The Future of Healthcare: “We are relentlessly focused on driving genetics into mainstream medical care” with Sean George CEO of Invitae

For those of us who have been in genetics for a long time and saw the Human Genome Project as this harbinger of a bold new era of medicine, it’s been disappointing to see the slow pace of change in adopting genetic-based healthcare. To me — and to a lot of us — that frustration […]

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For those of us who have been in genetics for a long time and saw the Human Genome Project as this harbinger of a bold new era of medicine, it’s been disappointing to see the slow pace of change in adopting genetic-based healthcare. To me — and to a lot of us — that frustration and the desire to overcome the challenges holding back genetics, is really motivating. Let’s get this information in medical care so people can benefit from it.

Asa part of my interview series with leaders in healthcare, I had the pleasure to interview Sean George. Sean is the co-founder and CEO of Invitae, a leader in advanced medical genetics and one of the most rapidly growing genetics companies in the space. He has held various business leadership positions in the tools, technology and diagnostic industries, specializing in genetics and genetic technologies.

Thank you so much for doing this with us! Can you tell us a story about what brought you to this specific career path?

I’ve worked in genetics my whole career, beginning with my PhD and even going back to undergraduate work. I’ve always been driven by an intense desire to bring this incredible technology ‘down from the mountain’ to help more people benefit from its power to transform lives. For roughly 15 to 20 percent of the population, the primary driver of healthcare outcomes, decision-making and cost are their genetics. Anyone who starts a family understands the anxiety and concern for any and everything that could go wrong. Many of us look toward the future and think about the illnesses that have affected our parents, aunts, uncles and grandparents and wonder what’s in store for us as we age. For something that’s so important and fundamental to an individual’s health and wellness, genetics remains little used on a day-to-day basis.

For those of us who have been in genetics for a long time and saw the Human Genome Project as this harbinger of a bold new era of medicine, it’s been disappointing to see the slow pace of change in adopting genetic-based healthcare. To me — and to a lot of us — that frustration and the desire to overcome the challenges holding back genetics, is really motivating. Let’s get this information in medical care so people can benefit from it.

I think a lot about people I’ve loved who have been lost to cancer or other diseases and, as the years have gone by, I think about the increasing number of people I meet as part of my job. People who have had family members get diagnosed with cancer at an early age and grapple with what to do next, the implications for themselves and their close relatives. New, young parents whose children clearly have something wrong, but are bouncing around the medical system trying to find out what it is, with an increasing level of despair every day that goes by without an answer.

A little while back, I met a mom whose son died in his teens of a heart arrhythmia. She was confused, grieving and terrified for her other child. No one would help her get genetic testing for her surviving child. She found her way to us and we helped her and were able to give her information about the cause of her son’s death and the risk factors that her surviving child, she and her husband faced. And there are millions more like her. Those are the people that keep me pushing forward.

Can you tell our readers a bit about why you are an authority in the healthcare field?

From the outset, Invitae has been a bit of an outlier, a company intent on doing things differently in healthcare. Indeed, the long-term Invitae business model calls for a transformation of the genetics industry. We chose to drive into the heart of the system, establish a leadership position and affect change from within rather than just land glancing, ineffective blows on the surface. Today we are deeply embedded with one of the best brands in the industry, working with major medical systems, insurance payers, major biopharma companies, advocacy organizations and though-leading clinicians. We have a front-row seat to the challenges the industry faces in adapting to change and are working hard to be a catalyst for transformation, a company helping push the boundaries to help patients.

What makes your company stand out? Can you share a story?

In 2010, the cost of genetic sequencing was anywhere from $5,000 to $50,000 or more for a single test. Today those same tests can be completed for less than a thousand and Invitae has been a major force in driving costs down and passing those cost savings on to the customer. That alone would make us a bit unique in healthcare, which of late is defined by ever-increasing costs even as outcomes degrade.

Moreover, even as we’ve reduced costs, we have pioneered novel approaches to deliver the highest-quality results and continually increased the breadth and depth of the genetic testing services we provide. Our ability to do this is a direct result of our deep investment in science and technology, along with our commitment to our mission of building access to testing for patients. We have placed a winner-take-most bet that genetics should and will be a routine part of medical care in the years ahead and that we can help make it happen faster.

Can you share with our readers about the innovations that you are bringing to and/or see in the healthcare industry? How do you envision that this might disrupt the status quo? Which “pain point” is this trying to address?

At the highest level, all health information is getting less expensive — rapidly. As it does, the current information asymmetry that works largely against the individual to the benefit of payers, the Dx/Biopharma sector and medical systems will shift — rapidly — to a point that any entity in the ecosystem not serving the needs of those customers will be left behind. As to why this has not happened already, one only needs to look at the incredible inefficiencies in the healthcare ecosystem, perverse incentives and decades of unintended consequences from legislation and regulation. Nonetheless, it is happening.

We are relentlessly focused on driving genetics into mainstream medical care. To do that, two primary issues — one is not unique to genetics, I might add — need to be addressed: cost and access.

The first phase of our business was about attacking the cost issue. We’ve driven costs down to the point where people with insurance generally pay less than $100 and our self-pay price for most of our testing is $250. We hope to continue to pull costs lower, but we have helped move this into the realm of affordability.

Now we are increasingly turning to access, which to us is about removing barriers that get between a patient and a test. One great example is professional guidelines. In healthcare many clinicians follow the guidelines of professional societies for good reason — these groups evaluate evidence and provide clinicians with a data-supported way to care for their patients. The problem is that guidelines change at an incredibly slow pace and our understanding of the clinical usefulness of genetics is galloping forward. We’re focused now on building the data that show how genetics should be used in healthcare. As an example, we recently collaborated with a breast surgeon research group on a study that showed current professional guidelines for testing breast cancer patients miss as many people with disease-causing variants as they find. That research prompted the nation’s largest breast cancer professional group, the American Society of Breast Surgeons, to update their recommendations to say that all breast cancer patients should be offered testing, actually within weeks of the study’s publication in the Journal of Clinical Oncology.

What are your “5 Things I Wish Someone Told Me Before I Started” and why.

There are so many things… like don’t start a business in healthcare! Seriously, though:

Conventional wisdom is anything but.

True wisdom is based on in-depth knowledge and experience, and often rests contrary to commonly accepted beliefs. If you intend to start a company that changes anything of significance, by definition the current view of the industry held by consultants, analysts and investors will not be one that you’ll be subscribing to. One example, when we were starting Invitae, the general view from investors and the incumbent companies in the space was the entire medical genetic testing category would never be more than about 250,000 cancer patients annually. Many insisted there simply were not enough people who needed genetic testing to warrant the kind of investment we were talking about making. Last year we served 300,000 people across a wide array of conditions and this year we’re on track to serve more than half a million. We stayed focused on the obvious customer need, the size of that unmet demand, and let everyone else worry about the size of the market, competitors, and the ever-changing regulatory and reimbursement environment that seems to keep most other players in the industry occupied.

Price always matters.

Another refrain I can recall from the early days was “price doesn’t matter, why lower the cost?” This, of course, referring to the fundamental healthcare market breakdown that has made pricing totally opaque. Indeed, the vast majority of companies in the healthcare space execute some form arbitrage that takes advantage of this deep within their business models. Well, it turns out that price does matter, even in healthcare. As we’ve driven down prices, and made them transparent, more people get access, doctors start to change ordering behavior and indeed, professional guidelines start moving more rapidly and eventually the payers start to move toward better value. It may take 5–10 years longer than it would in other industries, but as we like to remind ourselves in the halls of Invitae “gravity still works.”

Not all cash is green.

Another thing I was told a few times by key mentors, but really came into full focus for me only in the past year or so, is that there are many different types of investors who might invest in your company, but it is crucially important to make sure to get the right ones on board. In our story so far, we’ve been in the fortunate position of having thoughtful, long-term investors who are passionate about investing in positive change in the broader healthcare industries. Without them, our path would not have been available to us. Conversely, I’ve seen many highly talented, well-intentioned, impressive start-ups go down as their short-term, bottom-line focused, business-as-usual momentum investors pumped up their valuations in heady times, kneecapped them in rough spots, and left them fully exposed in the final test.

Right is might, but don’t fight city hall.

You can be doing the right thing for the right reasons, the fundamentals can be shifting in your favor and the winds of change may be propelling you forward, but the politics may be against you. I’ve learned, and this is really not in my nature, that there are some things you can’t change head-on, unless of course you’re willing to become a career politician. Better to stay informed, involved and part of the conversation, try to educate, but focus on the customer and the business and realize the rest may come around, or it may not. The best way you can affect your desired outcome is to delight as many customers as you can in the process.

Success tastes like gravel.

I go out of my way to encourage entrepreneurs, particularly the ones who are dreaming big and looking to change things for the better, so I don’t want this to be taken the wrong way! The truth of it is, that if you get an idea of the ground, get funding, pull a team together and scale it over time, survive the response from established incumbents, hold off a number of new entrants once your model starts looking feasible — all the while doing whatever it is you’re trying to do when you’re not working — your success will often have very crunchy, chalky taste to it…. Tough decisions will need to be made, you’ll have to grow in the process and there will be sacrifice. I believe if you’re introspective and humble enough to know that with all your talents and all the right moves, there’s still a good amount of luck involved, you’ll always grapple with the success, what might have been, the people that didn’t come along for the ride, and trade-offs you’d like to take back if you could. I’m constantly reminded by my team that it’s all the more reason to be sure and look for the fun in it daily, and to carve out the time to celebrate from time to time.

According to this study cited by Newsweek, the US healthcare system is ranked as the worst among high income nations. This seems shocking. Can you share with us 3–5 reasons why you think the US is ranked so poorly?

First I’ll point out that I don’t think it’s shocking to anyone operating deep in the bowels of it! This is the number one issue that everyone talks about in the U.S. and for good reason. The amount we spend compared to the value we receive is a tragedy, especially when considering the talent and technology available to us. In my opinion, one of the largest factors is opaque, procedure-based pricing in healthcare. Nobody knows who pays what price, for what service and nobody gets paid anything to prevent disease but rather only to treat it. The natural result is a complete market breakdown in which costs skyrocket as outcomes decline.

The role of costs in limiting access to care and driving health disparities is not only wrong for the system, it’s wrong for our society. That is why central to our mission has been driving down costs and making pricing completely transparent. We don’t think something as fundamental as the ability to benefit from having access to information about your genetics should be gated behind a high cost barrier. We are working on the genetics portion of this, but I think the same is true for any aspect of healthcare.

Closely related is the complexity of the payer system and the deep challenges that exist in responding to medical developments. By and large, the idea that new advances bring astronomical costs is so ingrained in the payer landscape that breakthroughs are nearly always met with a push to ration access to them. Genetics is a great example of this. Most reimbursement policies date back many years, to a time when testing was extremely expensive. Payers created a system expressly designed to restrict access to testing to only the most serious cases. Today, a hereditary cancer risk test that costs under $1,000 is still subject to discouraging prior authorization processes, restrictive qualification criteria, excessive pre-test counseling demands and capricious denials demanding appeal for patients who somehow manage to jump through all the previous hoops successfully. An example that hits close to home: to this day, and after many years of inquiry and seeking resolution, the U.S. Centers for Medicare and Medicaid Services (CMS) is still paying one of our competitors somewhere between $600 and $1,000 more for the same services that we offer, again largely as a result of confusion arising from a coding and payment system that doesn’t anticipate technology lowering costs. The good news is that lately we’ve seen heartening examples of progressive payers who are trying to break through the bureaucracy to expand access and benefit patients, but it is extremely slow-going.

Another issue that has to do with costs, albeit in an indirect way, is the deep resistance to change that I believe stems from the phenomenon of medicine effectively acting as a guild. The model — limiting the supply of labor, an apprenticeship training model, relying on rote memorization and a human’s ability to recognize complex patterns accurately, protectionist licensing laws at the national and state level and an incredibly hierarchical and paternalistic approach to what is fundamentally a science and engineering problem — is beginning to run its course. Medicine remains fundamentally rooted in the idea that an individual physician should be the gatekeeper to all care for patients. It’s hard on all involved. Physicians are under enormous pressure to see too many patients in too little time and patients find themselves getting bounced around by a system that is anything but easy to navigate. We are living through the unintended consequences of one of the most highly regulated industries crashing into the era of the most rapid technological advances and it is putting clinicians in a no-win position to the detriment of all.

What would you do to change things?

To the extent those of us in the industry can help, I would start by encouraging more conversation about the changes that are needed and examination of the companies and organizations that are trying something new. Too much talk about healthcare ends up retreading a cycle of decrying the current state of affairs and lamenting the inability to completely reform the system in the political arena, followed by a dismissal of doctors ability to help and some nod toward technology being the ultimate solution if we could only get all the data in one place. I think we can start by having a different conversation, one that looks at the places where innovation is making things better and taking those lessons forward. I’d highlight three good examples:

Integrated systems in this country, ones that own the birth-to-death costs of healthcare are starting to demonstrate models that can work. Of late, they’ve been more effective at improving prevention and total customer care than acute disease, but some are starting to improve there as well. For example, Geisinger Health System is a partner of ours and is really an amazing organization that is trying to tackle some really big problems in health care, getting serious about the use of information broadly, including genetics, making decisions accordingly and is having success. I think there’s an important lesson here. Regardless of your politics, when a person or organization is on the hook for the cost of healthcare, different decisions are made and we should be understanding those differences and learning from them.

Another great example is United Healthcare. They recently announced a Preferred Lab Network including a few highly select labs — Invitae is proud to be among them — that have been vetted for quality and value. They created this network as a way to establish a value-based care model in which participating labs can offer physicians and members improved quality, access and service, at a lower cost of care, allowing UHC to make it easier for members to use those companies’ services. Encouraging competition to play more of a role in sorting out who gets paid for what will benefit everyone.

Finally, at the risk of being immodest, I’m very proud of the work we’re doing at Invitae to provide the highest-quality genetic testing services available but in a business dedicated to driving costs down. And there are many other young companies pursuing similar models in their respective sectors, and they will be an unstoppable force in the coming transformation of healthcare as we know it. It turns out that despite all the complexity, healthcare is a basket of goods and services like any other industry — and just like any other industry, creating value for those customers will ultimately win the day.

What are your favorite books, podcasts, or resources that inspire you to be a better healthcare leader? Can you explain why you like them?

I think there’s a reason the three biggest section of bookstores (or I guess used to be) are weight loss, parenting and business advice. I think this is because they probably all share in common the fact that there are a few fundamental, simple principles that you can put on one page and then a whole lot of stuff that really depends on what is essentially a unique situation.

With that said, I think Lencioni’s books are worth reading. First, they’re short and simple, but more importantly his observations focus very much on the team, the relationships between the people on the team, their capabilities and their motivations. That covers an awful lot of it in my opinion.

Another author with some great insights and straightforward style is Ben Horowitz. One of my favorite pieces of business advice, that I find myself heeding often and repeating to others comes from him. “If you’re going to be eating shit, don’t nibble.” You learn over time just how good that advice is.

For healthcare specifically, I wish everyone read more Deming. The later leadership stuff is good, but more importantly the early 80s book on quality, productivity and competitive advantage. Just about every industry in existence has been in some way improved in the last 50 years by these principles, it’s just beginning in healthcare and can’t happen fast enough as far as I’m concerned.

A podcast I find particularly inspirational, and I think a lot of it comes directly from the perspective and advice of the host, is Reid Hoffman’s ‘Masters of Scale’.

How can our readers follow you on social media?

Follow our company @Invitae on Twitter and LinkedIn or @invitaegenetics on instagram.

Thank you so much for these insights! This was so inspiring!

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