Interview with RxWare CEO Yishai Knobel

0:00:10 - David Williams
Specialty pharmaceutical companies think they're making life easier by offering patients access to a variety of best-in-class support services, but this collection of one-off vendors can actually make the patient journey more arduous and disconnected. That's not good for the patient experience, health care outcomes or company financial results. The new trend is for companies to rethink the patient journey tech stack. Today's guest, Yishai Knobel, is co-founder and CEO of Rxware, which helps companies do exactly that. Hi everyone, I'm David Williams, president of Strategy Consulting Firm Health Business Group and host of the Health Biz podcast, a weekly show where I interview top health care leaders about their lives and careers. If you enjoy this episode, please press that like button and subscribe. Yishai, welcome to the Health Biz podcast. 

0:00:58 - Yishai Knobel
Thank you, good to be here. 

0:00:59 - David Williams
Listen, we're going to talk all about the patient journey and the tech stack and all that kind of stuff, but before we do that, I want to hear a little bit about you and, in particular, your background. Your upbringing Start with any childhood influences, any childhood influences that have stuck with you through your career. 

0:01:15 - Yishai Knobel
Well, I think a theme in my life, in my career, starting from eight years in the Israeli ERD unit, is interoperability and connectivity, because when you have a large organization, you have a large system and you have different entities, interoperability is always a challenge. 

What struck me was when I, you know, growing up in Israel, which is a universal healthcare system that has universal insurance, 99% coverage of EMR records that are connected, pharmacies are connected and moving to the US and noticing the fragmentation in the US really struck me. 

So I became, you know, right after I moved to the US, I became head of mobile in the company called Agamatrix that invented the first smartphone glucometer and that company works for type 1 diabetes patients who you know. We were the first one to invent a glucometer that actually tests into the iPhone and gives you feedback to tell you hey, you know, you're low, you're high, this is what you should be doing now, and that's where I got exposed for the first time to the fragmentation in the US. It occurred to me that your insurance company is completely separate from your doctor and they can switch you to a different insulin because they have a better deal on that insulin, and that just drove me nuts. So when I started help around, originally the company was help around. It was around connecting patients and getting help around wherever they are, and that's really weird all of them. 

0:02:46 - David Williams
Got you. Well, you know, it's interesting to string a few things there together. I have other Israeli friends that they tell me about their childhood influences, like running through the orchards and all these different things that they saw. I'm sure you have some of those are growing up in Jerusalem. I have another one who's like you know 5,000 year old things in his backyard, but it was just a regular upbringing, is what he said. 

But it's interesting, you know, when you talk about, of course, if the IDF is a lot of complicated systems to try to link together and there's a lot of different pressures and things that are harder than in civilian life and more critical in a way. But with the Israeli health system, I mean, of course the pharmacy is connected with the doctor and the insurance company is connected with you and the doctor and all that. So you just take that for granted, and so I think it's an interesting juxtaposition to see solving like really, really challenging interoperability challenges in the IDF and then coming and saying, wait, we don't even have it in healthcare, you know, in the US. So to me that's the perspective, you know. That's interesting. 

0:03:41 - Yishai Knobel
And I think you know when you come at it from mission critical systems and you realize what's going to happen if, if you know one way, an Air Force does not get a signal from a field unit and they're going to bomb their own forces. That's called mission critical systems right Now. What's going to happen if a script doesn't get to the right pharmacy? Completely different question. But the solution is called interpability and it's called how you put that connectivity serve the right Content and even though it doesn't seem to okay, so the script gets lost. Well, guess what? Many, many scripts get lost and a lot of patients are not getting their medications. So I mean we should be worried about that just as much. 

0:04:29 - David Williams
So you started the company. As you said, it was a help around change to rx, where talk a little bit about. You know how things got started and what the evolution was, because you obviously had this main Insight you saw how it could be applied in the US healthcare system. But in any company, it isn't just be okay, we have this problem, we solved it now. Gee, that's exactly what we expected. How did it evolve? 

0:04:49 - Yishai Knobel
Yeah. So we started help around as a diabetes support network under the notion that, you know, mobile phones just just became much more common and People with diabetes, what we noticed again and again, we're getting stuck without supplies. They were not able to afford them, they forgot them at home, they they dropped their you know the insurance, they got the insurance Switched and people get stuck all the time. So we start to help around with the idea hey, what if, wherever we are, we can find, you know, a helper, someone who can Assist me whenever I have? And we we really, you know, took off, took off in terms of the number of patients. We had more than 100,000 people in type 1 diabetes. 

Type 1 diabetes is not that common of a condition Of people who were really helping each other or trading. Turns out that there's a lot of imbalance, but we couldn't monetize, we weren't able to tie it to a business case that that really made sense for it to do, to build this as a company. So but we did notice one thing one of our communities, patient communities that we're there to support each other. They were actually Helping each other to get on therapy. They were, they were actually getting on home dialysis and it was very often their, their caregivers were getting their patients from going to dialysis in the clinic, helping them go back to the house and do the other says while they're sleeping, which is which was you know game-changing company called next-stage Well, wait a second. This is interesting. So this kind of support that we can provide can actually drive a business case in Getting patients on the therapy that were person that was prescribed to them. 

That is very complex and overwhelming. That's what we said. You know what? There's maybe something here. And we double down on specialty, because that's where the drugs are expensive, the drugs are complex, it's difficult to get on therapy, and when you look at the business case and you look at the big, the business challenge there, you see that 30 to 60 percent of specialty prescriptions are abandoned. Yeah, 30 to 60 percent. That is a mind-blowing number. Okay, and of course, it's associated with cost, is associated with complexity, associated with a lot of fragmentation, but though, but that's what we really find found our footing and we said you know, we're gonna focus this. And the rebranding to our square came on the heels of oh, we're gonna be not so much anymore a consumer facing help around Company. 

0:07:27 - David Williams
We're gonna focus on what we do, which is infrastructure for specialty pharmaceuticals to connect the patient journey you know, when you talk about your abandonment rate for these Prescriptions, it is fairly profound and maybe I'll think about it in a slightly different way, which is it is so, you know, takes so many years and hundreds of millions or even billion dollars in order to get the drug Developed, and many don't make it right, so you get all the way to having the drug Developed. 

It means that it that it works, that it's safe and it's for somebody if it's a specialty medication, typically a very, you know, serious Condition then you've got somebody actually found their way to a physician who could actually diagnose the patient, do the right test, prescribe the medication. So you have those things happened and that it's still only about 50 percent chance that the patient is actually gonna get the benefit from it, even after all of that. And so that is, you know, that is a big enough problem. I think that's as big of a problem as the Air Force bombing the wrong formation. So If we look at across the whole, the whole US, so especially, especially. 

0:08:29 - Yishai Knobel
You know, just imagine what could happen in a world where does you know that would be a no-brainer. Oh, you know, the doctor prescribes the drug done to get it. 

0:08:37 - David Williams
Yeah, we should, yeah, and I think people who don't, who aren't close to the space, have trouble understanding with that mean. So I remember once I was telling more technology oriented person that this is true with specialty drugs, including Cancer drugs. You know they didn't believe that people. Actually you get prescribed a cancer drug and you don't pick it up or you're stopped taking it. But in fact, yes, it's true. 

0:08:58 - Yishai Knobel
That's right and you know, cancer is as its own dynamic oncology drugs. But in general there is a very fragmented system between the prescribers, the pharmacy, the treatment center if it's an infusion. These are all different entities that all take care of the patient and those are very often disconnected or very manual, these organizations that they're not necessarily tech savvy. And then comes the drug manufacturer who is the business beneficiary of getting these patients on therapy, because they spend the money developing the drug and putting it out there and actually detailing the doctors and the doctor did prescribe the drug. And the drug company looks at this disconnect where patients get lost on the way, says hey, I wanna help. So they put together 25, they invest $25 billion a year on these patient support programs. 

But there's this regulatory barrier in the middle that says pharma, you cannot help this patient until the patient reaches out to you. And that is a huge barrier that could unlock, and if that barrier is removed or overcome, it could unlock massive resources that the drug manufacturer is putting out there. By the way, these resources are also quite complex to navigate. So you want to get it. It's not enough to just like hey, say hey, reach out to the drug manufacturer or the hub services and everything will be golden. No, but today they are extremely underutilized, all these pharma patient services, and that's a big challenge, but it's also a big opportunity. 

0:10:43 - David Williams
So one of the things I liked when I was reviewing the companies, you'd put out some predictions at the beginning of the year and a lot of people put out predictions that say there's gonna be recession or some general thing. Your predictions are fairly specific and to this industry and where there's a lot of people that really care about this and have some understanding. So before I go into those, I have to ask you to explain a term or two. So your first prediction had to do with that there's gonna be insourcing of the patient journey tech stack. Now I think a lot of people know about what a patient journey is more or less, and some people also know what a tech stack is. But what is a patient journey tech stack and who cares if it's insourced or outsourced? 

0:11:23 - Yishai Knobel
So imagine again the drug manufacturer putting together this support program Copic cards, hub support, patient assistance and the outsource to different vendors. So if it wasn't challenging enough for the patient to figure out how to get to these pharma resources, now they also need to. Now they also interacting with different vendors on behalf of the drug manufacturer. Okay, and then when a drug manufacturer is coming saying, you know what I don't really like the way that this vendor works, that that vendor works and I wanna switch them out, that's a huge undertaking. 

So the trend that we started seeing in the beginning of the year and is only picking up is drug manufacturers saying you know what we're gonna take, we're gonna own our own destiny, we're gonna insource, we're gonna bring in all our services and, for example, our hub is we're not gonna outsource it anymore, we're gonna run it internally. We're gonna build our own sales force for our own CRM around patients. We're gonna develop our own messaging or texting capabilities and we're gonna own that so that we can switch vendors. But these vendors are not necessarily gonna bring their tech with them, but we're gonna own our tech and I think we're seeing all the big ones are either doing it or on their way to doing it and that's a prediction that, frankly, in hindsight, eight months back, yes, it's happening. 

0:12:50 - David Williams
Yeah, good. Now what about this one about manufacturers will uninstall patient support apps. Is that a related topic? I mean, why are they gonna uninstall the support apps and they put all the effort to get them installed, so in 2015, starting 2015,. 

0:13:05 - Yishai Knobel
There was this gold rush towards apps yeah, 15, 16, 17, 18 and then something happened. Something happened our phones have become so central to everything we do and the plethora of apps that are out there has become unmanageable. People starting curating and throttling the number of apps that they're willing to engage with. So today, when you go to a restaurant and you wanna pay, you are rarely asked to download an app. And actually the specific stat is that 78% of consumers, when they are asked to download an app on the way to a transaction, they stop the transaction. I'm not gonna buy that dress anymore If you're gonna force me to download an app. Macy's, I'm not gonna. You know, I'm not gonna check. I'm not gonna buy this thing online if I have to download an app first. No, check out, click, click, click. 

And, by the way, when you see the, you see Apple and you see Google, both of them building into the operating system, into Android and iPhone, more and more capabilities that allow you to not even think about downloading an app. So what we saw is and my prediction is that you know, they're going to uninstall apps, meaning they're going to stop investing in building more apps, because consumers don't want apps and the relationship between the patient and the drug manufacturer is not. They already have an app with their provider. They already have MyChart from Epic, they already have the CVS app from their pharmacy or from their Safeway app or from Walgreens. They don't have the same type of relationship with the drug manufacturer factor and the earlier drug manufacturers understand that they're going to kind of move on with the program and provide experiences that don't require to download anything and we think about this framework as the level of usability that is appropriate for 2023. It's frictionless. I have no time, I have no patience. Get me what I need and get out my face. 

0:15:10 - David Williams
Yeah, I think, when you're talking about that Gold Rush of 2015 to 2018 or so, I think what happened is the pharma companies had the realization then, hey, we're pretty disconnected from the patient. Here's a way to actually be with them on their phone. And then there was a lot of good or decent app developers or excellent salespeople also, who managed to sell all these apps. And if you looked at the cost per download, never mind per use, it was pretty high. That's good, but in some ways, you benefit from the lessons that have been learned. People did this and they found out okay, you had all this great functionality, some people downloaded it, but that's really not going to get you there, so you take a different path. 

0:15:46 - Yishai Knobel
And we call it. We relate to this experience today as the age of consumer attention squeeze, the consumer attention squeeze where it used to be that we're sitting in the office, we have an orderly nine to five, we go to an office, we go home, and now all that has blended together and we drive while we're on a phone call, while we're having coffee and the kids are in the back. Yeah, and COVID only exacerbated that. So that attention you're trying to fit into a very, very narrow window of attention and you better get what you want exactly the right time, be relevant, be contextual. Catch them at the right time, ideally when they just left the doctor, let them do what they want. Give them an SMS that is very kind of click, click, click and done, get out of their face. 

0:16:43 - David Williams
Yeah, because otherwise you lost them. So I think this has to do maybe with your prediction about the patient journeys focusing on what you called moments of value creation. Is that the exact what you're discussing there? 

0:16:55 - Yishai Knobel
That's right, so there are very specific moments when you can really connect with the patient and after that you're out. So there's the parking lot moment, meaning the patient just left the prescribers office and they went to the car. They're still in the parking lot of the hospital, the clinic, and they're with all the paperwork and they're trying to figure out what to do now. Do I call a pharmacy? Do I, you know what? Would like to use a copic? What do I do right now with all the papers that I have here? That's the moment you have. You catch them when they just left the doctor. You have their attention. In five minutes they're going to be driving away and you lost them, okay. Or when they are talking to the pharmacy. Right, that's exactly the moment. 

Why did Google the you know, the original Google take off? Because they were serving you content exactly when you were looking for it. Now we don't have that privilege. We don't know what a patient is saying. How can I save money? Well, you know, some companies know that good are X, that's their model. Right, the patient goes a good are X looking for a coupon. They're like oh, got you. Here's a great moment. So pharma has already started, but not enough actually thinking about how do I catch the patient exactly when it's the most relevant moment for them, and that's when you can create value. 

0:18:18 - David Williams
Now, one of the ways that you were, I think, predicting that pharma might try to do that is through more use of AI and, in particular, there's this idea that, hey, the you know, the hub agents may only work certain hours and maybe on hold or whatever have have AI, that's always there, but you say AI is not going to replace hub agents. Why is that? 

0:18:36 - Yishai Knobel
Not anytime soon, nothing. So I think you know drug manufacturers are the old. Interactions between agents, between any representative of the pharma company and the patient, have to be incredibly, incredibly structured. For legal reasons, for compliance issues, and when you are trying to structure an exchange and you're trying to replace, you know, an agent with AI, it needs to be incredibly structured and incredibly limited. You know back and forth. 

So if you introduce an AI and that model starts learning more and more, you still need to stay within the realm of the script. So I think there is an opportunity there and you know we are pushing the envelope on AI driven access navigation. So you know, based on patterns that we've seen of patients getting coverage or not getting coverage, can you learn and make recommendations for the patient? Hey, you really want to try COPE as opposed to government, but we're still automating it. We're still at the stage that our industry is still at the stage of automating these interactions on a very basic level before we can introduce a learning model on top of it. So the answer is maybe, but not yet. 

0:19:58 - David Williams
So on that prediction, you know could say people would say aha, you know, the solution is AI replace hub agents. And you say why that's not going to happen. So that was something people thought that might happen and you said no. The next one you had was one I hadn't even occurred to me and you're saying it's not going to happen. And that one was about digital therapeutics and patient support technologies will not intermingle. Yet what would be the logic for those two things to intermingle in the first place? Because, like I said, it had not really occurred to me. So imagine that you're. 

0:20:30 - Yishai Knobel
You're going to the doctor and the doctor prescribes digital therapeutics. They say, here I'm going to send you when it prescribed an app for you and that app is going to coach you through controlling your diabetes. They're going to have to go to coach you through managing your, managing your blood pressure. It's going to coach you through something therapeutic. And I mean that's a vision of digital therapeutics right Now. Think that you would also in combine into that workflow A copy card. 

Oh, if you use it, oh, you can buy down the cost of the app and that's gonna be built in the same workflow. That gets very tricky. Why? Because the first is clinical. It's a clinical workflow. It had to go through all kind of tests, it had to go to demonstrate clinical efficacy and then it was prescribed by a doctor and a copy card is a promotional piece. That's considered marketing and the doctor and this FDA is actually very clear about that you cannot mix clinical and marketing content. You cannot weave those two. So it's very tempting to say, oh, I have my phone. My phone can do both the clinical work and the affordability work. Yes, but they need to be separate, completely separate. They cannot be interwoven because then, imagine, you're taking a pill and the pill also has a discount. You can't do that. 

0:21:59 - David Williams
Yeah, maybe you could have something. I know they've had these pills in the past as some couple of companies that didn't do too well. Will you swallow it? And it sends out radio signals and all that for adherence. Maybe it could send out promotional messages as it dissolves. The next time That'll be for next year's predictions, exactly exactly. 

0:22:16 - Yishai Knobel
You wake up in the middle of the night and you're like buy the next medication. 

0:22:20 - David Williams
Yeah, that'll be a good one. All right, so I think I've given you enough on the predictions, but I appreciated them, and you only have a few months to get ready for the next one, so I won't ask you to preview any of those just yet. But I will ask you a final question, and that is about any books that you've read lately. Anything that you would recommend to our listeners or in the spirit of your predictions about what not to do, any books you would recommend not reading. 

0:22:47 - Yishai Knobel
I will not. I will go off record for that, but I will think I will go. There's a book that I'm reading right now that I think anyone in the pharmaceutical industry would enjoy or appreciate. It's called the Empire of Pain and it's about the Sackler family and how they really introduced pharmaceutical marketing to doctors and how that went out of control with the opioid crisis. So I think it helps us all bring perspective to our work and to how things can go out of hand. I think a great book that I use every day the practices I use every day is Chris Voss Never Split the Difference, and I use that for negotiation, until my 70-year-old, of course, does negotiating with me and then I give up and I close the book and I go back to basics but I'm just kidding. The great book with a lot of practices about what he calls tactical empathy that can be used all the time and how empathy to the other person actually can help you do better and create more value. 

0:24:04 - David Williams
Now that sounds good. A lot of the CEOs I interview are at a stage where they're reading these advanced books, advancing their career and doing all sorts of things, but they're really anchored by kids around that age at home. So I do get those bifurcated recommendations. I haven't heard one that has bridged the two. Just, yeah, I heard Good Night Moon the other day. That was somebody a little bit younger, but yeah, that's more for a three-year-old. But you may be beyond that. Well, Yishai Knobel, co-founder and CEO of RxWare. 

Thank you so much for joining me today on the Health Biz podcast. Thank you, david. You've been listening to the Health Biz podcast with me, david Williams, president of Health Business Group. I conduct in-depth interviews with leaders in health care, business and policy. If you like what you hear, go ahead and subscribe on your favorite service. While you're at it, go ahead and subscribe on your second and third favorite services as well. There's more good stuff to come and you won't want to miss an episode. If your organization is seeking strategy, consulting services and health care, check out our website, healthbusinessgroupcom.