I wanted to use this as an opportunity to talk a little bit about scalable telemedicine + specialist care, what Thirty Madison is doing, and some of my thoughts on the company and space as a whole.
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Thirty Madison is a healthcare company that provides medications and virtual care for chronic conditions starting with male pattern baldness, migraines, and acid reflux. The company follows the trends of healthcare companies named after places they aren’t currently located (looking at you, Flatiron Health).
The company was started by Demetri Karagas and Steven Gutentag in 2017 and recently raised a $47M Series B round. Coincidentally they reached out about this piece soon after.
What does the company do and what pain point does this solve?
Thirty Madison is aiming to make it easier to connect with a doctor that has experience treating your condition and get medications for your specific recurring health issue. They have three products currently - Keeps for hair loss, Cove for migraine relief, and Evens for acid reflux management. I have 2 out of 3 of these, so I’m guessing Thirty Madison will launch an “anti constant existential dread” product soon.
Once you’ve started your meds and program, you’ll also have ongoing access to the same physician and care team to ask questions (primarily via a secure message portal), adjust your treatment plan, etc. You’ll also get tools to track your symptoms over time to better understand triggers for things like migraine, acid reflux, etc.
Some examples from their different products:
The first core pain point that Thirty Madison aims to solve is convenience. We live in a world of one-click buy, so getting your medications shipped to you should be equally as easy. The physician consultation for low-risk products should also be easy - you can complete an asynchronous consultation instead of scheduling an appointment, traveling to a clinic, making small talk with your doctor about traffic or weather or whatever, etc. By making it easier, it will make it more likely for people to take the first steps to treatment.
The second pain point is accessibility. There is a shortage of specialists for specific diseases and they aren’t evenly distributed by geography. This is very notable for migraines - where there are a little under 600 migraine specialists vs. ~40M people that have migraines. By using asynchronous workflows and shifting tasks to care teams, these scarce specialists can “see” more patients.
The company is betting that by making care more convenient and accessible, they can get patients that may not have previously sought out treatment or been able to access that treatment. The hope is over time, those patients will turn to them for care beyond just getting medications.
Thirty Madison ran a survey with its members to see how its migraine program was working. Obvious caveat for savvy Out-Of-Pocket readers, this will be a bit of a self-selecting group that chooses to complete a survey like this. But that being said, even amongst the surveyed group the severe migraine patients seem to benefit quite a bit with a reduction in symptom onset, symptom severity, and number of visits to the ER/urgent care.
What is the business model and who is the end user?
This one is pretty straightforward, you are the end user and you are also the one paying since it’s a cash based business.
For some treatments you can use insurance coverage, and Thirty Madison will use your pharmacy of choice and work with your insurance for reimbursement. One example is a migraine medication called Emgality for example.
Generally speaking you can expect your monthly treatment costs will be somewhere between $10-$60 depending on which level of treatment, the meds, etc.
The company is pursuing payer coverage for other aspects of the service in the future (hence showing the reduction in ED/urgent care utilization in the survey).
What does the process look like if you're a customer/user?
For each brand, users fill out a consultation that asks them questions about their condition and medical history. This is similar to the questions you’d get asked at a physician’s visit to help understand your condition, history with it, potential red flags, and more.
On the other side, a physician will review these consultations asynchronously and recommend a medication, supplement, and/or lifestyle regimen that’s based on your answers. Thirty Madison will mail these directly to your house.
Depending on which brand you’re signed up for, you will have continuous access to the same physician and care team as well as an online tool to help track flare-ups so your treatment can be tweaked.
Thirty Madison is hiring in just about every department, so take a look.
As I’ve written about in the past, I think there’s a lot of opportunity in the cash pay space and we’re seeing an explosion of new care providers that are being built in areas with high search intent (aka. things patients can identify with and Google around to answer). This is happening around demographic specific primary care and condition specific primary or specialty care. Thirty Madison is riding on those trends by turning search intent (“how to stop migraines”) into a relationship with a specialist.
The key here is developing telemedicine infrastructure that can be used across conditions to bring the cost of specialist care down. It would probably be a combination of the following:
Asynchronous telemedicine (online consultations, messaging, etc.)
Back-office automation (e.g. structuring data, handling billing and payouts, escalation protocols for patients, patient engagement campaigns, physician support tools, etc.)
Staff around the specialists (nurses, coaches, etc.) that can be used across the different products to help handle non-specialist related tasks. By using different members of a care team beyond just a physician you can maintain regular touch points with a patient and scale down the cost of care generally by increasing the size of the patient panels that any individual physician sees.
Product, engineering, marketing, etc. that build the tools across the portfolio of products and acquire new patients.
By using the same core infrastructure, presumably Thirty Madison can move into other lower-risk chronic disease specialties.
This is happening at an interesting time where we’re likely going to see regular protocols for diseases that require in-person care re-examined anyway. Since everyone is forced to stay at-home, we have a natural real-world experiment of what happens when care for some of these lower-risk conditions are done fully virtually. There are lots of conditions where physicians will say it’s impossible to take care of patients of X type without seeing them face-to-face, but now we’ll have data at a large scale to see if that’s true and if outcomes are any different. Thirty Madison has built systems that are native to telemedicine for these conditions, and due to the cash pay model they're way more incentivized to push care virtually vs. other providers that might be slower to adapt. I’m curious to see if this changes once the company starts getting into payer reimbursement.
It’s also worth noting that for a lot of people they have one or maybe two “dominant” healthcare conditions that deeply affect them and most of their care revolves around managing that condition (and its comorbidities). However in many cases this causes care fragmentation between the patient’s specialist and their primary care physician with both parties trying to fill in the gaps in information that the other probably has (changes in medication, health history, vitals, etc.). By focusing on a condition first and building a care team around the condition, you can potentially reduce the issues in passing and gathering information between a specialist and primary care physician to create a less disjointed care system for the patient.
The main question I would have is how a company like Thirty Madison expands into new disease areas. Right now Thirty Madison is building the “shit I’m getting old” portfolio of migraines, balding, and reflux. But how many other diseases fit the profile of somewhat self-diagnosable, lifestyle hampering, and relatively low-risk? If the company wants to expand to higher-risk areas it will probably require an offering that includes an online-offline handoff. Additionally, it will need to compete on branding and user experience vs. other competitors in the cash pay pharmacy space that will also be eyeing these markets.
I think it’s good that chronic care is becoming more virtualized and accessible to patients - the ratio of disease prevalence:specialist is getting worse over time so we need to make the care more efficient. I think Thirty Madison doubling down and expanding on these different consumer-driven product lines is riding the right trends. If you have any of the conditions they’re already tackling then you should take a look at the products and see if it makes sense for you. As someone who waited too long to address his acid reflux issues, it’s a game changer to find meds that work for you.
Nikhil aka. “yung GERD”
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