This is Janae Rideau, co-host of the Pulse podcast by Wharton Digital Health. Today’s guest is Marina Tarasova, co-founder and COO of Paloma Health, the first and leading virtual clinic modernizing thyroid care. Paloma’s model offers holistic care for hypothyroidism and Hashimoto’s, reducing the cost to treat these patients by over 60%. Paloma patients are thoughtfully guided through at-home diagnostic testing, personal treatment plans and lifestyle coaching. With their full stack approach, Paloma’s seen better outcomes and patient satisfaction than traditional brick and mortar clinics. They’re also drastically cutting the time patients have to wait to start treatment. Marina started the company with her co-founder Guillaume Cohen Scali in 2018, after Guillaume witnessed the life of one of his best friends upended by years of misdiagnoses and doctor visits searching for the proper treatment. Prior to Paloma, Marina advised large healthcare clients at BCG as a knowledge expert, led medical business development at Capsule Pharmacy and worked on some of the most successful drug launches across the biopharma industry. Paloma raised their Series A earlier this year, bringing the company’s valuation to $26 million. With the investment, they’re continuing to build towards their goal of becoming the leading thyroid care experts and highlighting the importance of personalized thyroid care. Welcome to the show, Marina. We like to start every episode with the same question. So keeping with tradition, when you were a kid, what did you want to be when you grew up? Such a fun question. I wanted to be a doctor when I was growing up. I had a really, a really caring doctor that would come to my house. I grew up in Moscow in Russia, and it was pretty common for doctors to visit people in their home, which is, there’s something really wonderful about that. And I had like some weird kidney things growing up that ended up just totally correcting themselves. But she was really closely involved in helping my parents navigate all of that when I was little. I just remember wanting to be like her, being able to go into people’s homes and help them out as a physician. Having her visit you at home and guide your family through that process must have been especially comforting as a little kid. I’m sure a lot of our listeners can point to an inspiring moment with the clinician sparking their interest in the healthcare industry. What drew you closer to digital health over the years? I was pre-med, and I was going to college with sort of the dot-com era, and I was sort of lured by the ability to make a lot of money right out of college being in technology. And so I sort of switched my major to information systems and computer science. Medicine just felt too daunting, and as the daughter of immigrants at the time, I really prioritized being able to make money right out of college and pay back my college loans. So medicine just went away, but I’ve, you know, through my work history and now through Paloma, it’s a kind of funny full circle being able to not be a doctor, but work closely with physicians to help deliver care and ironically in the home as well. So weirdly came full circle for me that way. Definitely full circle. So did you have long-term plans to start a company prior to Paloma, or was it truly right time and right problem to solve? Yeah, for the most part of my career, I’ve worked in large organizations out of Wharton. I went to work for Johnson & Johnson. I did a leadership program, worked up, I mean, it’s a massive organization. I think they have like 20,000 people. I was in biopharma. After Johnson & Johnson, I went on to another big biotech company to launch a drug on the market. I wasn’t really having startup dreams at that time, but I was sort of like reflecting after many years in biopharma and just really excited about where digital health was going. And with my undergrad having a computer science background, I wanted to kind of contribute to that, you know, exciting growth in digital health. And I joined an early stage startup at the time called Capsule. That was a really fun and interesting view and like building in the healthcare industry and modernizing a pretty antiquated part of healthcare, which was the pharmacy. That’s when I really started to say, yeah, I think I want to really build in this space. There’s a need for fresher and better perspectives for the patient. So I was really motivated by building something with the patient first in mind. A lot of times in healthcare, I find that we’re, you know, we’re thinking about how do we save money for the payer and how does a big health system make different arrangements and the patient ends up sometimes falling through. That was my motivation. It was really after a number of years of being out of Wharton and having different jobs at large companies that I had this dream, if you will. And then a bunch of stars did align. Well, speaking of stars aligning, how did you and your co-founder, Guillaume Cohn-Scali meet? Guillaume, we call him G. He actually reached out on LinkedIn very funnily, which, you know, a lot of times we get LinkedIn outreach and we might not even pay attention. But this one really stood out to me because he’s like, I’m building something in the thyroid space. And G was an entrepreneur and a VC in New York. He saw that I had some experience in the thyroid space and I was like, let’s, let’s chat. And so we had, you know, we’d met a bunch of times. I was at Boston Consulting Group at the time, advising large healthcare clients, but really dreaming and thinking about kind of what could be built in healthcare that would really move the needle. That’s where, you know, G had the idea for an at-home care model for thyroid care. What was it about thyroid care that motivated you to take that jump and build Paloma? One of the things I did early on in my career way before Wharton was actually, I was a drug rep and I worked on this main medicine for thyroid care called Synthroid. And I just saw how thyroid care has to be pretty nuanced. And a lot of times it’s not delivered in a very nuanced way. It’s actually delivered in a very one size fits all way. And as a result, a lot of people, mainly women, end up kind of really not getting the best care and living every day with a bunch of symptoms, mainly fatigue, weight issues and brain fog, and just not being able to find the right care. Primary care doctors are really busy, obviously, and have a lot of very serious conditions that they’re managing. There’s a huge shortage of endocrinologists in this country, and they’re really focused on diabetes. Thyroid care just ends up being this thing that kind of got left in the middle. I just saw it as a great opportunity. The market was also, frankly, quite big. There’s 25 million people on thyroid hormone, it’s a $35 billion market, it was perfectly amenable to virtual care, and no one was really attacking it in this way. It’s not often that you get to build and be a first mover in a market. We’re really excited to be capitalizing on that. Definitely. I saw recently that the American Thyroid Association estimated that 20 million Americans have a thyroid condition, and then 60% of those individuals don’t know they have the disorder. With that many people struggling every day, but not getting the right treatment or diagnosis, it makes what you’re building even more meaningful. Thank you so much. American Thyroid Association data is interesting because I think they’re getting it from epidemiologic data, but we know from prescription data that 25 million, just about, Americans take thyroid hormone, so it’s more than 20 million are actually diagnosed with hypothyroidism. There’s a bunch more that are undiagnosed, there is an undiagnosed issue, but the numbers are even more staggering than what is found from the ATA. Can you give us an overview of Paloma? What services do you provide and where are most patients in their thyroid journey when they come to you? Yes, I’d love to do that. Paloma Health is a, you can think of us just like a regular doctor’s office. We only specialize in hypothyroidism and Hashimoto’s. That’s really the bulk of the volume of thyroid care. What ends up happening to the thyroid is either it can start to produce less thyroid hormones than it should or more, and that would be hyperthyroidism. That’s very serious and happens to a small percentage of people, but more commonly and more commonly certainly for women is hypothyroidism. Paloma is a clinic for helping those patients manage their chronic condition over time. Patients can handle everything related to their care from home, so that’s lab testing. We send a test kit to their home, to prescription and actual doctor care, so our physicians provide care to these patients in a synchronous and asynchronous modalities from the comfort of home. And then we also believe in holistic care for the thyroid, so it’s not just about lab testing and providing you prescriptions, but it’s also about looking at the dietary lifestyle and nutritional components of your care that they have a big impact on overall wellbeing, but they particularly have an impact on thyroid health. And this is really where we’re innovating above and beyond the standard of care because in traditional system, when you go visit your doctor, there’s just not a lot of time during those visits, oftentimes, unless you’re maybe seeing a concierge physician, to really go through into detail about what you’re eating, are you getting enough nutrients for your thyroid health, for your thyroid hormone conversion to properly happen. So the nutritional and lifestyle piece is really where we’re adding a lot more value. You mentioned your focus on hypothyroidism specifically. Could you share a little bit more about that strategy? Does the complexity of treating the disorder play into that decision? Yeah. So hypothyroidism specifically is typically managed with monitoring labs and prescribing thyroid hormone to really kind of augment the thyroid hormone that your body stops producing for whatever reason. There’s a number of reasons for that. And so being able to do that, looking at lab numbers and prescribing thyroid hormone medication is perfectly amenable to be done from home. It’s sort of a no brainer and we’re able to capitalize on that. The majority of hypothyroidism is actually caused by an autoimmune condition. And that’s really not being addressed by prescribing thyroid hormone to folks. So that’s really what we’re doing. And there are a lot of coexisting things that do happen. So that gets a little bit tricky. We’re really the specialist focusing on optimizing thyroid hormone health. And when you do that, you improve a lot of things. You improve a metabolic profile for a patient. Certainly cholesterol improves. Some hypertensive folks see a lot of improvement. We actually see a reduction in BMI in our population and I’m sure the audience listening here will know all of the benefits that go along with reducing BMI in a population and all the costs associated with that. We certainly help the overall cardiometabolic profile by improving thyroid health. We don’t claim to do it all though. So we’re not, you know, we’re really the specialist that really does thyroid hormone replacement well and with a lot of nuance and personalization and addressing it from a holistic perspective. Right. And by focusing on quality, highly personalized hormonal replacement care, you’re solving the root cause of so many of the patient’s problems. Within the holistic treatment, where does the nutrition coaching fall in and how is that integrated to the medication treatment plan that the patients are on? Yeah, it’s really multifactorial there because like we talked about, the largest cause of hypothyroidism is an autoimmune condition. So we’re not treating the autoimmunity whatsoever. There’s really no medication for Hashimoto’s disease, which is the autoimmune condition that leads to a lot of hypothyroidism. So really the best we can do today is lifestyle modifications. The hypothyroid population that we see is really symptomatic. The degree of fatigue and brain fog and weight issues and just an impact of quality of life is pretty severe when patients come to see us. If we’re able to help them make a dent into the symptoms and we can do a lot of that through nutritional therapy, then the patients have a better quality of life. That’s where it’s really making an impact. Oftentimes, not all the time, but we do see some patients are able, certainly if they’re able to see a BMI reduction or a reduction in overall weight, they’re able to reduce the need for thyroid medication. We don’t claim that we can take patients off thyroid medication or cure this condition, although that would be a nice thing to be able to say in the future, but if someone needs thyroid hormone, they might likely need it for the rest of their life. But we have seen some patients be able to completely go off thyroid hormone and some patients reduce the need for thyroid hormone when they do the full suite of nutritional and lifestyle augment changes. So that’s really wonderful. Given how many symptoms that hypothyroidism can have, how does Paloma monitor patients’ ongoing progress once they’ve started treatment? Yeah, great question. We built a pretty wonderful app for patients. If anyone’s curious, I really would love feedback. If anybody wants to download it, it’s completely free on iOS and Android, but it’s a patient app where they’re monitoring their symptoms and those symptoms go back to our physicians and our health coaches for action. It’s great that those progress updates feed directly to the health coaches since the coaches are such an integral part of your model. Given the many psychological symptoms that are often reported with hypothyroidism, how does Paloma’s model address and monitor patients’ mental health? Mental health specifically, you call out. There’s a huge mental health issue obviously in this country. Thyroid conditions are a small part of a kind of tangential relationship there. About 60% of thyroid sufferers do have a concomitant anxiety and depression and sometimes it can be ameliorated with better thyroid care. Sometimes it’s completely separate. So we really focus on providing optimal thyroid care. Sometimes we are navigating folks that have unresolved mental health issues to the right provider. So our care management team will help get them to the right form of care, but we’re really focusing on getting ultimately their other symptoms related to thyroid care improved. I mentioned before fatigue is a big one. Certainly if you don’t have energy to get through the day properly, we hear people, you know, women mostly saying, you know, I have to take a nap at 3 p.m. I can’t finish my job. I can’t like spend the day like this. That leads to mental health issues. So if we’re able to improve those symptoms, mainly fatigue and some BMI issues that people are having, there can be improvement on the mental health. So we are monitoring that. We’re not claiming to solve mental health issues, but I think we make a small but mighty dent there. It’s a really multidisciplinary problem that requires a multidisciplinary approach certainly. You mentioned the role Paloma’s care managers play in helping to get patients to the right provider when they have unresolved mental health needs. Related to care coordination, how does Paloma connect with patients, specialty providers, and PCPs to coordinate? Yeah. So just like a traditional doctor would, after every visit, we’re sending a really detailed summary back to the primary care physician. And then when we work with self-insured employers or in other ecosystems, they have very specific mental health providers that they work with. And so it really depends by partner how we’re able to share information and actually share data back with the various mental health providers. So it really is partner dependent. But whenever we can, we’re available. Our doctors will get on phone calls if needed. We’re sharing notes, just like just a clinic down the street would do. Definitely. As we’re seeing the rise of specialty virtual care clinics, it’s great to see the patient-first focus as you all coordinate across care organizations, specialties, but also EHRs. How do you expect the physician shortage, especially endocrinologists, to impact Paloma’s model in the future? Yeah. There’s a real shortage of endocrinologists. It’s growing. It’s one of the specialties that have the greatest need, especially with the obesity epidemic, the diabetes epidemic. We actually get a lot of inbound from endocrinologists who are, frankly, burnt out. I mean, they’ve been working really hard on these very complex diseases. And honestly, they’re the lowest paid specialties. Things are breaking in that specialty and really should be addressed. So we’re getting a lot of inbound from endocrinologists who are seeking virtual work, and they can do it remotely or part-time even. We’re able to sort of, I guess, capture some endocrinologists that way. But really what we’re doing is leveraging other specialties. You don’t need to be an endocrinologist to deliver really exceptional thyroid care, but you do need to be up to date on all of the various medications, on all of the various links to other systems. It’s a very complex system, obviously. And so we hire integrative health physicians. So a lot of times they’re family health and integrative health board specialized. Some of our doctors have gone through a functional medicine training as well, which is very amenable and sort of aligns with what a lot of our patients would like in their thyroid care journey. So we’re evidence-based, but we’re going beyond kind of what the American Thyroid Association guidelines necessarily say in terms of providing holistic hormone management. So we’re augmenting endocrinologists with integrative health physicians. We’re also bringing on some really talented women’s health nurse practitioners to help us manage the volume of patients here. And we’ve amassed a whole host of research and sort of our proprietary kind of knowledge around treating this condition and educating patients and doing a multidisciplinary approach with coaching and nutrition counseling to really help move the needle. But yeah, we wouldn’t be able to do it with just endocrinologists alone because they’re really in great need out there. And right now, what does reimbursement look like at Paloma? Are payers covering these services or are patients paying out of pocket? Yeah. So we started really early on, almost at the founding of Paloma to apply for payer contracts to be an in-network provider. We knew that we didn’t want patients as much as possible to have to pay out of pocket. And we knew it takes a long time to get there. Right now, we have about 60 insurance contracts across the country. We’re seeing patients in 40 states. We’ve expanded to being able to cover about 80% of the US population. About 36% of people who see a Paloma health doctor have been able to successfully use their insurance to get that covered through their insurance plan, which is awesome. Our goal is 80% by the end of the year. So we’re expanding quickly on the insurance side, but we also have a few other products. So we have at-home testing, which is currently covered by FSA and HSA dollars. We have nutritional consultations, which is right now out of network. So a lot of our patients submitted for out-of-network coverage, but we’d love to see that being moved in network. Patients are also paying a membership fee. That’s cash pay right now. What we’re doing with payers is saying, hey, we have this whole suite of at-home thyroid care offering. Let’s look at what you’re spending for your population today in managing your thyroid care population. So that’s all the labs, all the prescriptions, the doctor visits, et cetera. And how can Paloma do that for you? It’s a much better member experience. Well, what does the current member experience look like and what are the benefits that their members would get from going to Paloma rather than a traditional provider? Patient dissatisfaction is so high in thyroid care. The American Thyroid Association did a really large study of 12,000 patients and they asked their frankly satisfaction with their current thyroid care. It was abysmally low, so an average of 5 out of 10 was the satisfaction that patients gave. The way that we’re currently treating thyroid patients is not adequate for a number of reasons. Patients aren’t satisfied. There’s actually scientifically reasons to kind of move the needle on how the standard of care is offered in a lot of cases without getting into too much nuance. We have a really nice story for payers to say, we can do this in a much more convenient way, deliver better quality and a really, frankly, much better member experience. In addition to the member experience, is there an ROI for the payers? Yes. So we always have to talk about ROI when we talk with payers. And so we look at the commercial population right now. That’s really where we’re starting. If you look at the diagnosis codes associated with care offered for a hypothyroid population, an average commercial plan is spending about $2,500 for managing a patient’s thyroid care in the mix of primary care and endocrinology care. That’s with how thyroid care is delivered today. Paloma Health can get it down to about $800 or $900 and do a much better job and deliver excellent outcomes because we’ve sort of, this is what we do. This is our specialty and we’ve really honed every aspect of this care in addition to providing holistic aspects of it, which are totally absent, largely speaking, from that $2,500 that payers are paying for today. Bringing costs from $2,500 to $800 is an amazing feat and clearly a testament that the model is working and people are responding to it and the patients are engaging. Could you share a little bit more around what customer acquisition has looked like? Has that changed since you’ve brought the payers on board? So we’ve been acquiring customers direct to consumers solely. So payers are definitely adding to the mix there. So we like to have a really well-rounded sort of customer acquisition strategy. We think that to be the number one thyroid care provider in this country, you need patients to know about you and you need payer coverage to be able to kind of pull through a lot of the patients. And so both of those sort of strategies have to work together. They’re both very different strategies, of course. We started direct to consumer. We’ve now kind of honed that engine pretty well. There’s ads, there’s organic acquisition that happens. We have a really nice mix there of initiatives. On the payer side, certainly there’s no CAC. There’s just a really long sales cycle and having payers pay attention to the fact that thyroid care is actually a really important driver of health outcomes and health costs in their population. That’s really the bar there. So it’s not to say it doesn’t cost dollars, but it’s a different equation when you bring a payer on board. Over time, I mean, the majority of our growth is going to come from those payer relationships. So we’re really excited to continue to do that, but we’ll always keep the direct to consumer engine on. It’ll actually complement the, you know, when we launch with a new payer, being able to tell patients that what Paloma does and that it’s actually reimbursed by their plan is going to help convert that much better. So what’s on the horizon as you continue to build Paloma in 2023? Yeah. So over the last three years, we’ve been doing a great job at building our model, launching it in direct to consumer fashion. Patients are finding out about Paloma through search, through various wellness partnerships that we have, through dieticians and health coaches. We have a whole ambassador program and just a variety of direct to consumer efforts. And sort of what’s on the horizon for us is growing with payers and actually making sure that patients don’t have to pay out of pocket for really excellent thyroid care, which is what’s happening today. We’re building our partnerships with insurance companies like the various Blue Shields, United, Aetna, Cigna, and Humana to really increase access to this care that’s so greatly needed out there. We’re also working with some self-insured employers who want to provide great access to innovative models of care for their employees. And lastly, are you currently hiring right now? We are hiring. We’ll be looking at bringing on an MBA summer intern. We are hiring on the health coaching side. We are going to be looking for a chief operating officer and really across the board. So just keep an eye out. We tend to hire off of LinkedIn. So that’s really where all the latest job posts will come. I’m sure our listeners are excited to follow along as the team builds the future of thyroid. All right. Thank you for joining us, Marina. Thanks so much. This was so fun. Thank you.
