutions, they're not really personalized. I, as you participate, you could participate in something and your brother's sister or wife could do it, and you could hold the app side by side. You're really getting the same experience or just minor adjustments. So I think part of that has come from and we see the same thing with use of AI, the term AI, and just sort of overplaying overhyping some of these things rather

Carrie Nixon (09:31):

A lot of if then

Dr. Omar Manejwala (09:33):

They, right, right. That's thing. Right, exactly. So I think it's important to look under the hood, and digital health has produced amazing marketers. And so then the question is, what's actually going on inside? So the one thing I would say, the things that there are, things are really interesting that are going on. I think there are novel partnerships happening in this space. People are collecting more data there's more publications of outcomes. There is, I think folks are waking up to the idea that how people use these solutions is really just as important, almost as important, or maybe just as important as are they effective? Because you've got a lot of solutions out there that might work well in very sanitized clinical trial populations, but will they actually work in the real world? And so there's this move towards real world. And so I think that's right. Democratizing access is a big one. So people talked a lot for a while about social determinants of health. We talk at Dario about the personal determinants of health because,

Carrie Nixon (10:38):

Oh, say more about that.

Dr. Omar Manejwala (10:39):

Yeah. A lot of that can't be solved at the population level. So for example, if I have food insecurity, your listeners, viewers may know about this where I'm not able to, I may live in a food desert. Healthy food is not available near me or requires significant public transportation to get there or I have poverty, or maybe I have intimate partner violence or domestic violence going on in my home, or any of those areas that we think of them as socially determined health. The problem is that most of the solutions we're using to solve that, and there's some great stuff out there try to solve that at the population level or at the city block level. But the challenge with that, unless we get really personalized, is I could have food insecurity and literally my neighbor might not have it or my partner or somebody else. So it really has to be at the personal level that we solve this. And so it really has to do with understanding people's motivations.

Carrie Nixon (11:40):

Like data analytics isn't going to solve that for you necessarily.

Dr. Omar Manejwala (11:43):

Not at necessarily at the population level. So the kind of aggregate data that you get at the population level can't necessarily drill you down to Jane or Johnny and how specifically what challenges they have and how they're facing these things. And so digital has an opportunity to solve that at scale by dynamically personalizing user experiences. And so that's one area I think where people are looking. So look, I think overall, we're seeing progress. We're seeing digital health companies being held accountable as they should be for outcomes. And we're seeing a broader evolution towards multi condit because the ecosystem, I think, is very appropriately tiring of point solutions because if I'm a health planner, but what am I supposed to do, partner with 45 digital health companies, it doesn't make any sense. So

Carrie Nixon (12:34):

Yeah, I heard a crazy statistic that some hospital had a hundred different digital health solutions.

Dr. Omar Manejwala (12:40):

I believe it. I it. And what is the probability that they actually know what's going on or that any of them talk to any of the other ones, or it's a disaster.

Carrie Nixon (12:48):

Yeah. I want to go back to something you said about social determinants of health, personal determinants of health, because I actually do think that that is, we've where we've got to get to. I've been thinking about what a health insurance company, an employer, private company can do to actually solve for social determinants of health if they don't plug into social services which sounds like a full nightmare given we all know what their systems look like, right. Integrating with systems like local housing support agencies and food banks and things like that.

Dr. Omar Manejwala (13:39):

The banks, right? Sure. Yeah. Right. Domestic violence, shelter and all of it. Yeah. Right.

Carrie Nixon (13:43):

Yeah. I mean, there are some cities in the US that have aggregated these services. I think San Diego's a good example of one but by and large, all of these services even if they're sort of organized at the local level, to plug a digital health solution in and help plug that in to help it scale, seems to me it seems like a huge challenge.

Dr. Omar Manejwala (14:10):

Yeah, it is. I mean, look, it is, and plus you have to come up with things that work in rural West Virginia and downtown Atlanta and San Francisco and other places. I mean, it's got to work everywhere. And no one solution can necessarily work everywhere. And that's really where partnership comes into play. And you have the same problem with network, where if you're plugging into provider visits and trying to schedule, everybody's not on a single platform and the ability to integrate across that. And so who will the winners be? I think the winners will be solutions that have architected themselves such that they can be flexible and those that decide on a specific mode of integration or connection are going to work in certain geographies. They say all politics local, all healthcare is local. I mean, part of that's true. We're breaking some of that now, I think with tele and some of the new. But at the end of the day, I think that flexibility, the ability to integrate and connect across a variety, and using a combination of human and digital to perform that, sometimes it's as simple as making sure that this person knows that this resource is available in their area. And sometimes it's a question of more articulated handshakes.

Carrie Nixon (15:26):

Yeah. I'd love to get your, speaking of digital and human, I'd love to get your perspective on what I'm seeing happen fairly rapidly in the sort of moving healthcare into the home, not just through a broadband internet connection, but through people coming and doing mobile phlebotomy, people doing mobile radiology. We've got our hospital at home programs and Sniff Without Walls programs, and now we've got pretty big players that are essentially going to be providing a full suite of services on site. How fast are we going to see that? Where is that going?

Dr. Omar Manejwala (16:04):

Yeah, it's a good question. I saw somebody asked a question on Twitter, I don't remember who it was, but it was sort of like, how much would you pay to have your blood drawn at home? What would you be willing to pay? And I think about Instacart and other types of at-home services, and they asked me would I pay 30 bucks for that? And I just actually thought to myself, no, I would not pay $30 for that. Now, if my situation were different, I might but I would just drive to one of the many places around here. But not everybody's so situated that they can do that. And so again, it's about providing an array of services in the home that can solve those kinds of problems. And I think it makes a lot of sense. But having said that, I mean, there's a lot of great things that should be provided at home because that's where we are.

(16:48):

But many of us spend a lot of time at work, and I don't think I want my blood drawn at work but I do need my blood sugars checked at work if I have diabetes and stuff. So I think it's about really deploying an integrated suite of services that work where I am that are both discreet let's call 'em phenomena, like a phlebotomist visiting or something like that. But also continuous capabilities that articulate with the devices and the ecosystem that I live my life in, and not just me, but those folks who can't afford such things. Like I think a lot of digital health has designed sort of for Apple watch type things, which is great but we've got many folks out there who are using very, very old smartphones. The kinds of phones that you pay for 20, 30 bucks. These are the folks that are driving their children to the Wendy's and the Walmart parking lot, so they can do their homework on the wifi there. And are we really designing for those folks too? So as health go? So I think it's a good thing, but also as health goes into the home, and as health becomes more continuous rather than discreet, as we move beyond telehealth, as we think about these innovations, let's make sure that we're designing for the full range across ethnicities, across underrepresentation, and really testing in those areas and solving for that. And I think some digital health companies are doing that. Those are going to be the real winners in the space.

Carrie Nixon (18:10):

I'll just sort of make a plug for the companies that are investing in real world evidence and decentralized clinical trials to make sure that we have data on folks that are in Peoria and not just at the Mayo Clinic or able to get to the Mayo Clinic.

Dr. Omar Manejwala (18:28):

You are, right.

Carrie Nixon (18:28):

Yeah. Right, exactly. Yeah. That we actually need not only their participation and they not only deserve access to these things, but also we need their data to make sure that we're making equitable decisions about this about the solutions that we deploy.

Dr. Omar Manejwala (18:45):

One of the ways we've gotten at that, which is kind of interesting, is because we started as a direct to consumer, and we still have a direct to consumer channel, which can function as an innovation laboratory, is if I want to study a group of users who live in the lowest socioeconomic zip codes, I could just look at the direct to consumer population and see we've already got people that live in those areas that are using the solution. And so that's the power of companies that have a direct to consumer user base is there's an opportunity to study that.

Carrie Nixon (19:16):

Yeah.

Dr. Omar Manejwala (19:18):

I don't have to repeat them. They're already participating.

Carrie Nixon (19:20):

Yeah. Yeah. Well, and you also mentioned sort of partnership, and I am a big, big believer in partnership. It just has to be the case that all of the disparate solutions and disparate players in the ecosystem are going to need to start to get together, get together. And I can't miss bringing up that Dario just executed on a 30 million partnership with Sanofi, which is a massive pharmaceutical company and I'm dying to hear what that's going to look like, what that partnership is going to bear.

Dr. Omar Manejwala (20:01):

It is really interesting because they're one of the 10 largest pharmaceutical companies in the world. It's actually interesting, their mission statement or their vision is that they're chasing the miracles of science that make people's lives better. And I feel like digital health is one of these miracles that makes people's lives. So it's a natural kind of thematically it's a natural fit. But more importantly, I think we've seen a few digital health companies dip their toes in the water with pharma. We've seen some failed acquisition attempts. We've seen some more sort of, let's deploy digital health alongside our pill kind of model, the obvious kind of partnerships. But I think that what's unique about this is that, and we've never really seen a partnership of this type, is that we're partnering in three key areas. One is around robust evidence generation. So if you think about who is better at conducting research studies on populations than pharma, clearly they have a deep infrastructure.

(21:02):

And so Sanofi will be leveraging that infrastructure to help do companies like to help our company Dario develop additional robust evidence that meets that kind of criteria. And that's something that digital health companies simply cannot do on their own. They do not have the infrastructure to do that. So when you partner with a, I don't know the size, but hundred plus billion dollar company that's doing this for their core, that that's their core value, then that's in incredible. So that's one. And then the second area where we're partnering is in the co-development of solutions. So that means that the teams there at Sanofi are actually working with Dario to design, co-design additional areas of focus in our application, things that would be of joint value. So that's another area. And then the third is these pharmaceutical companies have really, really strong commercial teams. They have relationships with health plans, with employers, with broker. They're out there doing this, and they've already begun offering Dario out to their client bases and using it. So we think that this type of partnership around not just distribution, but, and research represents a significant portion of the future for digital health.

Carrie Nixon (22:21):

Yeah, that's super, super exciting. I'll be absolutely be following. All right. So I have one more sort of substantive question for you about chronic care in particular. This year, I'm focusing a significant amount of my mental energy and learning on transitions of care in particular post-acute transitions of care. And of course, there's a good population of folks who are chronically ill that are cycling in and out of hospitals, and those are high flyers. Those are folks that, in particular, the folks who pay for healthcare are focused on. But we've got a lot of solutions out there focused on the chronically ill population. I'm interested in the role that you think digital health companies are going to play in enabling smooth care transitions and working together to manage patients in this population.

Dr. Omar Manejwala (23:27):

So this is its own, could be its own separate.

Carrie Nixon (23:31):

Agree. Maybe I'll make it another one too.

Dr. Omar Manejwala (23:33):

Yeah, yeah. No, it's great. It's great. First and foremost, I'll say people are going to use the things that are relevant to their lives. And for a long time, healthcare has tried to push people to do things that are in its best interest and some of these regulatory value, you're the expert here, but there's a lot of push on reducing readmission. But once that clock hits X number of days, then it's like, oh, where's all my support? And where's the support for repeat admission? I think we all know, and it passes the grandmother test or the LE five test, explain it like I'm five test, that we want to keep people out of the hospital. And the main thing that we can do to keep people out of the hospital is get them to just do, help them do different things. That's really hard for them to do that reduce their chance of being hospitalized.

(24:17):

So first and foremost, before we even get to care transition, it's about getting people healthier and keeping them out of the hospital. And if they have recently been in the hospital, ensuring that they're addressing the areas that are important to keep them from going back into the hospital. But going to this question of care transition, I think that it's one of those things where you've been in the hospital, you get some really long discharge instructions, maybe a packet, someone talks to you then you go home, or you go somewhere else, and then you're expected to do all the things that they've asked you to do. And if you're like Ben, I'm a doctor, I'm going to do maybe half the things they asked me to do. I'm not going to do everything. It's really hard. I know we shouldn't tell anybody. There was a study of adherence to antibiotics, I think, in Harvard medical students, and it was terrible.

(25:04):

So we just, it's really hard. And here's the problem. We can't just educate people on what to do and expect them to do it. We are experiencing the cost of that broken model. Let me give you a list of the things you need to do now. Go do them. And that's the problem with discrete care. It doesn't work because what I haven't done is empowered you with what it takes to form those habits and behaviors on, that's where digital can really shine. Because if something's relevant to me and in my life, and I can even use it in the hospital and then I keep using it when I'm at home. So it's like, don't tell me what to do. Show me do it, and then stick with me through it. And that's, we've tried to solve that with human beings and with home health nurses, other types of support. We've tried all kinds of things but what we haven't done a good job of is the thing that I take everywhere that I touch 300 or more times a day. That's always in my pocket. We haven't been using that to help, because I trust for

Carrie Nixon (26:05):

The listeners, he's holding up his cell phone.

Dr. Omar Manejwala (26:09):

Yeah, right, right. Yeah. I'm holding up my cell phone. Yeah, yeah. Sorry for the audio. But yeah, so I think it comes down to this idea that instead of adapting ourselves to weight, to the ways that people live their lives and trying to provide value for them, we're trying to force them to fit into our very broken healthcare ecosystem. And that that's just not fair. And we're paying the price. We're paying the price.

Carrie Nixon (26:34):

Yeah. Well, I'm really glad that your intellect and experience and passion around this is part of the equation. I think folks like you are what's going to help us break, unbreak rather, the system. And so I appreciate you sharing your thoughts with me and a couple thousand of my friends. And I just want to close with one thing I always close with this, I always like to ask of my guests for the people listening sort of what is your one piece of advice for them that they could do right now today to supercharge their success?

Dr. Omar Manejwala (27:14):

Wow. Okay. That's a tough one. I would say that the big, so I've recently been bombarded with a lot of messages, and everybody's trying to sell you something and everybody's trying to do, it's very, really, really tough. And my rule of thumb has been, for every one thing that I ask you to do for me, please let me find three things I can do for you. And that kind of model of trying to generate value for others and generate opportunity for others that math always seems to work out. So let me try to do more for you than you're doing for me. And then that rising tide tends to float everybody.

Carrie Nixon (27:52):

Oh, I love that. I'm really going to take that in. I'm going to do that today. I'm going to do that today. So thank you so much, Dr. Manejwala, for joining me. It has been enlightening and delightful. For those of you listening, if you haven't already, please subscribe to Decoding Healthcare Innovation, follow us on LinkedIn and Twitter. Join us next time. We'll be interviewing Liz Powell of G2G Consulting about raising non-dilutive funding and healthcare, and why it's important to have a policy and government strategy even as a startup. As always, you can check out the links and resources in the show notes, and you can find out more about our work with healthcare innovators at nixongwiltlaw.com. Thank you so much for listening, and I will speak/see you next time.