At Invent Health, investors say it's scandalous to abuse citizens by pushing pharma-therapy
Last week, Vator and UCSF Health Hub held our first salon of 2019 called The Future of Mental and Behavioral Health, where VCs, innovators and adopters (payers/providers) discussed how mental and behavioral health startups are creating solutions to help those suffering from mental health conditions.
The second panel of the night, moderated by Bambi Francisco Roizen (Founder & CEO, Vator) and Archana Dubey (Global Medical Director at HP), featured panelists Alex Morgan (Investor, Khosla Ventures), Lynne Chou O'Keefe (Founder and Managing Partner, Define Ventures), Eva Borden (Managing Director, Behavioral and Medical Solutions, Cigna), Blake Wu (Investor, New Enterprise Associates), and Danielle Ramo (Director of Research Operations, Hopelab).
One of the biggest, and more controversial aspects, of the way we treat mental health in this country is the over-prescription of psychotropics, which Francisco brought up, noting a blog post from Quartet Health that said that 70 percent of all the prescription medication antidepressants come from primary car physicians, not mental health experts.
"How do we equip the providers? Everybody’s aggregating all these therapists, getting all of these digital technologies together, but that’s not access if more people are going to their primary physicians. How are we helping these PCPs at the front lines?" she asked, to which Dubey agreed, calling "the primary care physician dilemma, in which you don’t have the tools, the time and the education."
Morgan spoke first, voicing his displeasure with what he perceived as "equating availability of pharmaco therapy at scale with a healthy healthcare system."
"Anyone here, you should never discontinue any medication given to you by a provider, however, if you have a situation where, in some populations, 10 to 15 percent of youth are diagnosed with ADHA and treated with very powerful psychoactive substances, it is not an indication that the system works," he said.
He pointed to Japan, which is where he said methamphetamine was discovered, where tjey have also totally banned Adderall even with a doctor’s prescription.
"These are dangerous medications given out like candy. If you look at the research that’s done on the law of antidepressants; if you’re in an antidepressant trial, all the of the patients turn out to be able to unblind themselves to the placebo group, and if you know that you are getting treatment that affected your feeling, it’s very hard to get a sense that that actually is a significant benefit that you are obtaining," Morgan said.
"There are lots of wonderful things, and anti-psychotics that are like magic in many patients with schizophrenia, that help many people, but the rate at which we’re giving out medications where I think the supporting evidence or efficacy is not sufficient, is, I think, a huge scandal. If I were to short end the industry, I don’t have the timescale of the decades ahead, it may be like like the prescription epidemic with opioids and we will see an issue in the decades ahead that we are terribly abusing our citizens by pushing pharma-therapy. So, what you said about PCPs giving medication, I want to say that’s not equating with goodness."
Francisco responded that she agrees with what he was saying, and all that she meant was that PCPs are the ones giving out these drugs and that they are under pressure from various groups to show results.
"The problem is PCPs don’t have time and they have ROI and it comes down from their health plans and the insurer that we want evidence. They don’t have time so they have to push these medications. We are not for that. In fact, that’s what this entire salon is about," she said.
Ramo spoke next, and reiterated the point about the pressure put on physicians to make money and to show results, and how that can manifest itself in prescribing drugs for a faster solution, particularly when it comes to working with adolescents.
"A lot of what we know works for adolescent mental health problems in the area of behavioral interventions, work as well, or better than, medications," she said.
"With adolescents, which is the space that we’re in at Hopelab, one of the biggest challenges for us is that most startups that we meet with would love, and sometimes their heart leads them to want to work with adolescents, in a space like ADHD, for example, but they can’t pay. And it’s really a challenge. So they end up pivoting, even when they want to go there first and we end up seeing the first trials being adults. So, we try to partner with organizations to maybe think about how, because we are driven by impact and not ROI, as an organization, we can work with someone who actually wants to make a change in adolescents, or move into an adolescent market, so that’s an opportunity."
O'Keefe spoke next noting that digital health, in her belief, is over reliant on technology, and doesn't take other important aspects into account.
"I don’t think it's just technology and a smart team, you have to absolutely understand the healthcare system as an ecosystem and as a business, and then create technology as an enabler around that. This is where we get into trouble with digital health, and I will not go on that tirade, but when we think that technology solves everything, that is where things will not scale. I think we can all believe that in the heart of why we are in digital health, because digital health is so hard to innovate in, it’s because we want to impact people and we want to things that scale," she said.
"The second layer we have to think about is the provider to provider interaction. Sometimes PCPs, through no fault of their own, they want to help them, they don’t have enough time, ad they don’t have enough clinicians that are specialized in this to actually have the consultations, to actually have the networks, because there aren’t enough clinicians in this space. I think we can solve some of those access problems via telemedicine and other ways, but, still, we have a small base of clinicians, so we need to develop and grow that base overall. There’s a whole class of companies, I put Quartet in that milieu of physician to physician, getting to the right network and getting people the right care."
O'Keefe's final point was that the really important aspect of getting people well are the social determinants of health, which is why she invested in a company called
And then there’s a whole other basis as well, is what I’m now calling community care. That’s actually the investment that I just made two weeks in a company called Unite Us, which is trying to become the network layer for all community service, which includes housing, food, and mental/behavioral health.
"Social determinants of health is actually 60 percent of your healthcare. It’s not your genomics, it’s not what happens in your clinicians office, it’s really the social determinants of health. So, UniteUs is actually creating the network layer around the social determinants of health, of which mental/behavioral health is one of those. They’re really tackling what I call community care around this. So, we need the individual, we need the physicians connected to one another, and then we also need the community connected to each other around this issue."
Borden then reiterated O'Keefe's point about the social determinants of health.
"The social determinants pieces becomes so critically important, and it’s often times, as I’ve met with different clients, gets very dismissed. “Oh, that’s the Medicaid population, they’re not my employees.” I was meeting with a group of about 12 clients around the room who had let’s say 50,000 plus employees. They were talking about a zip code in southern Chicago, which has pretty high murder rates, very traumatic type area. So, just growing up in this zip code oftentimes drives PTSD, trauma, etc. It’s interesting because as describe it you can sit there and say, “Oh, well, so glad you’re helping them.” Across the 10 or 12 clients, I was able to pause and say, “I just need you to know, eight of you have 50 or more of your people living in that zip code.” It’s not a them, it’s an all of us problem. And it’s hugely important in terms of, if I go back to what does it ultimately drive, the biggest spend is going to be that medical spend.
(Image source: twitter.com)
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Khosla Ventures offers venture assistance, strategic advice and capital to entrepreneurs. The firm helps entrepreneurs extend the potential of their ideas in both traditional venture areas like the Internet, computing, mobile, and silicon technology arenas but also supports breakthrough scientific work in clean technology areas such as bio-refineries for energy and bioplastics, solar, battery and other environmentally friendly technologies. Vinod was formerly a General Partner at Kleiner Perkins and founder of Sun Microsystems. Vinod has been labeled the #1 VC by Forbes and Fortune recently labeled him as one the nation's most influential ethanol advocates, noting "there are venture capitalists, and there's Vinod Khosla." Vinod Khosla founded the firm in 2004.