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Episode 9:  Oh my aching back! Why your iPhone may be your new physical therapist: The digital MSK clinic with Jim Pursley of Hinge Health

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June 23, 2022

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Episode 9: Oh my aching back! Why your iPhone may be your new physical therapist: The digital MSK clinic with Jim Pursley of Hinge Health

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Fifty percent of American adults live with musculoskeletal (MSK) pain. Jim Pursley, president of Hinge Health, joins Justin to talk about how digital technology and new medical devices are rapidly changing MSK treatment and improving pain management. Jim shares some big ideas on how digital MSK therapy can improve quality of life, reduce unnecessary and costly surgeries, and how digital MSK may even help kick America’s opioid addiction.

Justin and Jim also discuss some pressing questions about the United States’ changing care landscape. Why have MSK insurance claims doubled in 10 years despite patient populations staying flat? Who is responsible for quarterbacking a patient’s care plan when you have multiple providers and devices, all of whom straddle both physical and virtual therapies? And what’s the connection between chronic pain and depression, and what can we do about it?

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Episode transcript

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 a 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 Jim Pursley, president of Hinge Health. Hinge Health is building the world's most patient-centered digital musculoskeletal or MSK clinic. Something that I'll ask Jim to explain in just a moment.

Justin Steinman:
But did you know that 50% of Americans experience MSK pain in a given year? So that's a pretty huge market for MSK solutions. Hinge Health sits at a really fascinating intersection of preventative care, digital technology, pain management, and physical therapy and recovery. They're also extremely well funded having raised more than 1 billion dollars from leading investors like Tiger Global and Coatue management at a 6.2 billion dollar valuation. So let's just say that we've got quite a lot to talk with Jim about today. So Jim, hello and welcome to Definitively Speaking.

Jim Pursley:
Thanks Justin. It's great to be here. I appreciate you having me.

Justin Steinman:
Well, we are glad to have you join us. And so let's just get started. What is a digital musculoskeletal clinic?

Jim Pursley:
Sure. So musculoskeletal, as you said is think about joint and back pain. So hips knees, shoulders, wrists, neck, all the aches and pains that some of us just getting older experience others of us because it may be an old athletic injury, maybe an on the job injury, but that's the concept. The musculoskeletal, one in two Americans are experiencing MSK pain today which is pretty-

Justin Steinman:
That's a lot.

Jim Pursley:
Pretty phenomenal not in a positive way. And it's costing the US economy over $600 billion a year. And that's hard dollar spend. That's not calculated spend. That's not estimated spend. That's hard dollar spend eclipsing the cost of heart disease, cancer diabetes. So it's a big issue not only from a quality of life perspective, but from a cost to the healthcare system perspective.

Jim Pursley:
So historically we've tackled this a couple of different ways. One is, I think we're all familiar with traditional physical therapy. You find a physical therapist and you go see them and physical therapist are doing some really fantastic work, but we've got challenges with access and affordability and convenience. And we can talk more about those, whether it's geographic access, whether it's socio-economic access but access and affordability is a challenge, but PT is one way to solve for it. Unfortunately, opioids is another way people have looked to solve for it. And I think we've seen if you've been paying attention to headlines over the last five to seven years, the impact on opioids in this nation on the opioid epidemic is just devastating. It's ravishing families and communities. And that's one way that people are trying to solve for MSK pain.

Jim Pursley:
And the third is surgery and there are absolutely cases where surgery is the appropriate clinical response to MSK pain. But we know there's a lot of unnecessary surgery. People who have either rushed to surgery or have not had access to other more conservative models of care. And that's what's driving a lot of that cost. It's 600 billion, a lot of that's coming from surgery. So all to say is, we've got this big problem affecting a tremendous number of people, both here in the US and around the globe. It's costing us a huge amount of money and the historical options haven't been all that great to be candid. So enter Hinge, digital patient centered musculoskeletal clinic or patient centered digital musculoskeletal clinic. So what that means is one patient centered. So let's think about how people live, work and play. What friction exists in the system.

Jim Pursley:
Again, whether it's access, whether it's affordability, whether it's resources, education, but let's put the patient at the center. And let's think about that friction and make it as delightful of an experience as we can. And we're going to focus on MSK pain, but not just on the mechanical element to that. There's also a huge neurological element to it. There's a behavioral health component to it. There's sometimes pharmacological components. So we want to put a full, comprehensive care team around that person and support them.

Jim Pursley:
And then digital meaning we're going to interact with people both telephonically, video, and also through the Hinge Health technology. So centered technology, computer vision, our mobile application to create this force multiplier effect so that people can do their physical therapy when they want to, where they want to, in a way that's most convenient for them, allowing them to get fantastic results that fits into their life and not the other way around.

Jim Pursley:
So that is a little bit of an overview of kind of what we're doing and we're seeing fantastic results. As you mentioned, we've been around for a little while now about six or seven years. And in that time we have grown to become the world's largest digital MSK clinic. We are serving tens of millions or tens of millions of people have access to Hinge today. And we're seeing fantastic results, both in reduction in pain and clinical outcomes, and ultimately in banging that cost curve, which is kind of the double bottom line that I think we're all looking for not just in MSK, but in healthcare more broadly.

Jim Pursley:
So in that 600 billion, you kind of break it down roughly let's call it about 400 billion that is surgery. So that's actually [inaudible 00:05:56] surgery. Then you have imaging, which is a big part of that. So that's you go see your primary care doc and complain of lower back pain and he or she prescribes you maybe to get an MRI done. And so there's a big chunk of that is imaging. You have pharmacological so you've got drug spend and then you have PT, which is about 10% of that as well. And we actually spend quite a bit on PT in this country. So to your point, that's all hard in the claims data spend then you have all the other impacts the loss productivity, the disability, short term disability, there's all those downstream impacts as well.

Justin Steinman:
Got it. Got it. That really helps. Thank you for that. Now, as I'm thinking about this, like how does this thing work? Because you're not replacing physical therapy. If I throughout my back, I'm still going to need PT. So are you replacing? Are you supplementing? Are you more preventative? How do we think about this?

Jim Pursley:
Yeah, yeah. It's a good question. So first we're going to engage a population of folks, whether it's through an employer, through a health plan, through a healthcare provider and we're going to assess the clinical appropriateness of Hinge for a member, because to your point, there are some folks who maybe really should be getting surgery or who need a different intervention than we're able to provide. So we're going to assess the clinical appropriateness for Hinge. We are delivering physical therapy, but not hands on. And so we've a little bit like a previous life when I was at Livongo, we took this concept of the elegant integration of hardware, software, and clinical services to deliver a solution that largely looks and feels like in person care but again brings all the benefits of being digital around convenience and access.

Jim Pursley:
So in the case of Hinge, we have a physical therapist at the center of the care team who's going to be overseeing the treatment of that individual. And so once we let's say I come into the program and adjust that I've got this horrible, lower back pain, we're going to do a quick clinical assessment with the physical therapist-

Justin Steinman:
Over my iPhone.

Jim Pursley:
Yeah, over whatever device you want. So we leverage a modern architecture, bring your own device.

Justin Steinman:
So there's a telemedicine kind of angle there. Got it. Okay.

Jim Pursley:
Yeah. Okay. And then we're going to ship you in the case of [inaudible 00:08:16] we're probably going to ship you a kit that has some sensor technology that you're going to wear. So we can see, even when we're not looking at you, we can see whether you're doing the exercises appropriately, and then we're able to modify your exercise therapy, your physical therapy based on the data that we're getting. And so let's say fast forward two weeks now, physical therapist gets back online and says, "Justin, first of all, great job. I know you're doing your exercises. You've been doing three times a week. Fantastic. Secondly, I noticed these three things. In this exercise, you're not bending over far enough on this exercise. Let's tweak this a little bit. And this exercise you skipped every time." "Yeah. You know what? That exercise is really painful."

Jim Pursley:
"All right. Well, let's, take that exercise out and we'll replace it with this exercise that maybe gets to the same intention, but doesn't cause as much pain." So the sensor technology allows the physical therapist, even though he or she isn't in the room with you to have that same richness of insight into how you're doing is able to personalize and customize that care plan and repeatedly evolve it. And then we're going to deliver that over a course of time, depending on what the issue is. Last thing I'll mention is just not everybody can be helped by PT. Maybe I'm in too much pain to even start PT or maybe PT actually exacerbates the pain.

Jim Pursley:
We've also developed and brought to market what's called Enso, which is noninvasive non-addictive high frequency technology that almost instantaneously eliminates pain. It doesn't solve the underlying cause and so we still want to, we still want to work through physical therapy, but it reduces pain and allows you to engage in the physical therapy that's going to get you sustainably better. And that has been incredibly well received. It's almost life changing. I joke with people that if you've ever seen somebody using Enso and they describe the experience, oftentimes it's a mix of giggling and crying because you hear stories of I've been able to sleep for the first time through the night, in two years. I've been able to get down to the ground and play with my kids for the first time and over a year.

Jim Pursley:
So it's that combination of sophisticated technology, clinicians, physical therapists, supported by health coaches, orthopedic surgeons, nurse practitioners, and then intelligent software that's looking at how you're doing your physical therapy and looking for ways to constantly adjust it for greater impact. So that's in a nutshell kind of what that would look like.

Justin Steinman:
Let me dig into this a little bit because my mind's a little bit blown away by some of this. You're actually sending people like devices to put on their back or to help them manage their pain, like real hardware. Right?

Jim Pursley:
Correct.

Justin Steinman:
Yeah. That can't be cheap.

Jim Pursley:
In some cases it's not. It's not inexpensive, but the alternative is significantly more expensive. And so yes, whether it's sensor technology, whether it's Enso there is a real cost to that. But if you look at the alternative, whether it's 10 PT visits in person, or again, unnecessary surgery or imaging, the alternative is drastically more expensive. And so if we're successful in our endeavor, we're able to really deliver a pretty powerful ROI to the buyer, which is in a lot of cases, a big employer here in the US, a health plan, a health system, maybe some type of at risk health system, Medicare advantage plan, et cetera.

Justin Steinman:
Do you worry that people know how to use these devices? Like I'm not trained to put a device on my back or do Enso therapy. How do you train people? Just the regular Joe?

Jim Pursley:
Yeah, sure, sure. So the first thing is just in design, we all have become power users if you will, of smartphones and iPads and the idea that somebody reads the instruction manual with the iPad, I didn't know if they ship them with instruction manual manual.

Justin Steinman:
They don't. They ship it to you.

Jim Pursley:
Right. And you take it out of the box and turn on. That is elegant design. That is user-friendly design. So that's the goal is that it is so simple and so intuitive that anybody can use it. Having said that if somebody needs support, that's back where that physical therapist and doing the video visit says, "One, let's look at your..." I'm having wrist or back pain and, "Justin, do you work from home sometimes?" "Oh, you do. Well, let's, do the video visit in your office. I'd love to see you at your desk, because I'd love to see how you're sitting. I'd like to look at the ergonomics and if you're having trouble putting on your sensors, I'll help you with that as well." And so it's that combination of really person-centered design coupled with actually having a person on the other end who can assist you through that process.

Justin Steinman:
Is there any sort of like we talk a lot about virtual and physical and hybrid. It feels like I read these days is talking about hybrid this, hybrid that, hybrid workforce, CVS is doing virtual first primary care. They're doing it. Do you have a physical version of this? Or do you have like local PTs or like, "All right, Justin we can help you over the phone, but you are making a lot of progress, but you need someone to lay hands on you too." Do you kind of have that hybrid model?

Jim Pursley:
So today Hinge does not offer in person physical therapy. So there's nobody wearing a Hinge polo shirt that's going to come to your house or you're going to go to a brick and mortar Hinge facility today. We do though work with some of the nation's leading health systems, as an example who have not only in person physical therapy, but other in person resources, surgeons, nurse practitioners. And so our ability, if we're serving a population, let's say in collaboration with that health system, we're going to build models. Let's say if this then this, if that then this and then this maybe, and let's get you into the health system to see any number of those clinical resources, including maybe in person physical therapy. We've also built the plumbing through Hinge connect. We have over eight, 800,000 providers today, feeding data into our Hinge connect platform that allows us to share EMR data.

Jim Pursley:
So not only are we able to communicate back to the provider, but we're able to get way upstream. So like claims data as you know can sometimes be 90 days before it's adjudicated and available, we're getting about 15 minute latency. So almost near real time feed of EMR data coming from over 800,000 providers. So when you get that MRI order from your PCP within 15 minutes, I can see that and intervene and interject to say, "Hey, let's talk about that for a second. What's going on there?" Which really one, it's a great experience because you get that second opinion. And two, it allows us to intercede well before cost is incurred and before maybe inadvisable decisions are made. So anyway, that kind of gives you some sense of how we think about trying to bridge the physical and the digital in new and novel ways.

Justin Steinman:
So who's quarterbacking my healthcare. So I'm an individual. I have back pain, my employer offers Hinge health. Obviously I've probably seen my PCP about this, the odds are, is my PCP my quarterback, is my Hinge coach, my quarterback, who owns my overall care plan?

Jim Pursley:
Yeah. The short answer is you do at least that's our philosophical belief recognize now not everybody maybe has the experience or the education level to ask all the right questions or to advocate for themselves. But I think any of us who have wandered through the healthcare system know that you have to be your own advocate. You have to be in charge of your healthcare. So philosophically we believe the answer is you. Having said that we want to come alongside you and support you and help with that. So you've got your Hinge quarterback, but then like you said you may have a PCP. You may already be engaged in discussions with an orthopedic surgeon. You may be that far down the path. And so our ability to connect those dots, we actually have an embedded EMO in the Hinge offer, which is the only MSK digital solution that has an embedded EMO because there's times when-

Justin Steinman:
What's an emo for our [inaudible 00:16:43]?

Jim Pursley:
I'm sorry. Thank you. Expert medical opinions.

Justin Steinman:
Okay.

Jim Pursley:
That's a Hinge orthopedic surgeon's able to have a conversation, a consultation with other clinicians in your physical care team. Okay. And look at are we making the right choices both is it the most conservative cost effective decision, but also whether it's site of care and we're able to have those interactions ultimately with you in mind being at the center of that. And then I sell that some of our clients actually have, you've heard the concept of care navigators, whether it's an employer who's deployed a care navigator and they want the care navigator to play more of an active quarterback role. And so we're going to assess when we kind of walk into an environment, what's the landscape look like, who's involved, who are all the actors and how do we coordinate them and sometimes we have to maybe take a deferential position to somebody else who's already kind of raised their hand as the quarterback.

Justin Steinman:
Yeah. I think that is one of the real emerging problems, not your problem but emerging problem in the healthcare system today. I think back when I was working at Aetna, we had care navigators. People would help people. We called them Cerner, a whole department, hundreds of thousands of people out there helping Aetna members manage their care. Many of them had doctors or primary care physicians. Then if they're engaging with a Hinge health, you've got your care navigators there. And then maybe if you're a diabetic, you have your old Livongo care manager. Also a lot people have comorbidity solutions. And so suddenly you've got everybody and their mother trying to navigate your healthcare. And you're just like, "Oh my God, how do I think about this?" I don't have an answer for that, but it definitely jumps out to me as a problem that we have here.

Jim Pursley:
Yeah. And there is companies that are actively working to solve that with varying degrees of success. I think we still have ways to go there's different philosophical approaches to that. You'll hear CEOs from those companies on stage and each of them maybe has a slightly different opinion on the best way to achieve that. I think all of us need to recognize though with humility that we can solve a whole bunch of problems on one hand and potentially create additional problems on their hand whether it's data fragmentation, experience fragmentation. And so our willingness and again, with humility to collaborate and in some cases be deferential, I think it's going to be really important to ultimately building that delightful experience for the healthcare consumer.

Justin Steinman:
Yeah. I think you're right and I think humility's a really strong word and a good word to describe the situation that we're in. We are awash in technology. Imagine having the conversation we just had for the past 10 minutes, 20 years ago, it'd be like Star Trek, right?

Jim Pursley:
Yeah. Truly.

Justin Steinman:
It really truly would be. And so it's amazing that we have all these different capabilities now and the ability to treat, I think the next challenge that we as an industry have to work through is how do we get our stuff to work together and everybody has the right intentions. Everybody's trying to do the right thing, but sometimes we all step on each other's toes a little bit here and there with the best of intentions I think.

Jim Pursley:
Yeah. I think that's fair.

Justin Steinman:
Yeah. So let's talk a little bit about [inaudible 00:19:53]. So we've talked about our 600 billion in spend here, but this is another interesting fact for me as I think about this. So MSK insurance claims have almost doubled, or I think they have doubled actually in the US over the past 10 years. But the number of people with MSK conditions has stayed relatively flat. So we got double the claims, but the same number of people. What's going on.

Jim Pursley:
Yeah. Well, it's not easy to point to one specific thing, but you do see an increase in surgery and there's a tremendous cost associated with that. There's provider, there's the implantable, the orthopedics, there's all the extra things that come along with that. If you've ever seen a bill from your healthcare provider, there's the professional fees and a whole bunch of other stuff. So surgery is driving a big percent of that. And I think also that's the challenge of this empowered back to there's always kind of two sides thing, this empowered healthcare consumer you've seen it with the pharmaceutical industry marketing directly to consumers some of these bespoke drugs, these specialty drugs, the biologics they're trying to convince you, there is a better way through them.

Jim Pursley:
And so you start asking your doctor, "Maybe I should start taking fill in the blank specialty drug." And we're seeing some of that in with MSK as well and depending on where you're getting your information from, and who's advising you and what their interests are, not everybody's worried about total cost of care. Not everyone's worried about banging the cost curve. And so I think a lot of that's what you're seeing and... So anyway, I think that's a lot what you're seeing.

Justin Steinman:
Yeah. It's kind of funny. I joke about this. I think we need to take costs out of the healthcare system, but we can take it out Jim, when you go to the doctor, when I go to the doctor, I want the best treatment at the best hospital with the highest cost drugs and cost be damned. But-

Jim Pursley:
That's right.

Justin Steinman:
... you save money buddy. Your [inaudible 00:21:59]

Jim Pursley:
That's right. And I think that's how a lot of us approach it. And this, it is not just MSK. You could go through oncology [inaudible 00:22:12] scale, behavioral health, chronic conditions. There has to be that credibility, that authenticity that I can actually deliver you better care, at least equal care if hopefully better care in this fashion. And if not, then I'm not going to try to push something on you and that again but that's harder for all these companies that are actively trying to grow their user bases and justify evaluations. And so kind of clinical appropriateness is always kind of should always be in the forefront of our minds, but not everybody is approaching that way.

Justin Steinman:
Right. And there are new hospital things that need to be built and you can fund them with elective surgeries. So let's not forget that.

Jim Pursley:
Yeah.

Justin Steinman:
And speaking of that, you said elective surgeries have gone up. I pulled some interesting data from the Definitive Healthcare database and this blew my mind actually. So we read everywhere that elective surgeries went down during the pandemic, et cetera, et cetera, et cetera. But the number of total hip replacements between 2019 to 2020 increased 14%. And then from 20 to 2021, they increased 25%. So that is two consecutive years of double digit growth in one year 25% growth even the midst of the pandemic.

Jim Pursley:
Yeah.

Justin Steinman:
I didn't even know how to process that. What do you think of that?

Jim Pursley:
So some of that is macro demographics driving that. There's not a lot of 25 year olds getting total hip replacements. There's a point in time when just wear and tear on the body, the hip or the knee starts to wear out. And so as our population ages, some of that's just macro demographic trends. Some of it's kind of what we talked about around depending on, on who you're talking to and their interest. The good news is though I live right next door to an orthopedic surgeon and we have a lot of interesting conversations over the fence. And his comment to me once was, "I think what you guys are doing is fantastic here." And he said, "You sure about that because one of our goals is to reduce unnecessary surgery."

Jim Pursley:
And he said, "I think that's a fantastic goal. Jim, if you look at my OR caseload, I'm going to be busy all day every day, whether you exist or not. My desire is to get the right people in, operating the right people." There's enough demand back to that kind of macro demographic shift that I'm not worried about my OR sitting empty. I've got more than enough. I want to get the right people in who need it, that I can really help. And just based on the numbers, I'm going to have more than enough to do.

Jim Pursley:
So surgeons are not the bad guys in this. They're doing fantastic work and there's plenty of people that really need surgery. Unfortunately, there's a lot of people that don't need surgery yet or should try something more conservative, lower cost before they get to that point. And we definitely need less opioid use. And that is, I know we just touched on a little bit but that's something that we're really passionate about our ability to hopefully impact the opioid epidemic in a meaningful way.

Justin Steinman:
Yeah. We're going to get to the opioids in a second because I got some stuff I want to talk to you about there as well [inaudible 00:25:28] stuff, but before I go there, you guys help with like hip and you avoid hip replacement. You have a whole authoring there. And so I want to think about you made the aging demographic population. And so you're a digital solution and it all almost seems look, maybe I'm biased by my own personal thing, but I feel like I'm my father's personal iPhone tech support line. He calls me with the most basic things every day, like shouting into the iPhone on speaker. And so here you are, you're a pretty modern solution requiring digital technology with frankly a generation that may not be so comfort... My dad is in his late 70s. It may not be so comfortable with digital technology. How do you cross that chasm if you will.

Jim Pursley:
Yeah. It's a very good question. So we just released a little while back a study on older adult use and outcomes. And the interesting we've found, and this is by the way, this is what we found also at Livongo with diabetes care. In a previous life, I worked in global aging with Intel and we found this in a lot of, and kind of repeatedly, we found this that the older population tends to be slightly slower to adopt, but is actually surprisingly engaged even to a higher degree than younger populations and stays engaged longer.

Jim Pursley:
And so it's this idea of maybe there's a little bit of skepticism, but once they engage, they see assuming it's been well designed technology, how easy and delightful it is. And they become incredibly loyal and stay engaged over longer periods of time. And we'll share that data with you, but the baby boomers in particular had higher odds of seeing symptom improvement, longer duration on the program and more use in engagement than the younger population.

Jim Pursley:
So I think it's a little bit of a misnomer. I think we all have that story of I have to be careful, I don't want to tell too many mother-in-law stories, but I think we all have that example of maybe somebody who isn't, but if you look across the data, the older generations are ready. They have smartphones, they have iPads, they're a lot more willing to embrace technology than I think we give them credit for.

Justin Steinman:
That's really interesting. I only tell stories about my parents, not my wife's parents. That's key to a happy marriage.

Jim Pursley:
It's definitely safer.

Justin Steinman:
Yeah. It's absolutely safer. So are you guys doing like focus groups with like baby boomers, bringing them in, giving them your tools and saying like, "Hey, how's this working for you?"

Jim Pursley:
We have a lot of populations. Medicare Advantage is an area that we do work in. And we have a lot of members that span the age spectrum from young folks who may be sustain an acute injury, an ankle sprain in a softball game. There is somebody on the other end of the spectrum who's got osteoarthritis or degenerative hip or knee. And so we're very interested in understanding the unique needs of our population and delivering solutions that we have an acute program, we have a chronic program, we actually have a separate pre and post surgical rehab program. We just launched our women's pelvic health offering, which we're really excited about. And I have really been almost overwhelmed by the positive response and demand there. And so short answer to your question is, yes, we absolutely engage in a very targeted and focused way with different demographics to understand is this solution really targeted and personalized for them. And if not, then let's figure out how to do that.

Justin Steinman:
Yeah. So let's come back and talk a little bit about the opioids. Because I think that's a really hot topic. And from there, I also want to pivot a little bit into mental health. But starting with some of the opioid. It huge problem in our country just in. According to the National Institute of Health and the National Institute on Drug Abuse, roughly 21 to 29% of patients prescribed opioids for chronic pain misuse them. And between eight and 12% of people using an opioid for chronic pain develop an opioid use disorder. And then just to top it off, according to the American Psychiatric Association, nearly 5% of American adults say they have been they've or been addicted to opioids or prescription pain killers. So you've mentioned a couple times how Hinge can help with this. How?

Jim Pursley:
Yeah. First I appreciate asking. I'm sure you'll ask a bunch more good questions before we're all done, but the opioid issue really is something that really strikes that I think the heart of a lot of people, all of us or at least a lot of us have, have a personal story of a friend, a family member, a neighbor, our neighbors lost their son in high school to heroin overdose. And he started on opioid abuse. And so it's very personal. It's very real. And I think with COVID it took a little bit of a backseat in the front page of the headlines, but the epidemic didn't lessen in fact it was exacerbated by COVID and like a lot of behavioral, mental health challenges I think kind of flew under the radar for many people. So first of all, thank Justin for shining some light on it.

Jim Pursley:
So opioids can be either proactively prescribed inappropriately as kind a first line of defense or it's somebody who feels like they've tried everything else and they've lost kind of hope. And it's a last ditch effort to live without pain. Pain also by the way, high correlation to anxiety and depression. And not only is there a causal effect, they also exacerbate each other actually. I didn't actually know this until I started spending more time here, but the neural pathways used by pain and also are the same ones used by depression and anxiety. And so behavioral health challenges can actually exacerbate the perception of pain. So all it to say is that there's different ways people get into opioids. But all of them share a common desire to live without pain.

Jim Pursley:
And I think we all, it's like a innate human desire is to live without pain. So we assess folks right off the bat when they come into the program and understand where they're on their pain scale. Are they currently on opioids or are they not. Are they considering just like we asked someone, are they considering surgery? Are they considering opioid use? And we're going to get to work right away on try to eliminate pain again, whether it's through physical therapy, whether it's through coaching.

Jim Pursley:
So someone that's trying to bring therapy to the behavioral, mental health effects aspects. But if somebody either is reticent to start physical therapy, because they're in too much pain, physical therapy actually exacerbates the pain when they're done or somebody's already using opioids, that's a great place again for ENSO, which I should have sent you one before the podcast so you could try it for yourself, but I can get you on. So, but-

Justin Steinman:
[inaudible 00:32:45] I'm pretty pain free. Thank God.

Jim Pursley:
Yeah. It is a phenomenal technology that again, nonaddictively, noninvasively can eliminate pain almost instantaneously and gives that person the relief they need then to engage in maybe physical therapy. So we can solve the underlying root cause of issue and avoid the need for opioids. But opioid manager and by the way, we collaborate with some of our partners as well. We work with some of the largest prescription benefits managers in the country that have their own opioid management programs. And we work to collaborate also with them maybe maybe in some cases, you're already addicted to opioids and you need actual medical intervention, pharmacological intervention.

Jim Pursley:
We're going to come alongside you and support you with that in conjunction with some of our partners. So it's a big deal for us first and foremost, trying to avoid having to use them at all in the first place, trying to get you off of them as quickly as possible. And if that doesn't work, how do we get you additional help to help address that abusive issue?

Justin Steinman:
Yeah. I really do think it's a big issue that our country needs to solve. It's a macro problem, but when it's your friend or your family or your neighbor or something, it's a micro problem, it's your problem. And I think we all need to have the fact it's my problem. And that's the only we're going to be able to fix this if everybody says it's my problem.

Jim Pursley:
Absolutely. Absolutely. And just one other side, just other kind of not a [inaudible 00:34:13] but a related comment is there's about a 50% increase in risk for opioid abuse before and after back surgery as just an example. And so just eliminating the need for surgery is going to change the risk profile for a lot of people. You're just eliminating that event. 0% of people get into car accidents who are not in a car kind of thing. If we can avoid the need for surgery, just by that very fact, we are going to reduce opioid reliance fairly substantially.

Jim Pursley:
But it's a multifactorial problem. And it's going to require just as again, a related comment to dentists are actually a big part of the issue and that's something that we're solving for at Hinge, but our PBM partners, that's a big deal. You're seeing 30 day scripts being written for having your wisdom teeth out when all is you need is five days. And that's where a lot of the abuse starts as well. Sometimes it's not related to MSK pain. So it's going to take a lot of us, like you said to think of it as my problem not their problem, I think for us to make a difference.

Justin Steinman:
Yeah. I remember that dentist thing back for again, when I was at Aetna and CVS, we used talk about the dentist over prescribing the opioids as a macro problem that we had to solve.

Jim Pursley:
Yeah. Exactly.

Justin Steinman:
Very familiar with that one. Another thing, Jim that we mentioned earlier, we touched on it briefly, but I want to come back to it is health equity or more accurately health inequity. And a lot of the guests that I've had on this podcast have talked to us about health inequity, whether it's in rural parts of the country or socioeconomic health inequities. It's a massive problem in this country. What are the trends you're seeing around MSK and health equity?

Jim Pursley:
Yeah. So access and affordability are big issues in MSK. About 3.6 million Americans have transportation challenges preventing them from not just getting muscular skill care but from getting the medical care they need. If you're a shift worker and maybe you're a single mom or a single dad trying to balance childcare and a full-time job, you're trying to find time to get to a physical therapist, it's not a trivial challenge. And then you add in accessibility of physical therapists. So let's take women's pelvic health as an example. If you're going to go to see a physical therapist, you need to see a trained and certified pelvic health physical therapist. And there is a shocking limit to the availability of these folks.

Jim Pursley:
We have an employee who lives in Omaha, Nebraska. Within a hundred mile radius of Omaha, Nebraska, which is not that it's a metropolitan area. There are 18 pelvic health PTs within a hundred mile radius of Omaha, Nebraska. So you think about that if one in four women are suffering from pelvic health, that's about 43 million women who need to see a pelvic health PT. And I don't know what percent of them live in Omaha, Nebraska, but I'm pretty confident that 17 or 18 PTs is not about to effectively service that within a hundred mile radius. No, one's driving a hundred miles to get PT. That's just not going to happen. You're going to suffer in silence, you're going to suffer alone. So there's this idea that affordability access it's just a matter of willpower and that's just not the case.

Jim Pursley:
And so we're really committed to addressing like you said the inequality in healthcare, whether it's rural America, whether it's women trying to get access to pelvic health PT, whether it's making physical therapy affordable to somebody, nobody should have to pick between, especially in this inflationary environment, nobody should have to pick between filling up their gas tank, buying groceries, or getting physical therapy to live a life without pain. So we're really committed to addressing these and the good news is we're pretty successful in a lot of areas. We haven't solved all the problems yet but if you see somewhere not solving, raise them and bring them my attention and we'll see what we can do.

Justin Steinman:
Well, I got a hotline to you. That's awesome.

Jim Pursley:
Yeah.

Justin Steinman:
We'll start to wrap up here. I got one last question first again. Thanks for taking time to talk with me today. This has been great. It's clear, you're passionate about helping Americans with our MSK passionate about the healthcare ecosystem and the healthcare market broadly. So as we close out here, maybe you could share a little bit personally why you chose to join Hinge Health. You've had a long career, longer than you probably care to admit. Long career as a successful healthcare entrepreneur. You could have gone anywhere. Literally you probably had your choice of jobs. Why'd you go to Hinge?

Jim Pursley:
Good question. So I think back on the things I've done over the last 25, 30 years and the majority, especially the ones in the more recent past have been around having a life changing impact at scale. And I think about Livongo, which was where I was most recently. And I think about the story. I was talking to a mother, for example, who has a child with type one diabetes who hasn't slept in years because they're constantly living in fear of what happens if my son or daughter has a hypoglycemic event in the middle of the night and thinking about how can what I do give that mother the gift of peace and the gift of safety and security. And when you figure out how to do that, and you were able to repeat that you're able to scale that there's something profoundly rewarding about that.

Jim Pursley:
And as I stepped away from Livongo and reflecting on what I was going to do next, it feels like I've been doing this a long time. I still though have hopefully some runway ahead of me.

Justin Steinman:
You and me both.

Jim Pursley:
My wife certainly didn't want me to stay at home any longer, but thinking about what are you going to do next? I want to do something that mirrored some of that ability to deliver life transformation at scale in a very authentic way. And I had been an advisor to Hinge going back to 2017 and we shared a lot of the same clients. And I would go into a Boeing or an AT&T or another large employer and ask, "Hey, tell me about this Hinge thing. Is this thing legit?" And that's back when there was no reason not to get the straight scoop.

Jim Pursley:
I think it was an objective conversation and people would say, "Not only is it legit Jim, no disrespect to what you're currently doing. It's the most popular program we've ever launched. It is the number of handwritten, thank you notes. The numbers of testimonials we get from our people is absolutely overwhelming." And so I had a sense that this was authentic. This was the real deal. But then I also saw while Hinge come so far, how much further they had to go. I mean Hinge is about six years old, now seven years old.

Jim Pursley:
And so in some ways we've accomplished a tremendous amount, but are really in the early innings of what we can and really need to do. So it just felt like that perfect opportunity to bring some of the experience, you gain experience by making mistakes and learning the hard way bringing that to Hinge, to help hopefully accelerate our shared chance to have an impact at scale. And the good news is Justin, it's every bit of what I had hoped for and more and the quality of the people and the quality of the work that we're doing. I feel tremendously blessed to be here and hopefully get to achieve that goal of giving life change to millions of people around the globe.

Justin Steinman:
I like that goal. What could we do to make the world a better place every day? So, Jim, thanks for taking the time. I really enjoyed our conversation today.

Jim Pursley:
Justin, thank you. And all the best to you and your family and here's to building a healthier world together.

Justin Steinman:
Amen brother. Amen. And to all the listeners out there. Thank you for listening to Definitively Speaking a Definitive Healthcare podcast.

Justin Steinman:
If you like what we've heard today, please remember to rate, review and subscribe to the show on Apple podcasts, Google podcasts, Spotify, wherever you get your podcasts. To learn more about how healthcare commercial intelligence can support your business, please follow us on twitter @definitivehc or visit us at definitivehc.com. Until next time, take care and please stay healthy.

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