“It says here you drink four or more cups of coffee a day. Do you feel like you really need that much?”
Yes. Yes, I do, thank you very much.
I’m on the phone with a doctor in Sacramento. He’s looking at the results of the blood-chemistry tests I recently commissioned through WellnessFX, along with some health and nutritional data I entered into the company’s website.
This particular doc has a holistic bent, and he’s wondering whether I might be eating or drinking something that’s unbalancing my immune system (I have a longstanding autoimmune condition called psoriatic arthritis). He thinks the same irritant might be contributing to the higher-than-normal cholesterol levels showing up on my chart.
“If I were you, I’d want to find a naturopath to evaluate you for food sensitivities,” he’s saying. “If they found something, you could potentially decrease some of the inflammation in your body. Any excess inflammation could be contributing to higher levels of cholesterol than you’d expect.”
In the last few years, as I’ve hit my mid-40s, I’ve stopped eating meat, sworn off dessert (mostly), and become a marathon runner. But as much as I respect where this doctor is coming from, I’m not about to give up coffee. Cheese and cereal, maybe. But I don’t think I could be a proper writer without my daily half-gallon of caffeine.
So I’m listening carefully to the doctor’s advice, and taking lots of notes. But the bitter seeds of non-compliance are already sprouting in my head.
And I’m worried that this feeling, writ large, is one of the stumbling blocks that could limit the effectiveness of online personal-health services like the one WellnessFX is trying to build.
The San Francisco-based startup, which is backed by $5.8 million in venture funding from Javelin Venture Partners, Floodgate, Voyager Capital, and Health Tech Capital, provides customers with private, personalized assessments of their blood chemistry and summarizes the results using colorful, easy-to-understand online charts. For $199 you can order a diagnostic panel that goes way beyond the tests your primary care physician would normally request.
You’ve probably had your HDL (“good cholesterol”), LDL (“bad cholesterol”), and triglyceride (fatty acid) levels checked at least once—but WellnessFX also measures a bunch of other important-sounding quantities, such as Lp(a), Apo B, hs-CRP, TSH, glucose, HbAIc, BUN, creatinine, AST, ALT, total bilirubin, albumen, total protein, Vitamin D, sodium, calcium, potassium, and CO2.
The WellnessFX fee also includes a 15-minute phone consultation with a licensed medical doctor, like the one I’m doing now.
I’ve scored in the green zone on everything except cholesterol and Apo B, so that’s what my advisor is focusing on. From what he’s saying, it sounds like figuring out whether I’m really sensitive to wheat, dairy, coffee, or other foods is going to require some office visits, some time, and probably some serious out-of-pocket costs. So I’m not in a huge rush to investigate further.
I suggest to the doctor that maybe I could just take bread or milk out of my diet and see how I feel. “That’s problematic because we’re talking about cellular changes here,” he says. “For example, you couldn’t tell me, based on how you’re feeling, that you have high or low cholesterol.”
Basically, he’s saying that I’m going to need professional help adjusting my diet, and I’m going to have to go back for repeated blood tests to see if it’s working.
And there’s the rub. If you’re really proactive about your health, you can pay out of pocket for a WellnessFX screening, as I did. Or if your benefits package happens to include a really excellent wellness plan, you can get your employer to pay for it. But that’s just the first step on what can easily become a very long road. How many people have the will, and the wherewithal, to go down it?
It may be that this brand of self-testing can greatly improve health outcomes in the long run, and that there’s plenty of room for personalized health startups like WellnessFX to succeed. But I can’t help thinking that we need to work out some big social, economic, and political questions first. Like whether consumers who want to radically change their own health habits can expect much support from their traditional doctors and insurers, to name just one.
I got some insight into how WellnessFX thinks about this stuff from CEO Jim Kean last week. I’d had my blood drawn the week before as part of the research for the interview, and ironically, I was bleeding again when I showed up at his office. (My bike chain had come off during the trip over, and my finger got caught while I was fixing it. But the nice folks at WellnessFX bandaged me up.)
I asked Kean, to start, why WellnessFX provides such a large panel of diagnostic tests. “About 70 percent of the information you need to understand your current state of health resides in your blood and urine,” he answered. “At an average physical you might get total cholesterol, HDL, LDL and triglycerides, but the things that are far more predictive are Apo B and other fractions. Those have always been seen as things that you don’t get tested unless you are the CEO of Exxon.”
Kean says he’s a fan of the old Lord Kelvin quote: “If you can’t measure it, you can’t improve it.” Cost is the main reason primary-care doctors don’t order more thorough panels of blood tests, he says. Many insurance plans will pay for the less common but more revealing tests like Apo B, but only after it’s too late for preventative purposes—once a patient has already had a heart attack, say.
And there’s another diseconomy at work: some blood tests are expensive simply because they aren’t ordered in large volumes, meaning labs don’t always keep the necessary reagents on hand. “I thought that if we could add more volume to the market, we could be disruptive and change the cost structure,” Kean explains.
Kean has been in the business of helping people to take better care of themselves for a long time, but until WellnessFX, he’d never tried to intervene directly in the medical system. Back in 1995 he founded the Sapient Health Network, which grew into a group of 20 online communities for people with specific health problems such as breast cancer. WebMD acquired Sapient in 1999, and for a time Kean was its vice president of consumer services. But he soon went on to become a financier (at Bridgespan Capital, a boutique real-estate investment firm) and a consultant to builders of health-and-wellness resorts.
He says the results of one focus group that he ran in 2008 gave him a new idea. “There was this switch going on in our society. People were realizing that if you address health problems that start in your 20s, 30s, or 40s, you can stretch out your aging curve. You might not live longer, but ideally you could have healthy longevity until the last weeks of your life, then die quickly.
“But to facilitate that, you need to coordinate with a team of practitioners of your choosing, and have access to a whole bunch of biomarkers, and not have to do it within the framework of a doctor’s appointment. You want access to preventative care wherever you happen to be, even if it’s on your laptop, your iPad, or your iPhone.”
Kean designed WellnessFX’s testing and reporting service not just to drive better economies of scale in the lab business, but to make the results more understandable, and to tap physicians with underutilized time. “Most urban areas in the U.S. have a shortage of doctors, so it generally takes eight weeks to schedule a physical, but we can harvest well-trained practitioners in other areas,” he says. The average billable rate for physicians varies by geography; in the Bay Area it’s around $475 per hour, Kean says. But rural docs are happy to do WellnessFX phone consultations for $200 an hour, because it doesn’t require any up-front investment. “We are their digital storefront for telehealth,” he says.
WellnessFX deliberately recruits doctors who are open to the trend toward holistic and integrative medicine—the idea that patients’ physical, social, psychological, and spiritual health can’t be disentwined, and that there’s an important role for nutritional supplements, meditation, acupuncture, and other “alternative” treatments in optimizing health. “We are about how you manage your lifestyle,” Kean says. “I don’t see how you can manage your lifestyle if you don’t consider all the elements that go into making you who you are, which include things like nutrition and sleep. So by definition we had to be integrative.”
What’s more, Kean asserts, traditional Western doctors are crisis-oriented—they typically won’t suggest action until a biomarker is well into the red zone. “They are trained to spot a fire, grab a hose, and put it out,” he says. “But if you give [a case] to a practitioner who has an integrative overlay, they will say, ‘You are in the gray, but you can do better.’ And that will keep you that much further away from aging and chronic disease.”
Which is all great. But the big catch with holistic or integrative medicine is that the patient has to be involved, too. It’s relatively painless to shell out $199 for an initial blood panel. It’s another thing altogether to start exercising more, find foods with a lower glycemic index, and go back for another panel every four months to see how you’re doing, especially if you’re going outside the insurance system.
Kean knows cost is an issue for most people, which is why WellnessFX isn’t focused on signing up customers one at a time. Rather, it hopes most of its revenue will come from selling its testing services in bulk to large self-insured companies that offer wellness programs as part of their health benefits package.
But let’s say cost is taken out of the picture. That still leaves the problems of knowledge and motivation. I’m not sure that 15 minutes on the phone with a doctor is enough to help people extract action items from a big pile of numbers and charts. (To this point, Kean says that in the near future, WelnessFX customers will be able to pay for extra phone time.) But more importantly, the U.S. healthcare system simply doesn’t provide people with incentives to be more proactive about their health.
Kean is right that doctors are trained to be firefighters—and a big part of the reason our healthcare system is so broken is that they only get paid for putting out fires, not preventing them. But patients need to bear some of the responsibility too, and right now they don’t. If you’re insured, somebody pays you when you get sick, whether or not you ever bothered to exercise and eat right. Nobody pays you to go out of your way to get healthier—and I don’t see a lot of evidence, outside of granola places like the Bay Area, that people are proactively seeking ways to “stretch out the aging curve.”
Until those macro-level problems are fixed, I’m not sure that companies like WellnessFX will be able to thrive. At least, not in isolation. There are plenty of other companies, many of them right here in San Francisco, working to change the incentive system around health and wellness—AchieveMint, FitBit, FitnessKeeper, HealthRally, Healthy Labs, InsideTracker, Keas, Massive Health, Sessions, and Skimble are a few of the names that come to mind. Perhaps, by building on each others’ efforts, these startups may eventually be able to persuade patients, doctors, and payers that prevention really is the best cure.
Kean, for his part, is gung ho about his company’s chances. “In a perfect world, would a robust healthcare system have WellnessFX built into it? Absolutely,” he says. “But I have a lot of faith in American consumers, that if you give them the tools, they roll up their sleeves and tackle it. I don’t think it’s an intelligence issue, I think it’s a communication issue. If we can put the tools in place, and make them cheaper and more accessible, and make it okay to talk about prevention, that would be pretty good work.”
It would be good work indeed, and I hope Kean’s optimism is justified—but I’m still not giving up coffee.
Note to readers: I’m heading out on vacation, so there will be no World Wide Wade column on September 28 or October 5. The column will return on October 12.