Equip Health: An Interview with Co-founders Kristina Saffran & Dr. Erin Parks

Last week we sat down with Equip's co-founders to discuss Equip's approach to treating eating disorders. Kristina & Erin provided an overview of Equip and discussed its clinical model, go-to-market strategy, and it's rapid growth. See below for a video of the conversation and summarized version of notes.

Equip

‍What is the origin story of Equip?

Equip was founded by Kristina Saffran and Dr. Erin Parks to address the challenges they’ve seen and experienced in the eating disorder treatment space first hand. They have spent their careers on a mission to ensure that 100% of people in the US have access to the support and care they need to deal with eating disorders, and Equip is their approach to doing so.

They evaluated approaching this via both non-profit and academia, but found those paths unable to adequately address the issue in those settings with them being hard to [incentivize building the right team] and too much risk aversion, respectively.

Eating disorders are still a grossly underfunded condition in healthcare and the stigma around it makes it even worse with over 80% of people not getting treatment for it. The core problems to solve today center around lack of access and the model in which care is provided given the specificity of treatment required for eating disorders.

How have you structured the Equip clinical model?

Equips clinical model is based on the idea of Family Based Therapy. Equip uses a five person care team, consisting of the following roles:

1. Therapist 

2. Dietician

3. Medical Provider & prescribing doc

4. Peer mentorship 

5. Family mentorship 

The peer and family mentorship is “the secret sauce” as people with eating disorders need support from a village. Peers are able to help shed the stigma and identify relatable experiences - because treatment is hard, having someone that can sympathize makes it easier. Families are the support system that the patient is going back to that will be around to help - these people also need to be educated on how best to actually support their loved ones. 

The decision to build a virtual model was based on two principles:

1. The support takes a village - with regular, in person visits, it becomes difficult for family members to attend. Virtual visits make it much easier for a family member to call in or attend virtually when there may be 4 to 5 appointments a week

2. Access - virtual chats with the care team and peer support group is more accessible 

From an acuity perspective, there is a question generally about virtual care’s ability to treat more severe patients as there is a presumption that those patients need to be seen in person. However, the Equip team challenged that notion, as it comes from a place of comfort for providers. The types of scenarios that every provider worries about - i.e. a patient commits suicide - generally don't happen in front of a provider during an in person visit. They happen outside of the visit, which is exactly when you should be providing support for those patients. Being there to support those patients virtually should be a key component of any model. Given this, Equip was encouraging of more virtual-first startups to treat patients with higher severity conditions, versus the trend today of focusing on only low severity. 

How do you think about measuring Equip’s clinical outcomes?

The Equip team shared their general belief that people are better off to go untreated than receive bad treatment. In mental health there is a problem that people don’t discern between treatment that feels good vs. works. Additionally, oftentimes there can be a belief that if the patient is not getting better from treatment, it’s because the patient is too broken or doesn’t want to get better. This of course can be devastating for a patient. It also isn’t fair to the patient. In any space outside of mental health, we assume the opposite - if a treatment doesn’t work, it’s because the treatment was ineffective, not because the patient is broken. We need to think more about ensuring that we are providing the right type of treatment that will help individuals. Measuring that treatment’s effectiveness is imperative to doing so.

Equip discussed how they currently measure 5 types of outcomes:

1. Behaviors (i.e. the absence of purging)

2. Biomarkers (i.e. weight - residential adolescents typically gain 1 lb / wk week; benchmark to that)

3. Symptoms (i.e. measure cognitive systems)

4. Quality of life (i.e. spending every moment in treatment or alone limits someones ability to enjoy other things in life)

5. Parental self-efficacy and empowerment (empowered caregivers are the #1 predictor of success in recovery)

Then it’s all about leveraging this data to conduct peer reviewed research and publish it.

How have you approached Equip's go-to-market strategy?

Starting with the first patients

Equip’s first set of patients was through a beta test of two families being serviced by eight employees that five different treatment teams were created from. The goal was testing and getting the clinical model right during that beta test.

After the first beta that wrapped in August of 2020, the team focused on building clinical ops to ensure the model worked just as well for the 200th patient as it did for the 10th. In 2021, the team started really creating commercial payor arrangements.

Those payor discussions had started even prior to starting Equip with Erin and Kristina’s prior work in the space. Before starting Equip, they had sat down with payor execs, talking about how to build a better outpatient model - and so they were able to define and build Equip’s model with input from the payors. That has made payor conversations relatively easy to enter into, as they’ve been much more about building upon existing relationships than cold intros. 

Value-based contracting approach

Philosophically, Equip believes in VBC because their approach provides individuals with the right level of treatment tailored to their needs, and VBC models allow you to focus on meeting those needs of the individual receiving treatment. Peer and family treatment is not reimbursable under traditional FFS approaches and a value-based model provides the flexibility for those individual treatment plans. 

To date, Equip has been dipping toes in VBC. They have a case rate, based on what the patient needs and working with one payor on upside risk. The approach from the start has been taking the hardest patients - patients have been in rehab 3 or 4 times and/or attempted suicide. In doing so, they have realized the margins are not all that different for more severe disorders - because there are not really any “mild” eating disorders. Part of this is building out the data to successfully manage VBC contracts - data on eating disorders is very poor given the tremendous portion of spend that is out of pocket.

What business model choices have you made as you handle the tension to scale against a sound clinical model?

Clinical team hiring

All therapists are W-2 employees of Equip, which was a decision made from the beginning. The reason being that talk therapy is not the same for PTSD as Depression as Eating disorders. 1099 therapists often try to establish breadth in order to generate business, but the reality is you can’t specialize in 30 different things. 

At the beginning, the W-2 team members were hired at 20 hours per week because of a hypothesis that people wanted to keep their private practice. That hypothesis was proven wrong in that it was really hard for employees to do both. So when the therapists at 20 hours were asked if they wanted to convert to 30-40 hours, most people wanted to come into Equip full-time even if it was economically better for them at the 20 hours split time.

Also, they have found that a key to hiring clinicians into a “tech” company has centered around change management by focusing on, and talking about, base rates to help clinicians feel more comfortable making the move into a “tech” company (e.g. no clinician has been sued doing xyz differently).

Team to patient ratios

Patients per clinician team: Found that this really depends on the providers and the patient’s overall time with Equip. They have found though that the original estimates of case loads were incorrect. This was because with the team based approach, the clinicians are able to share the load and take on much higher case loads.

Face to Face time in patient care: 65% of clinical team time is face to face with the patient. Wish this was a bit higher but have found this model works for now.

Pressures of Venture Funding / Alignment of stakeholders

Equip has found that aligning investors and payors around quality and patient retention has helped with the freedom to not feel pressure to make scale decisions that compromise outcomes. Part of that has also been clarity of mission from the start.

Equip has seen the cycle of people who started residential treatment centers in the 1990s because they thought that was the best way to care for patients at the time, sold those centers to private equity and made a good deal of money, but now those people wouldn't send any of their family members to those same residential treatment centers because the quality of care is so poor. They intend to avoid that at all costs and believe they can by building a clinical model that has strong clinical outcomes.