Lessons from Kristina Saffran, Equip Health, delivering patient- and margin-first tech-enabled services model for eating disorders
Kristina Saffran, CEO and Co-Founder of Equip Health, a leading virtual, evidence-based eating disorder treatment provider.
Welcome back to the Pear Healthcare Playbook! Every episode, we’ll be getting to know trailblazing healthcare leaders and dive into building a healthcare business from 0 to 1.
This week, we’re super excited to chat with Kristina Saffran, CEO and Co-Founder of Equip Health, a leading virtual, evidence-based eating disorder treatment provider.
Founded in 2019, Equip Health helps families recover from eating disorders at home. Equip provides virtual, evidence-based care provided by a dedicated five-person team that empowers families to help their loved one achieve lasting recovery.
Kristina has dedicated her life to ensuring people have access to quality and affordable treatment. Before starting Equip, Kristina was CEO and Co-Founder of Project HEAL which she started at age 15. Project HEAL is a foundation that provides funding for eating disorder treatment grants to those without financial access and has a network of 100,000 people across 40 chapters worldwide. She is a Mental Health Advisory Board Member at Verily Life Sciences and previously worked as a research coordinator at the Stanford University of Medicine after graduating from Harvard in Psychology.
In February 2022, Equip announced that they raised a $58 Million Series B Funding Round led by The Chernin Group, joined by Tiger Global, General Catalyst, Stripes Group and more, to scale access to their treatment.
In this episode, we talk about Kristina’s experience with eating disorders, her journey through nonprofits and academia to eventually founding Equip, and how she has scaled a tech-enabled services business profitably in all 50 states.
Kristina’s journey through recovery and founding Project HEAL:
Kristina jokes that she’s been dealing with an eating disorder for her whole life— diagnosed with anorexia at age 10, she spent her entire freshman year of high school in and out of hospitals. She shares that she feels extremely fortunate that her parents found family-based treatment, which we now know is the leading evidence-based treatment for kids, adolescents and young adults with eating disorders.
“Eating disorders are brain disorders that make you fight your brain upwards of six times a day. With that in mind, it's not only ineffective, but mean to treat it as an individual illness. You really need people around you to help structure the home environment for pro recovery. That's what family based treatment does.”
While in recovery, Kristina quickly learned how inequitable this field was. 80% of the 3 million Americans who struggle with eating disorders don't get treatment. Determined to do something about it, Kristina started Project HEAL in 2008 at 15 years old, originally just intending to raise money for people with EDs who couldn’t afford treatment. It soon developed into 40 nationwide chapters before they had a single staff member.
2008 was the same year the Mental Health Parity Act was passed, a law that says mental health has to be covered at the same rate as physical health. Kristina shares that in response to this act, more money started being invested in eating disorder treatment— but mainly in constructing more residential facilities. While working on Project HEAL, she started to see the problem: people had access to residential care but no quality outpatient care.
Moving from nonprofit work to academia:
While studying psychology in college, Kristina continued researching eating disorder treatment: in addition to being incredibly expensive, residential treatment had no evidence base to support its effectiveness. She learned that family-based treatment was the only evidence based treatment, but despite the 20 years of research behind it, it seemed to be stuck in academia.
After graduating, Kristina moved to San Diego where she first met her co-founder Dr. Erin Parks as a potential PhD advisor. Erin invited her to come work on her research at UCSD, the first evidence-based peer support program for folks with eating disorders, but Kristina had begun to work full time at Project HEAL. She realized the PhD path wasn’t for her, but they continued to stay in touch— when Kristina eventually decided to move out of the nonprofit sector, Erin was the first person who came to mind for a clinical co-founder with incredible business acumen.
3 years ago, Kristina and Erin started to gather together payers and researchers to start brainstorming a better model of outpatient care. They all knew the problem: evidence-based treatment was completely inaccessible, and patients were spending money on care that doesn’t work as well.
“They essentially said, if you build it, we will come.”
Equip’s care model of family-based-treatment (FBT):
At a high level, Kristina shares that FBT empowers the healthy people in the household to be involved in the recovery process. Nutritional rehabilitation and initial weight restoration are the first priorities.
“The old thinking was— let’s motivate you to want to like your body, to want to do this work. We know that that actually doesn’t work. You need to feed people first to get their brains nourished before they can actually do any of the work.”
FBT is cause agnostic and future focused. Kristina shares that the Equip team recognizes that there’s a lot of room to continue improving it: even though it’s the only evidence-based treatment for kids, adolescents, and adults, it only results in 86% positive outcomes and full recovery for 50% of adolescents.
Given what they’ve learned from patient/family feedback and the results of their first peer-reviewed study, Equip’s model modifies traditional FBT in a few key ways:
Traditional FBT is delivered once a week by a therapist— Kristina shares that they received overwhelming feedback that this is not enough support. Equip provides all families with a dedicated 5-person care team: therapist, dietician, an MD, a peer mentor, and a family mentor. This is a reflection of the people that helped Kristina through her own journey.
The peer mentor: As a patient, Kristina was told this would be a life-long struggle, and she hadn’t met anyone who had successfully recovered. Traditional treatment often facilitates group therapy among people who are actively struggling, which can often be triggering given the competitive nature of eating disorders. The peer mentor provides a person who’s in an active state of recovery, which Kristina believes is the secret sauce to the Equip treatment. “How do we take the beautiful parts of peer support and protect against the harmful part?”
The family mentor: The family mentor provides a support system for families who are having a difficult time supporting their child. “Keep going, this is the thing that will get them better, my kid got there, you can too.”
Equip treats their patients virtually, which after 2.5 years of seeing families, Kristina fully believes is the right approach for eating disorders. Treatment is hard— it requires a village to get someone to in-person treatment. With virtual, you’re able to have your entire village in a way that wouldn’t be possible in a traditional brick-and-mortar setting.
Equip recruits folks that are actually reflective of the diversity of the patient population. Eating disorders affect people equally across race, class, ethnicity. Up to 40% of people who suffer are men and the majority of people who suffer are not underweight. Equip is focused on bringing on a diverse treatment team that can match patients with shared experiences beyond the eating disorder, which leads to stronger outcomes.
“You can have the best evidence-based treatments in the world, but if people don’t engage in them, they won’t work… A core part of an eating disorder is not knowing how sick you are and not wanting to get better.”
Standing up the first product
Don’t let tech hold you back from starting the pilot— if the idea’s right, it’ll hold up.
Kristina shares that Equip’s mission has been present since the beginning. They always knew the product would be fully virtual and would partner with payers.
“What Erin and I used to say is that while all the individual pieces of this model had been validated, nobody had baked the pie. That’s what we were doing. We brought together the FBT, the peer mentorship, and the family mentorship, and all of the things that we knew worked.”
Kristina calls Equip a services company enabled by technology. They started their pilot in the summer of 2020 with Erin as the therapist, a family mentor (who’s now Equip’s Head of Lived Experience), a dietitian (who’s now Head of Dietary), and a peer mentor. They recruited folks for free treatment to come on even when the tech was very rudimentary. Even when the video feed broke, parents didn’t care. Equip was an incredibly different treatment program— one that was effective.
A beta patient who had been struggling for 5 years gained 10 pounds in the first 4 weeks of the program. She shared that what was different about it was everyone on the treatment team being on the same page and having day-to-day support. With positive results from the first 10 beta patients, Kristina had renewed clarity that the model would work.
The next steps: “How do start building up our tech team? How do we start getting the payer contracts in the door? How do we actually start thinking about scale?”
Your early power customers can provide insight on what your product needs to move forward.
Kristina attributes Equip’s success with getting a first contract to a strong initial payer champion— while at Project HEAL, Kristina met the Chief Medical Officer of Optum, Martin Rosenzweig. He was one of the initial voices that said: “if you build it, we will come”.
They knew from the beginning that a value-based care model solved for important factors a fee for service contract would not be solve:
Compatible for individualized care, providing the right amount of support in the moment when patients need it.
Able to compensate folks on the medical side (MDs and dietitians) and the behavioral health side (therapists, mentors).
Able to provide continuous long-term care in order to get patients to a full and lasting recovery.
Martin introduced the Equip team to the folks at Optum Ventures. They had a tremendous amount of expertise in how to think about alternative payment models and find the right pathway forward.
Equip’s B2B2C model to enable 90% in network usage:
Kristina shares that 90% of Equip families are utilizing in-network benefits, and most of their patients are found through more consumer channels like very active parent groups.
Their strongest source of patient referrals is from providers: pediatricians, hospitals, and people who can give a trusted recommendation to families. A large part of Equip’s mission is also to educate providers on how to spot eating disorders, screen for them, and give good treatment. Kristina believes there’s a tremendous amount of marketing by the residential centers to be the first line of treatment when it really should be outpatient, family-based treatment.
As Equip continues to strengthen their relationships with payers, Kristina shares that they’ve seen more and more referrals from the payers that helps patients get to Equip sooner.
“About half of patients with eating disorders who end up in a hospital have never had outpatient treatment. How do we get to those folks sooner and avoid that hospitalization?”
Scaling Equip to serve 50 states at Series B
No margin, no mission - focusing on a strong business model to hold up the Equip mission
Kristina and Erin had tried to improve ED treatment in the nonprofit and academia worlds, and Kristina shares that she’s admittedly skeptical of venture backed healthcare. However, they knew the nonprofit wasn’t a scalable business model.
“One of our colleagues Brooke likes to say ‘no margin, no mission’. I think that’s true, we’re not going to be able to achieve our mission unless there’s a strong underlying business model there. With that said, we were really selective about choosing investors who [viewed this as] more than an investment.”
Kristina shares that she feels fairly rare among her founder friends that she’s never faced pressure from the board or investors. They’ve always emphasized quality of care and never pressured the team to ramp up the margins.
Eating disorders are really expensive to treat. Holistic, evidence-based outpatient care is cheaper than the traditional model, which gave Equip the runway to compensate the treatment team and spend money on training/supervision.
Don’t forget your North Star when it comes time to scale.
Kristina shares that the Equip team wants to grow as quickly as humanly possible. 5 million Americans have an eating disorder every year, 80% of them aren’t getting treatment, and it’s the second deadliest mental illness. Families were moving across state lines to utilize Equip, which is why they moved so quickly to be in all 50 states.
Kristina shares that their next priority is to expand so that everyone can utilize their in-network benefits, commercial, Medicaid, Medicare, and not have to pay out of pocket.
Equip’s north star is to make sure patients have strong clinical outcomes and that their providers are well-trained and feeling supported. Kristina shares that curiosity and humility are two of Equip’s most important cultural values: listening to providers and patients and families while scaling is what helps them not compromise quality care.
Kristina’s advice for people who want to start a company or work in digital health:
“My greatest strength as a CEO is hiring people who are better than me. I don’t need to be the smartest person in the room, but I’m pretty good at finding them and putting them in conversation.”
Kristina recognizes that her eating disorder experience is not representative of the whole: she wants Equip to understand the full spectrum of people who struggle with eating disorders. They created a community advisory board of folks with different lived experiences to create a more universal treatment model.
Similarly, she went out and got folks on the business side who had decades of operational chops her and Erin missed out on while in academia/nonprofit. It all starts with curiosity and learning from people who are better than you.
“Starting with curiosity, learning from people who are better than you, and having the humility to kind of say, ‘I need help. I don't know.’ That is something that we absolutely look for, and the people that we surround ourselves with has gotten us to be pretty successful.”
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