At the “Apple Store of Doctor’s Offices,” Preventive Care Is High Tech. Is it Worth $150 a Month?
What if going to the doctor's office could be … nice?
If you didn't have to wait for your appointment, but were ushered right in; if your medical data was all collated and easily searchable on an iPhone app; if a remote scribe took notes while you spoke with your doctor so you could make eye contact with them; if your doctor didn't seem horribly rushed.
Would you go to the doctor to get help staying healthy, rather than just to stop being sick?
Would that change the way you thought about your health? Would you go to the doctor to get help staying healthy, rather than just to stop being sick? And would that, in the long run, be much better for you?
Those are the animating questions for Forward, a healthcare startup devoted to preventive care. Led by founder Adrian Aoun, formerly of Google/Sidewalk labs, Forward opened its first office in San Francisco in 2016 and has since expanded to Los Angeles, Orange County, New York, and Washington, D.C., with a San Diego location opening soon.
It's been described as the "Apple Store of doctor's offices," which in some ways is a reaction to Forward's vibe: Patients have described the offices as having blonde wood, minimalist design, sparkling water on tap — and lots of high-tech gadgets, like the full-body scanner that replaces the standard scale and stethoscope.
The interior of a Forward office.
(Courtesy Forward)
The more crucial difference, though, is its model of care. Forward doesn't take insurance. Instead, patients, or "members," pay a flat $149 per month, along the lines of a subscription service like Netflix or a gym membership. That fee covers visits, messaging with medical staff through the Forward app, the use of a wearable (like a Fitbit or a sleep tracker) if the physician recommends it, plus any bloodwork or diagnostic tests run in the on-site labs. (The company declined to disclose how many people have signed up for memberships.)
Predictability is Forward's other significant, distinguishing feature: No surprise co-pays, or extra charges showing up on a billing statement months later. Everything is wrapped up in the $149 membership fee, unless the physician recommends visiting an outside specialist.
That caveat isn't a small one. It's important to note that Forward is in no way meant to replace standard health insurance. The service is strictly focused on preventive care, so it wouldn't be much use in case of an emergency; it's meant to help people, as far as is possible, avoid that emergency at all.
Ani Okkasian's family recently went through such an emergency. Her 62-year-old father, an active and seemingly healthy man living with diabetes, had been feeling unwell for a while, but struggled to receive constructive follow-up or tests from his doctor. It finally emerged that his liver was severely damaged, and he suffered a stroke — the risk of which can be elevated by liver disease. He seemed to deteriorate completely within mere weeks, Okkasian said, and in January he passed away.
"He was someone who'd go to the doctor regularly and listen to what they said and follow it," Okkasian said. "I shouldn't have had to bury my father at 62. I still believe to my core that his death could have been avoided if the primary care was adequate."
"I could tell that the people who designed [Forward] had lost someone to the legacy system; it was so streamlined and so much clearer."
Okkasian began researching, looking for a better alternative, and discovered Forward. Founder Aoun lost his grandfather to a heart attack; his brother's heart attack at age 31 was the impetus to start Forward.
"I could tell that that was the genesis," Okkasian said. "Having just lost someone, and having had to deal with different aspects of the healthcare industry — how complicated and convoluted that all is — I could tell that the people who designed [Forward] had lost someone to the legacy system; it was so streamlined and so much clearer."
So Who Is Forward For?
The Affordable Care Act mandates that evidence-based preventive care must be covered by insurers without any cost to the patient. Today, 30 million Americans are still living without health insurance; but for most of the population, cost shouldn't prevent access to standard, preventive care, says Benjamin Sommers, a physician and professor at the Harvard T.H. Chan School of Public Health who has studied the effect of the ACA on preventive care access.
For Okkasian and her family, it wasn't a lack of access to primary care that was at issue; it was the quality of that primary care. In 2019, that's probably true for a lot of people.
"How come all other industries have been disturbed except the medical industry?" Okkasian asked. "It's disturbing the most people. We're so advanced in so many ways, but when it comes to the healthcare system, we're not prioritizing the wellness of a person."
Is Forward the answer? Well, probably not for everyone. Its office are only in a handful of cities, and there are limits to how scalable it would be; it's unavoidable that the $149 per month charge restricts access for a lot of people. Those who have insurance through their employer might have a flexible spending account (FSA) that would cover some or all of the membership fee, and Forward has said that 15 percent of their early members came from underserved communities and were offered free plans; but for many others, that's just an unworkable extra cost.
Sommers also sounded a dubious note about a maximalist attitude toward data collection.
"Even though some patients may think that 'more is always better' — more testing, more screening, etc. — this isn't true," he said. "Some types of cancer screening, ovarian cancer screening for instance, are actually harmful or of no benefit, because studies have shown that they don't improve survival or health outcomes, but can lead to unnecessary testing, pain, false positives, anxiety, and other side effects.
"It's really great for people who are in good health, looking to make it better."
"I'm generally skeptical of efforts to charge people more to get 'extra testing' that isn't currently supported by the medical evidence," he added.
But relatively healthy people who want to take a more active approach to their health — or people who have frequent testing needs, like those using the HIV-prevention drug PrEP, and want to avoid co-pays — might benefit from the on-demand, low-friction experience that Forward offers.
"It's really great for people who are in good health, looking to make it better," Okkasian said. "Your experience is simplified to a point where you feel empowered, not scared."
When doctors couldn’t stop her daughter’s seizures, this mom earned a PhD and found a treatment herself.
Twenty-eight years ago, Tracy Dixon-Salazaar woke to the sound of her daughter, two-year-old Savannah, in the midst of a medical emergency.
“I entered [Savannah’s room] to see her tiny little body jerking about violently in her bed,” Tracy said in an interview. “I thought she was choking.” When she and her husband frantically called 911, the paramedic told them it was likely that Savannah had had a seizure—a term neither Tracy nor her husband had ever heard before.
Over the next several years, Savannah’s seizures continued and worsened. By age five Savannah was having seizures dozens of times each day, and her parents noticed significant developmental delays. Savannah was unable to use the restroom and functioned more like a toddler than a five-year-old.
Doctors were mystified: Tracy and her husband had no family history of seizures, and there was no event—such as an injury or infection—that could have caused them. Doctors were also confused as to why Savannah’s seizures were happening so frequently despite trying different seizure medications.
Doctors eventually diagnosed Savannah with Lennox-Gaustaut Syndrome, or LGS, an epilepsy disorder with no cure and a poor prognosis. People with LGS are often resistant to several kinds of anti-seizure medications, and often suffer from developmental delays and behavioral problems. People with LGS also have a higher chance of injury as well as a higher chance of sudden unexpected death (SUDEP) due to the frequent seizures. In about 70 percent of cases, LGS has an identifiable cause such as a brain injury or genetic syndrome. In about 30 percent of cases, however, the cause is unknown.
Watching her daughter struggle through repeated seizures was devastating to Tracy and the rest of the family.
“This disease, it comes into your life. It’s uninvited. It’s unannounced and it takes over every aspect of your daily life,” said Tracy in an interview with Today.com. “Plus it’s attacking the thing that is most precious to you—your kid.”
Desperate to find some answers, Tracy began combing the medical literature for information about epilepsy and LGS. She enrolled in college courses to better understand the papers she was reading.
“Ironically, I thought I needed to go to college to take English classes to understand these papers—but soon learned it wasn’t English classes I needed, It was science,” Tracy said. When she took her first college science course, Tracy says, she “fell in love with the subject.”
Tracy was now a caregiver to Savannah, who continued to have hundreds of seizures a month, as well as a full-time student, studying late into the night and while her kids were at school, using classwork as “an outlet for the pain.”
“I couldn’t help my daughter,” Tracy said. “Studying was something I could do.”
Twelve years later, Tracy had earned a PhD in neurobiology.
After her post-doctoral training, Tracy started working at a lab that explored the genetics of epilepsy. Savannah’s doctors hadn’t found a genetic cause for her seizures, so Tracy decided to sequence her genome again to check for other abnormalities—and what she found was life-changing.
Tracy discovered that Savannah had a calcium channel mutation, meaning that too much calcium was passing through Savannah’s neural pathways, leading to seizures. The information made sense to Tracy: Anti-seizure medications often leech calcium from a person’s bones. When doctors had prescribed Savannah calcium supplements in the past to counteract these effects, her seizures had gotten worse every time she took the medication. Tracy took her discovery to Savannah’s doctor, who agreed to prescribe her a calcium blocker.
The change in Savannah was almost immediate.
Within two weeks, Savannah’s seizures had decreased by 95 percent. Once on a daily seven-drug regimen, she was soon weaned to just four, and then three. Amazingly, Tracy started to notice changes in Savannah’s personality and development, too.
“She just exploded in her personality and her talking and her walking and her potty training and oh my gosh she is just so sassy,” Tracy said in an interview.
Since starting the calcium blocker eleven years ago, Savannah has continued to make enormous strides. Though still unable to read or write, Savannah enjoys puzzles and social media. She’s “obsessed” with boys, says Tracy. And while Tracy suspects she’ll never be able to live independently, she and her daughter can now share more “normal” moments—something she never anticipated at the start of Savannah’s journey with LGS. While preparing for an event, Savannah helped Tracy get ready.
“We picked out a dress and it was the first time in our lives that we did something normal as a mother and a daughter,” she said. “It was pretty cool.”
A sleek, four-foot tall white robot glides across a cafe storefront in Tokyo’s Nihonbashi district, holding a two-tiered serving tray full of tea sandwiches and pastries. The cafe’s patrons smile and say thanks as they take the tray—but it’s not the robot they’re thanking. Instead, the patrons are talking to the person controlling the robot—a restaurant employee who operates the avatar from the comfort of their home.
It’s a typical scene at DAWN, short for Diverse Avatar Working Network—a cafe that launched in Tokyo six years ago as an experimental pop-up and quickly became an overnight success. Today, the cafe is a permanent fixture in Nihonbashi, staffing roughly 60 remote workers who control the robots remotely and communicate to customers via a built-in microphone.
More than just a creative idea, however, DAWN is being hailed as a life-changing opportunity. The workers who control the robots remotely (known as “pilots”) all have disabilities that limit their ability to move around freely and travel outside their homes. Worldwide, an estimated 16 percent of the global population lives with a significant disability—and according to the World Health Organization, these disabilities give rise to other problems, such as exclusion from education, unemployment, and poverty.
These are all problems that Kentaro Yoshifuji, founder and CEO of Ory Laboratory, which supplies the robot servers at DAWN, is looking to correct. Yoshifuji, who was bedridden for several years in high school due to an undisclosed health problem, launched the company to help enable people who are house-bound or bedridden to more fully participate in society, as well as end the loneliness, isolation, and feelings of worthlessness that can sometimes go hand-in-hand with being disabled.
“It’s heartbreaking to think that [people with disabilities] feel they are a burden to society, or that they fear their families suffer by caring for them,” said Yoshifuji in an interview in 2020. “We are dedicating ourselves to providing workable, technology-based solutions. That is our purpose.”
Shota Kuwahara, a DAWN employee with muscular dystrophy. Ory Labs, Inc.
Wanting to connect with others and feel useful is a common sentiment that’s shared by the workers at DAWN. Marianne, a mother of two who lives near Mt. Fuji, Japan, is functionally disabled due to chronic pain and fatigue. Working at DAWN has allowed Marianne to provide for her family as well as help alleviate her loneliness and grief.Shota, Kuwahara, a DAWN employee with muscular dystrophy, agrees. "There are many difficulties in my daily life, but I believe my life has a purpose and is not being wasted," he says. "Being useful, able to help other people, even feeling needed by others, is so motivational."