A Value-Based Path to Better Obesity Care w/ Elina Onitskansky, Founder & CEO, Ilant Health

Obesity is a pressing and complex challenge.

GLP-1 meds are a game changer, but on their own, they may just bankrupt insurers without doing a whole lot to improve health. Can we build a better system for weight management that's clinically sound cost effective and scalable?

In this episode of the HealthBiz Podcast, we’re joined by Elina Onitskansky, Founder & CEO of Ilant Health. Elina explains why the current approach to obesity care is broken and how Ilant Health is making treatment more accessible by making it affordable, available, and accepted through value-based care.

🎙️⚕️ABOUT ELINA ONITSKANSKY:
Elina Onitskansky is the Founder and CEO of Ilant Health, dedicated to enhancing access, affordability, and equity in healthcare.  Prior to founding Ilant, Elina was the Chief Growth Officer at Health at Home, SVP & Head of Strategy at Molina Healthcare, and an Associate Partner at Co-head of the Commercial Service Line at McKinsey.

🎙️⚕️ABOUT HEALTHBIZ PODCAST
HealthBiz is a CareTalk podcast that delivers in-depth interviews on healthcare business, technology, and policy with entrepreneurs and CEOs. Host David E. Williams — president of the healthcare strategy consulting boutique Health Business Group — is also a board member, investor in private healthcare companies, and author of the Health Business Blog. Known for his strategic insights and sharp humor, David offers a refreshing break from the usual healthcare industry BS.

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Transcript

David: 0:00

Obesity is a pressing and complex challenge. GLP one, medications are a game changer, but on their own, they may just bankrupt insurers without doing a whole lot to improve health. Can we build a better system for weight management that's clinically sound cost effective and scalable. Hi everyone. I'm David Williams, president of Strategy consulting firm, health Business Group, and host of the Health Biz Podcast, where I interview top healthcare leaders about their lives and careers. My guest today is Elina Onitskansky, founder and CEO of Ilant health of value-based obesity treatment company that strives to improve access and reduce costs. Do you like this show? If so, please subscribe and leave a review. Elena, welcome to the Health Biz Podcast.

Elina: 0:51

Thanks for having me.

David: 0:52

All right. So it's such an interesting topic. I wanna start though, uh, in the way back times and ask you about your childhood and what it was like, uh, growing up. Any childhood influences that have stuck with you throughout your career?

Elina: 1:05

I. Yeah, so I am actually, uh, you know, an, uh, an immigrant. So my family's from the former Soviet Union and we came over actually, uh, as refugees to the US when I was about six years old. And like anyone pursuing the American dream, I. We went straight to Cleveland, Ohio, because naturally, you know, that would be the first place, uh, that you would think of going. But no, I had frankly, you know, a great, uh, childhood in Cleveland. Um, as you know, Midwesterners, very friendly, very nice. Um, so, uh, you know, uh, great experience there. I would say, um, one thing that was always true is my family's very big into education. Um, and so that was just super core to what was important for them. Super core to our frankly, American Dream and a lot of what, um, you know, I attribute sort of my life to which is, you know, the power of learning, um, you know, gaining experience and being able to really sort of, uh, change what you're doing and sort of chart a course. Uh, so yeah, that's a little bit of my background.

David: 2:12

That makes sense. Well, the, the truth is that it, it may, may not have been obvious to someone coming from the former Soviet Union about what Cleveland was like, but it was obvious to the, uh, community leaders in Cleveland that they need to reinvigorate the place and they, uh, you know, they invested in that actually attracting people. So, uh, that was a strategic move. Yeah. I'll say I don't

Elina: 2:30

live in Cleveland anymore, but I will give it a plug, like great sports teams, great cultural locations, great healthcare. So, you know, it's a, it's a little bit under club. Um. Uh, city.

David: 2:43

Yeah. Good. Alright, so in terms of education, I think you got a couple of Harvards in your, in your background. Is that what I. What I had seen.

Elina: 2:50

Yeah. So I was, uh, part of that growing up. I was a giant science nerd, so I spent my high school years in the super cool activity of doing lab work. Um, actually ended up patented, uh, for a microsensor that I, uh, invented and then, um, you know, went on to Harvard, uh, as a chemistry major. Thought I would be, um, a research professor. Both. I am deeply practical, so I like things that actually like, have less than a hundred year or 40 year timeline to sort of real human impact. Um, and I also like people and they're, you know, like spending time and really sort of that extroversion factor. And so, um, yeah, uh, ended up sort of pivoting into that business world. Uh, but sort of, you know, I. Um, for me I was, you know, chemistry and physics. I deeply believe the scientific methods probably like the most useful thing you can learn. Like how do you, it's not about what you know, it's actually how do you figure out what you know and what is true and what is not true. And so, um, yeah, that was a bit of my, uh, educational journey.

David: 4:01

That sounds good. So let's talk about early career after that. You did go, uh, into some, uh, business ventures along the way, a stint in, in consulting, some with insurance, some other things, you know, what was that career path? Uh, like before your, your, your current company, what were some of the key things you did where, any turning points that you faced?

Elina: 4:19

Yeah, so I would say before business school I did, um, you know, generalist consulting and was a generalist private equity investor. Both of those were. Phenomenal experiences. So I was at McKinsey and h and F, which I think are, you know, some of the smartest people I've worked with in both. Um, obviously sort of McKinsey's an incredibly robust training ground on how do you think about strategy, how do you break down a problem? And, you know, h and FI mean, I learned so much about what I know of what makes a good business, how do you break apart businesses, how do the economics. Need to for, you know, a business to actually be functioning well and. You know, so I could not have thought of better, frankly, training ground experiences. Um, and then sort of went business school knowing though that I did want this sort of ownership and operations and impact of been really important to me. Um, came out of business school, you know, and having picked healthcare as my area of focus, um, partially because, you know, I actually do have a lot of family members in healthcare, but also it's just such a meaningful area that is just frankly so messed up. Um, and so even at a younger age, I felt really strongly that there's gonna be so much room to change things and have impact and drive value. Because it was just deeply needed. Um, so actually spent some, you know, went back to McKinsey, uh, you know, became an associate partner there, headed up their, uh, commercial service line focused actually on value-based care and value-based insurance design. I think one of the things that's always interested me is like, how do you line up incentives, right? Because I think if you don't have incentives aligned, like everything else is just so much harder. Right? And if you have incentives aligned, then actually like a lot of things work without like a ton of oversight and sort of process. So that's always been an area that's sort of like fascinated me, which is like, how do you actually make things work better as opposed to what I think we often do, which is take a system that's sort of not aligned and doesn't work and then just like keep trying to. Wrap things around it to try to like, you know, fix problems and every problem you fix creates another problem. And you're like, why don't we just like, go back and like, I mean, you can't reinvent the system, you've gotta work in the system, but like, let's actually look at what's not working. And instead of sort of putting in like another bandaid, like let's think about is there a better way we. Spent, you know, about a decade doing that, and then was, uh, recruited to Molina as part of the turnaround there. And that was just deeply meaningful for me on two fronts. So one, you know, Molina serves the underserved or the underprivileged. It's largely Medicaid and duals populations very high need, very high acuity. You know, there are challenge, like it is legitimately hard for someone to get to a doctor's appointment, not because they don't wanna go, but because like the bus may not run that often and the doctor's an hour away by bus. Right? And like, how do you actually think about, you know, serving individuals that need care so badly and are so constrained? And then, you know, the second piece that was deeply meaningful is turnaround room. Because it was, you know, frankly, a company serving so many people that needed it. But where there was real opportunity to change the way things were done to make, you know, frankly, better outcomes for members and better outcomes for investors. And I would say like, you know, to me, the Molina turnarounds an incredible example of how like you can create win win wins, right? You can actually. Doing better by members does create economic value, right? Creating better operations, like driving efficiency, being smart in what you invest in and not. And so, um, that was my, uh, you know, experience there. And I would say, you know, what I feel really privileged in is every place I've been in my career, career, I feel like I've learned from great people and learned a different skillset that frankly has been incredibly valuable for, uh, the.

David: 8:32

Well, you know, all the places that you'd been before Ilant were kind of big. Institutions, a lot of resources, a lot of people you could learn from. Big impact, well-known brand. And so it's not obvious about why you would make a jump into a startup. Was it obvious to you or what, what was the The spur for it?

Elina: 8:50

No, the spur was personal. Right. So, um, you know, the spur for me was actually, frankly, I've lived with obesity for a lot of my life. Um, and I will say like every solu, you know, solution out there that anyone has ever proposed, I have done so, like literally every diet you've heard of. I'm not just talking about every variation of the keto diet, including Atkin, south Beach, you know, intermittent fasting. I'm talking. Cabbage soup, diets, grapefruit diets, juice, cleanses, you know, CrossFit, equinox, SoulCycle, weight loss, I mean like everything out there. Right. Um, you know, and a couple years ago, I frankly sort of referred myself into evidence-based care. I got bariatric surgery, um, I got obesity medicine support, and I had a giant realization, um, of just, you know, frankly. How transformative those that care was for me, but also how broken the care was. And, you know, frankly, coming from a place where I am deeply healthcare knowledgeable, right? Like, and like in ways that like I show up to my physician visits with a copy of my, like literally a physical copy of my labs and medical record, because like, I assume that like the data didn't make it in, right? And like, you know, for, even for me with this like very deep knowledge of the system in all, its. It was just not a, well, you know, not a great journey. It was a great set of care, not a great journey, and I felt really deeply we needed to do better. Um, and I also felt really strongly that the way we provide better care in this country is by integrating it with the existing system. So working with payers, right, with employers and with health plans on fully insured business. I just didn't see people getting that type of care in obesity. I mean, I still don't see that in many ways today. A lot of the focus in obesity to care today is direct to consumer self-pay options and like to me. We have over 40% of this country with obesity. 70% of this country with obesity and overweight, like the solution here is not direct to consumer prescribing of, you know, medication that may work for a subset of the population and they maybe also will create their own wraparound care. But like we deeply need something that, you know, provides that care within the auspices of our medical system and our payment systems.

David: 11:20

You had basically your own professional experience, personal experience, and uh, you know, a very significant problem to, uh, go after. And so it naturally made sense to found a company, uh, to do that and, and go after it. But I thought on the other hand that, you know, I thought the GLP ones are supposed to solve all the problems and, and save the healthcare system money, but it, it doesn't sound like that's how it's working out.

Elina: 11:44

So look, I think LPs are absolutely transformative, right? In term, you know, I think if you roll back the clock before LPs, we had basically diet and exercise solutions, which we literally have at least 30 years of data showing that that doesn't work on a population level. So there are individuals that may be successful, but we have run. I mean, there are meta-analyses every decade that basically show like it's just not working. And you know, part of, like the thing I found it would've been funny if it wasn't so sad and scary is if you, I went to various states to see what initiatives they had in obesity, and you'd literally have like 1990 obesity rate in the state is 25% goal is to get to 23%. And they're. Encourage healthy eating and run five Ks and then like 1995 obesity rate is 30%, they wanna get to 28. And you know what they're gonna do, like encourage healthy eating and like do 10 Ks and you're like, and you can literally like trace these state five year plans and you wanna be like, Hey guys, like when you making the plan and like. Did you like go back and look at the last like 20 years? Because it looks awfully the same and the numbers are not going the right way. So we had that, we had bariatric surgery, which is incredibly impactful but not relevant for lower levels of acuity. And you know, people especially. In the last sort of five to 10 years, it's gotten much safer. It's now the safest surgery out there. But before that, you know, there were concerns around safety and then we had really impactful medication, but which generally topped out at around 10 to 15% weight loss. And so we had a really big gap between sort of where 10 to 15% weight loss was enough and where you needed the bariatric surgery, weight loss of sort of the 30%. We can actually get 15, 20% weight loss, which is relevant to the population. But I think a lot of what's happening right now is we're not optimized. So I mean, say so great that we have this treatment option that creates the ability to transform care. I think the problem is we're not optimizing the value of that treatment on so many dimensions. Right? So, you know, even at a clinical, you know, the GLP trialed. Physical activity and nutrition. Right. And a lot of times we're actually not doing that. We're not actually sort of seeing and sort of standard care that this is being implemented in a supported model. So even from that perspective, like it's just not enough. It's not. We very much view LPs as an enabler to care, not as a replacement for care. Right. Um, so I think that's a really big miss in the market. And, you know, look, the reality is like, I think that's probably a less compelling pitch on TikTok, which is like, I lost, you know, 80 pounds with this drug and also like all I doing. Um, and then look, I also think the reality is. Even the best executed solution. So even if we said we have glp every single person's getting the support they need with social determinants of health and accessing food and food changes and is like all of that is true, the reality is still like. You need to match people to the right care. And in order for it to drive value, you have to target the right people. And so I think the reality is when you have 45% of the country with obesity, we're oftentimes not thinking about what is the right care for different people within that 45%. And how do I actually make sure that the people who need the care the most, the very acuity individuals are ones with multiple comorbidities are really declining metabolic. Are accessing the care. And so I think amazing that we have this sort of transformative technology, but it's not enough and so much more needs to be done to drive clinical value. And then so much more than that also needs to be done to then also drive financial value.

David: 15:59

So it sounds like I can hear your kind of Molina experience coming into play here talking about what kind of populations are gonna get access, uh, to care, and then it sounds like diet and exercise, not a bad idea, but it has to be all kind of, you know, put together. And if you've got a better, uh, drug technology like glp, then they can make a difference. But how do you put all of that together and actually make the numbers add up?

Elina: 16:24

Yeah, so by the way, and, but we're huge fans of physical activity. I don't like the word diet because I think, you know, one of the challenges is people view diets as like, I do a diet and then I become, you know, whoever I wanna be, and then I go back to normal life. We, you know. And similar to physical activity, I sometimes joke, I feel like I get on LinkedIn and people are like, if I wanted to lose 25 pounds, I do seven simple things. One work out for two hours a day, like two like walk 20,000 steps. And I'm like, we have different definitions of um, simple but Sure. Um, but look. By the way, like eating nutritionally and physical activity are good for you, separate from whether you want to lose weight or not, right? Like both have longevity and cardiovascular benefits. So we are huge fans of, you know, eating healthier. Having finding movement that you enjoy and we very much view medication and bariatric surgery as enablers to helping people do those activities, which obviously support healthy weight, but also support a whole host of other benefits and like ultimately. The goal for everyone is not to become thinner. It's to become healthier and live a longer life and be able to play with your grandkids and run that 5K that your state is gonna put in place for the 30th time in a row to enable it. So I just wanna talk there, but in terms of like, how does it all come together? So one of the things we talk about is what I term averaging care. So getting the right member on the right treatment with the right level of support. So let me just take each of those one at a time. So first of all, right, member. So I mentioned about 45% of the population has what is considered obesity, which just to be clear, that definition comes off of body mass index. So BMI, it is a deeply imperfect metric. It's also a very easy metric to sort of measure at a population. So if you have an individual with a certain BMI, you don't know everything about them obviously, but at a population level it's helpful to say like, where are we generally, um, the levels of BMI really impact your likelihood of disease and your cost very differently. So three levels of obesity. Class one, class two, class three. Class one is 30 to 35, class two is 35 to 40. Class three is over 40 BMI, about 10% of the country, 9.2 exactly has class three obesity. That population has very, very high acuity. They're two to three times the cost of someone at optimal weight. They have a much higher risk for every obesity related disease state you've thought of. So yes, diabetes and obstructive sleep apnea and chronic kidney disease and everything else. And so. Really important to make sure we're getting some of those higher acuity folks. Now, depending on your family history, depending on sort of, you know, some of what your is going on, depending sometimes on your race, you can be at a lower BMI and very cardio metabolically complex. So really important to engage those people. So I think. Is to understand like beyond that BMI level, so A, that more obesity is worse. And so we definitely wanna get folks that are higher acuity, but two, that actually BMI doesn't tell you everything you need to know and you wanna really understand where are the folks that you wanna engage proactively now because you're basically at a. Having sort of o you know, obesity treatment, reducing, you know, that weight reducing sort of that adipose tissue really fundamentally change health today. Right? So in. We see people, you know, we see diabetes remission, right? We see people coming off CPA machines, right? The question is like, can you get to those people where the treatment will have that very like, that have that very high impact of obesity, their now or very near term, and really use the treatment to sort of drive that change. In their current clinical condition and the associated cost and where they're trending. Right? So that's step one, right? Member.

David: 20:45

Is the right member? Is that the most important thing? Obviously you have to do it first'cause you don't wanna apply the right treatments to the wrong member, but like right member, is that maybe the number one thing? Because this can sometimes be the hardest people to bring into treatment.

Elina: 20:58

Yeah, so I, you know, it's, it's funny, no one's asked me that question before and I think, yes. I mean, if I think about this foundationally like adverse. I think what we're seeing a little bit in treatment right now, and now you're gonna get a little bit of the insurance wonk, is adverse selection. Right? And so I think what's happening, and by the way, this is super normal in an area that's deeply stigmatized, right? So I think it's what we saw in mental health in areas where we've stigmatized people and basically sort of. I told them things were their fault or created bad care. The more you had of something, the more stigmatized you were. So it's decently natural for that person to be less proactive. Not again, not every person, but at a population level. So I do think we're seeing some level of adverse selection. I think it's really hard. You're, A lot of times when I hear people talk about obesity, they use average, so they're like someone with obesity is. We now have approximately the same level of people with obesity as we have like men in the country, right? And so if I said to you like, the average cost of men is X, so therefore Y, you'd be like, shouldn't we know something else? Like, are they old men, young men? Like is, um, so to me, like that average is really problematic. And if you doing everything on. I do think that can be a very big, like a very big gap and it's, I.

David: 22:32

Good. I'll let you go onto the second one now.

Elina: 22:34

All right, so let's say we engage people. Like the second question is like, what treatment do we put them on? Right? And you know, for us, you have to have the full treatment spectrum, right? So some people are gonna be really successful on intensive behavioral therapy. So modifying that nutrition, their physical activity, their stress management, their sleep habits. So. That's great. And if you can be successful on intensive behavioral therapy, that's what we wanna have you on. By the way, many people would love to be successful on I intense behavioral therapy. For other people, they need medications. Sometimes a glp, sometimes a non glp. And by the way, I'll tell you, we even see adverse selection sometimes in what people want. We'll have folks coming in where they say like, look, I'm strong enough. I know I can lose weight. By myself and we're like, Hey, like you've done like 10 years of diets and exercise. Like do we really wanna try that again? Or should we actually think about like, you have, you already have obstructive sleep apnea, you're having knee pain. Like should we think about actually sort of getting, you know, medication support? And then we have folks coming in who, you know, maybe are a little bit lower acuity and they gained, you know, a little bit of weight for various reasons and they're like, I must get a GLP and say like, Hey. You actually might be like, you may not actually have a metabolic syndrome, right? You may have had stress related weight gain. It can become metabolic, but are you sure we don't wanna try intensive behavioral therapy and modifying some of your behaviors? And so really important that we're getting the right treatment to the right member. And that's saying, you know. You needed a glp, but you're 70 BMI, that actually bariatric surgery is a much better option, right? And so for us, you know, frankly, like you asked what's most important, and I do think there's right member, but only if you also got the right treatment. If you attract all the right members and you put them on, you know, the cabbage soup diet again, like that's not gonna drive a ton of value either.

David: 24:35

And so, and what you're talking about here, right? Treatment is more than step therapy, which is sometimes saying, let's do something cheap before we give them something expensive. You try to get it right the first time.

Elina: 24:45

We try to get it right the first time, right? So to me, I. Um, you know, step therapy is not a great solution. I think step therapy is a great solution if you're trying to avoid treatment, right? Um, or if you don't know what the right treatment is. So sometimes we'll sort of say like, look, we don't know. Like, there's no data out there. We just don't know. We're just gonna step folks through. But to me, your best case scenario is you get like, obviously it's not possible to. If you that someone really needs bariatric surgery, you're frankly wasting money in multiple ways if you try them on. A GLP or you know, another anti-obesity medication or diet and exercise first. Um, you know, in that case you're both frankly wasting the cost of the treatment that isn't gonna work, and they're probably progressing in metabolic unhealthiness over that time. So you're actually now. Bringing them into that solution at a higher cost, higher risk place. And now I would say on the other side of the equation, if you have someone that has a very high chance of being successful and intensive behavioral therapy, or let's say another anti-obesity medication, you put them on a GLP-1, you know, obviously you're expending costs that didn't expended because it's higher. That person then says, well, gosh, like I don't be on this medication. That coming on and off treatment has its own, you know, own risks associated with it. So to me, you know, like yes, if you have no other option out there, step therapy, sure. But like the right answer here is deeply personalized care. And by the way, right now we personalize care, what I call a phenotype level, right? So we look at a lot of characteristics and we say like. We're, you know, looking at initial understanding of mechanisms of action, of medications, of remission, data on treatment, like where should someone go? But the reality is like we actually need to get to a biomarker level, right? Because especially as more and more drugs come out on the market, and this is a lot of where we're going. These drugs have different pathways. By the way, bariatric surgery has different pathways, right? That it's working on. How do we begin and you know, matching those pathways. To even further sort of optimize their likelihood of success and frankly, the ROI from treatment, right? Because I think you wanna manage the amount you're, you wanna minimize the amount you're spending per unit of outcome. And you do that both by reducing amount, you're spending and increasing unit of outcome, right?

David: 27:33

So there's also the timeframe for the benefit versus, um, you know, what, what's, what's happening on the cost side. And I'm wondering here, you know, you mentioned before, I think something we would all agree with that you're looking not just for, Hey, could I lose. 10% of my weight now, but what's my, uh, lifetime gonna look like? Am I gonna live longer? I'm gonna be healthy along the way, but chances are I'm gonna change insurance carriers, employers during that timeframe. Yeah. How do you deal with the, you know, the near term cost versus the potentially a different timeframe for the, for the benefits?

Elina: 28:07

Yeah, absolutely. So look, I would say, David, I think what you're pushing out, which is exactly right, is if we get people to sort of adhere to treatment and sort of maintain the reduction in weight. On a lifetime basis, right? It is, you know, unquote positive ROI for everyone as like a human, because life extends, quality of life extends, you know, all of that is great. I will say like, one thing that we often miss is like, we've gotta adhere to the treatment. So weight cycling traditionally known as yo-yoing is a risk factor in and of itself, right? And so like, we actually don't want like this idea of like, don't try. We don't want weight cycling because actually on a lifetime basis, that is like in and of itself, ROI negative for someone just literally from a lifetime and quality of life standpoint. But as you rightly point out within our system, the fact that something pays out in 20 years doesn't make it compelling today because people switch employer. So I do think that the first piece is to act there to identify the subset of the population where there is near term ROI. So one of the things we do is we have an analytics engine driven by machine learning where we do claims-based analytics and identify the subset of the population, which has positive ROI in two years or less. And so what does that look like? So that positive ROI is going to look like taking people off existing medications. It's going to look like avoiding near, near term knee replacements. It's gonna look like avoiding the second heart attack. Right? And again, I think a lot of the ROI work that's been done. It said, well, look, if we look at a broad population. It's RI to treat. There weren't enough and. To have a heart attack, to have a knee replacement that's already on a lot of existing cost and treatment and you treat them, that population is ROI positive. And you know, David, this is where people often get into, like, is that right? Like, shouldn't this be sort of a, like a right to treatment? And my answer is like, look, that's a sort of qualitative debate that like people can have. I have like, there's no, like you, everyone can have a different opinion there. The quantitative answer for me is if you treat the ROI positive group and you accrue savings, that is an investment that can be made and further treatment, right? So like. We actually have a, a fi an healthcare system that's not financially sustainable, right? Like people literally can't pay, they avoid treatment because it's so expensive, right? Like if you make the system more financially, you know, sustainable, then like that actually creates opportunities for more people to get care in a variety of different ways.

David: 31:08

So where are you finding your initial traction? Are you finding it with, say, the health plans that have this population that's been stigmatized and therefore there's the most opportunity? Is it somewhere else? I mean, what are the, what are the ways that you think about going to market and where, where are you actually seeing the most demand?

Elina: 31:26

Yeah. So I would say we, we see a lot of demand from what I would term like sophisticated, sophisticated, innovative buyers, which I almost made sophisticated buyers, so that may be a, a new patent. And we're, we're, we find sophisticated buyers, uh, really great. So that can be sort of, you know, employers that a lot of whom have, you know, experience with their employee population. They're thinking about, gosh, I have a lot of diabetes. I have a lot of mulet. I'm also paying for those musculoskeletal issues and workers' comp and disability. So we do see interest, you know, in those employers. And what I would say is a lot of times people say like, look, I wanna make changes in a financially sustainable way, right? So I want people to get healthier. I wanna add treatment, but I also need to do it in a way that my budget works, right? So. We find that really resonates. And then I think for health plans, we also see for a lot of health plans, right? Like they've been trying weight loss solutions, they know that they have a share of their book, right? That classic 20% that drives 80% of the cost and like. Our folks sit in, you know, many of those folks sit in the 20%, or if they're not in the 20% right now, they're like one hair turn away from heading into that 20%. And so I think the ability for, you know, health plans in particular, to be able to identify that group and say like, Hey, like you are going to be paying for their treatment one way or the other. Or are you paying for the trend to continue to head up? You know, that's deeply compelling, but again, it has to be done financially responsible, right? You have to sort of be able to say like, this is, like all the pieces have to come together so that it's great experience and you can get member engagement. So you're, you know, driving quality clinical care and you're getting those financial outcomes.

David: 33:29

I've been seeing headlines in Massachusetts about the financial results from the insurers, and they've been losing a ton of money, and it seems to be they're blaming, uh, glp, GLP one's, uh, coverage and even they, you know, to the point of laying off people and all that. Where, where is that headed? Are they gonna wake up and say, Hey, we need an approach, like what you're doing, you're just gonna cut back on coverage, or what, what might be the response to that?

Elina: 33:53

Yeah, so look, I think the unfortunate part here is we're seeing a lot of this play out in like classic, uh, not incentive aligned healthcare, which is sort of, you know, a benefit was added. It wasn't always used in a very responsible manner, and so it led to really dire sort of outcomes. And by the way, dire not just on financial, we oftentimes see like. Rates going up when people are put on treatment without the right support. So like, just so we're very clear, both GLP and bariatric surgery actually very, very safe, uh, in like the grand scheme of things, right? By the way, same thing for other anti-obesity medications like contra and Qia. But any medical treatment has side effects and things that need to be managed. And so you know when that is not done, when you're seeing medi spas prescribing, when you're seeing sort of these direct to consumer do a 10 minute intake and an asynchronous bot is like, you are approved. Here's your, you know. Payment information to put in and here's your script. Like that has adverse consequence. And I would say unfortunately, a lot of times the like very quick gut reaction to that is like, okay, now we're gonna eliminate all the care. Which is like deeply unfortunate because like there are people for whom the care is actually, you know, well done, um, you know, is being managed well. And so I would say in. You know, immediately after that gut reaction, we actually have a discussion that says like, look, it's not all or none, right? It is about this de averaging care that right member, right treatment, right support. And so we need to drive value through managing treatment. So essentially avoiding putting inappropriate people on treatment. And from driving treatment value. And unless we do both, we're just constantly gonna be in this push pull as opposed to actually sort of carving a path forward to, you know, a healthier and more financially compelling future.

David: 36:06

Ilina, last question for you is about, uh, book recommendation. I'm wondering if there's any, uh, good books you've read lately or at any point, anything that you'd like to recommend to our audience or, or conversely, anything you'd like to recommend that they avoid reading.

Elina: 36:19

Um, I, you know, it's funny, the last, uh, book I read is called The Gambling Man, uh, about maan, um, and just like fascinating, um, about, you know, how he thinks about the world. It's just a very different, um, mindset. So that's been fascinating. Um, and then right now I'm reading a book called Below, which is all about sort of the resources that. Um, a lot of modern life. Um, so yeah, those are maybe, uh, two really interesting books. Nothing to do with healthcare, but, um, fascinating nonetheless.

David: 36:56

No, that sounds good. Well, that's it for another episode of the Health Biz Podcast. My guest today has been Elina Onitskansky, founder and CEO of Ilant Health.