Michelle Carnahan, Thirty Madison, on a human-first approach to healthcare

Michelle Carnahan has spent her entire career ensuring patients get the treatments they need to live a happy and healthy life. After graduating from college, Michelle joined Eli Lilly as a pharmaceutical sales rep. Fast forward 26 years and she will have led two of their largest product lines before launching their international business unit in 2017. She joined Thirty Madison as President in July of 2020 — just as the pandemic was reaching its head and digital technology adoption was fueling rapid changes in the way consumers access care. Thirty Madison is a direct-to-consumer healthcare company intended to provide specialized care to individuals with chronic conditions. They currently operate four unique brands: Keeps, Cove, Evens, and Picnic focused on treating hair loss, migraines, GI issues, and allergies respectively Within a year of joining, Michelle helped Thirty Madison to a $140M Series C raise with a valuation of over $1BN (*unicorns neighs*) led by HealthQuest Capital.

After a quarter century with Eli Lilly, including time spent leading their musculoskeletal and diabetes product lines, Michelle joined Sanofi as a Senior Vice President, with full P&L responsibility for their $4BN General Medicine’s portfolio as well as a board seat for Onduo. In addition to her business acumen, Michelle is known for her compassionate leadership style and as a champion for women in business. During her time at Sanofi, she increased employee NPS by 20% and has served in multiple roles dedicated to female executive mentorship, including organizations like the Healthcare Businesswomen’s Association Gender Parity Collaborative and JBW Women in Management Center at Purdue University. Thirty Madison represents Michelle’s first jump to the startup world, but she’s far from new to the challenges facing patients with chronic conditions.

In this episode we discussed:

• Michelle’s pivot from seasoned pharmaceutical executive to a role leading a rising health-tech unicorn
• Thirty Madison’s human-centric approach to chronic condition management and growth plans following their impressive Series C raise
• Michelle’s thought leadership on the topic of gender equity in the workforce and as it applies to her new role at Thirty Madison

3:00–12:00 — Michelle’s experience at Eli Lilly

• On spending 26 years at a single company: Michelle jokingly chided me for revealing her dinasourishness (not a word, but it should be!). First and foremost, Michelle proudly stated that she was a Hoosier, which tied her to the state of Indiana where Eli Lilly is based. While her love of science and healthcare brought her there, she mentioned the diversity of challenges she was given as the critical factor that kept her there for so long — working in roles in sales, marketing, HR, finance, strategy, P&L management, etc. To summarize, she said that she was never bored and it was an amazing place to work for her professionally and personally during a time when she and her husband were raising a family.
• Why change careers, why now: Michelle recounted an anecdote about working on a JV with Boehringer Ingelheim — she saw this German company, family owned, totally different than working internally at Lilly. While she was still able to achieve success working on this project, she felt it was more difficult to reach. Looking back on the experience, she reflected that working in a different culture created an opportunity for her to grow and it was this realization that led her to take her first call from a headhunter, and eventually to leave for Sanofi. Sanofi was still in therapeutic pharmaceuticals, an area of comfort for her, but it was also a French company with a very different culture than she was accustomed to. She compared this jump to somewhat of a “palate cleanser” that gave her the confidence to move into the startup world.
• Why health tech: Michelle recognized that, while it was a big jump, that she had a great supporting cast, including an important mentor, that encouraged her such that she didn’t feel like she was jumping alone. She then recalled a story from a talk that the then CEO of Eli Lilly, Randy Tobias, gave where he said that ‘all of their pills were just unfulfilled potential until they reached a patient’. That framing struck a cord for Michelle. When she measured some of the work she was doing related to diabetes care, noting the issues with insulin delivery in the US, against opportunities for technology to drive change in the way that healthcare is accessed, she knew it was the right pivot.

“Whether it’s a medicine, or a diagnostic, or an appointment to your doctor’s office, none of it matters unless it gets to a person. And there are just too many people in this country who still don’t have the opportunity they need in healthcare.”

12:00–19:30 — Overview of Thirty Madison’s approach

• On Thirty Madison’s mission statement: Michelle has seen first hand — working with people like Kelly Close of Close Concerns — that people aren’t their conditions. Thirty Madison seeks to use technology to focus on the human experience of healthcare — a focus Michelle believes is a big differentiator in a world where many conditions become statistics.

“Nobody wants to be known as their condition. Nobody wants to be known as the diabetic, or the high blood pressure sufferee. Patients are humans first…in a world of overused words, it’s the most important one you’ll hear from us”

• On the benefit of Thirty Madison being distinct from their individual brands: We began the discussion reviewing some of the brand names that they left on the cutting room floor — interestingly, Thirty Madison actually uses these failed brand name ideas as conference room names in their New York office. Michelle was sitting in a conference room named “Mr. Cool”, which she admits scared her initially because it was so, so bad. Jokes aside, Michelle reiterated that the names are vital because they help people connect with their health condition differently — enabling them to identify with more than just the name of their illness.
• Three key benefits of Thirty Madison’s model: 1) built from a therapeutic care model, 2) personalized treatment, 3) technology and services that make the care model work. Michelle spent the discussion here highlighting how they build their care models — they start with determining how best to use specialist-level care, often solving this access issue upfront with telemedicine. From there, it’s determining how best to personalize the actual treatment and support the patient as they shift into the ‘ongoing condition management’ phase. The brands then represent their understanding of the unique patient journey for each condition while Thirty Madison represents the underlying infrastructure that allows them to be more than a point solution.

“We’re not about urgent care, we’re not about primary care, we are about chronic care and chronic conditions. And all of that is really underscored by a platform of technology and services that make the care model work.”

• On choosing a cash reimbursement approach (as opposed to traditional insurance): Before getting into the decision itself, Michelle emphasized that this was an initial choice — one they are continually evaluating as they look at growth opportunities. Aside from the obvious reason of lower barriers to entry for DTC care, Michelle explained the decision as one that allowed them to focus on understanding the journey through the consumer lens as opposed to the payer or employer one. Now that they’ve proved out what a consumer focus can do in the healthcare space, they believe it may be time to talk to payers and employers about the role that Thirty Madison can play for them. Within that reimbursement space, they’re exploring opportunities to use FFS, PMPM fees, or even shared value as potential revenue models.

19:30–35:00 — Michelle’s experience joining the organization and where they’ll go from here

• How Michelle first heard about Thirty Madison: Michelle credited conversations with Darren Carroll and Amy Schulman of Polaris Partners with her move to the company. At Sanofi, Michelle was also on the Board of Directors at Onduo, a JV with Verily for patients with Diabetes. Similarly, at Eli Lilly, Michelle had done some work in the connected care division of their diabetes platform. Based on these experiences and her interest in getting into the high growth startup world, Amy connected Michelle with the founders of Thirty Madison.
• On her first impressions of the founding team (Demetri Karagas and Steven Gutentag): Michelle admits that, at least on the surface, that they are an odd couple — the two founders were two friends that had met at NYU 10–12 years ago and started this consumer focused company together whereas Michelle is a woman from the Midwest with a son graduating high school. That said, they seemed to hit it off immediately — having a lot of fun getting to know each other, even during a pandemic. What stood out to her as she dug deeper was their consumer-first approach to tackling chronic condition management, a problem space that has historically been extremely difficult to unlock. When they decided to work together, Michelle recalled that Demetri and Steven said she could be the ‘third leg of our stool’ which she noted was the ‘worst proposal ever’ and that whenever Demetri actually proposes to someone, Michelle intends to help.
• On building a working relationship during a pandemic: Michelle and each of the two founders bring unique perspectives to the table that are valuable because they each acknowledge that you can always learn more. Michelle recalled advice her first manager gave her to ‘invite your team over to your house to dinner. No one can hate you when they’ve eaten at your house’. While this was difficult to do during a pandemic, Michelle, Demetri, and Steven found other ways to get to know each other — whether it was spending the first 20 mins of a meeting telling stories or finding dedicated time to share about themselves and their lives. This made the transition back to the office so much easier, Michelle says, because they built trust and trust is the basis of business success.
• On the Series C raise and next steps for Thirty Madison: Michelle sees Keeps and Cove as the proof points to what could amount to a huge healthcare transformation. The success of these brands told her the strategy was sound and the results they were seeing told her that the model works. Then it all came down to timing — the pandemic has accelerated the adoption of technology-forward health offerings and the market isn’t waiting for them. She notes the timing of the raise as a way to accelerate their expansion into new conditions and markets.

“If we want to be the premier healthcare company for chronic conditions, you know, get with it! Because this healthcare machine that has lugged along for so many years is now moving”

• On selecting new condition categories: Three principles: 1) focus on chronic conditions, low acuity to high acuity, 2) find gaps in the current healthcare system, 3) go where there is an opportunity to dramatically improve the consumer’s experience. When Thirty Madison thinks about gaps in the current healthcare system, Michelle says they often see them where a) there’s not enough specialists relative to the number of patients or b) where the cost of care is not matched with the benefit people are receiving. She also notes, with an air of incredulity, that the net promoter score (NPS) for healthcare is a 9 in the US — emphasizing the zero before the 9 on that figure — whereas Thirty Madison boasts an NPS of 79. As they try to select new conditions to address, they want to have that same consumer effect of creating an amazing experience.
• On organic growth as opposed to M&A: Without ruling out M&A in the future, Michelle has experienced that it’s a delicate blending of healthcare technology and consumerism that makes their model work in a way that is incredibly scalable and has enabled them to learn while becoming a better healthcare company.

“We see ourselves as taking the best of the consumer centric approach to care because we think it’s important — so the Hims & Hers, the Ro approach. As well as the best of the longitudinal care management approach of companies like Livongo and Omada…So when you look at things like our net promoter score, we want it to be in the 80s, we want consumers connected to what we do, but we’re excited to be remaking specialty care and to remake specialty care, you have to have longitudinal health outcomes”

35:00-END — Personal leadership style

• On the importance of a diversity of perspectives on boards: Michelle first addresses the core of the question, which is the importance of Amy Schulman, the first female board member for Thirty Madison, by saying that she not only brings a woman’s perspective, but also the perspective of an accomplished healthcare executive and investor. Michelle then mentioned Jason Stoffer from Maveron who brings a consumer lens and Randy Scott from HealthQuest that has helped them understand the payer and employer space. This diversity of experiences as well as gender and backgrounds has been fantastic, and it’s the combination of these folks that Michelle has found so powerful for Thirty Madison.
• On structural changes companies can make to promote gender equity in the workplace: Michelle references learnings from Eli Lilly here, but noted three primary structural pillars: 1) measure it 2) tie some accountability to the measurement, and 3) be inclusive as an organization to different styles and different ways of wanting to work. We spent the majority of the discussion talking about the third of these as Michelle has loved seeing how the pandemic has allowed her colleagues to bring different styles to work. She believes flexibility in working models has gone forward 10 or 20 years. Beyond these three pillars, she mentioned things like mentorship and sponsorship that can be helpful in certain situations — sharing that she tries to personally take as many of those phone calls that she can because Amy Schulman and countless others took that call for her.

“As you’re thinking about diversity, it’s really important to know what your diversity numbers are, know what you want to hold accountability to, and then create a workforce that includes people.”

• What individuals looking for new career opportunities should look for in an employer: 1) Find a place where you can be you, 2) believe what you see — everybody can talk the talk but look for which companies you see yourself reflected in and 3) get out of your comfort zone and make it interesting for yourself. On the final point, Michelle jokingly says “from the woman who worked at the same company for almost 26 years”.

“Find a place where you can be you right now…all the energy you spend being a different person, frankly, takes away from doing the work.”