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Healthy Conversations brings together leaders and innovators in health care to talk about the biggest issues facing patients and providers today. Every month, we explore new topics to help uncover the clinical insights and emerging technologies transforming health care in real time.
Sam Holliday:
Like my dad died of colorectal cancer, it was never screened. Would he have done a fit test at home? Maybe, and maybe he'd still be here. I don't know. But I think we need to get these new innovations out to really scale access and make sure people are getting the care they need as easily as possible.
Dr. Daniel Kraft:
Welcome to Healthy Conversations. I'm Dr. Daniel Kraft and today we're in Healthy Conversations with Sam Holliday. He's the co-founder and CEO of Oshi Health. Welcome Sam.
Sam Holliday:
Excited for the conversation.
Dr. Daniel Kraft:
Yeah, I'm excited for this conversation. It's one of those areas, as a clinician, I've tried to avoid, which is the GI system or gastrointestinal related care. It's hugely complex and has all sorts of cross elements. The brain/gut connection, the microbiome, everything from obesity to anorexia, to our immune system is tied to our gut. And it's probably plays a huge component of our health care costs. Maybe help frame the current state of gastrointestinal care in the United States today.
Sam Holliday:
It's a bigger condition set than most people realize. One in four people in the US have a diagnosed GI condition. It's more than double the impact in terms of population as diabetes, and I think that surprises a lot of people. But when you start talking to friends, almost everybody has their story, whether it's the more severe side, inflammatory bowel diseases like Crohn's and ulcerative colitis. I think those have long been understood to drive really high cost and an unfortunate impact on people suffering. And a lot of the energy in GI does go to managing IBD patients and care. And I think there's this emerging understanding that the signaling between the gut and the brain can get dysregulated and when that happens, it can actually trigger symptoms. We're in an exciting time where we're starting to learn about microbiome, what we eat can impact GI symptoms.
Dr. Daniel Kraft:
We'll just go to the economics. What are some brief stats? Inflammatory bowel disease on the more minor side to GERD to SIBO.
Sam Holliday:
IBD, so Crohn's, ulcerative colitis, anywhere from $25 to $40,000 per year of spend. A mix of escalations in the symptoms that drive hospitalizations, ER admits, as well as pretty high cost biologic drugs that are used to manage the conditions. Then you have the longer tail of other functional and gut brain disorders that have largely been overlooked. There's a lot of stigma. You mentioned GERD, that's about 15-20% of the population. Irritable bowel syndrome, it's a syndrome because it really doesn't have a definitive diagnosis. We have to sort of test and see what might be triggering the symptoms and a lot of the spend comes from the diagnostic journey, often taking two to four years to get correctly diagnosed and to find a treatment that's going to work.
Sam Holliday:
My mom has irritable bowel, she had extreme constipation and abdominal pain, went to the emergency room. Lot of imaging, overnight observational stay. If we can just get upstream and actually help people when these symptoms start to find the right treatments for them, we can avoid a lot of these escalations. IBS, if you look at the people who seek GI care for the symptoms, the cost is much, much higher than you see if you just look at the whole population. There's a lot of people with lower acuity IBS that don't seek care, and are just able to manage it on their own. It's when they hit that point where it's bad enough that they seek care that you see the really high cost. And we believe that's about 60% of people with IBS that can drive $15, $20,000 of spend in the year that they seek diagnosis.
Dr. Daniel Kraft:
And I imagine, like with many diseases, they're often bucketed, but they're highly heterogeneous. I mean as we now get to metabolomics and genome and microbiome, I assume we can start to subset these in more precision medicine ways.
Sam Holliday:
I hope so. We're just starting to see a lot of companies and a lot of investment go toward better diagnostics. I worked in diabetes prior to starting Oshi and by comparison it was sort of simple, where you could prick your finger and you got a number, and the number helped us diagnose, and the number helped Tell us how are you doing treating this and managing it. Pretty consistent across people. Then you look at something like GI conditions. The symptoms overlap across many, many different potential conditions that they could be.
Sam Holliday:
And then oftentimes you're left with, "Okay, good news. It's not cancer, it's not IBD. It's probably irritable bowel syndrome or a functional condition." The challenge is what to do next is not straightforward. We don't have definitive tests that say Daniel's going to respond to changes to his diet and cognitive behavioral therapy, whereas Sam might just be entirely driven by anxiety.
Dr. Daniel Kraft:
Are you seeing sort of an improvement in the way to sort of bucket some of these elements and how are most current diseases in the gut diagnosed?
Sam Holliday:
I think there are some diagnostics being developed to try to tease out more definitively, is it irritable bowel syndrome or is it gastroparesis. We have the tests for celiac, but many of these other things we don't yet have good tests. So the idea is if it looks like IBS and it doesn't have these alarm features like sudden weight loss or certain patterns of blood in the stool, let's treat it as though it's IBS and let's see if the patient responds. And if they respond, confirm the diagnosis. That's just a really hard pathway to execute in today's fee for service health care world.
Dr. Daniel Kraft:
And are those clinical guidelines starting to blend with other fields? You mentioned a lot of the gut issues tied to the brain and anxiety, as one element. Do you see many gastroenterologists prescribing a meditation app or an anti-anxiety approach?
Sam Holliday:
We have two now, FDA-approved digital therapeutics for IBS. One is cognitive behavioral therapy. The other is GI-directed hypnotherapy. And we've known for a long time that these interventions work for many people with IBS, but we don't have a big supply of psychologists or behavioral health providers who really understand the nuances of these GI specific versions of those interventions. So we have to scale that access and one way to do that is digital therapeutics. Another is telehealth based models.
Dr. Daniel Kraft:
Our focus here is on folks who already have disease, but I'm wondering, big picture, whether there's an opportunity to be much more upstream and proactive, whether it's understanding who's at risk based on underlying gene type and certainly a lot of inflammatory bowel disease elements seem to have genetic component, all the way to neuropsychiatric, et cetera, where you can start to be optimizing kind of GI gut health, particularly for folks that might be identified at risk early in life.
Sam Holliday:
It tends to be diagnosed pretty early in life. As I'm sure you saw working in pediatrics. Many of these other functional gut brain disorders develop in people's 30s, 40s. I don't know that we yet understand how we could see them further upstream through these kinds of tests. There's a lot of interesting work in the microbiome and in some of the genetic testing that hopefully will yield better prediction on this, to your point, get ahead of that before it all escalates.
Dr. Daniel Kraft:
Yeah, it seems like some of them are complex and multifactorial. I have a cousin with SIBO and going through that journey and there's the microbiome elements, there's treatments with antibiotics, there's breath test analysis, there's endoscopies. There are now everything from virtual colonoscopies to given imaging pills, a pill you can swallow. With Oshi, which we'll hopefully get to in a minute, are you finding ways that you are learning how to better define these often bucketed disease subtypes?
Sam Holliday:
You're right. There are a lot of things that could trigger these symptoms. What you're eating could impact it, so it could be bacterial overgrowth in your gut. It could be the signaling between your gut and your brain gets dysregulated/ When people experience physical emotional or sometimes even medical trauma from surgeries, they can develop IBS afterwards. It's a dysregulation of that signaling. Anxiety, chronic stress, sleep. So we have to really look at all these factors and what it really requires is getting to know the person. Because we don't have the clear testing to figure it out in most cases, we then still need to step in and figure out how do we stop those triggers from occurring? How do we teach people the tools to calm that signaling between the gut and the brain?
Dr. Daniel Kraft:
Can you tell us a bit more about your sort of virtual care model and how that works?
Sam Holliday:
There was a study done in Australia a number of years ago that showed that if you brought all the clinicians, someone might need to identify these triggers, that if you had a dietician, a psychologist trained in GI interventions, in the same clinic as a gastroenterologist and a nurse practitioner, all of these experts working together as a team and then test the different interventions, you actually saw better experience for the patient. It drove better clinical outcomes and it lowered the cost. You saw fewer escalations into the ER.
Sam Holliday:
Okay. If we replicate that with telehealth, can it enable us to scale this, to reach more of these people? It is a big issue. So we really brought together the multidisciplinary care team, our members, we call them members, not patients, because it's a relationship that we're developing that'll last over time, meet with someone on our care team, whether it's a dietician, a psychologist, their nurse practitioner, their gastroenterologist, every two to three weeks. We're having the patient track their symptoms, their bowel movements, in between these visits as a signal to our team.
Sam Holliday:
We see if, hey, when we remove these common trigger foods, do the symptoms get better? Do the bowel movements get more consistent? Okay, let's start reintroducing the foods, because each of us have different triggers. We also might be working on a behavioral intervention using a cognitive behavioral therapy with that same person in parallel, where one of our members might develop food related anxiety, where they're anticipating that a food is going to trigger their symptoms. They start focusing on it and all of a sudden it's this sort of terrible cycle that reinforces itself. So we have to break that with the combination of both the dietary and the behavioral interventions.
Dr. Daniel Kraft:
Because data is only data, you want the actionable insights and ideally much more personalized, proactive and actionable ones. How do you make sense of all these disparate signals?
Sam Holliday:
It starts with really trying to track down past records for the person that we're meeting for the first time, so that we're informing our care by what's already been done, what's already been tried. And then we have a long intake visit with our member. They're meeting with typically a nurse practitioner who's really asking them a detailed set of questions, trying to tease out what might actually be going on here. But we also are asking questions that often get missed. Things like trying to figure out if trauma could have been a trigger for all of these symptoms and the new onset, other medications that could be triggering the symptoms.
Sam Holliday:
After that, we may order some diagnostic testing or we may say, this looks like IBS, we want you to meet with our dietician and or behavioral health team, and we may even order a prescription. We try to use the lower cost medications first and iterate in two to three week increments using all of the tools at our disposal, until we're able to figure out what triggers that person's symptoms.
Dr. Daniel Kraft:
What do you see sort of now and is might be emerging in the next couple years that gastroenterologists or clinicians of all sorts could be using to better quantify and track gut health?
Sam Holliday:
There's great tracking tools now and we're able to have our dieticians see what you've tracked, if we're working on dietary interventions, to track your bowel movements. We are set up as a clinic, so we have an EMR, which also allows us to share records with other providers who might be treating that person. There are the smart toilets. Those will be great. I mean if they were ubiquitous. The challenge is going to be how do we get to the point where everybody has that in their home and it gets all the intelligence you'd need to tease apart different people in the same home, and what happens when you go outside the home? I think that's going to take a number of years to get there.
Sam Holliday:
There's also better diagnostic testing for colorectal cancer. We just lowered the screening age for colorectal cancer by five years in the US. That's a lot of the population that now needs to get some form of screening done. The gold standard being colonoscopy, but there's some newer less invasive modalities, blood-based and other, that are in clinical trials. That'll be a good compliment to colonoscopy for people who just aren't willing to do it. Like my dad died of colorectal cancer, it was never screened. Would he have done a fit test at home? Maybe, and maybe he'd still be here. I don't know. But I think we need to get these new innovations out to really scale access and make sure people are getting the care they need as easily as possible.
Dr. Daniel Kraft:
Yeah, 100%. It's also about messaging and hitting the easy button. I imagine with Oshi, you're also crossing over, you may end up having someone coming in with GI symptoms and it turns out they might have colorectal cancer or pancreatic or other elements that you might potentially pick up early. Do you have any sort of stories in that regard?
Sam Holliday:
I do. I'm really glad you asked that. A member who our team saw didn't have any of the alarm features, looked like IBS. We started treating the person. And a couple weeks into treatment, our clinical team noticed the member wasn't responding to the treatment. If people aren't responding, it's a flag. And we ran a blood panel and noticed something was a little off in the blood panel. And we were able to thankfully partner with one of the local GIs and get them fast tracked in for colonoscopy and sure enough it was colorectal cancer. We believe we caught this much earlier, because the access to get in and get this care from our team, have that rapid iteration and then be able to make a referral to a local gastroenterologist to say, "Can you fast track them to get in and get this procedure?" And yeah, sure enough, in this case, person's in treatment and getting better.
Dr. Daniel Kraft:
Talk a bit about sort of not business models but care models. So certainly the pandemic opened up sort of more virtualized care and Oshi seems to be fully virtual. How do you end up collaborating versus competing with current GI care providers?
Sam Holliday:
We set Oshi up at the very beginning to be complimentary to what the current GI infrastructure in the US is built to do. Right now, in many parts of the country, there are really long wait times to get in and see a gastroenterologist as a new patient. I've heard stories of up to nine months. We also have an aging group of providers in GI, and you've got private equity coming. Many of them are selling their practices now. We're seeing early retirement across all specialties, and I think this is going to make the access challenge even greater, at a time when we just created five years worth of new demand for colonoscopy by lowering the screening age.
Sam Holliday:
And so I think access is really a big part of why we set up Oshi, but it was also to add these parts that were missing. That clinic in Australia, that ran the study, they had dieticians, they had behavioral health providers. If you look around the US at GI clinics, a majority don't have those two critical team members. And when we started interviewing GIs early on, we realized the reason they don't have them is payers haven't reimbursed that care. And so a big part of our mission was to show that if you actually integrate these into GI care, you can get people better, faster. And all of that adds up to saving costs. I'm excited to say we've been running a clinical trial with a national health plan to prove this out, and it's showing what we expected. And it's helping us now start to get coverage for the dietary and behavioral.
Dr. Daniel Kraft:
It's sort of win-win. You're helping, number one, identify patients who need to go get that screening upper, lower GI, but also enabling the care providers, whether they're primary care or gastroenterologists, to have a platform to amplify and drive better outcomes. Are you integrating, let's say more of the mindfulness training or Chinese herbs?
Sam Holliday:
The reason many people have sought out some of those solutions is that they haven't been getting what they're seeking. They haven't been getting better in the current care system for GI. And why is that? Well, the support for dietary and behavioral interventions is missing. And so people get stuck in this gap between their primary care physician who doesn't have the GI specialization or the time, frankly, in our current system to unpack these complex triggers and then figure out which of the interventions will work.
Sam Holliday:
What we've tried to do is really stick to what has clinical evidence behind it, because that's what we know health plans will expect to reimburse our care. As evidence comes out though, we've set Oshi up to be able to integrate that evidence faster than anybody else out there into our care.
Dr. Daniel Kraft:
How difficult is it to find the right kind of care members to support a virtual platform that's scaling?
Sam Holliday:
There's more awareness that so many people live with these conditions. I think the good news is we're starting to now get coverage from plans and from employers. But we really are also working to build these referring local provider partnerships, whether it's primary care or on the gastroenterology side. If you're a GI and you've sort of done a colonoscopy, you've rules out cancer, you've ruled out IBD, it's probably IBS. Many times the person needs dietary behavioral support, and if you don't staff that yourself, why not refer them over to Oshi and we'll coordinate the care back.
Dr. Daniel Kraft:
What's the sort of time course? Is this something that someone signs up for and they're on for three months, six months, or ad infinitum?
Sam Holliday:
At the end of the day, our goal is around each individual member, to give them control of their symptoms. So there's a metric that's been used in certain IBS drug trials that's called symptom control. And it's basically, do I understand what triggers my symptoms and do I have tools or changes to my diet or my psychology that can help me keep them down? That's our core measure. It usually takes anywhere from three months, on the very fast side of this sort of high frequency iterative care model. Some of our members have taken nine months to really unpack. It also depends how fast they want to go. Some people say, "Okay, well let me try the dietary first and if that doesn't work, I'll try the behavioral." Others want to just go all in.
Sam Holliday:
Getting to symptom control, really drives a reduction in cost, just in six months in our clinical study. And it's because we reduce a bunch of ER visits, a bunch of imaging that gets done when people have tried to get care, but they're still feeling bad. We're excited because we've seen a really high self-reported improvements in quality of life, in workplace productivity.
Dr. Daniel Kraft:
Let's futurescape a little bit. Any favorites, whether they're competitors or collaborators that you might want to highlight that are doing exciting things in the gastro or the GI space in general?
Sam Holliday:
There's a lot, and it's exciting to see all the innovation. The digital therapeutics are great. I don't view them as a competitor. They're a tool. So instead of needing our behavioral health provider to have the same conversation with every single member, we can use a digital therapeutic for that and it reduces the amount of human capital that I need to get to the same outcome. That's the kind of innovation that helps us scale, help those providers focus their time with the member on the personalization, on answering their questions, on teasing out the more nuanced, difficult parts that the person hasn't quite figured out. We can see that there are differences in people who have GI conditions. We can see even people with behavioral health conditions have differences in their microbiome. But we don't yet know how to make sense of it. And to your point, sort of get upstream and into a preventative approach.
Dr. Daniel Kraft:
Speaking of upstream, most microbiome comes from sort of the lower GI tract, relatively easy to collect. But there are folks who've now been looking at sequencing the upper GI, so the small gut, which is where a lot of IBD and other diseases live, which have very different microbiome than the colonic space. So it'd be interesting to see what dataset emerge from there.
Sam Holliday:
Yeah. It's an interesting space. And again, our goal at Oshi is to be the most data driven clinic in the country, maybe in the world for GI. One, it enables us to potentially participate in the research for all of these new interventions, diagnostics, to be a decentralized trial site in the future. But then also to incorporate the research and scale a whole group of providers that can use them almost overnight.
Dr. Daniel Kraft:
Virtualized, precise, personalized, digitized, care anywhere for the GI tract and everything else it's connected to, which is pretty much everything.
Sam Holliday:
Absolutely. You mentioned earlier the overlap of GI and other conditions. 70% of our members are women. We see cases where it's actually not a GI issue, it's a thyroid issue or a pelvic floor issue. So we're even looking at other ecosystem partnerships where they have those interventions, if we're not the right place for them to get care based on what we uncover.
Dr. Daniel Kraft:
Well, thank you so much, Sam for sharing what you're doing in the GI space with Oshi Health and beyond. The folks want to look more, you can go to OshiHealth.com. Thanks for joining us today on Healthy Conversations.