Episode 10: I’m shocked! The amazing potential and possibility of bioelectronic medicine with Doug Biehn of Cala Health

Justin Steinman:
Definitively Speaking is a Definitive Healthcare podcast series recorded and produced in Framingham, Massachusetts. To learn more about healthcare commercial intelligence, please visit us at definitivehc.com.

Justin Steinman:
Hello, and welcome to the latest episode of Definitively Speaking, the podcast where we have data driven conversations on the current state of healthcare. I'm Justin Steinman, chief marketing officer at Definitive Healthcare and your host for this podcast. I'm joined today by Doug Biehn, chief commercial officer at Cala Health. Cala Health is a bioelectronic medicine company transforming the standard of care for chronic disease. According to their website, Cala's wearable neuromodulation therapies merge innovations in neuroscience and technology to deliver individualized peripheral nerve simulation, and it's vertically integrated commercial model is reshaping the delivery of prescription therapies. Cala Health's lead product, Cala Trio, is the only non-invasive prescription therapy for essential tremor. And they're currently developing new therapies in neurology, cardiology and psychiatry.

Justin Steinman:
Wow. That was a lot there, a lot of science. If you're wondering what all that means, and I certainly did as I was preparing for this podcast, just stand by for a few seconds and Doug will explain it all to you. I'll admit, as I was getting ready for today, I had a lot to learn. I had never even heard of bioelectronic medicine. And frankly, the first thought that came to my mind was Steve Rogers in The Six Million Dollar Man. If you're of a certain age, then you'll get that reference. And if not, kids, that's what Google is for. Anyway, Doug, welcome to Definitively Speaking.

Doug Biehn:
Hello Justin. Thanks for having me here. I really appreciate it.

Justin Steinman:
We are glad to have you here, and I look forward to learning a lot about this new and exciting space. So I shared the corporate website speak a few moments ago, but let's de-geek the speak a little bit here. What in the world is bioelectronic medicine?

Doug Biehn:
All right. Well, it is an exciting innovation in healthcare. At the core, essentially, bioelectronic medicine is a new approach to treating and diagnosing disease. It represents a convergence of molecular medicine, neuroscience, bioengineering. Essentially, it uses device technology to read and modulate the electric activity within the body's nervous system. A type of bioelectronic medicine that's been around for decades is called deep brain simulation. In fact, it's been around since 1987. And the space has seen a lot of, actually very little innovation until recently. That's where Cala comes in, among other bioelectronic medicine companies. I'd be happy to share in a little more specificity kind of how Cala has pioneered bioelectronic medicine to create a whole new way to treat patients struggling with movement disorder, if you'd like.

Justin Steinman:
Oh yeah. We're going to get there. But you said deep brain therapy? Did I get that right?

Doug Biehn:
Deep brain stimulation. The acronym is typically DBS. It's the process of essentially brain surgery, where you drill holes in a brain and you attach electrodes to what's basically called the VIM, or the thalamus part of the brain. And it stimulates the brain to reduce tremor. It's almost like a pacemaker. You have these electrodes on your brain and this battery pack within your chest that modulates or calibrates to the tremor frequency and improves patients' ability to function on their daily activities without having tremor.

Justin Steinman:
That sounds really painful.

Doug Biehn:
Well, it's funny you say that. Only 1% of the population has been able to either be interested in or qualify for it. In all the years that big players out there in DBS, there's been only around 40,000 patients that have benefited from it over these decades. So you do the math. 40,000 out of the 10 million patients suffering from this in the US alone, you obviously have a huge treatment gap. So to your point, yes, it sounds painful. It is painful. It comes with a lot of health risks that really limit the qualification of people to have that type of therapy.

Justin Steinman:
Got it. And so is Cala built on that foundation, but taking it to the next generation and making it less painful?

Doug Biehn:
That's a great question. I'm going to try to tell the story of our founder, Kate Rosenbluth. She is amazing. I often think of her as this combination of genius and Ted Talk. She just has this amazing intellect and ability to communicate. And her story of how Cala was founded will answer your question directly. Cala was founded out of the Stanford Biodesign program, and that program is really about identifying huge patient unmet needs and putting the smartest people on it. And Kate is a neuroscientist. She's studied at UCSF and Stanford, and while at Stanford, she was studying a bunch of deep brain stimulation cases that we were just talking about.

Doug Biehn:
There's a point in the deep brain stimulation procedure where in order to determine exactly where to place those electrodes to apply the therapy, they have each patient open up their arm, and they use a paint brush on the back of the wrist to say, okay, where is the stimulation happening in the brain, because the radial and median nerve are within the wrist. And they attach to the exact spot in the brain where the tremor is sourced. And so Kate's big idea was, if you could actually stimulate the radial and median nerve peripherally from the wrist with enough power, let's say, you don't need to do it invasively. You could do it non-invasively. And that in fact is her idea, how it was sourced to start Cala. And in fact, we've proven over and over again with clinical studies that you in fact can effectively reduce tremor peripherally without surgery, or without drugs for that matter. Isn't that cool?

Justin Steinman:
That's amazing. So let's just define for our listeners out there. I come from a very non-scientific background. I'm very proud of my English degree. What is essential tremor?

Doug Biehn:
Okay. Essential tremor, it's one of the most progressive neurological disorders. It's characterized by this kind of involuntary, rhythmic shaking. It's the most prevalent movement disorder, and depends on your source. If you look at the International Essential Tremor Foundation, which is the largest patient advocacy organization in the world, they estimate it anywhere up to seven to 10 million people in the US alone, eight times the prevalence of Parkinson's disease, for example.

Doug Biehn:
ET patients have these abnormal firing patterns in the brain that cause the tremor that affect many parts of the body, but most commonly, almost 95%, it manifests itself in hand tremors. And these hand tremors are very disabling. So think about just drinking a cup of coffee, writing, typing on your phone or your iPad. Those basic activities of daily life, you can't accomplish, which then turns into a higher incidence of mental health issues like depression. Oftentimes, because this happens even in the 40s and 50s, people can't maintain their jobs. And this then manifests into a higher incidence of substance abuse and overall a higher cost of being a central tremor patient than a non-essential tremor patient. So it's really debilitating to people's lives, to their mental health, and to the overall healthcare system.

Justin Steinman:
Got it. And so the Cala invention is you basically put a bracelet on over your wrist, right? Your forearm area, and it delivers electrical stimulation. And it stops your tremor?

Doug Biehn:
Yeah. That's a great explanation. To your point, it's a wrist worn wearable, like a watch. It's patient activated, so it's kind of when you have either an episode, or if you want to just maintain your tremor. I would say the secret sauce though, Justin is in its what's called Cala TAPS therapy. And it does three things that are really compelling and I think really brings to life your first question. What in the world is bioelectronic medicine? So like deep brain stimulation, they're trying to focus the stimulation in the VIM, which is part of the thalamus of the brain. It's the same thing for Cala, but we do it noninvasively from the wrist.

Doug Biehn:
And so there are three things that I think are really compelling. First, with Cala, we're able to for each patient to detect their unique physiology, which really is their tremor frequency. So the frequency of their hand tremor is correlated to the irregularity of the tremor within the brain. So we're able to detect each patient's unique physiology, which is critical because the only way to improve tremor on a patient is to understand what their specific physiology is and then automatically calibrate to that physiology. And so the software algorithms on the wearable device evaluate that tremor frequency, and then automatically calibrate the stimulation to that specific patient's needs. And then the bands themselves have these precise, proprietary electrodes that specifically target the radial and median nerve in what we call this out of phase cycle to overall reduce the patient's tremor. And it happens automatically.

Doug Biehn:
The tremor relief could last 90 minutes. So think about this. I'm going to go to the coffee shop and meet a friend, and I want to be confident in that social interaction. Well, I'm going to have a therapy before I do that. Or I need to write a letter. I'm going to do a therapy in advance of that, so I can actually complete that letter successfully. And so it's beautiful in that it's really patient driven. It's very personalized. And what's beautiful about this, unlike drugs, for example, that over time, your body kind of adjusts and the efficacy of that drug goes down, that doesn't happen with Cala.

Justin Steinman:
But you don't wear this thing all day. You take it on and off, right?

Doug Biehn:
You can wear it all day. Each patient has his or her own approach. Some patients, just your daily activities. You get up, you brush your teeth, and then you have lunch later on. So it's like you get up, you do your Cala TAPS therapy in the morning, you do your Cala TAPS therapy in the afternoon, and you get relief throughout the day. Or I'm a piano player, and I'm going to play at 2:00 today. And so I'm going to start my therapy a little before 2:00 so I could play the piano. It really depends on how the patient wants to use the device.

Justin Steinman:
This is interesting because I did a little research in our Definitive database, and I looked at the number of claims filed with insurance companies for ICD-10 code G-250, which is essential tremor treatment. And what I found interesting was that the number of claims filed increased 11% between 2019 and 2021. So even if I account for the decrease in claims for COVID and everything else, 2019 and 2020 were up 11%. I don't think essential tremor is a new disease, so what's changing?

Doug Biehn:
Well, that's a great insight. We see that too in our data, both with Definitive and another third party data. So what you're saying is absolutely true. And I think the two main reasons for that, Justin, are one, as we all know, we have very much of an aging population, especially here in the US. And so it's a progressive neurological disorder, as I mentioned. So as you age, it becomes more acute, which then leads to more diagnosis. And then also what we've learned, which is really interesting, an essential tremor patient has on average 5.3 comorbidities. So as you accumulate more comorbidities, the incidence of the essential tremor goes up. So I think those are the two factors that are really driving that high, year over year growth rate of essential tremor patients.

Justin Steinman:
Got it. Let's pivot a little bit and talk about the business thesis for Cala. Let's assume for a second. I'll take the high end of your range. You said seven to 10 million patients [inaudible 00:12:56]. Let's just say 10 million. Okay? And I did some research. According to the Mayo Clinic, there are 200,000 cases, give or take, new cases of essential tremor every year. At some point, that feels like a relatively small target market. And yet you guys went out and raised a lot of venture capital. So where's the upside for Cala in all this? How do you expand beyond just essential tremor treatment?

Doug Biehn:
That's a great question. Thanks for doing your homework. Well, as we said earlier, our vision as a company is to continue to pioneer bioelectronic medicine to free people from struggling from chronic disease. Our first indication is essential tremor, and eventually we will expand into Parkinson's disease as well, which is also a very debilitating disease. But if you pull back, we are a very innovative company. And the movement disorder space in and of itself, whether it's 7 million or 10 million, for us, that's about a $20 billion market. And if you look at the data that we see, if you look at Definitive Healthcare data, we're seeing approximately a million new diagnoses per year in essential tremor, whether it be primary or secondary diagnosis. And so that translates into almost a $2.5 billion total addressable market from an expansion perspective year over year.

Doug Biehn:
I would actually say it's a pretty significant marketplace. And when you have a market that has a very low current standard of care ... What I mean by that is you have drugs that are not very effective that come with high side effects, or to our conversation earlier, you've got brain surgery that only applies to less than 1% of the population that is highly invasive and costly. You have a massive gap in care. And so for a differentiated, safe and effective therapy like Cala, the market opportunity just in movement disorder is massive. And that's just the US perspective.

Doug Biehn:
But our vision is not to stop at movement disorder, to your point. Our vision is to build this platform that treats multiple patients with multiple indications. So like you said earlier, we're moving to other areas like Parkinson's, like other indications within neurology, as well as psychiatry, cardiology, and the autoimmune disorders. And those kind of markets start to swell the business thesis, to your point, around the opportunity here. So yes, movement disorder, you could say it's our beach head. But we are building a platform to address multiple indications with this safe and effective therapy.

Justin Steinman:
Who are you selling this to? Do you sell insurance companies, doctors, health systems, patients, all of the above?

Doug Biehn:
Yes. All the above. I would say, just to kind of simplify it, I'd consider us a two-sided marketplace, no different than Uber or Airbnb. One side of the marketplace is the consumer, right? Consumers don't wake up in the morning and say, "Oh, I need to take my electricity." That's just not how they think, unless you're The Six Million Dollar Man, which there's only one [inaudible 00:16:01]. But my point is the consumer, we need to build the awareness that there is another treatment alternative other than drugs or brain surgery. And we need to build that trust in the eyes and minds of the consumer, so much so they're compelled to introduce Cala therapy to their physician, whether it be their general practitioner or their neurologist. And ultimately, we need to deliver an experience that delights them, both clinically and experientially. And if we do that, they will not only continue to advocate to their providers, but they will also continue to advocate to their friends and family and create that market pull that's so important to introduce new innovations.

Doug Biehn:
On the other side of the marketplace, it's the provider. Our goal with providers is not really just to sell new technology, but really is to become a partner in them in helping neurology practices and physicians raise their standard of care and differentiate themselves in the marketplace. Physicians do not care about cool technology. They're looking for solutions that change the way they treat their patients in a positive way.

Doug Biehn:
So typically, in my experience, novel treatments like ours, you have to deliver on four things. It's not about going in and saying, "Hey, look how cool this tech is. Now start prescribing it and using it with your patients." Rather, you have to prove to these physicians and practices that one, this clinically improves the outcomes of the care that you're delivering. Two, that it improves the patient experience and overall satisfaction with that novel technology. Three, in my experience, if you add a click to a physician's workflow, they'll forego a new technology. So you really have to demonstrate that this will help increase the staff productivity of that practice. And ultimately, which really matters a lot to the payers especially, you have to demonstrate how your new solution lowers overall costs, whether it's operating costs or total cost of healthcare. And if you do that consistently and reliably, then these practices and physicians will establish talent in this case here as the new standard of care and become a really healthy business, and ultimately create that flywheel effect of that two-sided marketplace that I started with.

Justin Steinman:
But it really is a three-sided marketplace, right? Because we all know the insurance companies control the purse strings, right?

Doug Biehn:
Yes.

Justin Steinman:
Whether you're one of the commercial insurance companies or whether you're Medicare. And you're right. If you can prove to them that you're going to lower the cost of care, they're all in. But short of that, they ain't doing anything. So how did you get the insurance companies on board?

Doug Biehn:
You are correct in that it's three sided. But unless you get patients that love it and physicians that adopt it, your payers will not cover it.

Justin Steinman:
Yeah. But you can have patients that love it, and my insurance company still won't cover it. It's going to be careful.

Doug Biehn:
And that's not uncommon with innovations. One of our first significant payers is the Veterans Affairs. We have both a coverage policy and a reimbursement policy with the VA, and the VA consistently prescribes Cala to their members. And we're seeing tremendous growth in that channel. We're also seeing growth in the insurance channel. We are actively working on establishing new coverage policies and contracts with large payers, including Medicare.

Doug Biehn:
In the meantime, we're doing it patient by patient. We call it a single case agreement model. And we're seeing strong adoption on the payer side, patient by patient, which allows us then to build a nice case of utilization to the payer and say, "Hey, payer, this number of patients within your membership population are continuing to use and demand this product," which compels them to take a look at it from a coverage perspective and a contracting perspective. And that's what we're seeing in the marketplace now.

Justin Steinman:
So how did you get the VA on board? What did you show them to get them over the hump?

Doug Biehn:
Well, it's interesting. The VA is an integrated delivery network, so your payer and your provider and your member are all part of one organization. And the VA has become, I would say a little bit of a bellwether in the health system in the sense that that integrated model has delivered innovation and savings to the overall system. And so, the VA is looking for ways to provide a higher quality of service to their veterans. And they were an early adopter. And they've been just a real great partner of ours in expanding this to the market.

Justin Steinman:
Yeah. That's really interesting. This whole space is just so rapidly emerging. I never thought I'd say this, but I actually almost feel bad for the insurance companies because there's so much stuff coming at them, and they have to try to figure out what's working, what's not, what's true, what's fake. It's got to be complicated to try to figure that out.

Doug Biehn:
You're absolutely right. And when you ask, say a payer, about essential tremor for example, and they don't truly understand the size, the complexity, the magnitude of that market, they kind of think of it as benign. So it's our job, it's any job of an innovative healthcare startup to play the role of an educator. And you've got to educate with data and with facts. And you also have to leverage your physicians as champions in really bringing to life the story of the patient in a more credible way to these payers. And if you could do that, then they listen.

Justin Steinman:
Interesting. I love your passion about this. How did you wind up here?

Doug Biehn:
That's a great question. Well, I started my healthcare journey at a payer, Blue Shield of California. And that's where I found my mission. If you think about industry out there, healthcare is one of those industries that has really yet been disrupted by new technology. Take music, take retail, take commerce. All of those industries, massive industries have been disrupted by technology. Well, 20% of the US GDP is derived by the healthcare system, and it's just stuck in the 20th century. And so, I'm on this mission to help bring the healthcare system into the 21st century.

Doug Biehn:
And working at a payer, especially an innovative payer like Blue Shield, you really get a great perspective on the different stakeholders in the system and how to innovate. And so I left the payer model to move more into technology. And my prior company was iRhythm, which was also a Stanford Biodesign alum in that they were the first to really develop this digital health wearable monitoring kind of technology for cardiology. I really loved being part of that team and growing that team. And to be honest, the reason to come to Cala was very similar in that the market opportunity is huge. The current standard care is very, very low. The innovation is founded on clinical evidence. And it was at a stage of the company where I get the most joy. I love designing, creating, building world class commercial organizations, and Cala had all those things in one package, which really attracted me. And I've been here almost a year, and I haven't looked back. It's just been a wonderful run.

Justin Steinman:
That's awesome. That's awesome. Not a lot of people know about this bioelectronic space. As I said, I didn't know anything about it before we were introduced through a mutual friend. And in my course of researching this, I read a report from JPM Securities that said, and I quote, "The new wave of device-based innovation known as bioelectronic medicine is poised to drive in expansive sea change in the treatment of a range of indications." That seems pretty optimistic, an expansive sea change. Right? So what makes you so bullish about this market for bioelectronic [inaudible 00:24:13]? Why are they so bullish about this?

Doug Biehn:
Yeah. I think it's most important to answer that question looking through the lens of the patient and the physician. Take neurology in our area of movement disorder as just a proxy for why we are so bullish on this. In our area movement disorder, the standard of care is really low. Physicians are very dissatisfied with the existing treatment options for movement disorder, especially in essential tremor. As I said earlier, there's really been no innovation in treatment for decades. And so think about these patients. They say, "Doc, I have this tremor. How can you help me?" Well, the doc is really unable to operate at the top of their license in providing treatment options to really help improve their quality of life.

Doug Biehn:
And so the common narrative goes as following. "Patient, I can prescribe you drugs. But they will likely not work, and you will have serious side effects. So here you go." And the patient will try the drugs, assuming they could actually tolerate the drug. And over time, it'll likely habituate. And so they'll come back to the doctor and say, "Well, what else do you have for me?" And the doc will say, "Well, the next option, once drugs fail, is brain surgery." And as we said earlier, very few patients are interested or even qualified for brain surgery, in fact, less than 1% of the patient population. And so here you have a physician who went to medical school, got into care to help people, and he or she cannot operate at the top of their license. No physician likes that. And then you have a patient who has no treatment options for a debilitating disease.

Doug Biehn:
And these are massive markets. We already talked about the size of this market. Think about the migraine market in the US. It's almost 40 million people, and all they have are drugs. And so I think this notion of wearable neuromodulation, bioelectronic medicine is proven to be safe and effective, non-habituating, and people could integrate it in their daily lives. And something we haven't talked about, data. What drug gives you as a patient or a provider data on your utilization, on your kinematic effect, the clinical benefit? None of them do. It's all analog. This notion of bioelectronic medicine, you have data now that gives feedback directly, safely to the patient and says, "Hey, when you utilize it in this way, you get a better benefit. Keep utilizing." And then that data goes back to your doctor and says, "Hey Doc, this is how often I'm utilizing. This is the clinical effect. This is my overall satisfaction and impact on my quality life." And then they could better treat your condition over time, and so that's another benefit. And so I think that's why everybody is so bullish.

Justin Steinman:
Yeah. The data point is really interesting because you think about it from a drug, how is the drug working? Well, it made me a little loopy. What kind of data point is that? How's your pain? Well, my subjective pain on a scale of one to 10 is a six, but my six might be Doug's two. You just don't know. And so it's completely, totally subjective. And here you're really going to a much more objective way of thinking about treatment and measuring effectiveness.

Doug Biehn:
Right.

Justin Steinman:
Really interesting.

Doug Biehn:
Well, you nailed it. You nailed it. For example, on Cala, we do a pre-post therapy session assessment. So we could tell you or your physician exactly how effective that therapy was on your tremor. Think about this through a drug lens though. Drug companies, they're going to continue to develop drugs, but they also have to compete in this marketplace. And so I think it's also very attractive for drug companies, more forward thinking drug companies to invest in these kinds of innovations to round out their portfolio.

Justin Steinman:
What changed in technology over the past 10 years to enable all of this? Is 10 years the right time horizon? Because we keep saying [inaudible 00:28:10] innovation since 1987, and yet it feels like in the past 10 years, there's just been a ton of innovation. What changed?

Doug Biehn:
Well, I think you have the innovation and advancement in sensor technology. That's clearly something that has advanced over the last 10 years. Obviously, artificial intelligence, machine learning algorithms, deep learning algorithms to take massive amounts of data and derive insights that could then improve at the patient level and the population level. The quality of care that's delivered has also advanced dramatically. I think this notion of, you look at it through the payer lens, payers want to ensure that patients receive care at the lowest cost setting. And so the more care you could provide at home or remotely is obviously a lower cost than administration into a hospital or to a clinic. And so I think that's not going away. This notion of value based care is here to stay. And so I think those are three great examples, fact-based examples of why this is going to continue to grow and accelerate.

Justin Steinman:
Yeah. You've hit on a couple of themes. We've only been doing this podcast for about six months, but you've hit on a number of themes. We've talked a lot about practicing at the top of your license. We've talked a lot about value-based care. We've talked a lot about chronic disease management. We've had a number of guests talk to us about the investment dollars pouring into technology and the pervasive nature of mobile devices. And you also touched on the medical consumerization of wearables. There's a catch phrase for you. Do you think we're on the precipice of a new way to manage chronic disease?

Doug Biehn:
Well, I think we're in it.

Justin Steinman:
In it. Okay.

Doug Biehn:
I think we're in it. And I think we've been talking about it for a while. And I would just say, I think the future is bright, and that chronic care management, patient driven, remote data driven services wrapped around that data will only continue to grow. I think we'll still have a lot of headwinds as it relates to the time. Our healthcare system is very complex.

Justin Steinman:
This just in.

Doug Biehn:
Yeah. Yeah. And that's probably a whole podcast right there. What are the factors that are of the greatest complexity and time barriers? But I do think that the more we can make it easier for patients to access these types of personalized care options that are safe and effective and to your point that you keep hammering home, continue to partner with health plans, to educate them, to cover these new treatment options so that they are affordable. They are affordable. We will then see the adoption of these innovations continue to accelerate. But there are still headwinds.

Justin Steinman:
Yeah. My old [inaudible 00:31:03] colleagues will be happy to hear you say that I'm hammering home to work with the health plans. Let's make them happy. I had Jim Pursley from Hinge Health on the podcast a few weeks back, and we were talking about digital musculoskeletal treatment. I've known Jim for years and years, and he was speaking passionately about the adoption of Hinge's technology within what we'll call the Medicare population. You probably serve a large Medicare population as well, that over 40. I think that's definitely, the 40s and 50s for people, the big onset of essential tremor. My experience with the Medicare population comes down to my parents and my parents' friends. And diplomatically, we will say they have, in air quotes, "Varying levels of comfort with technology." What's been your experience with that 60 plus year old population and how they're adopting your technology?

Doug Biehn:
When I worked at Alive Corps as the chief operating officer, our primary audience was Medicare. When I was at iRhythm, our primary audience was Medicare. And here at Cala, our primary audience is Medicare. All of which are high growth organizations.

Justin Steinman:
Yeah, with baby boomers.

Doug Biehn:
I'd say it comes down to a few things, Justin, what I've learned. In my experience, patients really care about two things that are inextricable, and I'll explain why. One is ease, and especially the Medicare population. You as an innovative, novel therapy or solution or device, whatever it is, it's your job to make it as easy to understand, to choose that product, and to use that product. That's one of the factors. The other factor is value. Value is to me, there's two parts to that. It's the access to quality of care at an affordable price. And the inextricability part of it is if you are seen to be not easy, like I don't understand it, or I have a hard time using it, you're actually perceived to be of low value. The same goes is if you're not affordable, then you're not easy. And so no matter how amazing your solution is, if you can't make it easy and make it perceived to be of value, affordable and quality, you're not going to get anywhere, especially with the Medicare population.

Doug Biehn:
Oftentimes we see with the Medicare population, they require a little more of a white glove approach. But I've got to be honest. A very significant part of our business is self-serve digitally. They're engaging with our YouTube videos on how to onboard, how to use the product, how to troubleshoot. They're not even calling our call center.

Justin Steinman:
Interesting.

Doug Biehn:
And that continues to grow. And so I think there's a little bit of a myth that the Medicare population is kind of stuck in that 20th century, the analog. I actually do see a lot of Medicare population. Obviously, they all have smartphones or iPads, and they're engaging with that. It's just your job as the innovator to make it as easy and as valuable as possible.

Justin Steinman:
That's good to hear. That's good to hear. Doug, this has been great. I learned an absolute ton today. But before I go, I got one last question for you here. I want to get your thoughts on industry roll up. As we've talked about multiple times today, lots of innovation in this space, just tons of it. And there are dozens, if not hundreds of companies offering tools for chronic disease management, entering with medical devices and mobile devices. Even that JPM securities report that I cited, they have more than 100 companies in this space, including 21 alone treating neurological disorders. They've got dozens more treating diabetes, pulmonary disease, inflammatory, metabolic, urological. I could go on and on. A lot of companies, a lot of devices. Do you see a roll up coming in all this? Does this industry head towards where the pharmaceutical industry is at today, where you've got a bunch of tiny startups with a bunch of drugs in their pipeline over here, and then you've got some really big companies on the other side that handle manufacturing and distribution? Or do you think this industry goes a different path?

Doug Biehn:
Yeah. Well, I think what you're referring to is, will there be consolidation in the marketplace? And I'll paraphrase a perspective that I learned from a colleague of mine not too long ago. He talked about there are market makers and market takers. And there's always that ecosystem. The market maker is that innovator. It's that startup that is unbridled by bureaucracy and constraints. And they're able to be very innovative and flexible and agile in the marketplace and move very quickly, which a larger company could not do. And that's what's happening. And we are not constrained by those large corporate barriers, let's just call them. That's naturally, and I think you're seeing that in the early phases of this bioelectronic medicine movement.

Doug Biehn:
But then there are the market takers, which really are the larger companies that rely on the innovation for these market makers to help differentiate their value propositions. And in healthcare especially, that's very common. So I think yes, absolutely, Justin. You're going to see consolidation happening with these market takers in order to robustly build out their value propositions. And I spoke to pharma maybe as an entree to this question early on in that in order for pharma to be relevant in the future, they have to have a digital offering. It cannot be just drugs and formularies. And so I would imagine you would see a lot of market taking by pharma, other companies like the Medtronics and like who were founded on brain simulation.

Justin Steinman:
Right. Great. Well, Doug, thanks for taking the time to talk with me. I loved it. This was really good. Really appreciate it.

Doug Biehn:
Appreciate it. Thank you.

Justin Steinman:
And for all of our listeners out there, thanks for listening today to Definitively Speaking, a Definitive Healthcare podcast. Please join me next time for a conversation with Dr. Carolyn Jasik from Omada Health. Omada is a virtual first chronic care provider, so I think my conversation with Carolyn will be a great follow up to today's episode with Doug.

Justin Steinman:
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