HIStalk Interviews David Bates, CEO, Linus Health

David Bates, PhD is co-founder and CEO of Linus Health.

Tell me about yourself and the company.

I’m a scientist, engineer, and entrepreneur. I spent 16 years in venture capital. I’ve also started a few companies along the way. I’m passionate about brain health, its importance in the world, and how much suffering can be alleviated by preventative, proactive care, equipping people with agency over their brain health.

That speaks to the introduction of Linus Health. We have a brain health enablement and dementia prevention platform that spans the care continuum. It is clinically integrated, but it’s not just in the clinic. We want to care for people all the way through their life journey to optimize their brain health and prevent disability.

How does the diagnostic process differentiate between occasional forgetfulness versus true cognitive impairment?

The approach we take is unique, novel, and well validated. We mimic what specialists have done for decades by analyzing the process by which a person carries out a task. We leverage multiple sensors in a tablet, smartphone, or laptop to analyze the characteristics of their behavior. 

Behavior is the primary observable output of the brain. We deconstruct that behavior to understand any kind of emergent brain dysfunction. There are many kinds of brain dysfunction, not just a catch-all memory. There is executive function, language, visuo spatial, and of course memory. For each of those, it’s important to understand the type of impairment and what is likely giving rise.

The treatment, the intervention, can then be specific to work on that particular aspect of brain function, and as much as possible, improve health, improve function in their daily life, and equip them with the tools and capabilities to compensate for whatever disability is emerging.

That’s really important. It’s not just a binary thing, impaired or not impaired. We need to understand what is actually going on with this individual and how we can help them optimize their daily life and promote health in their brain.

What is the trigger for performing the test? Is it a one-time diagnosis event, or does regular screening have value?

I’m a big believer in preventative health. We should not wait for disease. We should be proactive in our brain health. It’s important to have a baseline. Everyone should be their own metric of how they’re doing, especially when it comes to brain health, so you can catch things early.

I believe in doing a brain health screen wherever healthcare is delivered. Wherever you would check blood pressure, you should check brain health. It’s important because with these new tools, you can catch things years before they would show up as symptoms. When you catch it early like that, you can intervene early.

It’s akin to oncology. You don’t want to wait until you have a tumor bulging out of your neck or they’re all over your body. You want to find, as early as possible, any kind of emergent illness and then intervene during that window of intervention to preserve function and health. With the brain, it’s incredibly important, because neurons that are lost are not recoverable.

To your point of should we screen? Absolutely. We need to change the way that we think about brain health. We need to understand that there is something that can be done. There is incredible hope for people. Many of them don’t have to get dementia. Up to 45% or more of cases can be prevented through lifestyle modification. Treatments are coming to market and getting approved by the FDA, so the earlier the right people can get started on them, the better the prognosis.

I’ve talked to people with Alzheimer’s disease who are living, in their words, their best life. They have known they’ve had it for a number of years. They are on one of these disease-modifying therapies and are still living their life, traveling, doing things with their kids.

Alzheimer’s disease is not dementia. It can result in dementia, but it can also be slowed down. Not every person with Alzheimer’s disease will get dementia. It’s important that we have this education and understanding in the market so there’s not a fatalistic view.

People are proactive in assessing their brain health and proactive in doing the lifestyle modifications. Those who need it will seek treatment to preserve brain function. With dementia, every single person can benefit from brain health assessment, especially with good platforms, even if they have dementia. Equipping care partners with knowledge and resources, equipping the individual. It’s a dyad, the two together that the patient and the care partner know how to optimize health and quality of life. Not only the life of the afflicted person, the patient, but the life of the care partner. If they’re not equipped, informed, and supported, their health suffers tremendously in the majority of cases.

That’s on the dementia side. Back to Alzheimer’s, detecting it early, even so-called pre-symptomatic. Platforms like Linus Health can find them before symptoms are apparent. Intervening and preserving function is incredibly important. People can live a much higher quality life than if there’s not intervention.

Intervention is not just “take this medication.” It’s holistic, and they need to be engaged in many ways, including for some the disease-modifying therapies. For everyone, it’s a discussion among themselves, their doctor and the family, and figuring out what is the best treatment course for this individual. It stands and it is irrefutable that the sooner you engage, the better the outcomes, and the better the quality of life for the individual and for the family.

Can that diagnosis and management be scaled by using non-specialist clinicians instead of less-available specialists?

With the right tooling, primary care can handle the majority of cases. They’re rightly positioned to. It is similar to how they now manage diabetes when it used to be an endocrinologist. Managing hypertension used to be a cardiologist. Those specialties are still needed and are used on the more difficult cases as their training warrants.

It’s using the right resources for the right people. The majority can be managed in primary care. Platforms like ours provide those primary care physicians with the capabilities to diagnose and the decision support to triage, to guide them to care for those individuals right there in the primary care setting. Especially addressing their modifiable risks, addressing reversible causes. That can all be done in primary care.

For cases that need specialist care, they should be referred right away. This helps streamline referrals, reduce wait times, and get people to the right resource as expeditiously as possible. That optimizes healthcare.

What is the role of biomarkers, which are in essence a blood test for dementia? How does that fit with cognitive testing and could they be applied to a population?

The approval of Fujirebio’s blood test, Lumipulse, back in May was a huge step forward in Alzheimer’s care. You need to first establish a cognitive impairment. Some of the key opinion leaders in the field have shown that with these blood biomarkers, they need the establishment of some kind of functional impairment to make their predictive accuracy appropriate and meaningful.

It’s a great addition to what I would call the emerging service line for brain healthcare, especially cognitive care. The blood biomarker helps, once you’ve established that there’s a concern with memory or thinking, what is the likely etiology? What is causing that impairment? If the p-tau blood biomarker is positive, it is very likely that the individual has Alzheimer’s disease. They should be triaged, if appropriate, to disease-modifying therapy or one of the many drugs and intervention methods that are coming out that can deal with that etiology. 

It’s equally important to know that it’s not Alzheimer’s disease, because you want to work on other contributed factors to find out what is giving rise. That could be a co-morbid condition like unmanaged hypertension, unmanaged diabetes, undiagnosed sleep apnea, and the many other things it could be. Get those things treated and then retest. For those who are appropriate, getting them to a neurospecialist since it could be Parkinson’s, Lewy bodies, or a variety of things.

That blood biomarker is incredibly important to know how to triage people following a cognitive assessment.

How do payers approach cognitive conditions?

Unfortunately, we’re seeing a number of payers that are not, in my opinion, assigning appropriate value to brain health. I don’t know if it’s broadly appreciated yet how important the brain is and how important it is to the quality of life and health of the individual. The brain is that organ that you can’t transplant. It’s important to who we are. I don’t know if the health system and the willingness of payers fully reflects the value of brain health and function. 

Members should demand more brain health focused resources to preserve their quality of life. Dementia is the number one health fear of middle-aged and older people, yet it’s not standard to assess cognition to try to prevent dementia. CMS does reimburse. There are CPT codes for the digital cognitive assessment. There are CPT codes for brain health visits. There’s a reimbursable pathway. 

With value-based care, CMS has done a great job, especially Medicare Advantage. They have risk adjustment factors. They have certain HEDIS exclusions. They have the incentives aligned with identifying and caring for cognitive issues and dementia care.

That’s at the CMS level. Different insurers take different stances on cognitive assessment. Maybe they don’t want to pay for the expensive disease-modifying therapies, so they don’t want to screen.They don’t see that the patient will be a member that long. Some of them don’t take an active role to support brain health care, and that’s really a shame. We need to do better than that.

You could say, “That’s because you have a company that is associated with finding emergent illness with the brain.” No, it’s because I’m a human being. I care a lot about brain health and I hate to see people suffering from it. If your primary goal is to insure people for health, you need to make sure that the things that are most important to their health are being looked after. If you do the right thing, everyone will win. It will pay off in the long run. The total cost of care will go down. People’s quality of life will go up, and there will be a lot less suffering.

Have studies looked at the age of onset and the insurer at the time of initial diagnosis? I’m wondering how much of that happens before people reach Medicare age.

The studies are emerging. It’s early days. There is the empirical evidence, which we need more of and I’m sure is underway. We are tracking people and we want to make sure that we have those cases.

There is precedent in all other chronic conditions that early intervention, early management, leads to reduce total cost of care. The best thing that we could do, and we need our system aligned, is to incentivize prevention. But our system is aligned to treat sickness, and so all of the incentives are around treating sickness. This is a policy matter, but how do we incentivize prevention? How do we enable people to take action over their brain health and reduce significantly the disease burden?

Neurological disorders are the number one disease burden in the world. Neurology in psychiatry is still an emerging area, especially with new tools and capabilities. But there’s a real opportunity here. Most health stems from the brain, and every other function is to support the brain. It’s good to start on first principles. How do we optimize brain health, and from that comes total health.

To your point on the insurers, I do appreciate that they have a business to run, and you can’t paint with broad brushes. Some of insurers are proactive in promoting brain health, even some of the largest ones. Some have taken a stance, while others have decided to put their head in the sand. That has never been a good strategy. You’re saving some dollars on the front end, but you’re causing irreparable harm to so many families.

How has last year’s acquisition of Together Senior Health changed your capabilities?

It has given us another step forward to enabling people to have a higher quality of life, even those who are living with disease, and their care partner. We’ve taken the RADAR tool (Risk of Alzheimer’s and Dementia Algorithm) to a validated capability that is now in production. We can risk stratify entire populations for the risk of undiagnosed disease. That enables insurers and health systems to know who is likely to be suffering from illness, the presence of emerging illness, and the risk of it. That’s where we should focus our care resources to minimize disease impact as much as possible.

You take it all the way through our platform and through the clinic. Then, back at home, how do we care for those individuals and optimize their brain health trajectory? The acquisition of Together Senior Health was a big step on those bookends, risk stratification on the front end and the engagement and care on the back end. That has helped complete our platform to span the continuum of care, all the way from identification, diagnosis, treatment planning, post-clinic engagement, and health coaching and monitoring.

How do you expect the company’s business to change over the next few years?

We are seeing the engagement of health systems across the country. They are leaning in increasingly. So I expect to see in the next two years that the standard of care will be set, and the service line will emerge for cognitive care. It will be such a good thing for the world, for the population. I see it spreading into Europe, the UK, throughout North America, Asia, and beyond. Get to Africa, get everywhere, and promote brain health.

We need to work on the stigma that is associated with dementia. We should not have a stigma. People should realize that it is a new day. There is incredible hope. The drugs that exist today on the market, and especially the ones that are coming, are tremendous. They are showing such benefit, and it’s still early. Everyone needs to know that there’s tremendous hope for the future.

We need to treasure the senior population. They are pillars of the community. They have so much life experience. We need to honor them by caring for their brain health and getting them the attention and resources that are needed to prevent dementia. That is super important.