Episode 70

Addressing Financial Toxicity

with Ruby Gadelrab
Episode hosted by: Rishi Sikka, M.D.

May 23, 2023

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Ruby Gadelrab
CEO & Co-founder, MDisrupt

Ruby Gadelrab is the CEO and Co-Founder of MDisrupt. She is a seasoned digital health executive with a track record in successfully commercializing healthcare and healthtech products. She served on the executive team at 23andMe as VP of commercial marketing and has worked for many leading companies in the biotech and genetic spaces. Before founding MDisrupt, Ruby consulted for, advised, and mentored more than 25 digital health companies.



We didn't deliberately choose to go in this direction, the market pulled us in this direction.



Rishi Sikka, M.D.: Hi, I’m Rishi Sikka, co-host of Day Zero, and I’m thrilled on this week’s episode to be joined with Ruby Gadelrab, founder and CEO of MDisrupt. Ruby, thank you so much for being here on Day Zero.

Ruby Gadelrab: It’s a delight to be here. Thank you so much for hosting me.

Rishi Sikka, M.D.: Ruby, it’s usually when I have these conversations and we’re gonna get there, talk a little bit about your background and upbringing, but I think. What’s so important in understanding you is actually understanding MDisrupt. And if you wouldn’t mind just giving the quick 92nd on what is MDisrupt what you’re trying to do your perspective from a mission basis. Cause I think it sets the context so much about who you are and your leadership and what you’re aiming to, to transform in healthcare.

Ruby Gadelrab: Wonderful. Thank you. Maybe really quickly, Rishi, my background is I’ve been commercializing health and life sciences products for 26 years, and I founded MDisrupt three years ago. We are a tech enabled health expert marketplace, and what that basically means is for all of the future builders of our healthcare, the digital health market, the health technologists, the digital health founders, Anybody who needs healthcare expertise to build scale or commercialize their health product we have the most amazing network of health experts who can actually go into their companies and help them build, whether that’s a fractional chief medical officer, whether that’s somebody that they need for a regulatory to get them through a submission. Product person that knows how to build in a hip environment. And so I built MDisrupt because I believe that health experts and clinicians need to have a seat at the table and a voice in the process of digital health product development.

Rishi Sikka, M.D.: You, you talked. About experts and having a seat at a table at the table. And I know from our conversations and your background you come from an outsider perspective, maybe not always having that seat at the table. You were born in Egypt, raised largely in the uk. Tell us a little bit about your upbringing and maybe about that having or not having that seat in the table when you were growing up.

Ruby Gadelrab: I have come through the ranks, as it were, and I haven’t always had a seat at the table. So as I’m, as you said, I’m Egyptian. I grew up in the uk. I was the daughter of two doctors and I spent the majority of my former years in the UK. I went to UCL, studied molecular biology. And then got a started to work commercially in the life sciences and there wasn’t a digital health back then, but yes, back in the day when I was in the uk, there weren’t many people that looked like me in the companies or definitely not at the leadership level. And as I look back now, one of the things I’m very keen to do from a. Both a clinical perspective, a diversity, equity and inclusion perspective is create the seats at the table for clinicians, for other executives, for women, for people of color. So it does come directly from my lived experience, as it were, and then even when I moved over to the us. I’ve been in the US for 16 years now, and again, I’ve had some of the greatest teachers and mentors and people who were in leadership and elevated me and lifted me and created opportunities for me. But again, I will say that in a lot of the leadership teams that I sat on, there weren’t that many people that looked like me. And so I’m hoping that’s gonna change over the next four or five years or so sooner.

Rishi Sikka, M.D.: So grateful for that and. I would imagine, that some of the grit and resilience you have now probably even has its origins in your growing up in, in your childhood, in spite of the fact that you didn’t want to become a physician like your parents. You still had a lot of grit, resilience growing up. I’m sure.

Ruby Gadelrab: That’s right. So if you grew up, any brown person will tell you that we grow up, our parents telling us you have to be twice as good and work four times as hard to get to the same place. So we all know that. And so that’s kind of part that, that is a big part of the story is that you do have to prove yourself a whole lot more. And you’re right, I did not want to become a physician. Physicians work really hard and they’re massively underappreciated. And as I look at the healthcare system, both here and in the UK right now, it’s the same thing. There’s physicians are feeling the burnouts, they’re feeling the pain of the post pandemic. They’re struggling with some of this was a whole career choice that these folks made. And they do it for the passion and for the people, and the system isn’t working in their favor. So I think part of what we’re doing at MDisrupt is, how do we create new seats at new tables for them? And that is part of where we’re headed.

Rishi Sikka, M.D.: Yeah, no, thank you for that sort of reminder and bringing that to the forefront. And I do want to talk in a little bit because I know you had two profound experiences that kind of really affected. Personally your perspective on healthcare. But before we maybe talk about those experiences, I wanna accelerate your career that you did start out in life sciences. And then, and then with 23andMe as well, if you wouldn’t mind just tracking a little bit on that with us too.

Ruby Gadelrab: Yeah, so 23andMe was my, before I got to 23andMe, it was my dream job. They were taking the complex principles of genetics and they were making them. Easy educational, engaging for people to for people to interact with. And so it was literally my dream job. So when I got my dream job I was hired at 23andMe a little after the f d a had shut them down. And I had a couple of roles at 23andMe. One was to help them figure out some of their b2b businesses. And the second thing was, On my first day, Anne Ruski said to me, your job, Ruby, is to make doctors not hate us. And so part of what it was, one of the things that happens when you go direct to consumer in a business and you skip the providers, and by the way, 23andMe didn’t actually do that intentionally. It was just the way they thought the world was going to work at the time. What happens is that your you create a wonderful, accessible product. People buy it, they use it, they enjoy interacting with it, and then they go and discuss it with their physicians and their physician says, what is this crazy thing you’ve bought off the internet? Let me order you a real test. I don’t know what this is. Right? And it completely devalues the experience that person has just had. With what might be an incredible product. And so part of what we were tasked to do at the time was how do we educate the physicians on what these new genetic tests were and weren’t position them with physicians in that maybe it’s people aren’t gonna order them as a routine genetic medical test, but it’s a signal of a very engaged patient.

Rishi Sikka, M.D.: The other piece to the build though on Mret is, as I was alluding to earlier, was your own personal experiences with the healthcare ecosystem, your own consumer, patient, family, frustrations with the ecosystem, which I know is happening at the same time as your dream job. If I recall,

Ruby Gadelrab: Rishi during that five year period a couple of years before I was at 23andMe and during the time I had two major health stories happen. The first was that my mother who had diabetes and NASH for many years, Got diagnosed with hepatocellular carcinoma, which is a liver cancer, and she was in England and she was in the uk and her hospital was three hours away. The liver center was three hours away from where we actually lived. And one of the things that was interesting, that was that the cancer was caught early enough that. She was a candidate for a liver transplant. And so for the next three years my mother sat on a liver transplant list the first year nothing happened. The second and third year she was called eight times, I believe, for a liver. And if you know what happens in a liver transplant the patient is called in when they’re, when somebody is either dying about to die or has just passed away, right? And so they don’t actually know the quality of the liver until they actually go and collect that liver. So we went in eight different times. Taken in an ambulance to get my mother in. And every time there was something wrong, that liver was too small, the liver was too big, the liver wasn’t healthy enough. There was one time even that the liver was okay, but the hospital didn’t have the right blood type for her. And so sadly, she never did get the liver transplant. And then she passed away from liver cancer. And when I think about that now I think about, All the different technologies that are available to us now, drugs, therapeutics, tests that are available to us now, that would’ve made her life so much easier in those days. One of the things is a company is a product by a company called Acoustics, and what they developed is a. Scanning system that you can scan the liver at a PCP site. You don’t have to go into the big liver liver centers with the scanners. And that’s something that would’ve been incredible for my mother. She wouldn’t have had to go three hours every time she needs to get her liver scan. So like I say, these technologies that we’re dealing with today and we call them acutely digital health. They’re actually the healthcare of our future, and I, they’re things I would’ve loved to have seen, 10 years ago when that first big health story happened in my family.

Rishi Sikka, M.D.: Yeah. So you have now that sort of. Forward, look back on the digital transformation that’s occurred that could have helped your mom and it was very much clinically in orientation. I know you also had the unfortunate experience of seeing the administrative financial

Ruby Gadelrab: Exactly.

Rishi Sikka, M.D.: rigamarole of the US healthcare system too.

Ruby Gadelrab: I did. I did. So the day I started at 23andMe, I found out I was pregnant and so I was super, super excited about being pregnant. I was horrified that it was at the time of my dream job where I had literally just walked into the door of my dream job and so I was like, okay, millions of women before me have done this. There have been in, in an executive role and they’ve had babies. I can do this too. About four or five months in, I developed preeclampsia and I ended up being admitted to Stanford and I had my baby at 28 weeks. So he was at 28 weeks. He was 2.9 pounds, and it was the scariest thing that I’ve ever experienced. I a first time mom. Being a first time parent for anybody is hugely scary, let alone having a really tiny preemie baby. We had. Because 28 weeks is early, so I thought we’d got all the time in the world to build the nursery all the time in the world to buy all the things that you need, and all of a sudden we’re in Stanford in the nicu. And then I got postpartum preeclampsia, which is also very rare and scary. And we spent 12 weeks there. And I have to say, NICU nurses are also the unsung heroes of the space. They took amazing care of us, the NICU nurses and the doctors at Stanford. Neither me nor my son would be here today if it wasn’t for them. And again, I feel every time I tell these stories about how broken the health system is, we have to be careful to remember the heroes inside the health systems. So as we spent 12 weeks there, I lived in San Jose at the time. We were commuting back and forth. My husband had just gotten his dream job as well over at Netflix. And then when I came out, about three or four months later, I got two bills. One bill was $55,000 and it was for my nicu, it was for my C-section. And the other bill was 1.1 million and it was for my son’s NICU stay.

Rishi Sikka, M.D.: There you go.

Ruby Gadelrab: again, I’m speaking as a woman of privilege, right? I have come from a place where I have been the luckiest person in the world that I was employed, that I had amazing 23andMe, health insurance, and my out of pocket was relatively little proportion of that bill. Can you imagine those women that didn’t have that health insurance, what they’re doing? To me that’s horrifying. And it’s horrifying as a, in America, that we’re one of the, we ruled the world if as it were here in America in Stanford, we’re one of the richest cities in the entire country. And we’re still not able to go through experiences like that, which are horrific for families and for healthcare, but it’s also the financial toxicity as well that people experience.

Rishi Sikka, M.D.: What a powerful word. Financial toxicity. And thank you Ruby, for sharing both of those stories, which are. Which are obviously both personal but very different. Take us back if you can then, cuz this is, you could see now the reaction. You’ve got ingredients for the ch, you’ve got the ingredients for the chemical reaction. That’s gonna be MDisrupt. Now I actually know why you maybe came with the name mdrt because it was kinda like a chemical reaction, right? Take us back to that moment in time where you’re like, and this is what I’m gonna do now with all of this personally and professionally.

Ruby Gadelrab: So there’s a couple of other pieces. So the first piece was in the aftermath of my son coming out of the NICU at the Seal Packards, he was monitored for two years to make sure that there was no developmental delay. And in that two years nobody ever asked me if I was okay. Not once. And nobody ever asked me physically if I was okay or mentally, if I was okay. And quite frankly, looking back on it now, I probably wasn’t. And in that time, The 23andMe leadership team moved heaven and Earth to make sure that when I went back I was the first pregnant per person to go back after having a baby that I was comfortable, right? So they made sure that there was lactation rooms, wellness rooms, all the things you need because they are led by somebody who cares deeply. About women and women’s health and women in the workplace. And so that’s something that I really appreciated at the time that I went back to work and over the next two years, I was living in Silicon Valley and there was a little company falling down called Theranos and. That’s a whole story in itself. We could do an entire podcast on that one day. But one of the things that people like me and others around at the time, we’d look at Theran and we’d be like, there is no way that’s true. They’re defying the laws of gravity. Okay? The laws of science. Of physics, right? The way that they’re thinking about how you can detect some of these molecules from just a tiny drop of blood defies the laws of physics. So the reason I share that with you is because at the time there was a ton of other companies forming around that time, and many of them were making these really interesting consumer products. That would’ve been impossible to use in a healthcare setting. So there were things that hadn’t been through regulatory. There were things that weren’t ever gonna get reimbursed. There were things that a clinician had never seen or touched or been involved in the development of and couldn’t potentially use. And there was millions of dollars going into starting up these companies. So I thought this is an opportunity building and scaling a health product to me is a formula. And if you do this and you do this, you scale. And if you skip a step or two, you either fail or you become Theranos. Some that, you know what? This is an opportunity. I can go do this. So I left 23andMe and I decided to consult for some of those companies, and I did. I consulted for 25 of them back to back in two and a half years. And while I was in there, I had some really interesting market insights. So the first one was that the founders of these companies, Were incredibly passionate People who have all had a healthcare story like me, every single one of them was solving something for themselves or somebody in their family, and they’re incredibly passionate. The second thing, they were incredibly talented. They were talented, they were passionate, and they had access to capital. So why weren’t they building amazing health products that could actually scale into the health system? And when I looked around the companies, I realized it’s because it was two things. Firstly, the founders had come from outside of healthcare, they had marketing, tech, and finance backgrounds. And the second reason was as I looked around their teams, they hadn’t surrounded themselves. With the right people to be able to build legitimate health products. And so that was the kind of aha moment for me, which is if the future builders of our healthcare might be coming from outside of healthcare, how do we surround them with the best people so that they can build quickly but responsibly?

Rishi Sikka, M.D.: Tell us then about the moment that MDisrupt comes to be and where you’re at now.

Ruby Gadelrab: I really believe that it is the best of tech and consumer ideologies with the best of healthcare that will get us to a good place because quite frankly, every other aspect of our lives is consumerized and digitized, right? Healthcare’s lagging, right? We don’t think about, the customer journey and the customer experience. In healthcare, we never have. And yet every other aspect of our lives is thought through that lens. So how we actually started MDisrupt. So I was the, I have a friend of mine who I have worked with in many companies. She was often the chief medical officer and I was the head of marketing. And to me, the head of marketing and a health company. And the head of medical in a company need to be best friends. I did not grieve as the head of marketing without taking permission from my medical director, so she was also she’d also seen what I’d seen. We’ve worked together at multiple companies and we, in the very, very beginnings, we thought is it that we should surround digital health entrepreneurs with the best people or. Should we help investors make better invest investments? Maybe we could do medical diligence for investors first and then figure out how to help the companies. So anyway, so he thought, we are going to go and try and sell medical diligence to investors and for three months, that’s what we try to do. And do you know what happened? Not a single investor would buy it, not one. They didn’t think it was important. They had their own people to do it. In the VC world, there is a little bit of the failure’s almost baked into the model. That you’re gonna make eight or nine mediocre investments to get the one big one. Nobody would buy it. And nobody cared about, clinical outcomes at the time. It wasn’t a theme. But slowly we started to get messages from companies and then companies would say, you guys know what you’re doing in healthcare. Come and help us. Don’t judge us. Just come and help us. Help us do it well. And so what we found was the companies who were truth seekers, who genuinely wanted to do it well, suddenly started to emerge to the surface and they started calling us up and saying, How do we do this? How do we get through regulatory? How do we make this claim? What data do we need to generate for this? Which channel should we go to? And it was amazing for us. It was amazing because it’s like all of a sudden just our thesis of who we could and should be was bringing to the surface the truth seekers in the industry.

Rishi Sikka, M.D.: That’s right. And you are figuring out dynamically the issue of product market fit, right? Yeah. Two pass and then you figured it out.

Ruby Gadelrab: So we’d figured out service market fits in the, those early days. But like the two things grew organically. The company started coming and the experts started coming at the same time. And so we’re like, okay, we need to figure out how the experts want to engage, how the companies want to engage them. And so I interviewed the first hundred experts myself personally. And it was so insightful. It was. 50% of them were clinicians who wanted to do medicine and the other 50% were people who had come from industry, had worked in companies, knew the formula and the playbook of building health products and wanted to contribute. And on the clinician side, the piece that was really interesting was, They weren’t coming at it for the money. That’s not what it was. They were coming at it. One, they genuinely wanted to contribute their knowledge and their experience, and two, they were tired of the point solutions that they were seeing thrown at them. That were the things that weren’t working in their hands or weren’t making it into their practices. And so they said, you know what? We could really help. We could give our advice, we can share our knowledge. We can take some of these companies and share our clinical workflows, for example. And so that’s how we started and that’s who we became. I feel like we didn’t deliberately choose to go in this direction. The market pulled us in this direction and it fit the gap that we saw.

Rishi Sikka, M.D.: Tell us a little bit about, anything that perhaps has changed about your approach, your leadership style. Even where your resilience and grit has got to come from in a, in an incredibly volatile economy, in an incredibly volatile world. I think one of you, you and I had one of our first conversations, I think sometime book ended by Silicon Valley Bank. Just tell us a little bit about how you’re leading during this kind of time.

Ruby Gadelrab: So what I’m about to say does not apply, just to me, it applies to all founders during this period, right? So I feel like the founders that have founded companies in the last five years, When they come out of it at the other side, they will literally be the most resilient founders ever because you found a company and just as you’re find founding that company, Oh my goodness. There’s a global pandemic. Shut everything down. And so now every company is having some kind of impact by the pandemic. Everybody, the whole world had an impact by the pandemic. And then you start to get out of the pandemic and you’re like, oh my God. It’s the most frothy, volatile, not volatile high volume market in terms of. Which means all your competitors are being funded too, right? Crazy valuations. And then you get through that and. Now you’re facing your, the Silicone Valley Bank collapse. Which impacts not only people’s ability to make payroll, but also people whose customers are the digital health companies or the people that bank from Silicon Valley Bank. And so literally you are going, and now we’re facing one of the worst funding environments for digital health. That we’ve seen in a very long time. So all I will say is it is really hard. Not just for me. You saw it last week when we were at the Digital Health Founders Fellowship. It’s really hard. All of the founders are feeling it. You’ve got to be resilient.

Rishi Sikka, M.D.: What are the next 12 to 24 months for MDisrupt? What do you think? But where are you headed? Where are you going? Any. Peaks, you can tell us about the next year or two.

Ruby Gadelrab: Okay? And I love this question. Thank you. MDisrupt Act one was I call it Act one and Act two. Act One is about building the world’s best health expert network for the health technology industry. And when I say network, marketplace because everything we do is around creating value for the companies and value for the experts. And I believe that we have. I’ve done that. I hope so. But it’s been an incredible journey to get this far. At this point, that is our act one. However, our Act two is a little bit different, which is we are the mission of our company and it always has been our mission. We’ve just had to take steps to get there. Is to organize the world’s digital health products by performance or clinical outcomes so that everybody can make data-driven health decisions. But healthcare is a business that moves at the speed of trust, and we can’t come out of anywhere, just nowhere and start to say, we’re organizing the world’s digital health products by performance. We have to build trust with the digital health companies, with the experts, and now with the largest stakeholders in health in healthcare, such as health systems and payers. And so we’ve built the best. Expert network because we’re going to use the expert network ourselves to help us to organize the world’s digital health products by performance. And I’m not gonna go into too much detail now. This is gonna be a wait and see. But I’ll give you the end stage, which is I would like, if I ever say to you, Rishi, this is an aura ring. You should get one of these. I want you to say, let me go to Mdsr quickly and have a look at what cardiologists and PCPs think of that. That’s what I would like us to be when we grow up.

Rishi Sikka, M.D.: One last question before we wrap up. Speaking of imparting in a sort of a vacuum, so to speak, if you could impart your wisdom. We have a lot of, we have probably a lot of. First time CEOs, first time entrepreneurs, maybe folks who are, who haven’t quite they’ve got the idea, but they haven’t maybe taken the leap formally. What advice would you give to them?

Ruby Gadelrab: And for context, although I’ve had a 26 year long career, I am. Also a first time founder and a first time c e o myself. And when I look back on it, the one thing I would say is surround yourself with the best people. I would say that the executive team and the team at MDisrupt are the best people I could have hired. They’re brilliant, they’re smart. My advisors are the best people that I lean on. And the other thing I would say is, online people are all sharing the lovely, shiny stories of, I raised 50 million on the back of a napkin. It’s never that simple, right? You just gotta keep your head down, build and surround yourself with the best people.

Rishi Sikka, M.D.: Ruby, thank you so much for sharing your journey, and thank you so much for everything you’re doing in MDisrupt. And the broader digital health ecosystem. Thank you so much for being here.

Ruby Gadelrab: Rishi. We’re gonna, we’re gonna hit you up for act two because I know you’re gonna have an opinion. And the one last thing I’ll leave you guys with, in a world where we’re all talking about AI and chatGPT, the most valuable intelligence in healthcare right now is human intelligence. And so that’s where we, that’s where we’re indexing our efforts.

Rishi Sikka, M.D.: You said it. You said it. Now it’s the mic drop. Now we go off.

Ruby Gadelrab: Perfect. Thank you so much, Rishi.

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