Increasing Medication Adherence with Video Technology - Sebastian Seiguer, CEO of Scene Health

Shiv Gaglani: Hi, I'm Shiv Gaglani. As we've noted on the Raise the Line previously, the failure of patients to take their medications as prescribed cost the U.S. healthcare system more than $500 billion a year, not to mention the adverse health outcomes it causes. Well, our guest today is tackling this problem with a system that combines video technology, clinical coaching, and validated interventions to radically improve medication adherence rates. 

Sebastian Seiguer is the chief executive officer of Scene Health, a company he co-founded ten years ago that is currently supporting patients across multiple chronic and infectious conditions, including diabetes, asthma, cholesterol, opioid use disorder, hepatitis C, tuberculosis, hypertension, solid organ transplants, and sickle cell disease. 

Prior to Scene, he was CEO and co-founder of a German coffee chain that scaled nationally. Sebastian serves as the primary investigator on multiple grants, including with the NIH's National Institute on Minority Health and Health Disparities. He earned his bachelor's and JD degrees from Columbia Law School and his MBA in healthcare from Johns Hopkins University. 

Sebastian and I actually go way back to our DreamIt Health Baltimore days when I think Scene was called Emocha. My good friend Mike Batista was working on the Smartphone Physical with me on something we call Quantified Care. Sebastian, it's great to see you again. Thanks for taking the time to be with us today.

Sebastian Seiguer: Great to see you again, Shiv. Great to see you again. Glad you're back in Baltimore.

Shiv: It's really fun to follow along stories like yours where we kind of grew up together, but for those who don't know you or Scene or what was called Emocha before, tell us a bit more about yourself -- what got you interested in law and then eventually healthcare -- and then what the founding story of Scene was. 

Sebastian: Sure. I can't really remember what got me interested in law. I liked reading a lot in undergrad. I was an English major, and somehow just didn't like the job opportunities I had in front of me when I graduated college and ended up in law. It was a brief stint. I loved where I was. I was at a big UK law firm, and it was really interesting work, but I've always wanted to be an entrepreneur. 

I got the chance to do that starting a coffee chain in Germany where the law firm was sending me. They were sending me to Munich all the time for one particular customer, and there was nowhere to get coffee. All my law school buddies were doing great internet businesses. That was the best thing I could think of. Grew it to about twenty locations, started franchising it. It was a lot of fun, great coffee. We were making money. You could see it. It was real cash back then, but I was very bored and my whole family is in healthcare. Parents were physicians. My sister's an infectious disease doc. She introduced me to my wife, who's also an infectious disease doc. Healthcare's in the family, and I love how motivated people are in healthcare to help a patient improve their life. It's a great thing. Never wanted to be a doctor myself, but I love being on this side of it like you, Shiv, on the technology side where we can improve various aspects of it. Medication adherence jumped out at me during my MBA at Hopkins as just a huge issue, and I was naïve enough at the time to think I could pretty easily solve it. 

Shiv: I remember back in the early 2010s, it was a digital health renaissance. I think then in the mid-2010s, it was kind of like the valley of the trough of disillusionment if you look at the hype cycle. Surviving long enough for it to be exciting or to get to the zone of fulfillment is impressive. Tell us a bit about the problem of medication adherence and how you started solving it with Emocha, now Scene Health.

Sebastian: Yes, you mentioned at the intro it's a really big problem. The numbers are shocking. If you had a family member with a complicated regimen, you understand the problem. There is a solution to the problem in the inpatient setting -- in the hospital or in the clinic. Every single dose of medication with no exceptions for every condition that there is in

every single patient is done under something called Directly Observed Therapy, which is where you sit with a patient -- this is typically done by a nurse -- make sure the patient takes the medication, and then you monitor for side effects or other issues. If it's a multi-based thing, you adjust the regimen over time. 

In the outpatient setting, that falls apart. That was our idea...that we could take this gold standard process and translate it into the outpatient setting. Of course, it's really expensive to do that, so immediately the idea was asynchronous video which is video recordings exchanged from the patient taking medication, saying how they're doing, back to the provider. It seems obvious now. Like you said, at the time in the 2010s, nobody was doing anything healthcare related on a mobile phone. It was seen as a little crazy back then. 

Shiv: I think the first time I first heard about DOTs was actually Paul Farmer and Partners in Health. We had Sheila Davis, who's the CEO of Partners in Health, on the podcast a couple months ago talking about how effective DOTs and others were for TB treatment out in Haiti, in developing nations. It's very interesting how you've virtualized and made it asynchronous. 

Tell us a bit about maybe some of the actual outcomes that you're seeing. I know one thing that's always impressed me I've seen from Emocha was how research-driven you guys are. You partner with governments, health systems, and public health agencies and get all these grants. I think you just got an NIH award for pediatric heart transplant patients in Florida. Tell us a bit about that and the efficacy you're seeing with the work you're doing.

Sebastian: I love that you bring up Paul Farmer. I always refer people to the Bending the Arc documentary to see what DOT looks like in practice. It's not about technology at all. It's about one person helping another person through a very difficult situation. Tuberculosis happens to be a very, very hard regimen, and it's a hard disease. Paul Farmer used the technique also for HIV. 

In healthcare, as you know, you have to prove that something's actually beneficial to the patient. We immediately set out to work with academic medical centers that were running tuberculosis control departments at nearby public health departments. For example, in Baltimore, where we worked with Dr. Maunank Shah, who still runs the TB control department. We also got NIH funding to support this because I just don't believe investors should support your clinical trials, at least in the behavioral sciences. We have amassed about nineteen peer-reviewed publications to date through probably about ten or twelve trials. 

The amazing thing that happened last month was that the CDC finally recognized this body of evidence and stated that using asynchronous video directly for DOTs is equivalent to an in-person DOT. The two are not different, which is an incredible thing. It's the first time in healthcare that an asynchronous video appointment is treated the same as an in-person appointment. I think evidence is really, really important. 

On the other hand, we now sell into Medicaid managed care organizations, and it's really hard to get that level of evidence. It's really hard to take some of these trials, which are smaller patient populations -- the biggest one we had was about 300 patients -- and then translate that out to thousands of people. That's more of a business operations type of challenge than anything. 

Shiv: Yeah, that's fascinating. Nineteen peer-reviewed publications...congrats on all that. I can't help but think about even the last several years with the rise of telehealth forced by COVID and also how most companies have gone virtual. As you may recall, when we first met, I was running Osmosis. We were a virtual company from the start, and that gave us a lot of efficiencies because we didn't have to be commuting, you could work when you're most productive as opposed to nine to five when you have to be in the office. Now it seems like there's a movement towards async meetings. Let's get rid of these synchronous meetings. Let's use Loom or Slack for text messages or Loom for video messages. I can't help but see parallels between maybe live telehealth appointments where you're live video DOT versus async DOT, which is more convenient and hopefully reduces the cost to provide this because you don't have to have real-time provider time, right? 

Sebastian: Yeah. DOTs were being done live as early as the year 2000, but how are you going to get somebody who works out in a field to do something between nine and five and get them on video too, live? It's just very inconvenient. I think that the magic of asynchronous video is that you can workflow it. You can almost tell the person what they're supposed to do in this video so that you have the context of it. You don't have to just go piece it all together as unconnected videos. You can really script it out. 

I think it's pretty magical. A patient just hits record and they just start talking, right? They tell you everything. It's super interesting and it becomes self-journaling. Our team that responds has to not only understand a little bit about medication, of course, but they've got to be able to have a conversation. They've got to be willing to be extroverted enough to hit record as well and send a message back. I think it's a pretty fascinating medium. I haven't used asynchronous meetings for business yet though, but good idea. 

Shiv: Yeah, I recommend it. I like Loom a lot for that reason because a thirty-minute sync meeting can become like a six-minute async video. I found it just makes us more efficient. 

Sebastian: Interesting. Never tried it. Can't believe it. Okay. 

Shiv: Well, so being a video, your tech platform is video first, right? One thing I'm actually kind of curious about, just given how much video has improved over the past few years in terms of quality, speed, filters and features -- like Snapchat videos -- I think is how it's been described by the people I was talking to on your team. 

Do you guys do any video processing, like filters or automatic translations, captioning? The rise of generative AI makes all this stuff possible. Is there any application that you think would improve what you're trying to do?

Sebastian: Absolutely. Originally, it was a video from the patient only, just so you're aware. The provider didn't video back. In public health departments, they weren't even comfortable videoing back. I think by 2018, we started sending videos back to patients. That was a big deal. Really interesting is that when we first plugged in, you don't have to build all these things yourself, right? There are libraries and APIs that you can attach to get a lot of these features. When we first brought emojis in, they were immediately used. The usage was off the charts on day one, as soon as it was available. There are these common forms that you can plug in, like filters. We're starting to use captioning for teleprompting what somebody should be doing next. 

There's also transcription that allows our team to be able to respond to certain things before they've seen the video. So, there are so many things you can do. The big question becomes why? It's either to get efficiency or make it as entertaining if you can, because this is still healthcare. Healthcare is not as entertaining as social media for some. If you can get it closer to that level, then this is adherence. What that means is they're going to do it again tomorrow, which is exactly what you want. We're learning, and we're trying to catch up to the standards that are set by the social media companies.

Shiv: The good thing is a lot of the providers that I'm sure you're hiring grew up or will have grown up or been very used to Instagram, TikTok, and Snapchat. You're bringing this patient care delivery into the formats that maybe they're used to.

You guys just raised the Series B. That's huge news. Congratulations. Very validating. 

Sebastian: Thank you. 

Shiv: Tell us a bit about what you're going to do with that funding and what your next milestones are...whatever you're able to share.

Sebastian: This is the first big round that we did. It was led by ABS Capital. The grand total is about $17 million. For us, we leaned into Medicaid managed care about a year and a half ago as the big market for the company. That was really validated over the last year. We're going to use the funding to launch customers. We have some customers that we just have to grow with. That takes investment. 

For every condition, we can start with adherence, just videos back and forth. As you know, being an education platform with Osmosis, you have to have real tailored content. So, developing programs for every condition and going a little bit beyond just the medication adherence is important because sometimes we're not only responsible for making sure people take their medication, there are also metrics that the health plan is accountable for. 

In Medicaid, it's the HEDIS metrics (Healthcare Effectiveness Data and Information Set).

We have to get better on the data side. We'll also make some key hires, grow the team, grow the business, make sure everybody in the Medicaid MCO world knows that Scene Health is an option, and that medication adherence doesn't just mean putting meds in people's mailboxes, which is what it currently means in the health plan space.

Shiv: It's so interesting where the policy is versus where the technology is. I'm sure you remember back in the day there was Proteus Digital, which was super high tech. It's like, let's put chips on the actual pills so that we know that you've ingested it. Obviously, I think they raised too much money and it just wasn't as viable as something more simple but also more complex. It's like finding that happy medium where I think Scene is.

Sebastian: Yeah, people don't like swallowing electronics and people like people, right? Proteus was kind of doomed, I thought. I guess it made sense somehow. I think the personal connection is what drives somebody to improve their health. You see that in other wellness areas as well. It is a very interesting area that is at the intersection of healthcare and psychology and habit formation. The behavioral economic aspects here are pretty interesting. 

Shiv: This may be a bit of a tangent but what do you think of like, two things. How do you train your providers to be the best over this format? You mentioned they should be more friendly and outgoing - what's called “webside manner” for telehealth. But then also, do you see a future where maybe AI avatars can be the ones directly observing these therapies? Do we even need the doctors? We've seen some results showing avatars in psychiatry can be more effective. Or like in sexual health screening. It's a little less like judgment from another human, right? Imagine if you're like a seventeen-year-old girl in Utah and you're going into your OB-GYN who's like a seventy-year-old man asking you if you're sexually active. I mean, come on, you're more likely going to tell an AI avatar that looks like a cat about your sexual health than I think a seventy-year-old guy who could judge you. What do you think? 

Sebastian: Those are really interesting questions. I think in training the team, we have a culture of compassion and we are really following this Paul Farmer pathway, right? All public health departments seem to have that type of mentality too. It's in the ethos of the company. 

That doesn't mean though that your healthcare workers become actors and actresses. They have to be themselves. These aren't full-on production type quality videos -- it's a person shooting a video -- and I think the biggest thing is to get somebody to feel comfortable with that. That's actually pretty hard. You have to interview for that, for somebody who's willing to put themselves out there like that. It's okay when somebody's not a total extrovert and they're themselves because that's what the patient wants. 

Now, a few weeks ago, I would have said it's impossible to do the avatar, but there's been a lot of news the last few weeks. I'll claim to not really know the answer to that question. My first answer though now would be, it’s not possible to take out that human touch and I think that patients really respond to it. 

Yeah, you're right...I've never imagined what it's like to be a seventeen-year-old girl in Utah who wants to see their OBGYN and ask some sensitive questions. However, there are absolutely a bunch of scenarios where virtual counselors have worked. I don't know. What do you think? It's a brand-new world as far as everything that's come out the last couple months. 

Shiv: I think it all comes down to preference, actually. I mean, there's so much evidence that people are more likely to respond to providers. Again, this is averages, right? If we talk about individuals, some individuals -- maybe some seventeen-year-old girls -- will prefer the seventy-year-old expert. They'll follow what they say, whereas others may not and may think “I want someone who looks more like me” based on race, based on gender, based on all these different topics. 

Part of what's making this interesting is that the entertainment industry is driving all this innovation, really, because that's where a lot of the money is. If you can watch a movie where the protagonist or the love interest of the protagonist looks like the type of person you're interested in, everyone will have a personalized movie that they can watch, and that likely will happen in the next couple of years. If that can happen with movies, I'm sure there's some API or some tool that other companies can adopt going into healthcare. 

Sebastian: Well, one thing I'll tell you based on having been in healthcare systems to get care for family members in the last few years, providers have no time for care, right? They're rounding digitally now. I currently see that what we're doing in a lot of ways is making up for a lack of time that the provider has with that patient. If there are other ways to get them the attention, the time, the feeling of care, it might really beat that in-hospital experience because I've been severely disappointed with what the state is of care in a hospital right now. I don't know if you've been in the hospital lately, but bear it in mind when you're in med school. I think the pandemic's had a disastrous effect on the quality of the human care element. 

The fact is we shouldn't necessarily be expecting providers to be delivering that type of special touch if they're swamped. There have to be outlets like Scene Health and other virtual care companies that do have the time. Maybe in the end it is some combo like you're saying of artificial and person.

Shiv: Yeah. Whatever it is, it's very interesting. Companies like yours, I think, will be helping lead the way, so I appreciate that. 

We're coming up on time, so I have just two other questions for you. The first we like to ask all of our guests is what advice would you give to our audience about approaching their careers if they want to be innovators in digital health or in really doing anything in healthcare?

Sebastian: I think some background is very, very helpful. There's a huge advantage to being the naive person who doesn't really know what's happening because then you take the risk more readily than somebody who really understands. But if you have some education in healthcare or some experience to lean on that allows you to see a problem and then go fix it, like you've done, actually. I love you're going back to med school. Like I told you on our direct messaging, the physician-entrepreneur...wow, that's an incredible skill set. Most physicians learn the entrepreneurial skill set later and you're coming with it and going to med school, so that's going to make you an incredible entrepreneur later. 

I think healthcare is 20% of our gross domestic product. A huge area, massive need. If you're going to be an entrepreneur and you really care about people, then do it in healthcare. I think it's so fulfilling. Find a big problem and just go solve it. If you can't, then shift a little bit and go

solve something else that's kind of like that. 

Shiv: Totally. A $500 billion-a year-problem is quite a big problem. 

Sebastian: Big problem. 

Shiv: Well, thanks for that, Sebastian. My last question, is there anything else that you want to

tell our audience about you or Scene Health? 

Sebastian: Yeah. I'd actually like to just give a shout out to my team. We just raised capital in an environment that is very challenging for capital raising. The only way we were able to do that is with a stellar team that's really, really on the right track and doing everything possible to make sure that the patients and customers we serve are successful. 

Thanks for having me, Shiv. Thank you to the Scene Health team for getting us this far. I'm really excited for the next couple of years.

Shiv: For sure. Me too, Sebastian. It's been great seeing your growth. I'd like to thank you for taking the time to be on the podcast and more importantly, for the work that you and your team have been doing to, as we say, raise the line and strengthen our healthcare system.

Sebastian: Awesome, Shiv. Thanks for having me.

Shiv: And with that, thank you to our audience for checking out today's show. Remember to do your part to raise the line and strengthen our healthcare system since we're all in this together. Take care.