Q&A with Dr. Mini Kahlon
Tell us a little bit about Factor Health. It is groundbreaking, in our opinion.
We spend tiny amounts of time with the healthcare system, and the rest in the activities of our life. Yet we expect healthcare to solve for conditions that develop in the joys and messiness of our lives, heart conditions, diabetes, depression. And, even when we innovate in healthcare we revert to centering solutions in healthcare. We are like the person searching for the key under the lamplight, even though the key was lost on the other corner, which just happens to not be lit.
Factor Health is an incubator that takes seriously that we can meaningfully influence clinically-relevant measures of health - by starting outside the clinic, and going as far as we can creating better health, until the point when we have to escalate back to clinical expertise. We take clinical expertise, practice and science, extremely seriously - but believe it’s coming in at the wrong moment. So, what works in our lives? To answer that we have to understand what we need as humans, what motivates us, what we need in our environments, the science of structures and incentives that hinder and enable decisions which in turn determine our health outcomes. And we need stuff - for those without resources or even with - we don’t put the best things in our body, we don’t use our body in ways that make it healthiest, and our minds can either help or hinder us when we don’t support our emotional lives.
So, in Factor Health we start with ideas about what can improve health in the cadence of our lives and convert these to a protocol of services and products that benefit people - and that we confirm through rigorous trials can generate clinically-relevant outcomes. Then we take all the subsequent necessary steps to convert successful solutions into a sustainable, health system reimbursable program. We come from the belly of the healthcare beast, so we are comfortable in its kind of random complexity. And, we’re fortunate to have a new center of academic medicine as our home the Dell Medical School at The University of Texas at Austin, and an anchor partner in the Episcopal Health Foundation based in Houston.
We work on what others call non-medical drivers of health. Most will readily equate that with fundamental and societal challenges that could be addressed through policy changes — things such as poverty and healthcare accessibility. These are very important. However, what Factor specializes in is mitigating and managing individual risk factors through non-medical interventions. Our approach is bottom-up; we work directly with individuals and families on problems such as mental health, chronic conditions, and maternal health. When successful, these individually targeted programs can act faster than structural changes, and can create direct impact quickly while also providing evidence to inform policy. Because the programs are primarily non-medical and do not require the healthcare enterprise for implementation, they also provide a way to scale by bypassing the morass of our healthcare delivery system.
Most of the research we’re involved in is translational: moving from ideas to demonstrable results. There is a lot of excellent health-related research happening all over the globe, but few systems in place to help move from a paper to a product — doubly so in non-clinical work where sometimes we believe that policy change is the only route for action. Factor Health seeks to change that: a key part of which is delivering spectacular results for conditions that are otherwise hard to improve. Otherwise, the unfortunate truth is that the cost of changing the system to incorporate and pay for what matters is just too high.
Tell us a little bit more about non-clinical interventions: how did you come to focus on the general importance of this topic, and why does it matter to our system writ large?
Society coaches us in very broad strokes of how to be “healthy”, and the media focuses on one narrow corner of what that looks like. But the truth is that getting healthy is a different destination for everyone, and we can’t all get there the same way. If our health is a journey, then clinical care is going to the mechanic after your car falls into a ditch. Non-clinical interventions on the other hand, are the guideposts: they won’t tell you everything, but keep you on your way.
I’m a neuroscientist by education, but I became interested in non-clinical interventions for health because of how challenging the health system is to benefit from, when we must, especially when lack of resources and time throw up extra barriers. The overwhelming majority of our healthcare dollars are spent on elements of the clinical delivery system, some of it necessary, including marvels of science and technology, but a lot of it inefficient, unnecessary, and even actively harmful. Unfortunately that system has been hard to improve. So, after a stint in industry, I returned to my alma mater, University of California in San Francisco, and immersed myself in healthcare systems and clinical science, to try to understand how we could use science to create an improved system.
The United States healthcare system represents a four trillion dollar industry, which is roughly 20% of the entire GDP in this country — a truly staggering sum of money. A vast majority of what we end up purchasing through our healthcare system ends up being stuff, and not results. Whether or not you get to be healthy after seeing a doctor, or even just getting back to what may feel normal for you, is outside of the way our healthcare system operates.
In fact, the biggest influences on our own personal health happen outside of a clinical setting. Things like diet, mold in homes, where we live, and how much physical activity we get on a weekly basis. All of these factors don’t engage with the healthcare system, but are our benchmarks of whether or not we are healthy. We want to change how we look at clinical and non-clinical care, to put outcomes before the stuff that may be more easily paid for.
Factor Health is how we aim to do this. When we work with researchers to help them scale, we’re helping them cater to not one, but two different “customers” at the same time. The first, is the end user, where we help individuals and families become healthier, either physically or mentally. The second, and far more challenging customer, is the providers and insurance companies. The healthcare system, and insurance companies that work with them, are built around how care is currently administered and covered by insurance. We then need to package a non-clinical approach in a way that it can be recognized by the current system and reimbursement for successful solutions can be distributed as needed.
The easiest example of this is diet. In the United States, as of 2023, the federal poverty line for a family of four is $30,000 a year. What they eat heavily dictates their overall health, but any support they receive on diet comes from non-medical programs (usually cash-strapped, donor-dependent community-based organizations, or some government programs with huge barriers to entry - ever tried filling in a form to qualify for food support?). As insured individuals, their provider has a vested interest in them remaining healthy, but there aren’t currently ways to write a prescription for fruits, vegetables, and exercise and have it covered. So, we step in to help insurance companies see the direct benefit, de-risking their investment into their subscribers.
More importantly, we help these families adapt to the changes that accompany a non-clinical intervention. Shifting to a new way of preparing food takes time, when this is also a resource in short supply. Or if they have small children, preparing the food in a way that they will eat it. Sometimes this comes in the form of direct financial assistance, while others it will be additional stipends for food, knowing that there will be waste during the transition. Above all, we hear that working families are stressed and have limited time. We try to create periods of transition where they have mental space and real time to invest in taking care of their families. We believe they - and we - benefit when they have the ability to freely consider what’s best for their families and invest in themselves.
But the reason all this could change the system is we never let the payer out of our sightline — the results we target resonate with health and financial measures of relevance to payers. And our early results have delivered.
Tell us about the health callers project you’re focused on right now. What was the big “aha” and where are you at in terms of validating the science behind the work?
Factor Health started right before the covid-19 pandemic, and we always wanted to look at mental health, but it was something we kept on the backburner for when we planned to grow. When the pandemic began in 2020, we were working with a lot of people face to face, which was difficult to do when we’re trying to be in isolation. Even worse, many of the participants in our food and diet related work were already high risk health patients, and we didn’t want to introduce more risk of pathogens into their lives. Our work with diet and nutrition began to scale down or pause completely, but we still wanted to stay on mission. We were in the early stages of lockdown, but we’re all in the health field — we wanted to keep helping, right? So mental health came back to the forefront.
Our team went through a quick sprint, looking at the biggest problems facing everyone and how we could plug into it. We were in isolation, and so loneliness was top of mind. There wasn’t a lot of research on interventions that could help, despite loneliness being called an epidemic itself. So we designed a program and set up a clinical trial to do some fact finding of our own. We recruited talented and mission-aligned young people to have empathetic conversations with our participants — not just asking them about their day or the weather or whatnot — but actual conversations where they walked in their shoes and connected. We ran the whole trial over the phone with voice only, and surveyed the participants throughout.
At the end, we saw something incredible: what we found was really stunning effects on loneliness, but we also found effects on clinical measures of depression and anxiety. Loneliness is somewhat of a novelty for healthcare, but depression is not, which led to our results catching the attention of the broader healthcare community in a way we could not have predicted. We had participants who showed symptoms of clinical depression — people who would need to be seen by a psychiatrist — show improvement in their test scores across the whole study. We ended up publishing in some well reviewed journals, and it took off from there. A highlight was when the work was recognized and celebrated by physicians - who with deep experience understand that we have to go out of our boxes to really fix healthcare: the surgeon and writer Atul Gawande and the psychiatrist who led the development of the psychiatry manual Diagnostic and Statistical Manual of Mental Disorders (DSM), Allen Frances.
How is loneliness currently treated from a mental and physical health perspective in general today, and how can systems adapt to better suit people who are alone with their problems, without authentic connections?
Loneliness is a new topic for healthcare — but of course, not new for our world. It often gets conflated with social isolation, and that you can only be lonely if you are completely alone. Yet you can feel completely connected with your world and surroundings when you are alone, and you can be entirely cut off when you are in a crowded city. It all comes back to your connection and being seen by the world as you want to by others.
So the question is, how do you impact loneliness? There is a lot of international attention surrounding loneliness, so much so that there are ministries of loneliness in countries such as the UK and Japan, and the Surgeon General of the United States recently put out a book on the topic. Loneliness is a deeply fascinating emotion that lets us ask some fundamental questions about our society. For some people, their pronouns are very important for the lens through which they wish to be acknowledged and seen. To others, their mind is made up, they’ll call you what they call you, and do not wish to change. As a woman, if I am seen only based on my physical features and those are what are people reference around me, I will feel lonely because I am not seen as the thinker, neuroscientist or business strategist that I might feel is really who I am. From my perspective that’s a rational analysis that also lives within the emotional brain. It's about one person saying that something is important to them, and the other is essentially making the decision for them that it's not. That gap drives loneliness.
Treating loneliness is difficult, because the simple answer seems to be that we should just bring people together. You can combat social isolation that way, but in regards to loneliness, you’re not really getting at the heart of the matter. You need to have vested and communal interest, and build that into human connection. We have all these parts of our societies, both urban and rural, that are being redefined, like libraries and civic centers. How do we rethink these buildings and spaces that could be turned into ones more conducive for human connection? How do we create a better life architecture for being seen and seeing others on a personal level. What might it mean for us (and I’m guilty of this) to not dismiss when someone suggests your definition of them is wrong?
Our approach in our study compared results for perceived isolation, or loneliness, with a more objective measure of isolation using the Lubben Social Network Scale, which calculates the degree of contact from one’s family and friend network. We would have authentic, one-on-one conversations with participants with the goal of having them felt seen in a way that resonates most with them. The interesting thing was that we were able to have the impact we did on loneliness (and other mental health measures), yet people did not count these conversations as adding to their existing friends and family network. The two factors — isolation and loneliness — share some commonalities, but were not as connected as many first thought.
Are we ever going to be able to really get payers (health insurance companies and plans) to pay for outcomes and not just inputs? Is value-based care a dream or can it be a reality?
There are a few roads I could see the United States healthcare system going down. On its face, remember that healthcare is a 4 trillion dollar industry in the United States, a number that is trending upwards. I cannot imagine that we continue to see growth in healthcare costs without substantial disruption. On the other hand, the healthcare system is complex and unbelievably resilient in its current incentive structures. It’s been hard to improve. Many big commercial players have tried — remember Google Health? Or, Haven with Amazon, JP Morgan and Berkshire Hathaway pushing forward? Both of course failed — and so have many others. That’s not to say there isn’t a commercial venture that can help us tie the healthcare system’s incentives to getting results, just that the challenges are sobering.
Strangely, this is a case where more innovation is coming from the government-funded insurance programs, Medicare and Medicaid. The two healthcare plans for 10s of millions of Americans, as a government expenditure, are very concerned about their bottom line. More than private insurance, more than hospital systems, they are very interested in bending their spending curve downwards. They are stuck though with a pace that comes with large institutions.
Value-based care sadly gets bogged down with jargon. It also allows people to focus only on costs — whereas I believe the focus in healthcare should always be first about results - which by the way, net-net, will reduce the bottom line. In some cases it means spending more on needed technical solutions, surgeries, et cetera, but with less spent on wasteful and ineffective processes, we can spend on more and more sophisticated solutions to the killers of the day - cancer, for example. Then we can also spend more on all the key upstream determinants of health: education, income, and well-being, as well as new kinds of programs for individuals and families as Factor Health tests. Instead of a healthcare system where players focus on expanding market size, they could instead compete for best results. I don’t think that value-based care is a panacea, but the lessons we’ve learned from experimenting with it could create a system focused on raising the bar for patient health overall.
What are you working on right now?
My current interests center on the results we ourselves have been stunned by - we found that providing empathetic connection by talented - but not necessarily healthcare-trained - people actually delivered clinically-relevant results! So, it reinforced our interest in our emotional life and how it impacts our health. We have a vision of an entirely different starting point for health; maybe it’s the best ever customer service you’ve ever had, where the phone is immediately picked up, and the person at the other end has as their sole metric of success - how well they’re able to see the world through your eyes, your needs and priorities. Then we’d build backwards into the support needed for your health, and only if necessary finally escalating to engage with a clinical entity. And imagine the clinicians at the end of that chain - they see patients that really need their specialized expertise, that come to them with a layer of support and insights already taken care of. We are not alone here, interest is growing - I’m excited about companies like Waymark Health that are paying full-time salaries to community health workers and building technologies to integrate back into primary care. But even there - we can go further, community health workers and their roles are still being envisioned from the perspective of the healthcare system.
Because of our interest in the emotional life of humans, we have plans for the integration of AI. We must: our emotional lives are already being impacted by automated “intelligent” products; so instead of being at their mercy, we are interested in harnessing their power as part of an emotion-centered approach to health. Don’t forget, I’m a systems neuroscientist! In fact emotional creativity and learning is in many ways more like our brain’s neural networks than the systems we have today that are focused on generating rational or explicit intelligence.
I’m excited about digging into the power of emotion as a guiding principle for what’s human about us, including but not first, explicit intelligence. It’s not my idea, for example I’m inspired by cognitive neuroscientist Antonio Damasio’s notions of how we evolved - from emotional beings to rational thinkers. Are we innately thinkers that happen to be emotional, or are we emotional beings that learned to think? I’m of the opinion that we’re innately emotional, yet we’ve built computers to be powerful thinkers. This makes them very useful in complementing us, or in generating novel kinds of abilities, but teaching them to be emotional and empathetic, a characteristic that is something so core to us humans, turns out to be quite the challenge. We’ve got to start with a different architecture. That’s what I’m interested in - what is the compute framework for artificial emotion, and emotionally-driven intelligent systems.
