The Stretch – Heart Health at the Heart of Wellbeing

Maayan Cohen:
Thank you, Kevin. I'm super excited to be here.

Kevin Fyock:
So Maayan, why don't you tell us a little bit about yourself, maybe your background, how you end up by starting Hello Heart. Tell us everything.

Maayan Cohen:
Sure. So healthcare and science has always been a passion for me. As a little girl, I used to investigate insects. And for my sixth birthday, I asked for a microscope. And later in life I volunteered as an EMT and eventually ended up in the business space. I was doing management consulting, did my MBA and helped very, very inspiring brands like Hyundai and Nestle and American Express build competitive strategies, create new ideas and enter new markets. And life brought me back to healthcare. So when I was 25, pretty young at the time, my boyfriend at the time was diagnosed with a brain tumor. And overnight, I was personally, together with him, thrown into the patient seat. Or the caregiver seat, in this case. And I found myself collecting medical records and tracking vital signs at home on pieces of paper and an Excel and tracking medication and trying to make sense out of all of this.

Is he doing better? Is he doing worse? What can we do about it as patients? And how can we prolong his life and improve his chances? And in this very chaotic situation, I realized that although we went to the best doctors and he had the best treatment options, we found ourselves pretty helpless and very lost in trying to understand what can we do about it as patients. And that's when I realized that patients just don't have any tools to understand and improve their own health and catch risk in time. And there's a gap in our healthcare system between where doctors are and where patients are, and there's so much patients can do to really improve their condition and catch risk in time. So this story has unfortunately a pretty sad ending. A few years later, he did pass away, but the silver lining here is that I found my calling, which is to help people and empower people to understand and improve their own health and catch risk in time.

So that's what started or inspired me to start the company. When we started it after a few initial tests, we realized that we have to focus our efforts and we chose heart disease because it's the number one cause of death in the world.

Kevin Fyock:
Well, first of all, I'm sorry to hear about your friend. That is indeed heartbreaking. Although what an amazing foundational point to start such an incredible company. And what you're saying really resonates with me. Probably anybody who's ever been a patient, no matter how serious or benign, it's a hectic system globally. And so having to be your own advocate and look at medical records and bills and everything in between, I think can be tremendously overwhelming. I'm really looking forward to digging in. And by the way, I think it's super cool that you started your love of science with bugs. I would say the same thing about myself and especially my children as well who oftentimes bring bugs into our home. So I really like to start these podcasts with a broad question to build context to our discussion. So maybe, could you first start by defining what do we mean when we say heart health?

Maayan Cohen:
So heart health is the number one cause of death in the world today and in the US, of course, as well. It's a silent killer. So you can't see the risk factors, you can't feel the risk factors, which is why it's the number one cause of death. Although in 80% of cases, it's actually preventable. So because we can't see it and we can't feel it, we tend to ignore the chronic conditions that are associated with it and lead to cardiovascular disease events. And people end up dying because they don't have the awareness or the tools to catch it, which is why I thought it's such an incredible condition to go after because that's something that if you really give people the tools to understand what happens inside their body, you can make huge impact on their health and their life expectancy. So when we say cardiovascular disease or heart health, we mean, of course, heart attacks and strokes.

That's the far end of the spectrum when we talk about the catastrophic events, but we also mean hypertension, hyperlipidemia that together are the main causes of cardiovascular disease. We also mean women's heart health. Women's health is very different in terms of heart health than men. Women are not just small men. They have other components to their metabolic system and their body that are different. So women's heart health is very different when it comes to cardiovascular disease. And we also mean irregular heartbeat and other risk factors. So basically, what Hello Heart does is it covers all of these areas together. And one of the most common mistakes that I think many payers, employers, and sometimes even patients make is that they treat each one of those conditions separately. They look at their percentages of stroke and their percentages of heart attacks, their percentages of blood pressure and hyperlipidemia.

And although hyperlipidemia and hypertension together is more than 50% of Americans, they tend to isolate these things when they're actually all related to heart health, and that's what drives eventually heart attacks and strokes. So heart health is all of these components, and there's other risk factors like diabetes and weight, but a little bit further out than the key risk factors that are really related to heart health.

Kevin Fyock:
Gosh, so many things that you said there, I think really, really stick with me. One, to hear that 80% of cardiac issues are preventable. I would love your perspective on this too. But as an industry, I feel like there has been so much innovation in every single corner across clinical conditions, across payment models. I think we've almost lost sight to an extent about the importance of heart health and how incredibly basic it is that I'm so excited to be having a conversation today because so many things that you said there from the fact that it's oftentimes preventable to the way that women experience cardiac issues is different than the way men do. There's just so much. I feel like actually we can have this podcast be an hour and a half because I have approximately a million questions for you, but maybe our listeners wouldn't like that.

So maybe what we can do is focus back to the employer. So when we think about the environment that we're finding ourselves in today, I would love your perspective around, why should employers care about heart health? Why should they focus on this topic?

Maayan Cohen:
That's a great question. Employers on the provider side have access to the most advanced treatments. We have access, all of us as patients, to stents and to surgeries and to even heart transplants. If you get to a hospital in time, your options of making it are incredibly high and the treatment options are super advanced and really cutting edge in terms of science. What's lacking is tools at home for population management to allow people to track blood pressure, track cholesterol, track irregular heartbeat, track specific risk signals that could be related to women's heart health as well, catch risk in time and get to the doctor in time and advocate for yourself. If you don't have that, you do end up in the hospital too late and it's not just costly. It's deadly in this case. So what employers need to start paying attention to is, where does that fall?

Most of them have biometric screens and they see extremely high hypertension rates, extremely high hyperlipidemia rates. They know it's the number one in terms of prevalence. What they don't always look at is the cost side. So on the cost side, some of them understand it's one of the top three cost factors. Some don't because it's in different buckets. They look at like, oh, in the top 10, I have stroke and heart attacks, but hyperlipidemia is number 12 or 13. It's all related to one bucket. If you bucket it in the right way, it almost always is one of your top three cost factors. One, they need to start looking at their data in the right way to really understand what drives population health and analyze claims data in a way that makes sense in terms of population health and not just the coding on the claims.

Most of them do, but that is something that some employers do miss. And the second thing is that they need to start to acknowledge that they have something that they can do about one of these huge problems. I think employers tend to ignore or tended to ignore heart disease for many, many years because they didn't have any solutions. We're able to put a blood pressure cuff in some of their sites or to do biometric screens, but it ended up typically with, "Go talk to your doctor." And no one does. The ones that do, God bless them, but most people don't. And the reality is that we didn't have any tools to really change the course of cardiovascular disease and heart health and on a population level. And now we do, which is amazing because with such a simple tool, you can drive impact on 50% of your employees and their spouses.

You can reverse trends in terms of cost and clinical outcomes and you can help save lives potentially, which is amazing. There is a solution. And I think when there's a problem that's been there for so long and we don't have a solution for it, we just tend to start ignoring it. Have many other problems around us that are like that, I guess. But I think that's really what happened with cardiovascular disease. Everybody agrees it's huge, but nobody has done something about it until employers started to do things about it. We now have more than 150 very large clients. Most of them are Fortune 500, including on top of it, states and federal accounts that are doing something about it very successfully. But a lot of employers don't even understand that they do have an option today.

Kevin Fyock:
Just to even hear you talk about the importance of at-home monitoring, again, I go back to my comment around the innovation that has happened around us, even the promise of the wearable generation and how that was going to impact heart health. At the risk of what oversharing, my father had TAVR surgery not too long ago and he's doing just fine. But the focus that I recognize is so important around being able to monitor postoperatively a valve replacement or even prior to that, the difficulty that I found with linking things like a wearable to monitor things like AFib is difficult, and even sharing that back with your provider. So the fact that you're playing this role, helping to be that conduit and helping to monitor at home heart health is incredibly important. And you're totally right, Maayan. If people just spoke with their doctor a little bit more, I think maybe that would be much of the solving that we need here, but I suppose that's your role.

But I really want to touch on something you brought up around this point of women's health. This is something that I'm super focused on, my team here at Aon is super focused on. And in fact, in the first episode of our podcast, we talked specifically about women's health and how it's much more than just reproductive health and fertility. And our guest on that episode brought up that for so long the entire understanding of healthcare was based on men, primarily on men. And so the topic of heart health in particular, to me, seems like a great illustration of this. So maybe if you could, you tell our audience a little bit more around women's heart health specifically?

Maayan Cohen:
Sure. That is definitely something I'm incredibly passionate about as a female leader and as someone that also has a mother, two sisters, and 70% of my team are female. So this is something that I deeply care about. So first of all, heart health is the number one cause of death for women. That's not something that most women actually understand and know. Women die two times more than men during a heart attack, which is mind-blowing in my view. But why is that? Why do women die so much more during a heart attack versus men? This is basically two things. One, we don't have awareness in our population. Because women don't understand their own symptoms, they wait for much longer than men. They get to the hospital 37 minutes later on average versus men. So we take our time to get to the hospital. We don't call for help in time.

We don't fully understand our own symptoms. So for women, most men experience heart attacks, as you know, chest pain and left side pain and sometimes back and neck pain. For women, the symptoms can look very different. It can also feel like a stomach bug. So nausea, vomiting, stomach discomfort. It can feel like they just lifted something super, super heavy up the stairs. So shortness of breath, extreme fatigue, stiffness of back and neck. It's not always the left side and classic chest pain. So women in many cases mistaken it for a stomach bug or I'm really tired or something is off. But when they feel something is off and they're not aware of these symptoms, they don't take themselves to the hospital. And people around them don't understand these are the symptoms of a heart attack for women so they don't get to the hospital.

The second reason is the clinical team. As you mentioned, women have not been even included in clinical studies until 1993, which is not that long ago. I was in school back then. And it takes time for science to catch up, especially when you look at clinical guidelines and studies that have been built over studies, over studies, over studies with quotings. So women have not been included. So our clinicians are not fully educated. It's not mainstream, not in our clinical teams and not in pop culture around what does a heart attack look like for women. And unfortunately, in many cases, they get turned away in the ER. It's mistaken for mental health. They tell them they have anxiety or they're hysterical or they have a stomach bug and send them home and they're actually discharged 50% more than men during a heart attack without getting examined and they die at home, which is incredibly sad and heartbreaking.

And it's not because doctors have any bad intentions. Doctors have took the oath to protect all patients and to help all patients. It's really a lack of ability for women to advocate for themselves of what's happening inside their body and of clinical teams being fully educated on having it as top of mind. But when you send women to the hospital, you really need to make sure that they have the right tools to advocate for themselves, that they have the right blood pressure readings to quote that they now have, if there is an irregular heartbeat that they can mention, what is it, that they can properly quote which symptoms they're experiencing and flag to the doctors that, "Hey, a reminder. Remember from med school. These are specific symptoms that could be related to a heart attack." So we need to teach women about themselves. We need to educate clinical teams and we need to allow women to advocate for themselves because it's different. The symptoms is just one example of women's heart health which is huge.

Kevin Fyock:
Sure. I was just at a big symposium a few weeks ago, and we dug specifically into the idea of women's heart health. And I think even your comment around clinical studies and women being included in first 1993, but it's so incredibly important because even since then, there's oftentimes a disproportionate inclusion of women in studies more broadly. And so when you think about the physiological and the anatomy makeup of men versus women, they're very different. The way things like valves seat within the heart and the way that people respond to medications, it's a problem that I think has been addressed to an extent, but needs to be continued to be addressed. Even your stats, Maayan, just blow me away around women being turned away in the ER for symptom presentation is incredibly disappointing. So I appreciate you sharing, but those are very concerning stats.

Maayan Cohen:
Thank you. Thank you for helping us all put a spotlight on it. By the way, regardless of what I do for work, I think this is huge and I think we should take all of our frustration, our disappointment and funnel them into raising awareness, all of us, to the symptoms, to what we can do about it and really put women's heart health front and center. And when we talk about women's health, everybody immediately goes to reproductive health, which is incredibly important, and breast cancer as well. But again, heart disease is the number one cause of death for women. We need to start bringing it front and center and helping women advocate for themselves and educate them. And it shows up in other forms as well. Hypertension or high blood pressure is the number one cause of death for women who are pregnant. And we have to monitor blood pressure during pregnancy if you're a specific risk group.

And most employers don't have a solution for that. So that's one of the areas that we expanded to over time. During menopause, estrogen production stops in women's bodies or gradually declines and then stops. And estrogen is a hormone that protects our heart as women. So during menopause, for example, our chances of having irregular heartbeat triples and women need to get educated not just on symptoms of menopause, but also on what happens to their heart and how they need to start monitoring their heart health in a very different way than they have before. So there are many other aspects of women's heart health, and these are just two that are related to some degree to reproductive health, but they don't get enough solutions and attention. And guess what? 100% of women go through menopause. We all need to get educated on it because it's going to happen sooner or later.

And we need to start monitoring blood pressure, irregular heartbeat and make sure that we're on top of it as we start to approach that age. And in working population, it typically starts at 35 to 40 with premenopause. And of course, most women go through menopause while they're working. So this is something that has to be addressed by employers.

Kevin Fyock:
What you're touching on that I like so much about this conversation is just this topic of women's health, but you also touched on menopause where obviously we're talking about heart health. One of the most exciting things in our industry in the past dozen years has been this massive light shown on family forming and fertility benefits. But how much that has scaled, I think has created, and I talked about this on a previous podcast, almost inflation that women's health equals family forming and fertility benefits. But in fact, that's such a minority of a women's healthcare journey from birth to death.

And so the more we can talk about, to your point, menopause and heart health, there's just so much to treating, really, the whole woman. And so that's what I really like about our conversation here. So you've hinted at this a little bit, Maayan, but I would love to hear more specifically about, what are you and your team specifically doing at Hello Heart? And maybe the million-dollar question is, what are you doing to improve heart health for patients?

Maayan Cohen:
Great question. So at Hello Heart, we empower people to understand and improve their heart health and catch risk in time. We use technology and behavioral science to do that, and we really help everyone from all backgrounds, languages, genders, get equal treatment to their heart health risk factors and problems. So what we do is quite simple. We take care of all of your heart risk factors. We have a monitor that tracks blood pressure and pulse. We have an app that connects to clinics. You can also import data and enter it manually that tracks cholesterol. It tracks also other slightly further away. It's more cardiometabolic and less heart health, per se, but diabetes and weight we can track as well. We also track your steps, which is your activity. We track your symptoms because that's highly related to what happens inside your body and what happens when you are experiencing risky situations.

And we help you do three things. One, we help you make sense out of all of it. So every time you have a new data point, whether it's a new cholesterol reading from your clinic, a new blood pressure reading, a new pulse reading, we help you understand what it means in the simplest way possible with simple terms, emojis and explanations. We help you track it over time. And then we do two things. We help you improve your heart health and cholesterol in a very effective way using digital coaching. So we have an engine that takes all the classic clinical guidelines, but also all the newest studies like how dogs can impact cortisol level and blood pressure and how sunlight can actually reduce cardiovascular disease, not just taking vitamin, but actually sun exposure can reduce cardiovascular disease risk. When we throw it all into an engine that optimizes the tips that we give every patient using AI, that's the only thing that's used there, but it uses AI to optimize the tips.

So each patient gets tips that are most likely to help them and for them to actually implement it. So as an example, to tell a patient to stop smoking, if they're smoking, is probably the most effective way to improve their heart health, but the chances of them doing it after reading a tip online is very close to zero. Not only that, they will statistically, based on our studies, will disengage from the solution if you just tell them, "Hey, why don't you stop smoking?" Clinically, it's the most effective thing. In real world evidence, it doesn't work. But guess what? Telling patients to hug their dog because it reduces cortisol levels and improves their blood pressure is highly engaging and there's a very high chance they'll actually do it. So that's a tip that gets to the front of our engine for the patients that of course have a dog and gets you to try new things to improve your heart health.

And that's how we actually were able to generate incredibly powerful clinical evidence. We had a three-year study that was posted in JAMA Open Network, one of the leading clinical magazines in the world. There was a three-year study with 30,000 patients and another study with 100,000 patients that demonstrated that in the one-year, three-year and two-year mark, basically over the three years, patients have reduced their blood pressure when they started in stage two hypertension and 21 point systolic. This is two times better than anything that was ever documented in the clinical literature.

And it's really because we engage with people and are able to drive meaningful behavior outcomes without rubbing them the wrong way, or forcing them to talk to a human. We of course connect to their clinical team, but we don't force human intervention if patients are not interested in it. Only if they are. And then we tend to utilize the existing care teams and not replace the existing care teams because we do believe that if you have a PCP, you should go to your PCP and not replace them with somebody else.

Kevin Fyock:
Wow. So one, I had always thought that my cycling was the reason I could say I take good care of my heart, but now I'm recognizing, Maayan, that it's actually my dog. And so the fact that I have a dog is number one reason why I take care of my heart. So after we're done here, I'm going to go hug my dog. So thank you for that nod. This is great and so fascinating. What phenomenal results that you shared. And I'm going to go look up the JAMA open source after this call. What a great study. So thanks for sharing. So Maayan, you talked about the behavior change and I think it was well documented in the studies that you referenced. When we think about reduction in cholesterol, reduction in blood pressure, I would love your perspective. What are the easy steps that patients can take to actually drive change for their own heart health?

Maayan Cohen:
That's a great question. So the first thing is really to track at home on a regular basis. And these are the American Heart Association guidelines. You have to track blood pressure at home if you have elevated blood pressure or more, and same with cholesterol. So tracking is basic. And after that, there are basically two key things you can do. One is behavior change, which is hard, but with tips that are step by step, you can make huge differences in your lifestyle. They're not that hard and you can adapt to whatever tips make sense to you. And the second thing is medication. Medication for cardiovascular disease are incredibly cheap. They're incredibly effective if only people would take them. The vast majority of patients that are prescribed hypertension, hyperlipidemia, medication are not taking them on a regular basis. So what we need to do is first make sure that all patients have the right medication prescribed, many don't, and two is to help them take them.

And it's hard because if you can't see or feel hypertension, hyperlipidemia, you don't really understand the effect of it. So people tend to ignore it. What we've done is we created a suite of tools for medication adherence, and we're about to launch a very, very, very innovative solution, which is a digital pillbox that alongside our blood pressure monitor that connects to your phone with Bluetooth. The pillbox will also connect your phone with Bluetooth, and both of them talk to each other. So if you took your medication and you took your blood pressure, you can see how taking your medication gets your blood pressure to get lower or higher. So we connect the dots for patients so they can actually see what happens inside their body and that reinforces medication adherence. On top of it, we just forget. I need to take meds and I forget.

So I have the pillbox in front of me every morning, but sometimes I forget. And then did I take it? Didn't I take it? So having a digital tool that helps you track what you're taking every day and get yourself organized is incredibly powerful, especially by the way for patients that need to take multiple medication, three or four more. So medication adherence and lifestyle, again, not very hard and very basic, but getting people to do something about it is the hard part, and that's what we specialize in.

Kevin Fyock:
And harkens comes back to what you're saying, Maayan, which is the percentage of indications where heart health can be prevented, an event can be prevented. So something as easy as taking a medication, incredibly important. But again, we're human and we forget things. So I think that type of innovation is why you all are certainly changing behavior and driving the results that you are. So I appreciate you sharing.

Maayan Cohen:
For sure. And the whole thing with Hello Heart is that we make it super simple and fun with positive reinforcement to engage with your heart health. And that's why we're so different because we're not coming from the clinical side. We have, of course, preventive cardiologists on the team, but we really come to it from the gamification side, the gaming world, the social media world. And then that's the type of tools we implement in our solution to get people engaged with their heart health and use their phone for good instead of just looking at social media and ads all day.

Kevin Fyock:
All the folks that come on the podcast, I always have a similar question I like to end with. And I keep calling it the crystal ball question. So I would love your perspective around what heart health looks like in five years or even 10 years. And if we could continue to get more and more people engaged in their heart health, what does that look like down the road?

Maayan Cohen:
Sure. So the first thing that will happen beyond, of course, population health is something that is on everyone's top of mind these days. Cost trends are spiking everywhere and employers are expected to do something about it now. So the first thing that will happen is costs will start to reduce significantly. We just published a peer reviewed study that showed in valuing health, it showed $1,700 of savings. And Aon's actuary team actually just published a new study that showed Hello Heart for the Aon clients reduced cost in $1,400 per patient per year. And it's not rocket science. It's just because we also have risk flags that flag when you're at risk and encourage you to go to see your doctor and refer you to your doctor. We get patients to see their PCP way before they end up in the ER. So in the study, you can see an increase in PCP visits and a decrease in inpatient outpatient costs, which is exactly what we all want to see.

Less people ending up in the hospital, more people showing up at their PCP office instead. So the first thing that will happen is a very significant reduction in cost. And we've seen it across our entire client base. All of our clients that have done an ROI study, for example, see positive results. So we now even have 100% performance guarantee on clinical outcomes and ROI, which is basically the only solution in the category that can do that because we actually reduce cost. So I think that's the first thing that we're going to see. The second thing I hope is less mortality, and that's something that we will hopefully improve one day, but the fact that we can catch risk in time and reverse trend, especially for women, but for everyone, is incredibly powerful. So start educating at such a huge scale. Again, 50% of employees have hypertension or hyperlipidemia.

You can really make an impact on a clinical level on population. That's two. And three, I hope less damage will happen. So I think today we have risk flags that can spot irregular heartbeat, hypertension, spikes in blood pressure and pulse that we developed in house. In the future, it sounds very futuristic, but it's probably not that far out. We'll be able not to just catch risk in time, but to also predict who's the next person that's going to have a heart attack or a stroke and reverse it before it even happens. And that's the world I want to live in. I want to live in a world without heart attacks and strokes and without the fear of heart attacks and stroke. That's a cloud over everyone that have a history of cardiovascular disease's head.

Kevin Fyock:
Well, I think that is one of the best use cases of artificial intelligence, is the predictive capability. When you look at reams of data. And heart health is no different, right? So how do you predict stroke? How do you predict cardiac events well before they happen? So like you, that's a world that I want to live in. So I appreciate you sharing and looking into your crystal ball. But Maayan, thank you so much for coming onto the show, lending your expertise. This was a lot of fun and it was so good to see you again.

Maayan Cohen:
You too. Thanks, Kevin. Thanks for your time. And thank you on behalf of your dog. It sounds like he's going to get a hug now.

Kevin Fyock:
He's going to get a hug. Yes, a very big hug.

Maayan Cohen:
Immediate action already came out of this podcast-

Kevin Fyock:
That's right.

Maayan Cohen:
So I'm happy.

Kevin Fyock:
Yeah. Who knew I was actually piloting Hello Heart right here on the podcast? So this is great. I'm already taking one step towards my heart health. And to our listeners, thank you so much for tuning in. We hope you enjoyed Heart Health at the Heart of Wellbeing. This is the seventh episode of season two of The Stretch, a podcast dedicated to the ideas that are revolutionizing the world of workplace health and benefits. If you've enjoyed this episode, we encourage you to check out the previous episodes. And if you haven't already, subscribe to the podcast so you can get the latest updates. Thanks so much and have a great day.