Investing in knownwell

Nearly 2 in 3 Americans have overweight or obesity; over 40% struggle with obesity. Our adolescents aren’t spared: 1 in 3 children have overweight or obesity, and over 14 million children and teens are currently living with obesity. And the annual excess medical expenditure attributable to obesity is >$170B. There is perhaps no bigger healthcare market opportunity than obesity care.

Indeed, obesity may be our country’s single greatest healthcare challenge. Overweight and obese conditions drive immense patient suffering, comorbid conditions ranging from cardiac disease to osteoarthritis, and tremendous cost to our already struggling healthcare system. New and highly efficacious drugs (yes, GLP-1 receptor agonists, but also an emerging pipeline of additional novel therapies), advances in behavioral science, and a rapidly evolving obesity medicine evidence base has contributed to a surge of exciting innovation in the field. A welcome boon for patients!

So what is missing? And what do patients and providers still need?

A medical home for metabolic health

Patients fighting overweight and obesity are systematically underserved (sadly, often overlooked or even ignored) by both our primary care and specialty care delivery infrastructure. Some patients may benefit from short-term weight loss programs; but the evidence is mounting that a majority of patients with overweight and obesity need a longitudinal, evidence-based, deeply clinical, and compassionate medical home. This home might ideally live somewhere in between traditional “primary care,” and the “specialty care” (e.g., endocrinology, cardiology, nephrology) offered by most health systems across the country. You might call it specialized primary care, or a specialty wrapper around primary care since obesity care and primary care are often so tightly intertwined. It is a single place where patients can access almost everything they need to improve their metabolic health.

This medical home is exactly what knownwell is building–and scaling. Through a hybrid virtual and in-person care model, knownwell offers both primary care as well as longitudinal specialty care, inclusive of weight management, diabetes care, medication (and side effect) management, multi-disciplinary nutritional counseling, and behavioral health services. knownwell navigates complex step therapy, brings repeatability and automation to critical processes such as prior authorization, and is building an ecosystem of clinical referral partners (both PCP referrers and providers such as bariatric surgeons to whom knownwell patients may need downstream referral) in every geography where we launch.

The vision? To deliver precision medicine at scale for patients with obesity, matching the right patient characteristics to the right, evidence-based treatment pathways. Their acquisition (announced today) of the technology company Alfie further advances this goal.

Founders with a personal mission

The knownwell founders Brooke Boyarsky Pratt (cofounder/CEO) and Dr. Angela Fitch (cofounder/CMO) are a perfect pair for the challenge they’ve accepted. Brooke started her career in the tech industry at Hewlett Packard and Google. She was a star student at HBS (delivering her class graduation speech), and grew quickly to become an Associate Partner at McKinsey and EVP and COO of Production at Berkadia. People who worked with her recall that Brooke was always someone with whom peers “desperately wanted to work”–and a powerful “cultural center” for the teams that she led. But perhaps even more important than her impressive background is the fact that Brooke has lived in the shoes of knownwell patients, struggling with obesity herself since she was young. Her journey to quitting her job and founding knownwell is chronicled in an HBS case study–and she shared the passion that she brings to knownwell in a podcast with our team recently. Hers is a phenomenally inspiring founding story.

Dr. Fitch cofounded knownwell from the clinical lens: she has dedicated her career as a physician to helping patients with overweight & obesity and is now a clinical leader in the space, having just wrapped up her tenure as the President of the Obesity Medicine Association, overseeing a time of significant growth for the organization. She first fell in love with the field while caring for children with obesity at the University of Minnesota; she then became medical director for the Metabolic Health and Weight Management Clinic at Park Nicollet before returning to Cincinnati (where she originally completed her clinical training) to create a new multidisciplinary medical and surgical weight center. Just prior to cofounding knownwell, Dr. Fitch was serving as Co-Director of the Massachusetts General Hospital Weight Center, where demand for the center’s excellent services was so high via referring physicians that thousands of patients had to be placed on a waitlist. She became convinced that we need a more scalable path forward.

Parallels to behavioral health: patient access, impact, value, and scale

The knownwell team is driven by both a personal and professional calling–to serve patients living with overweight and obesity, in a way that is free of bias or stigma. Their mission reminded us of the behavioral health space a decade ago: not everyone recognized mental health as a disease deserving of care, not everyone appreciated the true prevalence of disease, and not everyone understood the connection between behavioral health and many other medical conditions (and costs). But as these trends became better understood by providers, employers, and payors, enormous value creation (and patient impact) has followed.

Just as behavioral health has become a busy innovation sector, so too will obesity medicine. Entrepreneurs and investors in the behavioral health space have learned a few key lessons over the last several years, however, which I believe are all imminently applicable to obesity medicine, too:

• Start with access: Patient access is the first challenge to solve. Payors and employers are motivated to act when they face a pressing access problem for their members. Building these access points and solving the access problem is an entry point to broader collaboration with multiple stakeholders.
• Deliver reimbursed care: The vast majority of patients do not want to (and cannot) pay for their own care. In order to scale, care must be reimbursed by insurance plans, or employer-sponsored.
• Keep CAC low: Because patient demand is already so high, and providers are already so desperate to refer patients, CAC (the cost of customer/patient acquisition) can–and should–be nearly zero to support profitable growth. As Dr. Fitch saw at MGH, provider clinical referrals represent a “zero-CAC channel”–my favorite way to onboard patients!
• Grow into value: Finally, even if a company starts on ‘standard’ fee-for-service rails with an initial focus on enabling access, there exist many paths to earn “full credit” for your care. As a company demonstrates high impact and exceptional care quality, the ability to earn preferred fee-for-service reimbursement and value-based reimbursement can follow. And indeed, these can become important drivers of a differentiated long-term business model.

As the knownwell team has become better known to us, it is clear that they are building an enduring company with all of these principles in mind (and many more which I am sure we will learn together). I am delighted to have led knownwell’s Series A financing and serve on their board alongside some truly wonderful colleagues.

If you want to help solve our greatest healthcare challenge, please reach out or join us!

Thank you to Daisy Wolf and Annie Collins for their contributions.