In 2011, Sean Duffy and Adrian James sat in San Francisco’s Dolores Park discussing what to name some of the employees at Omada Health, the company they founded.
Omada, launched the same year, provides virtual treatment for chronic diseases. The company solves problems with a team of employees—some traditional clinicians and others dedicated to encouraging patients to manage their hypertension, prediabetes, and other conditions day in and day out. They thought this second group was crucial. The founders ended up asking the patients what name to use.
Was this man a “concierge”? The patients thought it sounded like someone had helped with their bills. Guidance? Where? The founders settled on “carriage.” Patients liked the term: it suggested someone who could provide support and help them “not feel alone,” Duffy said as they dealt with their health problems.
This decision was an early marker of a possible trend in technology companies. Since then, dozens of similar health coaching-focused startups have sprung up, often backed by big money. KHN’s review of press releases, the Crunchbase industry database and sites like LinkedIn found nearly 50 companies with nearly $7 billion in venture capital.
These startups offer people or software to provide motivation, direction, or moral support to manage what goes wrong with the human body, including chronic diseases, musculoskeletal disorders, obesity, and even attention deficit/hyperactivity disorder and eczema. Business models vary. Some startups accept payments directly from consumers; Wellory’s “anti-diet” app asks $45 per month. Other startups receive monthly per-member funding from companies to offer regular coaching to their employees. Some services access 24/7 and an average connection time of 60 seconds. In some cases, coaches refer serious problems to more established clinicians.
The enthusiasm for coaching is, at first blush, a curious twist for an industry that loves to show off its billion-dollar pills and super-sophisticated artificial intelligence.
“As these digital health startups got going, they realized that technology wasn’t enough to drive change,” he explained. Michael Young, managing partner of OMERS Ventures, who has invested in coaching startups. Patients may need to eat better, follow a physical therapy plan, talk through emotional turbulence, etc.
Coaches—whether human or software—can support patients between official doctor visits. This kind of encouragement can be important for adherence to a care plan, which is very important in a world where good habits go a long way to maintaining health. Whether a patient needs a team to help with the physical aspects of orthopedic surgery recovery or help avoid behavioral illness triggers, these coaching companies are on the app or website.
“The model has become very strict,” Yang said. In many startups, coaches “do the lion’s share of the work.”
However, many people in the healthcare industry are ambivalent about this trend. Some think it adds a human touch to the part of the economy that can be identified by offhand doctors and obscure bills. Others wonder if this is just a way to take advantage of cheap labor.
Proponents say coaches are actively involved, even performing tasks that would otherwise go unnoticed. “We need an alternative workforce to fill some of these gaps,” Omada’s Duffy said. At Omada, trainers have many responsibilities: they review glucose data, track changes in patients’ lifestyles, and can show empathy that other people in the healthcare system can’t. Coaches are “people who ask questions before making judgments,” Duffy said.
Health care for people with diabetes or other people with chronic conditions requires many more workers than the health care system has, Duffy said. So a coach, whose salary is typically in the tens of thousands rather than hundreds of thousands of dollars, looks like a solution for many startups.
“Coaching is a way to avoid the need for clinical licenses or FDA approvals.” Bob Kocher, an investor in Venrock, wrote in an email. “This allows you to start serving patients much faster.”
Coaches already play a role in established institutions.
Dr. Pushpa Raja, a psychiatrist with the Greater Los Angeles Department of Veterans Affairs, said colleagues play a prominent role in VA. Often people with the condition interact with veterans who have the same condition. “They may treat patients differently,” she said. “They can encourage patients on their way to the goal. They can educate patients on planning and strategizing.”
They are also teamed with psychiatrists and primary care physicians, which means they can relay observations – for example, if someone’s depression worsens over time.
Some health startup watchers worry that they don’t have that ability. According to trainers, trainers can “do a lot of little things that annoy” doctors. Liz Chiarello, a sociologist at St. Louis University in Missouri who studies healthcare organizations, but a surge in these workers could “further fragment our healthcare system.” A behavioral health coach at a given startup may have to take the problem to a psychiatrist or primary care physician, and it is often unclear if startup coaches have close ties to institutions that offer next-level experience.
Moreover, trainers may be poorly trained and may serve too many patients to be useful.
“I cringe when start-ups say, ‘We’re going to hire 100 people and train them for two weeks,'” Yang said. “You won’t learn anything in two weeks.” Training at some companies is “quite intimidating in its lack of rigor and depth,” he said.
Coaching qualifications may not be all they seem.
Wellory promises to put users in touch with a nutrition coach after they take the test. These trainers, in turn, offer users healthy food. But some quiz contestants, like Dr. Seth Truger, emergency room physician at Northwestern Medicine; and a KHN reporter – were matched with a trainer who described himself as “RDE”, which stands for “Registered Eligible Dietitian”. This is a term for dietitians who have fulfilled most, but not all, of the requirements required to qualify as a Registered Dietitian.
But there is no RDE professional designation, according to the Dietary Registration Commission, and anyone using it should stop “immediately.” The Commission is an attestation body Academy of Nutrition and Dietetics, a trade group for food and nutrition professionals. Wellory removed the link after KHN contacted the company about it.
Yang said some startups see coaches as almost a “call center model” and plan to hire dozens of coaches to support tens of thousands of patients.
Some startups do use small teams. Take Home-grownnew company just raising $20 million to support caregivers of the elderly or other patients. The company is committed to using a combination of tech tools and social workers to provide caregivers with everything from emotional support and connection to wheelchair and walker guidance.
David Grabowski, a professor at Harvard Medical School who specializes in aging and long-term care, said there is a huge opportunity for these companies to fill. Caregivers may be unsure of how to perform certain daily tasks, such as bathing or picking up patients. But in the same way, “it’s loneliness, it’s the feeling that you’re here alone,” he said.
However, Homethrive relies on a small workforce. The company serves about 20,000 members, according to co-founder Dave Jacobs. It currently employs 40 social workers who provide “episodic” support in “most stressful” situations, such as deciding whether to relocate patients to homes, Jacobs said. In everyday situations, he uses technology to connect patients to resources.
Grabowski has questions about such models. “I’m definitely wondering if 40 social workers are enough” to deal with situations like this, he said.
Coaching startups are a highly heterogeneous field. Yang said he’s seen startups doing well with coaching, but he’s not sure how the public is benefiting. “Are we doing the public a good service at the end of the day?”
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