CareDelivey_a16z Podcast_Vineeta Agarwala: this mp3 audio file was automatically transcribed by Sonix with the best speech-to-text algorithms. This transcript may contain errors.
Manav Sevak:
Welcome to the Memora Health Care Delivery Podcast. Through conversations with industry leaders and innovators, we uncover ways to simplify how patients and care teams navigate complex care delivery.
Manav Sevak:
Hey, everybody, this is Manav here from Memora, and we have a really, really exciting guest on today. Her name is Vineeta Agarwala and she’s a physician and investor, and somebody I’ve had the wonderful pleasure of getting to know over the past couple of years. Vineeta, thanks so much for coming on.
Vineeta Agarwala:
Thanks for having me.
Manav Sevak:
Yeah, absolutely. So you have probably one of the most fascinating backgrounds that I’ve seen in, you know, of folks working in digital health. Would love if you can just share a little bit more around what your career path has been and just maybe a little bit about what you do.
Vineeta Agarwala:
Sure, so I grew up a science nerd and grew up more of a biologist and gradually became a computational biologist and was really much more of a molecular nerd, to be honest, and learned that the data on that side of the house was vast, it was well-organized, was growing quickly and could teach us a lot. And actually that particular thread, that data can teach us a lot about human health, kind of led me into digital health as well because it became a conundrum and a little bit of an irony that was frustrating to realize that molecular data was so much more acquirable, analyzable, and even understandable at some level compared to clinical data. Even though we were collecting hoards of clinical data in the clinical system, we are documenting till the cows come home, we are meeting with patients all day long, we have patients hospitalized 24 hours a day, and we weren’t collecting very much of that data in a scalable way. And so that was the particular nugget that got me excited about the digital health and health tech industry to think about ways to scale our collection and understanding of that data to really improve patient care. And that’s kind of a theme for me across all of my health tech investing now as a physician investor.
Manav Sevak:
And particularly on just that last point that you made around being a physician investor, so, share a little bit about that. What’s kind of your breakdown like? Do you still actively practice? What does that look like?
Vineeta Agarwala:
Yeah, I see patients once a week at Stanford. I have part of a unique practice at Stanford called, our Cancer Survivorship Clinic, and this is actually clinically an interesting example of interdisciplinary collaboration that can really help the patients, we think, which is that patients who undergo complex, high acuity, kind of intense cancer treatment, whether that’s surgery or radiation or chemotherapy, often have a hard time adjusting back to primary care. They have a hard time going back to a busy primary care office where that primary care doctor may only have 10 or 15 minutes and doesn’t have the full context of their cancer journey and how complex that was and the unique side effects and symptoms and screenings and surveillance that that cancer patient needs, especially true for subpopulations of patients like those who’ve undergone a bone marrow transplant, need to be revaccinated or adolescent patients who have cancers and need to kind of transition to a very distinct set of surveillance activities in young adulthood. So these are all kind of unique patient populations that, to some extent, I view it as care model innovation that we’re kind of trying to do at Stanford, but really, it’s a really great opportunity for primary care and oncology to think about how to work together to serve patients. Not to mention that a lot of cancer patients, unfortunately, just don’t even have a primary care doctor, which, as many listeners know, is sort of a problem across the country. And so we also do transitional primary care. So I do that once a week and spend most of my time though, working with our team here at a16z to support startup founders.
Manav Sevak:
Now that’s awesome, and maybe related to that, it would be, it’s always interesting to, you know, as personally as somebody who at a point in time contemplated wanting to go to medical school and practice medicine, plus, for a lot of people that listen, who work in the healthcare system in some capacity or work at healthcare organizations and are thinking about making the switch into digital health, making the switch into investing, I would love your perspective on what went into your decision choosing to only practice one day a week or choosing to move more into investing rather than potentially, let’s say, starting something, potentially continuing to do research that you would spend time on earlier.
Vineeta Agarwala:
I wish I could say these decisions were more linear and predictable and mapped out. But really, the honest answer is that a lot of my decisions, a lot of the decisions that I’ve observed my mentors make are really about people. And so we’ve all gravitated towards working with people who energize us and who give us the opportunity to have the largest scale of impact that we think we can have at any given point in time. That might change, you know, at some point in the future, the calculus may change. At some point in the past, the calculus might have been different. For me at the moment, you know, when I look at the startup ecosystem and clinical medicine, I see kind of two things that really drew me to this particular balance of activities. One is that despite the number of startups and the extent of digital health funding that the sector has seen over the last 2 to 3 years, despite all of that, despite all of the so-called COVID tailwind of health tech adoption, in my observation, nothing has changed at most clinics in the country. And that’s striking, that’s striking. We all read about, oh, my gosh, the video visit has taken over, and oh, my gosh, patients are suddenly tech literate, and, you know, but I just don’t see it. Even in my Silicon Valley Stanford practice, most patients actually prefer in-person appointments and nothing in my workflow of documentation or patient communication has really changed. And so I think that’s notable and that’s kind of one trend that I’m curious to change. And then the second is, which is maybe related or potentially causal for the first trend, is that there are still so many startups that seek to sort of build entirely around the existing healthcare system and find the existing healthcare system and the incumbent infrastructure so frustrating that there is an attraction to say, stand up a separate system or figure out a way for patients to avoid the system or figure out a way for patient payments to not flow through the system. And I think in some isolated settings, that’s going to be an attractive route and an important offering for some patients. But for the majority of patients, as I see them, cancer patients, heart failure patients, sick patients, who are going to require emergency and inpatient stays at some point in their journey. You know, I think building around the system is really problematic. And that’s something that I think we’re starting to see a shift away from in the startup ecosystem. And so I think both of those trends, A, not that much on the ground change yet at our biggest incumbent systems and, B, you know the rise of startups that are really willing to engage incumbents on working together, both make the startup space a really, really exciting and impactful place to be because there’s a lot to do and people are willing to do it. So it’s a real, real pleasure now to be able to be in the system as a physician and also try to help make the system better by working with all the great startups that we have a chance to do.
Manav Sevak:
Yeah, that’s, that’s awesome. And that’s, it’s a really, really interesting framework and hopefully one that’s helpful for some of the people that are listening. So maybe related to that, you’ve been with Andreessen Horowitz for a little over two years now. Maybe it’d be interesting to hear what are some of the types of companies that excite you the most and what is your split between how much time you’re spending on digital health versus other areas of healthcare.
Vineeta Agarwala:
So I spend a lot of time in the biotech world and the life sciences world, and that’s a core area of interest for me and our broader team at a16z Bio Health. Within the health tech realm, what I find particularly exciting are companies that figure out a way to align patient quality and economic incentives, and I’ll actually leave it at that. I find that that itself is a quite unique feature, is can you enable a provider to, a provider or a payer, some other incumbent in the health system to act in such a way that both improves patient outcomes and makes economic sense? And that’s really hard to do. I’ll give kind of maybe like a real-world, almost anecdotal example of this, just to kind of drive home the point that economic impact is really important to pay attention to early, no matter how well-intentioned you are in terms of a product workflow or a clinical outcome change, I think it has to connect back to economic sustainability. And the reason is that, that’s what drives change. It’s also where measurement and data sometimes take root first, and so I’ll give you an example right now. There’s been a lot of discussion and observation that post-COVID, there has been a delay in cancer screenings and there has been care that has been deferred such that epidemiologically in this country and globally, we may have an increase in late-stage cancer diagnoses that are, would clearly be a terrible thing for patient outcomes and also cost. But because our ability, some of our cancer registries are fairly slow to update some of our ability to jump on this and understand it from a research and patient perspective, and to understand the drivers of why, which patients, who was lacking access, who wasn’t reminded about their screenings and so on, all of that is actually hard. It’s hard to get a hold of that data and to analyze it and to make it clean and, at least with the infrastructure we have, but the data that’s actually cleanest is the cost data. And so, while I haven’t seen kind of really great definitive, more clinical workflow-oriented data on this question, what did just come out recently was a large employer survey where 13% of employers had access to their cost of healthcare data and reported on this survey that they have seen an uptick in the number of their employees for whose healthcare costs they are largely responsible, they have seen an uptick in late-stage cancer diagnoses, correlated with an increase in cost of oncology care. And so just think about that whole scenario for a second. The place where we have observation of the trend might be an economic place and the place where we have the data and also, frankly, the incentives to drive change might be the economic place. Those employers are burdened, it is a zero-sum game. They can only spend so much on healthcare, and so they are motivated to either figure out how they can get more for their cancer-spent dollar or change the fundamental cost of cancer care or something, and that provides an opportunity. Maybe that group is suddenly incentivized to send their employer, employees, or to work with providers in their healthcare network, or to work with their partner payers to close care gaps, right? And they now have an economic incentive to, let’s say, remind patients about screenings or help educate patients about the relative risks of skipping a screening versus going into an inpatient center during a COVID wave or guiding them about when there’s not a COVID wave locally and all of these all this type of education. But imagine if you started kind of just describing a product stack or a workflow change without that economic context. The motivation to implement, the motivation to drive change forward, unfortunately, is just different. And so I like thinking about examples like that because it could be this amazing win-win-win where patients get their cancers diagnosed earlier, providers are less frustrated with late-stage diagnoses that feel avoidable, payers don’t bear the cost of extraordinary care that would simply not have been required with an earlier diagnosis. I mean, it’s like, it’s something, these kinds of scenarios are things that our system should be on the hunt for, and I think it will become a lot easier if we marry clinical and economic incentives.
Manav Sevak:
Yeah, maybe one thing I’d even add to that that I think we have found really interesting at Memora is assessing implementation sustainability. So how is this actually going to impact the volume that a care team takes on the number of notifications that they’re going to get, the ability to do this, and really complex multidisciplinary patients where it may be helpful for one physician that is helping to navigate a care plan but not the other two or three, right? So just one component to the ones that I think we’ve learned a lot about in the work that we’ve done with Memora, which I’m sure you can also relate to being a practicing physician.
Vineeta Agarwala:
Absolutely, no, absolutely. It’s not, I didn’t mean to suggest that achieving that win-win-win is easy. It’s really hard because all change management is hard. All behavior change is hard, and it’s possible you get worse before you get better.
Manav Sevak:
Yeah, awesome. So obviously, for most of the people that either know you, know me, or have been following Memora in any capacity know that you are an investor in Memora and also a board member for Memora.
Vineeta Agarwala:
You’ve outed me.
Manav Sevak:
Yeah, I’m sure everyone would love to hear just a little bit around what was your thesis around Memora when we first chatted, and maybe what were the things that you saw that were really, really exciting and interesting to you about the product?
Vineeta Agarwala:
Well, I’ve learned a lot from the Memora journey, and I’m grateful for that. I think it’s been, it’s just been a great learning journey for all of us to see kind of how you’ve scaled this product and found so many different use cases to plug into. I think for me, I will say that the framework I just described of looking for alignment of economic and clinical incentives, as well as a desire to back startups working with incumbents really led to our investment in Memora. We were looking for products that seemed like they could actually move the needle, be implemented easily, pragmatically change patient care, but do so in a way that could have line of sight to a return for customers in terms of their workforce efficiency. And I really kind of felt that as a provider to the point that you were describing in terms of inbox overload and message overload and just kind of the absolute lack of time to conduct the type of follow-up that I would wish my patients had. If I’m prescribing a new medication, I want, in an ideal world, I would love to be able to call that patient every single day and say, hey, how’s it going? Did you take the med? Did you have a side effect? Did you not? By the way, we know that on day five, the following side effect is really common, are you having it? If you are, here’s how you deal with it. If you’re not, great. Are you having any alarming side effects that would otherwise make you think about coming to the emergency room? Let’s talk about it first. These are all things that most providers would love to do if only they could. If only they had an army of staff who could call patients or somehow track them down and call the pharmacy and make sure they fill, you know, all these things, but they just don’t, right? And so most of us have to rely on kind of a poor man’s version, which is like, well, we’ll call you back in two weeks and hope you show up for your follow-up appointment, and then I’ll ask you all my questions then. Point patients scratching their head to remember what happened on day five. And so it’s a big loss of a data collection opportunity, to go back to the original theme, it’s a big loss in the opportunity to educate patients, and it’s just a big loss in terms of saving on workforce efficiency as well. And so those are the kind of product and scenario vignettes that made me excited. And I think we’re learning a lot about all the places in the system where something like that could be impactful.
Manav Sevak:
Yeah, absolutely, and hopefully, it’s helpful for all of the folks that are listening. Maybe the actual last question that I’ll ask you related to that is, you know, towards the beginning, you mentioned that even over the course of the pandemic, we heard a lot about digital health adoption, but the way that that adoption actually looks and feels for 99.9% of our healthcare patients still is not dramatically different than it was 10, 15 years ago. So if you reflect on where the industry is right now and for the past couple of years of reflection, what excites you the most about digital health adoption as it currently looks about the direction that the industry as a whole is headed and kind of big signals that you’re seeing?
Vineeta Agarwala:
Yeah, I think it’s a few things. One, our ability to organize clinical data and share it across organizations in a meaningful way. I do think is, if not already, but at least is poised to take on a very different set of legs with a lot of infrastructure companies building the pipes to enable that, such that it’s not going to be required to reinvent the wheel for every company. Our ability to collect that data is also changing materially. It used to be the case that a new digital health company would feel obligated to build every part of their own care stack, and that’s just not true anymore. So today when I back, you know, founders who are saying we want to start a navigation service, a full stack care delivery service, or really any kind of clinical service, there’s absolutely no reason to build that full stack, and so that’s a huge enabler, right? That means my dollar can go a lot further because we’re not, we don’t have to hire 12 engineers to build just the opportunity to service patients in a documentable way. So that’s kind of one. The second is I think the incumbent posture is really changing. I think health systems are genuinely trying to sort of reach across into the startup world and figure out what a meaningful partnership could look like, how they could implement, to your point in a scalable way, how they could try to see change. I think they feel the same zeal that you talked about. But I was just on the phone with a health system CEO yesterday who said, show me a health tech company that’s changed anything about care. Can you believe that? In 2022, a health system CEO said, I can’t point to a single health tech company that I really believe has changed clinical care outcomes, snd so we have a lot of moving to do still as an industry. And so I’m still, I’m excited about the fact that despite that, some of that skepticism, health systems as well as payers, importantly, are, seem genuinely excited to partner with technology companies. And so I think those trends combined, the fact that technology companies can move faster than ever before, collect data faster than ever before, and that incumbents are willing to collaborate, make me super excited.
Manav Sevak:
That’s awesome, cool. Well, thank you so much for coming on and for sharing your perspective. It was wonderful for me to hear and hopefully, it’s wonderful for the audience to hear as well, and hopefully, we’ll chat again soon.
Vineeta Agarwala:
Cool. Thanks, Manav.
Manav Sevak:
Thanks for listening to the Memora Health Care Delivery Podcast. For more ideas on simplifying complex care for care teams and patients, visit MemoraHealth.com.
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