This Next Billion-Dollar Startup Raised $110 Million To Treat A Deadly Disease Virtually (1)

Forbes

With San Diego-based Equip, Kristina Saffran and Erin Parks have convinced health insurers from UnitedHealthcare to Aetna to pay for research-backed treatment for thousands of patients struggling with eating disorders.   A decade after recovering from anorexia, Saffran started a company to help make this same type of therapy more accessible by offering a single online portal through which families can treat and manage a child’s eating disorder. Equip also offers wraparound services that aren’t always offered alongside in-person therapy, with the full care team including a therapist, medical doctor, dietician and peer and parent mentors.   Equip’s virtual therapy is so powerful because of a shortage of specialized therapists and in-person clinics, said Saffran’s cofounder Erin Parks, 44, a clinical psychologist who previously worked at the UC San Diego Eating Disorder Clinic. Before starting Equip, Parks treated families who had flown in from all over the country seeking care.   Read the full story on Forbes: https://www.forbes.com/sites/katiejennings/2024/08/15/after-surviving-anorexia-this-founder-raised-110-million-to-treat-the-deadly-disease-online/  Subscribe to FORBES: https://www.youtube.com/user/Forbes?sub_confirmation=1  Fuel your success with Forbes. Gain unlimited access to premium journalism, including breaking news, groundbreaking in-depth reported stories, daily digests and more. Plus, members get a front-row seat at members-only events with leading thinkers and doers, access to premium video that can help you get ahead, an ad-light experience, early access to select products including NFT drops and more:  https://account.forbes.com/membership/?utm_source=youtube&utm_medium=display&utm_campaign=growth_non-sub_paid_subscribe_ytdescript  Stay Connected Forbes newsletters: https://newsletters.editorial.forbes.com Forbes on Facebook: http://fb.com/forbes Forbes Video on Twitter: http://www.twitter.com/forbes Forbes Video on Instagram: http://instagram.com/forbes More From Forbes:  http://forbes.com  Forbes covers the intersection of entrepreneurship, wealth, technology, business and lifestyle with a focus on people and success.

Transcript

00:00Hi, everyone. I'm Maggie McGrath, editor of Forbes Women. The 10th annual list of the

00:08Forbes Next Billion Dollar Startups is out now, and on this list is a healthcare company

00:14aiming to help patients with eating disorders. That company is called Equip, and we are joined

00:21by their two co-founders today, Christina Safran and Dr. Erin Parks. Thank you both

00:26so much for being here. Thanks for having us. Now, there's a study from Harvard that

00:33indicates that eating disorders and the unpaid caregiving, the lost productivity, and the

00:38treatments add up to a $65 billion economic cost every year. But Christina, your experience

00:46with eating disorders and the eating disorder industry, if I may, is very personal. You've

00:51joked that you've been in eating disorders all your life. Can you kind of explain what

00:56that means and how you got to this role? Yeah. So I was diagnosed with anorexia at

01:0110 years old, which is young, but unfortunately not that rare. We treat five-year-olds here

01:06at Equip. I talk about the fact that I had a whole lot of privilege, good insurance,

01:11a family that could afford to pay, lots of money out of pocket, and perhaps most notably,

01:17I fit that stereotype of what we think eating disorders look like. They actually don't have

01:23a look. They don't discriminate. They affect everybody. But even with all that privilege,

01:27I had a pretty horrific treatment experience, which is really the norm for folks with eating

01:31disorders. So I spent my entire freshman year of high school not in high school, in and

01:36out of four different hospitals for a total of seven months. When I got out and inevitably

01:40started to decline into my disorder because I didn't know how to take care of myself nor

01:45did my family, doctors said to my parents, send her to a long-term facility across the

01:50country and don't hope for recovery because people don't recover from eating disorders.

01:55And I'm really grateful that they didn't listen to that and instead dove into the research.

01:59This was two decades ago. They learned about family-based treatment, which we now know

02:02is the leading evidence-based treatment for kids and adolescents, that at a high level

02:07understands that these disorders make you fight your brain upwards of six times a day.

02:12It's not only ineffective, but kind of cruel to ask people to do that alone. And so it

02:15empowers the healthy people in the household to structure the home for pro-health behaviors.

02:20That was my road to recovery, but quickly learned how just grossly inequitable and inaccessible

02:26the eating disorder field is with 80% of the 30 million Americans who struggle not able

02:31to get treatment.

02:33Say that one more time. What percent of the 30 million Americans with eating disorders

02:37can't get treatment?

02:3880% of the 30 million Americans who struggle don't get treatment.

02:43So we'll bring Erin into this in just a second, but can you give us an overview of what EQUIP

02:49is and how the treatment is different than the traditional options?

02:54Yeah. So 80% of the 30 million Americans don't get treatment, and even smaller fraction have

03:01access to evidence-based treatments that result in lasting recovery. And so that's what EQUIP

03:06is designed to do. It is really to ensure that every person with an eating disorder

03:11has access to care that works and that results in lasting recovery. Every patient who comes

03:16to us gets matched with a multidisciplinary care team comprised of a therapist, a dietician,

03:23a med provider, and we have mentors, peers and family members who've been there, who

03:29have lived experience, and who help you go through the process. These are all employees

03:34of EQUIP, and we invest tremendously in training and supervising them in the evidence-based

03:40treatments for eating disorders and also the comorbidities because eating disorders

03:44never occur alone. And then we've worked with insurance companies to cover a year or more

03:50of access to this treatment, really enabling folks to get to that place of a strong and

03:55lasting recovery.

03:57We'll get to the insurance companies, but just to make, just to connect the dots, Christina,

04:01you had started a nonprofit, you were on our 30 under 30 list, but you realized that EQUIP

04:08was the better solution. What year did you launch?

04:11We launched in December of 2019 on this idea, a piece of paper.

04:17And then on a piece of paper. Erin, when did you enter this journey? What attracted you

04:22to the opportunity?

04:23Christina and I met, I think 2014, 2015, and we'd see each other at eating disorder conferences

04:30where the academics, which I am one of, would sit and discuss and debate little tiny nitpicky

04:37ideas. And we wanted to think bigger. How could we help more people? What was keeping

04:43evidence-based treatments stuck in academia and how could we disseminate it so everyone

04:47had access to it, even if you didn't live next to a major academic hospital?

04:52And so, yeah, in 2019, we started talking that maybe nonprofit wasn't the fastest or

04:56most capitalized way to help everyone, and academia was certainly not the fastest. And

05:01so we thought, let's do, let's do something unique. Let's go see some venture capital

05:06and have some money to try something new.

05:09And Erin was one of the co-directors at one of the leading eating disorder research and

05:13treatment folks in the country, where folks would literally fly from all over the country

05:18and all over the world to get treatment. And both of us bonded over the fact that that's

05:23ridiculous. You shouldn't have to fly across the country to get treatment that works. How

05:27can we bring it to you and keep you in your community, in your family?

05:32That's interesting. So Katie Jennings, our healthcare reporter, has a great story that

05:36goes really in depth on equip and everything that you're building. And she has an anecdote

05:41from a parent who says they were terrified to have their child in inpatient treatment.

05:47Erin, in your experience, how common is that reaction and how does equip provide a different

05:54solution?

05:55Yes. So right now, a lot of people think you're struggling with an eating disorder. You need

06:00to go away for treatment. You need to be separate from your family. And there really

06:06is not a lot of data to suggest that it works very well and it shouldn't be first line treatment.

06:11Because eventually you're going to return home and your triggers are going to be there.

06:15And your family, whether that be your biological family or if you're an adult, your chosen

06:19family need to be there to support you. And so what we want is to help families be able

06:25to stay together, but also adults. For adults with eating disorders, it's not realistic

06:28to take two months off work, to take two months off parenting and go someplace else

06:34to get better. You should be able to get better in your own home. And we have about 20 years

06:39of data to suggest that it's really effective. We're disseminating the evidence-based treatment

06:43that allows people to get better.

06:45One of the things we're really proud of to that point is that 80% of folks who join us

06:50here at equip had been eligible for that residential level of care. What I was recommended at 13

06:56is that if you have a care team where you go away based on their clinical presentation,

07:00we end up sending about 3% to a residential facility. And so the majority of folks are

07:06able to get better. It is really, really hard treatment, but work with their care team,

07:12work with their support system and get better at home.

07:16So let's actually go through a hypothetical, but realistic use case for equip. So I am

07:25a parent. My child is exhibiting signs of an eating disorder and or has been diagnosed

07:30by their primary care physician. I do not want to send them to an inpatient facility.

07:36I'm looking for other options. I find equip online. And what happens next?

07:41So a parent or their pediatrician would reach out to equip and we would connect you with

07:46care right away. One of the problems in the eating disorder field is a lot of people have

07:51three month, six month wait lists. And when your child is sick, you want treatment today,

07:55not three months from now. So we get you connected right away with services. What that will look

08:00like is you'll be assigned this care team and via video sessions, you will meet with

08:05your providers. You also will have the ability to message your providers in between sessions.

08:09You'll also have the ability to attend groups, take classes and be surrounded by people that

08:16are able to help you get your child better. It's really about empowering the family to

08:22make pro health decisions. Just to kind of do a little bit of an analogy. If you thought that

08:26your 15 year old was struggling with substance use, when you're a 15 year old goes to soccer

08:30practice, you would search their room for substances and dispose of them. You try to

08:34make it difficult for your child to drink alcohol or use drugs. Same thing is true if

08:39your child's having eating disorder urges. You're going to set up the home to make it

08:42difficult for them to act on their urges. So if your child is struggling with purging behaviors,

08:47you might say, Hey, as a family, after mealtime, you can have unlimited screen time, but you,

08:53I have to keep eyes on you. You can't go to the bathroom alone. You can't go take a shower

08:57immediately after a meal. So that's an example of setting up the home for pro health behaviors.

09:01And so what the equip providers do via one-on-one sessions, group settings, messages,

09:06however you want to receive the support is teach you these different skills to empower you,

09:10help you feel confident as a parent that you're going to help your loved one get better.

09:14I should also point out that, um, we do differentiate between inpatient and residential

09:20treatment, which is really what we're talking about. So eating disorders have the second

09:24highest mortality rate of all mental illnesses. Second only to some opioid use disorder. Um,

09:30some folks do need to be in an inpatient hospitalization for a limited amount of time.

09:36If their heart rates are in the thirties or forties, if they are at risk of cardiac arrest,

09:43that is not a level of care that we would place. And we work very, very closely with

09:48local inpatient facilities, but many folks upwards of 50% are discharging straight from that

09:55short inpatient stay to treatment. Interesting. Yeah. I think something that comes up though,

10:01is kind of why virtual, right? And want to talk about how virtual is a little bit different than

10:06going to brick and mortar. And it's great because where life happens is in your house

10:10and virtual is able to come into your house with you. And so we're able to watch mealtimes and see

10:15the fight happen in real time. We're able to have them pick up the laptop or their phone and show us

10:21their pantry, show us their fridge, talk about cooking. We're able to meet with someone before

10:25soccer practice. They can call in from the sideline and eat their pre-practice snack

10:30with their peer mentor or their dietician before they go and have their practice. And so by being

10:35virtual, it's not just taking the treatment that used to be delivered in brick and mortar and

10:39throwing it online. It's about using this technology to work around people's schedules,

10:44to meet people where they're at, to know that some people eat in their car before work, that some

10:49people are having a snack with a school nurse in the middle of the day, that some people are eating

10:53on the sideline at halftime. We can be there with you through all of these different activities.

10:57Yeah, we talk a lot about the ability to help folks build a life worth living while they're

11:03living life. You can't do that when you're out of your life in a facility. And as I mentioned,

11:07eating disorders require you to fight your brain many times per day. And so the whole idea is how

11:14do we give you that support in the moment when you need it, whether as Aaron mentioned, that means

11:20a five-minute check-in with your nutritionist before you're going to play soccer or a, you know,

11:27series of text messages with your peer mentor when you're in a really stressful situation,

11:32but not overdose you on treatment that you don't need. We want to empower you to go out and build

11:39that life worth living. Now, you mentioned earlier that a capital-backed startup is a more effective

11:49way to treat more people versus a nonprofit. So a question for you both, or maybe Christina can go

11:56first. What has it been like taking a quip in front of Silicon Valley? And what's been the

12:01reaction from the investor class? Because sometimes healthcare startups, if you don't have a person in

12:07the room who's experienced that condition, which you are trying to address, you get blank stares

12:13or otherwise dismissed. What has your experience fundraising been like? I think we learned very

12:19quickly that all venture capital is not created equal. And so we certainly had some pretty cringe

12:26moments as female founders in a healthcare space in a very male-dominated, tech-dominated industry.

12:34And we also had some pretty amazing experiences with investors who really understood healthcare,

12:42really understood the problem that we were solving, and candidly ended up with a board of

12:49some of the most mission-driven investors. Every person around the table has some direct experience

12:56with the problem. And we've always found that this team is mission-first. Of course,

13:05they want to make a profit, and that will come as we achieve the mission. But this team cares above

13:12all about us helping as many people as possible with high-quality care. I think something that

13:19was interesting about us going out and fundraising is it really proved our point that eating disorders

13:24affect everyone. When we talk about 80% not getting treatment, a huge part of that is that 80%,

13:30a lot of them aren't getting diagnosed. We don't diagnose men. We don't diagnose people in fat

13:34bodies. We don't diagnose BIPOC people with eating disorders the same way we do thin, white women.

13:40Those are the people who are getting diagnosed. But in fact, eating disorders affect everyone.

13:45At Equip right now, we have a four-year-old with ARFID, and a 60-year-old with bulimia,

13:50and every age in between, because there are seven different types of eating disorders.

13:54And so when we went out fundraising, I would say 80% of the time, we weren't even halfway through,

14:00and someone would be like, that's my son. That's my nephew. That was me. That's my cousin. That's

14:05my daughter. It was hard to get through a pitch without someone talking about how an eating

14:10disorder had affected them. And it just really proved our point that eating disorders are

14:14everywhere, affecting everyone. I just got goosebumps. That must have been an emotional

14:20process too, hearing those stories. But you've raised $110 million as of this date. Is that

14:29correct? Correct. And talk to me about how you make your money. Who pays you? Is it the family,

14:36or is it the insurance providers? Yeah, we're really proud of the fact that about 98% of our

14:41revenue comes from insurance providers. We're in-network with over 25 different health plans.

14:47Over 110 million Americans have full access to in-network benefits through full coverage through

14:54their in-network benefits for a year of equip or more. And that was core from the very beginning.

15:00I mean, access is really one of our North Stars. We didn't want families to have to pay out of

15:05pocket. And while we're so proud of the traction that we've had with insurance companies,

15:11we also are working every single day to expand that coverage such that every American has full

15:17access to this coverage. You talk about wanting to expand that coverage. What is the conversation

15:22with the insurance industry like? Is it like pulling teeth to get them to come on board,

15:27or do they see the financial opportunity and the human opportunity?

15:35Just like I said, all VCs are not created equal. All insurance companies are not created equal,

15:39if you can imagine. But I will say we've had some tremendous partnerships, and I really describe

15:46them as true partnerships. We were very fortunate from the beginning of Equip. I mentioned that we

15:51raised our seed funding on this idea in December of 2019. One of the catalysts for that was that

15:58we had become friendly with the chief medical officer, the former chief medical officer of

16:03Optum Behavioral Health, one of the largest insurance providers in the country, who we

16:08had a meeting with back when we were in academia, a non-profit, to talk about,

16:13how do we build a better model of outpatient care? You're spending a lot of money on these

16:19residential facilities that don't work. And there's evidence-based treatment that does work,

16:24but it's stuck in a handful of academic centers across the country and really not accessible.

16:30And he essentially said to us, you're right, and if you build it, I will buy it. This makes a whole

16:36lot of sense to me. And so that's how we got our marching orders. And I think being able to

16:41prove out with UnitedHealthcare that this model really worked, helped other insurance companies

16:47to come into the fold and say, yeah, I get it. It was also COVID. And so you had eating disorders

16:55rising, like all mental health issues, and you also had the acceptability of virtual health

17:02rising at the same time. And so we definitely had some pretty significant tailwinds at our back.

17:08The thing that's been perhaps most exciting to me is on Medicaid. So those were the conversations

17:17where five years ago, we went into them and it was like pulling teeth. They would just

17:22roll their eyes at us and say, not our population, not our problem. And it's been incredible,

17:30basically 180 degree reversal where now they are coming to the table. They are reaching out to us

17:36proactively saying, we know this is a problem in our population. We actually know that as food

17:42insecurity rises in a community, eating disorders directly rise and are coming to the table

17:48proactively looking for solutions. Wow. So how many patients have you helped to date as of now?

17:55We are over 5,000 patients have been treated with Equip, and most patients don't come alone.

18:02We encourage them to bring, certainly for the under 18, bring their family. And that's not

18:06just parents, it's step-parents and grandparents and siblings. And for adults, whatever family

18:11is to you. So we've got college roommates and coaches and siblings and aunts and uncles

18:18and best friends. So we've helped, we like to think we helped at least over 15,000. When you

18:23think when you help an individual, you help their family, but 5,000 patients have been treated.

18:27Which we're so proud of. Oh, I was going to say, it's the things that we talk about a lot. We're

18:32so proud 5,000 patients makes us one of the largest eating disorder treatment providers in

18:37the country. But that's also kind of horrifying. Like there are 5 million people today right now

18:43who need help. Someone dies every 52 minutes of an eating disorder. It's kind of a drop in the

18:49bucket in terms of the overall need for this type of treatment. And this goes back to our

18:55strong collaboration with payers. We have such aligned incentives. People with eating disorders,

19:01at least 50% are struggling with moderate to severe suicide ideation. These are people who

19:05frequently need to use emergency care, urgent care, and have a host of other physical and mental

19:11health illnesses that come from just having an untreated eating disorder for so long. And so we

19:16are able to both bring joy back to people's life through helping them find recovery, and also have

19:22them stop utilizing the medical system as much. Okay, so I have two follow up questions based on

19:27what you both said. And the first gets to recovery. What does recovery or success look like?

19:32Is it, I don't want to use the word cure, because I imagine this is a lifelong condition for a lot

19:39of people, you know, as is mental health, right? I've been in therapy for years, and I will continue

19:44to be in therapy for years. But so let's start with that first question. What does success and

19:49or recovery look like for your patients? How do you measure it? Such a wonderful question.

19:55Let's piggyback off of one another, because it's been a question we've been having internally,

20:01and as a field for many, many years. The reality is the field has not defined recovery, which is

20:06a really cool opportunity for equip to do just that. What we look at for our patients is a

20:13combination of eating disorder symptom reduction, comorbid symptom reduction, that depression,

20:19that anxiety, that OCD, that PTSD. For our patients who are on weight gain, that's a critical metric,

20:27because we know that you can't get to a place of recovery when your brain and body are

20:31undernourished, they're not going to be working properly. And then reduction in readmission to

20:38higher level of care, to other higher level eating disorder treatment, and of course, quality of life

20:44improvement. That's a whole lot of things. And that's just kind of a fraction of the metrics

20:48that we can look at. But ultimately, what Aaron and I talk about, and as somebody in recovery,

20:54what I really care about is pretty simple. On a scale of one to 10, one being never, 10 being

21:04every single waking hour, how much brain space is taken up thinking about food and thinking about

21:10your body. And that's ultimately what we want to try to impact. We want you to have brain space for

21:17much more important and joyful things than your eating disorder.

21:23When we're working with the parents, we ask parents, what matters the most to you?

21:27So especially for our parents whose kids have ARFID, they say, we can go on vacation,

21:32we can eat out, we aren't confined to our home where it's the only place to save food for our

21:37kids. And then the other measure parents care about is a measure of confidence. I feel confident

21:41that I can help my kid. I feel confident that I'll know a blip before it becomes a relapse.

21:47And those are the things that matter a lot to parents is feeling like they can exhale.

21:52My second follow-up question based on what you've been talking about earlier,

21:555,000 patients is incredible, but you said it's a drop in the bucket compared to the 5 million.

22:00What is going to be the key for Equip and maybe the industry at large, but let's just focus on

22:06Equip, in treating more patients? What will fuel your growth? What do you need in order to reach

22:13more people? The investment that we got in our Series C last summer allowed us to launch to

22:20treat adults. So we officially opened our doors to adults in around September of 2023. And by

22:26treating adults, it means we're treating a really wide variety of people. So I mentioned our youngest

22:31patient is four, and then we have patients at all stages of adulthood who also have a lot of

22:35different comorbidities. What we want to make sure is that when you come to Equip, you feel safe to

22:41get treatment. You feel like people understand you. Because this is a field that has really been

22:47designed for thin white women, full of providers who are thin white women, we understand why it's

22:53hard for a man in their 40s who's a professional in finance to come and seek treatment. There's a

22:59patient, there's many patients like that here now, but one said to us, like, I wanted to go to

23:03treatment for 20 years, but it's never been appropriate for me to sit in a room with a bunch

23:07of 20-year-old girls. And he's also like, now I have a job that would not allow me to go, you know,

23:12take a break from my job. And so really what we're doing now is investing in making sure that whoever

23:19comes to Equip feels safe. You mentioned that mental health treatment is really a lifelong

23:24thing. That's all taking care of our mental health, because there is no health without mental health.

23:28We want it to be such a great experience that if in the future you struggle, you have grief,

23:35someone that you love dies, in the future you go through a divorce, in the future you

23:39experience depression, that you feel safe and comfortable seeking mental health care again.

23:43We're down to our final minute. So I will ask for a prediction. If I were to speak with you

23:50one year from now, what do you hope to be able to tell me that Equip has accomplished in that time?

23:55I hope that we have doubled the number of patients that we've been able to help,

24:03that we've significantly increased our insurance coverage from 110 million Americans to many more,

24:11particularly excited around the Medicaid book of business and that population. And

24:18to Aaron's last point around really needing to change the stereotype of who we think gets an

24:28eating disorder, that we've made a significant cultural dent in helping people to understand

24:34that eating disorders don't discriminate and that they affect everybody. Well, Christina and Aaron,

24:40I hope to be able to have that conversation with you one year from now and to hear that you've

24:44reached those accomplishments and to hear where the industry is at that point in time. And in

24:48the meantime, thank you so much for your time. We so appreciate it. Thank you so much.

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