This week I am talking to Avantika Waring, MD, Chief Medical Officer at 9amHealth who focuses on hands-on, everyday help with diabetes, weight loss, and heart health.
Avantika shares her career journey into health tech and the virtual diabetes care program at 9 am Health. She explained how they provide comprehensive wraparound care including physicians, nutritionists, health coaches, and more to diabetes patients across all 50 states.
We discuss the emphasis on flexibility to reduce barriers and increase access to care that includes providing audio-only phone appointments for seniors without internet access. We talk about ways the group has found to mitigate the inequities including efforts to diversify the care team and tailor care plans to individual lifestyles and cultures rather than mandating one strict regimen.
Listen in to hear us discuss the new anti-obesity medications, which have an important role for some patients but should not be viewed as a cure-all. As Avantika puts it “I don’t want the goal of these drugs to be that we’re trying to eliminate, you know, eliminate fatness from society.”
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Raw Transcript
Nick van Terheyden
And today I’m delighted to be welcoming Dr. Advent Tika wearing she is the Chief Medical Officer for 9am health Avantika. Thanks for joining me.
Avantika Waring
Thanks for having me. It’s a pleasure.
Nick van Terheyden
So as I do with all my guests, and I think specifically, in this case, especially important, tell us a little bit about your journey to this point in your career, why you ended up here, your your clinical course, as well, as you know, stepping out and doing some, you know, slightly different things, if you would, please. Yeah,
Avantika Waring
certainly, I think I had probably a slightly circuitous path into the health tech world. I’ll kind of start when I was growing up, my father is a physician in a very traditional sort of way, he had a fever service, private practice in New Jersey suburb, which is where I grew up. So I sort of always saw medicine as a really stable career, gave my father a lot of joy to practice. And he really enjoyed working with his patients. So when I went on to college, I actually majored in French, and then quickly realized that I was like, far too social to spend my life, you know, working on research projects in a library loan. So So I thought, well, I know I like science, and I like talking to people. So maybe I will do pre med, and ended up going to medical school, with a thought that I would go into one of the more cognitive fields, so I don’t like emergencies, I’ll just be upfront about that. So. So endocrinology really appealed to me, because there are very few emergencies, any of you who are familiar with the field, and most of them can be solved on the phone, which is also really nice. If you’re thinking about having, you know, work life balance in your future, went on to do my fellowship at UCSF, so kind of across the country, from the East Coast to the West Coast, and just spend a little bit of time doing research. And then really, I would say, life circumstances kind of pushed me into practice. So I had one child and then two children and was sort of like needed, basically, I needed to make money to support our family while my husband was finishing his training. So I took a job in a multi specialty practice, doing general endocrine. And I don’t know that it was exactly what I wanted to do at the time. But I’m so glad that I did it. Because I really feel like no matter what path you take, having that hands on clinical experience really sets you up for anything you’re going to do later. And for me, that was definitely the case. And, you know, I referenced my sort of clinical past, often in my work now. So I was practicing for a couple of years, and then started to feel these, like, the confines of doing the same thing every day, looked around a bit in the Bay Area for something different to do. So we were in the San Francisco area, just didn’t see the right fit. So at that point, my children at that point, I had three, and they were all still quite young. So we thought, well, if we’re gonna move, this is the time to do it. And that’s what brought me to Seattle, which is where I am now. And the move to Seattle was kind of the first non clinical job I had taken in the role was at the Kaiser Permanente region here, and the job was to run the Diabetes Program. So it was kind of an interesting shift for me, because I had never had a leadership role up to that point. And the person who hired me, you know, I still stay very closely connected with him, he really took a chance on me, I would say, because I’m sure he got a lot of other CVS for people who had done, you know, other types of management roles, and I hadn’t, but we just really had a great connection. And I really credit that for sort of where I am now, because it allowed me to sort of think outside of like, one doctor, one patient, one single interaction and start to think more on like a population health level. I know this is getting kind of long, but I was there for a number of years before I sort of realized that in the scope of that huge organization, I was definitely kind of facing some sort of stifling feeling like I didn’t know where I was gonna go next. And that’s when I started looking around kind of outside of the traditional healthcare environment, and got connected to one of the founders at 9am health. And what they were doing was very similar actually, to it aligned with the principles that that we had at Kaiser in Washington, and I got really excited about the idea of being able to do the same great work, but to do it faster to do it with more scope, and to really be kind of like the leader driving, driving the programs. And so that’s what brought me to the current position that I’m in. Well,
Nick van Terheyden
I appreciate that. And, you know, the first thing I’d say is Sacra blue as Kanzi Dr. forsale. As my listeners will know, we could launch into a little bit of French but that would just upset it all. For a lot of people, and I suppose my poor, poor memory of it from my background, and clearly, you know, extensive career, and obviously that sort of, I’m going to call it shift into a specific area in endocrinology with the diabetes or diabatic. I say it differently every time it’s, you know, the mix of British and American in me. And then moving into a company that sort of focused in that, tell us a little bit about what’s going on at 9am health, because that really sort of underpins a lot of the discussion. Yeah,
Avantika Waring
so we run a virtual cardio metabolic clinic that’s truly end to end. So it’s very similar to functioning as a consultant, you know, and I like to translate this in case there are sort of clinician listeners that this is, I think, the best way to describe what we do. We have a comprehensive program that includes physicians, specialists, dieticians, health coaches, pharmacists, nurses, and basically, it’s imagine like the clinic of your dreams, and then put it into a virtual space so that anyone can access it. And we do coaching and lifestyle change, but also medication management all virtually, and using a lot of different modes of connection with the patient. So unlike, I think people think of virtual care as well, I schedule a video visit with my doctor, instead of an in person visit, we really tried to stretch that definition of telehealth to include kind of ongoing continuous care, remote monitoring, text based messaging, you know, secure message interactions with the patient, and then also having, you know, video visits and phone calls when we need that personal touch. So, so
Nick van Terheyden
I mean, it’s interesting, I was just listening to discussion on cancer care. And, you know, the prevailing insight that came across if you know, you’re unfortunate enough to endure cancer is you need multidisciplinary teams, you don’t need to go to the big ivory towers with specialists, you need to go to an institution that brings all of those teams together. And it sounds like that’s what you’ve done. Is it confined to I mean, I know virtual allows you to extend outside of the state. And, you know, we briefly realized during the pandemic that, you know, clinicians could practice across state lines. I think a lot of that’s been pulled back. Are you still? Where are you on that in terms of being able to extend the service, because obviously, doing that allows more people to access it, right.
Avantika Waring
So we’re available in 50 states, and we do continue to practice broadly, our physicians are licensed across all the states. And some of the other scopes of practices have different requirements about where they need to be licensed, some can practice in states where there isn’t there’s no licensing procedure, for example, for dieticians. So it can really vary, but we kind of are very closely watching all the legislation and sort of adjust our policies and our staffing and hiring to align. But the goal really is to be able to provide the same level of care no matter where the members living. And one of the things that, you know, just resonates with me, when you talk about going to the ivory tower versus having the multidisciplinary team, I think you should be able to have both. And that’s really what we aim to provide, right, we have top level specialists who have been trained at all the, you know, the best academic centers, and we utilize them as consultants to really drive those multidisciplinary teams. So let’s say you live in that rural area where maybe there is a world class specialist in the field of diabetes or obesity management, but they are four or five hours drive and they have a six month wait for an appointment, you can get access to that specialist through our service, not that specific specialist. But to that, that type of care. But also getting all these other kind of wraparound services that are often lacking. I mean, I can speak from personal experience, it’s really challenging as a physician, nowadays to staff up a clinic with all of those resources in any kind of financially viable way. So a lot of times what happens in the traditional system is you’ll see your specialist, then you’ll see your primary care, you’ll get a referral, you’ll go see a nutritionist, they’ll get a referral to go see, you know, lifestyle coach, and it’s just ends up being quite fragmented. And our goal really is to bring all of that care under one roof for the member just as conveniently as possible. So
Nick van Terheyden
one of the other things that really strikes me about this is that, you know, as you bring all of those resources together in a virtual setting, that obviously opens up the opportunity, particularly in the rural setting where you know, that remains Whoa, fully under served for lots of very good reasons and some not so good reasons. So you’re able to expand. But one of the challenges with that is connectivity access, even in the virtual setting. How are you addressing that? Because that continues to persist, at least in my experience? Yeah,
Avantika Waring
no, you’re completely correct. And there are millions of Americans who lack broadband access to this day, which is, you know, I live in Seattle. And it’s, we’re like one of the most tech forward cities in the country. But practicing here, I don’t know if you’ve been to Seattle, but we have all this water around us around the city. And if you kind of crossed the water, and then go into some of the areas, they become quite rural very quickly. And that’s something we struggled with here in my practice, before coming to 9am, as well, that there were just folks who didn’t have access to the internet. And so it remains an issue and a barrier. And I would say that the way that we address that is by being super flexible about the way that we connect with folks. So of course, we have an app, you know, we have a website, we also do a lot of audio only telephone care. So we have folks, especially seniors who have a landline. And if we’re you know, we’re working with a Medicare Advantage plan, so we’ve been connected with them through care management, we’ll walk them through on the phone, the steps that they might otherwise do, by themselves on an app to make it just more analog for them. The other thing I’ll say is that most of our care can be successfully navigated with a cellular connection. So you don’t really need to have video call bandwidth, like we’re doing right now. You know, just being able to text or make a phone call or send a message through your cellular connection will give basically give us all the information that we need. So that’s, I think that flexibility helps us to meet people who have kind of less robust technology capabilities as well.
Nick van Terheyden
So for those of you just joining, I’m Dr. Nick the incrementalist today I’m talking to Dr. Advantech. Here, wearing she is the Chief Medical Officer for 9am. Health, we were just talking about the distribution and the capacity to sort of include as many people as possible, you know, from a technology standpoint, trying to be as multimodal in terms of the channels that people access. The other thing that, you know, continues to sort of persist particularly in, you know, areas of sort of chronic illness and diabetes, obesity, you know, particularly, I would say is the racial inequities that continue to persist? How are you managing to address some of that?
Avantika Waring
That’s a great question. And I’ll just start by saying that, like, you always have to be humble about this, we do the best we can. And there are just so many underlying factors that make it really challenging to close those equity gaps. One of the things that I’ve been very intentional about since joining is really thinking about our care team. So we were very, I would say, it starts with the staffing our recruitment and hiring processes, we really look to try and hire folks who have a broad scope of experience, whether it’s a specific racial background, or a language ability that’s lacking from our team, or just personal experience and immigrant background. disabilities are different a boldness, LGBTQ plus. So I think creating a care team that has representation from a lot of different groups helps us to deliver care in a way that’s more inclusive. And I would say that’s not necessarily that we’re insisting that you’re matched up with someone who kind of aligns with your identity, but it kind of seeps into the whole culture of the group. And so I would say, that’s one of the things that’s really been important to me, and our team since we’ve started. And the next thing I’ll kind of move to is that we really try and I said, keep saying flexible, but I think when you’re talking about conditions that require lifestyle changes, and specific changes to the way that you’re eating and interacting with the world, if you’re not flexible in a culturally inclusive way, you’re just not going to have success. So we do not, with our nutrition programs, specifically kind of focus on one style of eating or you know, one thing that you have to do or one thing that you cannot have, instead, our our aim is really to give people options that will work within the lifestyle that they’re already living, because that’s why people stick around, they remain engaged and they feel understood, and then they’re more likely to take the next steps. The other thing I’ll mention is when we’re talking about telehealth, some of the data shows that actually, you know, contrary to what you might think you’re even during the pandemic, the groups that use telehealth most frequently we’re not what You would imagine to be sort of your higher socioeconomic, mostly white patients, there’s actually a lot of telehealth use amongst non English speakers, the bipoc patients focus on public insurance like Medicaid and people in lower income brackets. But the difference was that they were far more likely to use audio only or message technology as opposed to video visits. And we could probably spend a whole hour talking about some of the reasons that might be. But I think that by providing this multimodal access, that’s not we don’t have any requirements about how you have to interact with your care team allows a much broader group of individuals to want to engage and to be able to kind of stay connected with us as a health system. I mean, I think when you think about the way reimbursements work in the US, we still have a lot of trouble getting reimbursed for non video visits, non live video visit telehealth. And that, you know, for whatever the reason is, it’s beyond the scope of this conversation. But it really creates a lot of inequities in the system. When it comes to accessing telehealth, I mean, think about to do a video visit, you need to be able to take time off work or have time to yourself, you need a private, relatively quiet space to perform this visit. And you need to have a high speed internet connection or really good, good signal in order to do that. So if you’re a person who lives in a multi generational family, where are you going to find the time you know, you’ve got your grandkids here, and maybe you’re sharing a room with a couple people, it’s not really realistic to be able to set up and do that. So we really feel that by being flexible on how we interact with patients is far more inclusive than sort of the traditional vision of telehealth that people have,
Nick van Terheyden
you know, so many incremental points in the you know, finding a team that’s as broad and diverse, you know, walking a day in the shoes, it’s interesting, you bring up that issue of, you know, finding an opportunity to sort of interact, and I heard this in one of my other shows, you know, talking about brain health, mental health, you know, and individuals that essentially get into their car to find that opportunity, privacy, because they had no, I mean, just, you know, unless you have that experience, or you’ve heard it, at least, you have no concept to sort of process it. So it sounds like some great, you know, opportunities, you know, making inroads to be clear, not always easy, and, you know, full of lots of challenge. And, you know, as you said, being humbled through that, we’ve, we’ve seen a lot of activity and, you know, let’s not sort of conflate diabetes on its own has its own set of issues. But we’ve now seen a whole new drug set of structures arrive, that I, you know, if you believe the headlines are essentially going to solve the problem. You know, there’s a footnote to that, only if you can afford it, I think. I’m curious to know what your thoughts are on how this might bring potentially some relief, or is it? I mean, I have to see it as positive, but it’s not quite the panacea that some folks are making it out to be. That
Avantika Waring
so we’re specifically we’re talking about anti obesity medications and classes of the GLP. One, medications. So I think the way you’ve summarized it is a positive thing, but not a panacea that probably should be put on a billboard, you know, on this, I
Nick van Terheyden
don’t know, if I get paid for it to be,
Avantika Waring
you can collect the royalties for that. But I really think, when have we ever, in life or in society found something that was so good that it solved a problem, you know, uniformly and that way? I can’t really think in medicine, there’s hardly any example I can think of maybe Hep C treatment, you know, is probably an example that. But yeah, I mean, as an endocrinologist, we’ve been using these drugs for a very long time, actually, for the treatment of diabetes, type two diabetes, and they can be incredibly valuable in that setting. It sort of started off like, well, one of the side effects is that people do lose weight, and that can be really helpful as well. I think, in the new world that we’re living in here, there these drugs, they have a role for sure there are people who are suffering incredible complications and health outcomes because of weight that is very challenging to lose and I, I fully appreciate that. We’re shifting our kind of model of how we think about obesity. To be less, it’s not a choice. It’s not a, you know, a lifestyle failing, it is a medical condition that some people are genetically far more prone to. So if we have a treatment that can help someone avoid or reduce a serious complication, then of course, we’re going to want to utilize that. But I think the issue that we come across is when we think about them as specifically weight loss drugs, then we’re focusing on something very specific, which is weight. And weight is usually defined as like your number on the scale or your BMI. And I, I really struggle with this, because I really want people to feel that no matter what their body looks like, it’s accepted. Right? And we were all allowed to be a different shape and, and size and color. And so you know, I don’t want the goal of these drugs to be that we’re trying to eliminate, you know, eliminate fatness from society. That’s absolutely not, I don’t think that would be a good thing. That would be the opposite of inclusive. Right. So I think the, the, the way I think about these drugs is they’re highly useful in certain situations for the right patients, and other folks, I think it’s really important that we explore all the possibilities of what else we can do to help them avoid developing those metabolic complications before they happen. And this comes down to you know, okay, tell someone to eat healthy. But it also goes back to your your kind of inequity issue. How do we get them food they can afford that’s healthy? You know, how does our we can start with that. Right, right.
Nick van Terheyden
And so we saw with $1,000 drugs that Exactly,
Avantika Waring
yeah, I mean, organic, healthy food is expensive, but it’s still cheaper than what go fee. So, but I think we do a lot of things with our team. Just trying to find options to improve somebody’s health through lifestyle means that fit within their budget, too. We have this joke at our office that all of the Healthy Eating handouts and templates, a show pictures of quinoa and salmon on them. If you live in the middle of a country, if you’re on a fixed budget, if you culturally do not eat salmon, and quinoa, that’s just not going to resonate with you and talk in and help you, you know, make your diet healthier. So thinking about either more affordable options, we have resources to help people navigate how to eat healthy out of a convenience store grocery, we work with a lot of folks who are have life on the road, so drive trucks or commercially drive for a living. And that was a big question that they had was like, Well, how am I supposed to eat healthy when I’m eating at the, you know, the gas station, that for most of my meals? And so like we went out to one of those gas stations and looked around to see what could we put together that would be healthy for that individual? So I’ve kind of deviated from the topic of the GLP. One. But you know, it’s a really complicated situation. And I think, we don’t know, honestly, what, what will happen in 20 or 30 years. If you remain on the drugs for that long, you know, likely you’ll have a plateau. And then the question is how, how do we maintain that weight loss? You know, we just don’t know, it’s really early to say.
Nick van Terheyden
So, first of all, I’m just going to say a plea for me. And you know, pretty much a bunch of other people that those guidance. Documents that you talk about, would be fantastic for road warriors, and I was a road warrior. And you know, still to this day, the idea that you can find healthy eating, I’m just fascinated to know what’s in there. So that’s, that’s really good news. I hope you’ll share those. But as you think about the future, I mean, there’s lots of things going on. What are you excited about? What’s what where do you see all of this going? It seems like you’ve made some real substantial progress. But what what’s coming and what are you excited about?
Avantika Waring
So I would say on the GLP, one front, I’m excited about having more data and a better understanding over the coming years to really be able to develop good plans where we can identify who’s really needs these drugs, who’s going to benefit from them, and where is it either not kind of worth the investment of time and energy on the patient side, and we’re another method, you know, would be better. So that’s something I’m looking forward to. I think a lot of these unknowns are actually great opportunities for Future Learning, which is exciting. And I’m just excited about finding ways to spread high quality care to more people, you know, whether it’s through insurance partnerships through, you know, state governments, whatever it may be, my goal is that I want more people to be healthy, and to be able to feel empowered to manage their their conditions. So anything we can do to expand that is that those are my kind of my North Star at this point.
Nick van Terheyden
So we do have good healthcare. We do have of goodwill care. It’s just not evenly distributed. And I think you know, the opportunity to make that possible I think is a tremendous way forward. And unfortunately, as we do each and every week, we’ve run out of time. So it just remains for me to thank you for joining me on the show. Avantika thanks for joining me.
Avantika Waring
Thank you so much for having me. It was a pleasure.
