Mayo Clinic-backed Better launches personal health assistant service

By Brian Dolan
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Better iPhone 3Mayo Clinic-backed, Palo Alto, California-based Better officially launched its service this week after a year of private beta tests following a high-profile debut at the All Things D event last year. Geoff Clapp, who was a co-founder of early digital health success story Health Hero Networks, co-founded and is CEO of Better. MobiHealthNews caught up with Clapp ahead of today's launch to discuss Better, working with Mayo, and how the Better startup experience has differed from launching Health Hero back in the late '90s. An edited transcript of the interview follows:

Mobi: What is Better and what problems is it trying to solve?

Clapp: This new company, Better, we formed with the Mayo Clinic to try to remove complexity from healthcare. What we have found is that many others working in digital health are trying to change behaviors and [is focused on] wearables. You know about my experience with Health Hero, and the VA, and care coordination -- well, we really wanted to take that model and make it available to everybody. That model was very successful for the VA, the National Health Services, and others. After selling the company [to Bosch] and being there for a couple of years, retiring for four years and spending some time at Rock Health,  not only did I decide I wanted to get back into the game, but that I also wanted to make that care coordination offering available to everybody. With the ACA and all of these things, the timing is right for a consumer-driven care coordination model.

Better offers everything from really basic administrative tasks all the way up to really high-end clinical work. What it comes out to is -- across the board -- having a personal health assistant -- what the VA would call a care coordinator -- who just takes cares of everything for you. Whether it's appointments, prescriptions, or finding new doctors all the way up through -- something is horribly wrong and I want to see a specialist, or nurse, or doctor. 

What I am learning is that in order to do this on a consumer basis, first we have to take away all that complexity for people before we can actually fill that time with real healthcare. The idea that people are just going to pay $15 for 15 minutes with a doctor, isn't really an idea that anyone is aspiring to. What people are telling us is that they want a relationship with someone, which they don't get from the healthcare system today. So, that relationship is with a personal health assistant who then is able to coordinate all your care. They are also backed by the Mayo Clinic. So your safety net, if you will, is the Mayo Clinic. We can also get your doctor onboard and there are other organizations that we are going to be announcing soon as well. But we can always promise that, 24 hours a day, seven days a week we can bring you the Mayo Clinic.

Can Mayo Clinic really scale up to support a remote care system like this?

It is absolutely their desire to do so. As Dr. Noseworthy put in place, their goal is to reach 200 million lives by 2020. The look on your face is exactly the look I had on my face when they said it to me. "Wow, that's something." That seems almost silly in a way because they are an amazing organization, but they are an amazing place. Rochester is amazing. Arizona is amazing. Florida too. Whenever someone tells a story about Mayo, it's: The Saudi prince or the president flew to Rochester. It's always about the place.

What Mayo realizes now, and I really give them a ton of credit for this, to extend their brand, they really have to understand technology and mobile. They have to get outside of being just the places that they are. Their vision of the future of healthcare, my vision of the future of healthcare, and [Social+Capital Partnership's] Chamath Palihapitiya's vision of the future of healthcare -- they're all very much aligned. So it made sense for us to try to start this entity together.

If you look at the vision and where we are heading, the payment structures in healthcare, the regulatory structure in healthcare, all of these things are changing and pushing in that direction, but there are other big things like federal licensure and more when you really get into telemedicine -- but that's my whole career. That's what I want to do. That's where the rubber meets the road for me. Mayo has the clinical resources -- I'm not a doctor, you know. They've really doubled down in terms of the resources made available to us and scaling those things up. Over the past year we have already implemented a ton of technology at Mayo that it probably took me six years to get implemented at the VA.

To what extent is Better integral to Mayo's 200 million lives by 2020 goal? 

I would love to tell you that we are all of it, but I don't think that would be very fair. I think we are a big part of it. I think that's fair to say. Also, we can put you in contact with people at Mayo to talk to. Mayo gets 40 million uniques on their website every month. They have ways to stretch outside of their physical place right now and I think they are thinking about it in a lot of ways. What is the Mayo experience on your mobile phone? That's Better. There certainly will be other things that they will do to extend their brand though. I wouldn't expect a 150-year-old institution to put all of their eggs in one startup's basket -- that's just not realistic. 

How has Better's offering evolved since your presentation and demo at the All Things D event last year?

Better iPhone 2It's changed a lot. At that demo the company was two months old and Better was more of an idea. It has changed in two main ways. We have really driven the simplicity of the user experience. We've learned a lot about what people really want from a personal health assistant. What fascinated me was that we learned a lot about basic administrative tasks -- things that people just don't want to do because they are so complex. I think that when we envisioned the company at the beginning it was always going to be much more clinically oriented, but we realized that we really had to balance that because the problem people really wanted to solve was time. This is really complex and healthcare takes a lot of time so people don't engage with it. Take flu shots. How do we get people to get three flu shots? What's the difference between a fall flu and a spring flu? Helping people with that may not be as glorious as reinventing the Framingham Study, but it has a huge effect on people on a day-to-day basis.

What we have learned through our private beta these past 12 months is how important time is and how complex people see the healthcare system as being. They are not engaging with things like the quantified self and behavior change vehicles, because everything is really poorly designed and not easy to use and really, really complex. We ended up balancing between the high end, real clinical problems and the day-to-day stuff like appointment setting, finding doctors, helping you with refills, and understanding insurance bills. We found that people are really willing to pay for that because they really value their time.

What kind of background do the personal health assistants have?

When you think about the assistants, there are really two tiers. There are the people on the phone themselves but then there is really a team of people. There are RNs, MPHs, insurance experts, Medicare experts, and more. The trick is to make sure that these are people who are really good on the phone -- and good at texting -- but also that there is a team of people that are also behind you that can solve almost any problem. We even have a couple of folks from the CDC. Then we have the 24/7 Mayo nurses available anytime you need them and a growing network of doctors and medical experts as you need them. And your doctor too some day as we add more doctors into the loop.

So, the person helping me schedule my doctor's appointment, for example, isn't a recent graduate with no healthcare experience?

No, not at all. This is one of the important things about trust. You know, I got asked this on another call: "Are you just sending this overseas to a foreign call center?" Absolutely not. The reason for that is healthcare is very personal and very much a trust issue and we all aspire to this idea of healthcare where you have this longterm relationship with your doctor and maybe they would even come to your home. None of us have lived that. We maybe get eight minutes a year with our doctor. That relationship in healthcare is really what is missing. So that person you are talking to is not a recent grad or an intern. I'll give you an example -- [one of our personal health assistants] is Meg, who has 10 plus years in homecare nursing, palliative care and end of life. There are, unfortunately, many of our users who are in that situation. We will make sure that even if Meg is not your main PHA, you will always have access to Meg. She has helped people with all sorts of things like living wills to selecting different agencies. We are not trying to commoditize anyone in this process. Doctor -- the idea of $15 for 15 minutes -- we're not trying to commoditize them like that. We're not trying to commoditize the relationship either. Better is a high touch, high trust relationship.

Are the services provided an open ended list -- you mentioned drafting a living will -- or is there a menu of services available from Better?

It is very open-ended, yes, but there are some limitations, legal limitations, especially about practicing over state lines, about reciprocity. We can't prescribe and send you narcotics -- like Oxycontin -- through the mail. There are limitations. I wouldn't want to pretend that there are none, but what we ask our users is: How can we help you today? And we will do whatever we can to help, but if we can't help you for some reason, we will find you someone who can. So if we can't do something for you in your state -- and Mayo can't either -- we will find you the specialist who can. Someone who is close to your home or office. Most of the stuff that we've been asked to do, we can take care of it.

How does Better make recommendations on who to send its members to? What's your process for filtering that?

Yes, say you are trying to find someone locally. We have a couple of different algorithms and there are a couple of people we are working with on that. Certainly things about ratings, how they are reviewed, and we also talk to the person before we recommend them to you. We don't just find them on the internet and say here you go, here's a picture of them. We always will give you several choices. The most important thing we do early on in the process is ask if there is a certain gender doctor you prefer, certain cultural preferences, close to home or office -- and then we narrow down using all that. There is also the Mayo alumni network and a lot of other data sources. As big as healthcare is, a lot of people are well known, and it is fairly easy to find information about people. Then we always follow up with the member and say, well, that was how we expected it to go but what was your experience like? Do you want to see doctors like that one in the future? A lot of it is just really active listening too. 

Let's switch gears and talk about pricing, business model, and your expectations for what kind of people will be early users of Better.

Yes, those are very related. We expect the average user, if you will, especially in the early days to be a family, especially someone with a chronic disease or condition that they are challenged by. When we talk about family it's not just people with young kids it's also caregivers who are caring for older adults. So, really people who are spending more than two hours a month dealing with the healthcare system, whether it's making appointments or other things. The reason I say two hours a month is that Better [with access to a real live personal health assistant] is $49.99 a month. That's unlimited access to the PHA and nurse and it's unlimited for you and your family. It's not, well, you can have two kids but not your parents -- or whatever.

Here's how we got to $50 a month: If you make about $60,000 a year, your personal hourly rate is about $27. If we can save you about two hours a month of dealing with the healthcare system and remove that complexity for you -- forget peace of mind, forget healthcare -- just on a purely economic basis, two hours a month. For those people who have the need, they say this feels like it saves more time than that because it was two hours waiting on hold or two hours of obnoxious forms or internet searches.

There is a free version too. It gets you complete access to all the Mayo content, symptom checker, personal health records information, and all of this is tailored to you. You're not just getting random information or information you could get just by Googling. The only limitation is you don't get the human touch -- the unlimited access to the nurse line and PHA. The free version really should be that health resource in your pocket. It is all of that Mayo content highly personalized to you. It has no ads and there is no selling of your data. When we say free we mean real free and not Silicon Valley free. That is really important to us. Our investors -- and Mayo Clinic in particular -- have a really longterm view. The idea of covering a page with advertising or trying to aggregate and sell people's data is not a trusted relationship. That's not what we think the future of a consumer-driven healthcare model looks like. We are taking a really hard stance on that. There will not be ads on the full system. Full stop.

Marketing is a big challenge for direct-to-consumer health services. How are those families making $60,000 a year going to find out about Better?

Better iPhoneIt is a challenge with any consumer product. I won't pretend it's not. We've been going to the communities themselves. Most people dealing with chronic care go to where the 80 percent of the spend is -- heart failure, diabetes, COPD, maybe mental health and hypertension. One of the things we figured out early at Health Hero and it is certainly part of the model here at Better, is that there are huge swaths of people [for whom] the market itself isn't big enough to support a particular type of application. Take cystic fibrosis. It's 150,000 people and if you get 50,000 of them and they are paying $50 a month, our users are telling us that we just took so much off their plate. There might be hundreds of thousands of apps out there for healthcare, but they are doing a very limited amount of things. Part of this is being really important to underserved patient communities which digital health has ignored, but that we are actually able to serve in a meaningful and scalable way. That's one place where digital health has not gone wrong, but needs to expand. I don't think the world needs another glucose tracker in the AppStore. We are missing out on all of these other populations. We have been really focused on Crohn's, cystic fibrosis, and other areas that are a little less served.

There's a big difference between telling somebody something, doing it for them and actually, eventually, teaching them how to do it for themselves. Right now we are still in this very nascent phase of consumer-driven healthcare where we try to tell you. We will put up a page with lots of studies, a link to the Framingham study, and 20 pages of documentation, but there is no one to do it for you, no one to support you in the process, no one to be your advocate. We are trying to meet people where they are, when they are searching for stuff, when they are at these events. As we come up through those communities and start providing value to people, there is a lot of word of mouth. There's also Mayo and their channels. It's their 150th anniversary, so there is certainly a lot of press around that this year. But I think there is something organic that comes from serving our patients well and that's where we are starting.

Can you bring me up to date on the company itself -- how big is the Better team? How much have you raised? Any new investors?

Mayo Clinic is both a strategic partner and an investor. They have invested a significant amount of money and are on the board. Social+Capital Partnership is the other investor. Total raised right now is $5 million. We have 20 employees and all are based in Palo Alto, California. Eventually we will do the Alere thing and open up a call center in Nevada just like they did, but right now it's just really important to keep this team together. The Mayo team is in Rochester mostly so that's where most of the nurse line staff is based, but they have staff across the United States since that is a 24/7 service.

What are the immediate next steps following the launch?

The most important thing that happens next is going to be about growth and supporting those communities. From a product development standpoint, the Android version is coming out later in the fall. Right now this version is iOS only. We want to push toward telemedicine. That is the long term goal: How can we provide care to people wherever they are. Rather than going the commoditizing the doctor angle, we decided to start by building a relationship and starting to solve real problems for people. I was shocked when we first started because I didn't think there really would be this much complexity for us to solve to really gain people's trust. The analogy I like to use is, it's like AAA for healthcare. It sits on top of the system you already have and works with it but it is really important that it gives that peace of mind because you know it's there. Internally, over the next several months we also have different initiatives in the works with these patient groups I've mentioned too.

Mostly this next phase is going to be focused on education. Most people haven't heard about care coordination or personal health assistants. The best thing any of our members can say to us is: I didn't know you could do that for me. We are still very much in an education phase. We are trying to teach the American populace that you can get your healthcare wherever you are. It can be super high quality. You deserve a simpler, more patient-focused system. There is a lot of education that needs to happen this year, because none of those words are ones that people associate with the healthcare system.

Since you've been -- in some ways -- down a similar road when you co-founded Health Hero, how has launching Better been different given recent changes in healthcare?

Let me start by giving you one similarity: We are early. We're early in a market, trying to define the market, and solve a big problem, because it's not interesting to be the seventh person to solve a problem. There is no doubt that we're early because I get the same look from people that they gave Steve and I when we started Health Hero and they say: I'm not sure I totally get it and not sure the world is ready for this. I hear that phrase and think that's good, because that means we are onto something. We are actually tracking to where things are going rather than to where things are.

The single biggest difference this time around is that anybody cares. Launching a health technology company back in 1998 -- there were crickets. No one really cared about it. People would have been much more interested if I had a sock on my hand and I was selling pet food over the internet than anything related to healthcare. What's fascinating is the idea of healthcare and the internet has so exploded and there is so much more interest in it. I am certainly a different entrepreneur and am making different mistakes this time. The market itself has changed -- with the FDA, there is still all this talk about regulatory complexity but it was so much worse 10 years ago and even then it wasn't that bad. I think people are pretty wrong about that having gone through it. If anyone complains about it, first thing to ask them is whether they have ever done a 510(k). Most of the people complaining about how horrible it haven't. We will do that. We will connect to medical devices this year and I think that puts us in a kind of leadership position. HIPAA. It was an idea back when we started Health Hero. Now, most people can name the 18 things you have to protect. They have a better idea of security and privacy. The other thing is that people's expetation of healthcare has finally improved. It's still very low, people have very low expectations of healthcare. Thanks to ACA, the HITECH Act, and even things like Blue Button.

The thing I love the most is how many smart people have come into the space and are pushing the boundaries and trying new, hard things. There is a core of us that has been doing this for 15 years and I think it is a very welcoming community. We want those people to come in. That's why I enjoyed my time at Rock Health so much. Surround yourself with great people and great things happen -- that's why we have the 20 people we have. They include some very well known people within digital health that want to make a difference mixed in with some 20-somethings (including one Thiel Fellow) who want to change healthcare. It was really hard to get people in 2000 and 2003 to choose to work with you.

Finally, Mayo's involvement is a great example of a change. Back when we were selling Health Hero it was really hard to get institutions interested because they saw technology as a threat. Now we are talking about one of the best medical institutions in the world saying we need to figure this out, let's go partner with Silicon Valley. We had to pull teeth to get people to talk to us at Health Hero. I have a lot of scars from the healthcare system from the first time around and I'm really surprised how much that has changed and how people realize now that partnering is the path to go on.

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