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The Evolution of Functional Medicine with James Maskell

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The Evolution of Functional Medicine with James Maskell

What if we completely reimagined the way we deliver healthcare, what would it look like and how would you do it?

In this inspiring look into the future of functional medicine, entrepreneur and health advocate James Maskell discusses his work in revolutionising the medical model from one on one sessions with a doctor to shared healthcare with groups of people and teams of doctors, coaches, and practitioners in order to prevent and predict disease before it happens. 

Covered in this episode

[00:27] Welcoming James Maskell
[02:41] How medicine is evolving
[04:53] Facilitating the transition
[07:16] Bringing personalised medicine to the masses
[13:33] Shared medical appointments 
[15:55] Doctor as part of a health team
[20:10] Functional Medicine 3.0
[24:13] Battles between Lifestyle Medicine vs Orthodox Medicine 
[27:55] Using new technology in functional medicine
[30:37] Managing time and getting to the root cause
[33:25] Changing the medical model to predictive and preventative
[39:21] The problem with health insurance in America
[45:10] Accelerating the transformation
[47:35] Becoming a part of the change and building evidence

   


Mark: Hi, everybody, and welcome. Today, we're talking with James Maskell, who you probably all know. He's the creator of the Functional Forum, one of the world's largest integrative medicine experiences and conferences. He lectures internationally, and he is also regarded as probably the most influential non-physician promoter of functional medicine worldwide. Welcome, James. How are you going?

James: Great to be here. I'm doing very well, thanks. Great to be here on the show.

Mark: It's great to talk to you finally. You're making an influence on functional medicine right around the world, and it seems to have kind of hit the headlines with you. Tell me your background. Is it business marketing that allows you to bring this, you know, forward so that it's visible and right there in front of doctors' faces all the time now?

James: Yeah, so, I mean, if you go all the way back, I was the weird kid at school. I did natural medicine, and I had a chiropractor and a homeopath growing up, and didn't realise that that was abnormal until I sort of got to school. I took a pretty normal career path, initially, I did a degree in health economics and economics in England, and then, you know, I was about a year into just sort of like a normal job that people do when they get that kind of degree. I was an investment banker, and I just was a year into it, and I just realised like I had a sort of a moment of clarity and realised I was playing for the wrong team. And I moved to America, and I've been here for 13 years now.

So I started off working in a clinic that was really a sort of a vision for the future of primary care, integrative medicine being delivered in a spa. Then I was serving doctors, doing integrative and functional medicine in a sales rep role. I started a practice management company. And then in 2014, we sort of, you know, started to really execute on what's really a 10-year plan to transform health care, and the first part of that plan was getting a lot more doctors to go functional. And that's why we started the Functional Forum, and then the podcast…

Mark: Right.


Next Episode - Hacking the Genetic Code with Dr Nessa Carey


James: …and then I wrote the book, "The Evolution of Medicine," and then we created courses to help doctors shift towards building a functional medicine practice. So that's sort of like a quick overview, I guess.

Mark: Right. The need to transform medicine seems to be a recurring theme. I mean, it's happening right around the world. Medicine has been a very successful science and a very successful profession in disease care and disease management. What's happening? You know, there was…my parents came from a world of, "You trust the doctor. If the doctor says you do A, that's all you do," and health belonged to the professionals. Now it seems the public are taking it back, and the profession is responding in a way to create a new medicine. What's the impetus that's driving that?

James: Yeah, the impetus is just very radical change in what kinds of diseases that we're treating, and what the aetiology of those diseases are, and what the recovery from those diseases are. So, you know, I called my book and the business "The Evolution of Medicine" because I see medicine, like, trying to adapt to these new diseases, trying to work out how to do for type 2 diabetes what they were able to do for acute infection…

Mark: Yeah.

James: …and ultimately struggling to do that because they, you know, not essentially really understanding the aetiology of the disease, and also are sort of implicitly biased against some of the concepts that they really need to understand in order to get the kind of elegant, you know, resolution that they're hoping for. And one of those ideas might be, for instance, holism, right? You know, if holistic has been a word that has been sort of so bastardised…

Mark: Yes.

James: …in the mind of any doctor that any sort of holistic strategy seems like you're talking like this is sort of like not real medicine. But at the same time, a holistic understanding, a truly holistic understanding of what's causing type 2 diabetes and how to reverse type 2 diabetes, it's very necessary to come up with a kind of elegant solution that you would find for an acute disease.

So, you know, I think that there's reasons why it hasn't evolved quickly enough, and our organisation and its first iteration with The Evolution of Medicine has been there to help doctors understand this transition, and what role they can play in it, and try and share some of the best practices from sort of the early years to be able to see, "Okay now that we have 30,000 doctors in the U.S. and a lot in Australia doing this kind of care, what have we learned, how do we make it more reproducible, and how can we sort of speed up this evolution?"

Mark: I'm not sure of the layout in America, but in Australia there's been isolated groups. So as you know, the nutritional medicine, there was clinical ecology, environmental medicine, lifestyle medicine. There have been all kinds of names, and it's largely been doctors who see that there's a problem with medicine wanting to do better, different, and somehow expand their practice to make a difference in prevention and health, and a system that seems to not be well adapted to that. Their medical training is good at disease recognition, but not at premonitions, you know, being able to act early, intervene early.

The transition is painful on the individual level because you become isolated, and the profession kind of beats you up a little bit. Are you facilitating that transition? Isn't this a part of the kind of marketing of saying, "Look, this is valuable medicine, and it's not something doctors have to do one at a time. There's a coordination and a community that will make it safe as a career path, rather than an outlier of a doctor subject to criticism left, right, and centre"?

James: Yeah, absolutely. I mean, we're certainly similar in America, that there's a lot of different names and a lot of different organisations that are, you know, teaching a lot of the same principles…

Mark: Right.

James: …you know, "What is the difference between environmental medicine and lifestyle medicine?" You could look at those two things and see that they're very opposite, but actually, they're sort of like the delivery of those two things are actually about 90% the same. 

Mark: Yes.

James: So, yeah, we've been trying to make it easier for doctors to, you know, to build a practice doing this kind of medicine to, like, sort of make it easier for them to understand the names and where these names come about. And to also just… You know, I start, like in my book, I was able to make the right arguments in the right order…

Mark: Right.

James: …you know, depending on how the concepts are introduced to a new physician who's never heard of it. They either think, "Oh, wow, this is a necessary evolution of practice," or they think, "Oh, no, I've heard about this. I know that this is BS." And so, you know, just being able to make the right arguments in the right order, you know, I think, hopefully, created in my book something that most doctors, when they read, are like, "Oh, yeah, this seems, like, necessary." And if they're feeling the pain of practising a medicine that they don't care for…

Mark: Right.

James: …then typically this is like a good opening to them to have a new lease of life in medicine.

Mark: I want to just tell you this story. A good doctor, a very good GP, or general practitioner here. A doctor friend of mine, many years ago, went to do the ACNEM, which is the College of Nutritional and Environmental Medicine studies here, thoroughly enthused about the idea of nutrition, environment, and their impact on health. Came back to her medical practice after the training, and could not bring the two things together, "How do you efficiently deliver medicine at low cost to a large number of people?” versus what, at that stage, anyway, was more boutique medicine of, "If you've got the money, and plenty of time, and there's no pressures on you, you can do a lot more good in prevention, nutrition, and move forward."

She sacrificed the training in nutritional medicine for the pragmatism of doing medicine at an efficient rate. Is there a way of taking boutique, what has been the kind of boutique area of medicine for the rich, and bringing it to the masses? Is that a concept of...? In fact, that seems to be a concept of The Evolution of Medicine, "Until it becomes mainstream, it's just on the margins." How do you solve that?

James: Yeah, look, let's talk about that because, absolutely, it is doable. And we've been looking for that. That's really what the work is about. So first and foremost, the most important thing is not to judge where we are in the evolution right now, right? If you met an investment banker in 1982, and saw him have a cell phone the size of a brick…

Mark: Yeah.



James: …and he was the only one who could afford one, you'd be like, "Well, cell phone technology is no good. It's only good for the rich people. Look how big it is. No one's ever going to have one of these phones." And then 30 years later, you know, the same phone that I'm using right now is the same phone that a billionaire uses. And, you know, most people have access to a smartphone and its ubiquitous technology. So, you know, that's a journey where you could judge it where it is in 1982 and say, "Well, this will never happen."

So, you know, ultimately, we're at the very beginning of this movement where all you have so far is some doctors that feel a moral obligation to do things differently, trying to do things differently, and working it out, but, you know, maybe having success and maybe not. And what you typically see at the beginning of every one of these evolutions is that you go to the top end of the market, right? 

Mark: Right.

James: You learn at the top end of the market, because you can afford to spend the time. So, ultimately, there are many ways that we've seen that doctors are making this type of care available to the masses beyond the boutique doctor's offices. So I'll just share a few ways that I've seen that.

So one is, you know, leveraging the power of education. So, you know, a lot of what's going on, if you want participatory medicine, if you want your patients to participate in the care, they need to know what to do. And so, what we've seen is that if you can use, you know, content, or if you can educate people in an environment that doesn't take up your time, like using email automation, or making blogs and videos and then sharing them with prospective and current patients, you know, the education that's happening for people to know what to do isn't happening in the time that they've paid for, right? 

Mark: Right.

James: If you give $300 an hour to a doctor and the doctor spends 50% of their half an hour... You know, their appointment for an hour, if they spend half an hour doing it, you're spending $150 to learn something you could've learned by reading a blog post. 

Mark: Right.

James: So, you know, there's efficiencies created from using technology, and using content like books, and podcasts, and, you know, even things like you're listening to now, to be able to curate an educational experience for patients. So that's the first thing, is technology and education.

The second thing is taking advantage of the power of community. So we're really starting to see that the way that functional medicine will reach the masses is typically in a group structure. So you look at group visits, for example, you know, some people are doing group visits for the underserved, and just sort of like doing a diabetes education series, setting up structures where people can support each other who have the same issue, accountability buddies, and that kind of thing. We have one innovator in our practice accelerator program, a doctor from Wisconsin, who created a unique type of group visit where everyone is basically doing their functional medicine intake form directly. And the reason why I love it is, one, that's the most cumbersome process of functional medicine or integrative medicine, at the intake. You know, ultimately, it's kind of the old style for the doctor to do all the writing when really the patient is the one taking the action, so why not have the patient fill in their own chart? 

Mark: Right.

James: Because they're the ones that are going to be reading anything about it too. And also, like, questions come up. You know, one of the beauties of a group dynamic is that some people have questions, other people feel scared to ask. And so, you know, people ended up getting answers to questions that they were scared to ask their doctor, because someone else asked the question when you have a mixture of personality types. 

Mark: Yeah.

James: So I'm really enthused about the power of community, both digital but particularly in person, because of the levels of accountability, and trust, and support that are available through community structures.

And then the third way is coaching. You know, so health coaching has become an area where...essentially, you know, what we seen is that, you know, in a functional environmental, integrative lifestyle clinic, you know, there are two things going on. There's root cause resolution, right? So there's getting to the root cause of the dysfunction and taking the time as needed for that. And there's also helping people execute on lifestyle and behaviour change. And, ultimately, the doctor is way too expensive to be doing the second part of that. And so, by using health coaches who cost a lot less, who aren't focused on coming up with a plan but helping people execute the plan of a different provider - and that other provider could be a dietician…

Mark: Yeah.

James: …could be a doctor, could be a nurse practitioner - just help on the execution at a fraction of the cost. That also helps to make it more affordable. 

Mark: Yeah.

James: So I call it the three C's, Content, Community, and Coaching. And, to me, those are the three structures that will bring this to the masses.

Mark: There is a move in Australia to this idea of shared medical appointments being pushed by the lifestyle medicine group, and the Australian government funds a lot of...in fact, you know, makes medicine effectively free for the majority of Australians. The shared medical appointments is, "Can you have those appointments, instead of one at a time, can you put all 10 people in the room, have the shared appointment with that smallish community, and the questions that they ask of the doctor and the health coaches in that room expand the available information to a group of people, without repetition and, you know, with high efficiency?" Is that the kind of thing that you're talking about with the, in effect, the patient community groups? How they learn, stop it being one on one, and start making it an educational experience and a journey for each of those kinds of communities and groups, self-supporting?

James: Yeah. No, you've hit the nail on the head.

Mark: Does that work?

James: Yeah. No, it works. I mean, definitely.

Mark: Okay.

James: They're very far ahead of it. I mean, ultimately, the success of the group is going to be a function of a number of things. But is the concept sound, and is it being executed well in different places across the country? I would say yes.

Mark: At my own profession, I had an easy win early on because you could go for proximate causes, you know. What did the person have? They had pneumonia. What did the person have? They had a heart attack. And you could use powerful medicine at the end stage of a disease to do something very dramatic and very compelling. And I think what medicine's moved into is an area where you can't do that to type 2 diabetes. There is no quick fix, there's no pill that's going to do it. And so medicine's out of its depth in a way. It keeps on going down the same path that, "We can cure it. There will be a pill," without ever going back to the roots of medicine, which is lifestyle, diet, you know, they're giving power back to the person who's health you're looking after. That health coaching involves a handover of power from doctors to different groups of people with different skills, with different ability to motivate people. No doctors that I know have a high ability to motivate people, whereas health coaches seem to have different skills to take what's good information and then get people to do something about it. That transformation, I think, is going to be necessary, because when you move to ultimate causes, that is in the hands of the patient, that's not in the hands of the doctor.

James: Yeah. Agreed. 

Mark: Okay.

James: Yeah, definitely. So we're seeing different amounts of like physician excitedness about health, you know, handing over that power. 

Mark: Yeah.

James: And, ultimately, like, you know, for the last four years, we've been advocating for a physician-entrepreneur model, right? Physicians starting these practices, hiring health coaches, and starting to build this stuff, and we've been providing all the support to do that. Part of the reason why we're sort of hedging our bets and building now Knew Health, which is my new project, is because, you know, I think that the way that this will actually happen is that the system will be set up that, you know, the coaches do the coaching and the doctors do the doctoring.

And rather than relying on doctors en masse to get this and feel confident enough with their own finances and their own clinic to like do this in the right way...which some have taken on, but it's not moving nearly quickly enough for my liking. I feel like the way that this will actually happen is when all of the people in that system, the doctors, the coaches, and otherwise are employed, are employed by a business that does it that way…

Mark: Right.

James: …and they just come in and do those jobs, rather than the entrepreneur model which has limitations.

Mark: So you bring them all under the one umbrella. You kind of expand the options available to the patients and to the people seeking care rather than focusing on the entrepreneurial doctor who drives the whole thing from a personal perspective. Is that a kind of concept that you take your business skills, you take your health coaching skills, you take them all, and you take it away from medical-driven demands, the kind of high-cost medical care, and take it back out to simpler things that are sustainable, take it away from the consultation and put it back at an affordable price? Is that part of it?

James: It's more like, "Take everything that you've learned and build a system that only lets you do it in that order, and then get the right people in the right seats on the bus." 

Mark: Right.

James: So, like in our system, we basically took our own advice. So how do we start? We start with content. Everyone gets access to free content on how to keep yourself healthy. Some people don't know this, right? And for those people who don't know this, this is like a wakeup call…

Mark: Right.

James: …and a certain percentage of those people will make the changes by themselves to keep themselves healthy. Now, you know, that's just the information. If that doesn't work for people, and they need help in actually executing on that information, now we have group visits and community. Now we have coaching as two much cheaper layers that people can do…

Mark: Right.

James: …to start doing the healthy behaviours. And then if and only if they're not getting better with that combination of services, then you can get into, you know, the doctor-driven functional medicine where the doctor is taking time with the patient. But, ultimately, the doctor taking time with the patient, for anyone who hasn't gone through those first stages, is just… the chances of that structure reducing cost are minimal. Because seeing a functional medicine doctor can be more expensive.

Mark: Yeah.

James: Because the tests can be more extensive and the supplements can be more expensive, however, not compared to a lifetime dependence on medication.

So, you know, it's still cheaper, but it just needs to go in the right order. And so, ultimately, without the Knew Health, we decide what order the patients go through, and ultimately we create the structure that they need to follow, and our doctors are, you know, independent contractors that are only brought in at a certain point, and the patients that they're going to work with are already being coached and already being educated. 

Mark: Ah, okay.

James: And the health coaches are employed by us, and we hold them accountable to getting their members accountable to their own goals and actually starting to facilitate healthy behaviours.

So my feeling is that this is going to increase the speed of change because, you know, I don't think that most doctors want to be entrepreneurs. I think they just want to do their job helping people recover. It's just that the only way to do functional medicine was in private practice. And so you kind of had to become an entrepreneur in the version one of this, but version two is a lot more organised and a lot more structured. And, ultimately, there's an organisation and a system behind it and not just hoping the physician-entrepreneur is crushing it.

Mark: Now, did the doctors sign up to this? So this is the move from functional medicine 1.0 to 2.0, of creating a broader environment where the doctor is part of a team rather than the driving force behind it. How do you find the doctors to do that? Are these people that come from, say, nutritional, environmental, lifestyle medicine? Are they looking for a coordinator to make their practice run efficiently, or do you go searching for these people?

James: Yeah, so I would say, first of all, you know, I'd characterise these numbers like this. Functional medicine 1.0 was just everyone doing their own thing and hoping for the best. It's just like the early days. 

Mark: Right.

James: Functional medicine 2.0, which I believe we've been in for the last few years, is learning from those people who have done it right and to make the physician-entrepreneur model a lot more efficient. So now you've got people like, you know, Chris Kresser, and Dan Kalish, and me, and Sachin Patel, and other people, you know, showing how to build these practices from the physician entrepreneur model. 

Mark: Right.

James: What I think we're entering into now is functional medicine 3.0 which is like systems arriving, like medical systems arriving, that want functional medicine as their operating system where they now employ the coaches and doctors to facilitate the care.

And, yes, there's a ton of doctors. For every doctor that's been able to make it in functional medicine as an entrepreneur, there's has maybe 5 or 10 doctors who have tried it, or thought about it, and have not sort of either had the courage or have like fallen flat on their face as an entrepreneur, and don't want to try again…

Mark: Yeah.

James: …and are waiting for an opportunity where they can just get paid to do it like they get paid by their group, or a hospital, or otherwise, where they're just getting a salary and they're getting to do this medicine the right way. 

Mark: Yeah.

James: And, ultimately, that's the next phase and that's what I'm trying to kick off now, because I believe in functional medicine 2.0, but I think it's necessary, but not sufficient, to get us where we need to go.

Mark: So that, I mean, that fits with the data here of when you look at the number of doctors educated in the different areas of non-orthodox Western medicine. For the thousands and thousands educated in Australia, only many hundreds, you know, probably under 1,000 doctors, actually devote their life to their practice, because there is no model to make it work where they don't burn out. A lot of functional medicine doctors burn out because they are so committed to their own view, and they do it solo with skills they don't have. They almost need a capture net, something to cocoon them to make it safe.

And once that is there, young doctors come through and can make a career out of doing that. Whereas, generally, you don't make a career out of that, you'd be a good doctor in a hospital. You exit, you discover then that medicine is not as fulfilling as you thought it was and not as effective, and you go your own way. Bringing them together seems to be an opportunity for that functional medicine 3.0. You get the technologies, you get the groups together, you get financial kind of stability, and then doctors are back in the safe area that they're used to if they just do orthodox medicine, and so it's a facilitator for change that seems to be a very powerful way of making practices work.

James: Yeah. No, look, you've got the same issues in Australia that we have in America. You know, the number of doctors that have ever been trained versus the number of doctors that are actually doing it every day is a ratio that we need to improve.

Mark: Yeah.

James: And those doctors want to do it too. Like, at some point, they felt a moral obligation to learn about it. The way Jeff Bland refers to it as they've, like, "caught the virus." I caught the virus that there's a new way to do healthcare. And so, ultimately, we just need to try and make the easy for those guys to do it, and so I'm excited about it.

Mark: Yeah. And there's an interesting observation here. Australia is different because, I mean, disease is free and health is costly here. And I think the difference is, in America, disease is costly and medicine is just costly over there. But there's one area here, lifestyle medicine, the American College of Lifestyle Medicine's been over here in this on Australian Society of Lifestyle Medicine. And I noticed, in the last couple of years, it's attracting normal orthodox primary care physicians in large numbers, whereas integrated medicine, nutritional medicine, you know, supplemental medicine, there's always been a barrier between the profession and those groups.

But there's something about lifestyle medicine, diet, exercise, lifestyle psychology, all of that, which almost is attracting doctors from their general practice, sucking them in. They're learning the basics of lifestyle medicine, and there's no fight between lifestyle medicine and the orthodox profession. Is that something that you've noticed or is there other battles, lines still drawn there?

James: You know, what I've seen is that, you know, there is definitely...there's many battles going on. What I've seen in America is a drastic reduction in the number of times that doctors are being, like, called up in front of their medical board for practising the non-standard of care…

Mark: Right.

James: …physicians particularly. So I've seen that it's sort of like, you know, there's less issues. Like, 10, 20 years ago, this was a regular occurrence. You go outside the box, you're going to get your hand slapped and maybe you lose your license. I think that's not happening now. I think there's a greater sense of confidence from these physicians that they're changing the world, and changing the health of their community, and doing proactive care. And most people have sort of recognised the need for this kind of care. So I think that's a model, so I don't see that sort of embittering.

What I do see is, sort of, definitely some scope of practice issues. So, like, in the U.S., there's certainly issues where chiropractics are being, you know, taken to court for essentially practising medicine without a license, where they've been doing functional medicine for 20 years, and now, you know, are being called up because they're not physicians and they're not licensed to practice medicine. And so, I've seen that kind of thing happening and sort of battles in that direction. But, overall, what I see is just most physicians who are on the front lines and who aren't, you know, radical specialists, right, who aren't specialists in...who aren't so far down the chain in medicine that they're just seeing like one type of patient. But generalists, internists, you know, people on the front lines, primary care, definitely recognise the drug therapies for lifestyle-caused diseases is like, is not a sustainable solution.

And some of them are just sort of like, you know, digging their head in the sand and, you know, getting on with their day-to-day, and feeling badly about it. Some of them are committing suicide…

Mark: Wow.

James: …and some of them are like taking action to learn about what to do. And so, you know, I see it even in the UK. You know, earlier this year I was at a conference where there was 250 GPs at a conference. You could only be a GP, no nutritionists, no therapists, whatever, run by Dr Chatterjee. And the energy there was incredible…

Mark: Right.

James: …especially the younger doctors. The young doctors were really like, "Oh, this world is changing and we need to get ahead of it." So now the number of doctors that have like Instagram accounts and are trying to be like lifestyle medicine gurus is going through the roof, because they realise that this change is happening and they want to be on the front end of it.

So I'm pretty excited by the way the things are moving, and ultimately, you know, we're still ahead of the curve here. And so, I think a lot of people are just trying to work out, you know, how to be a an agent for transformation in a way that is valuable to everyone in the ecosystem, and ultimately our goal with Knew Health is the growth ecosystem.

Mark: Yeah. I just wanted to get you to kind of look in your crystal ball, just project a little bit. I know that there's this idea of predictive, preventive, personalised, participatory. I mean, you have the three Cs and you have the four Ps. How far can we go with that? Is this really a new medicine now that...? Let's take an example, genomics and genetics. We're now able to do things that, 10 years ago, were just in the fantasy world. We can look into the genome of people and we can start to look for tendencies and, in a sense, ultimate causes. How can you incorporate that, that high tech, extremely high tech and complexity, how do you bring that into a functional medicine practice? Is there a technique and a way that you've developed for that?

James: Yeah. I mean, the first off is like, "Do it at the right space," right? Do people need their genetic info to start to implement lifestyle behaviours that they never implemented? Like, probably not. Like, if you're not doing the lifestyle behaviours, which 99% of people aren’t…

Mark: Right, there’s no point.

James: …if you're not eating well and if you're not resting and relaxing, you don't need a genetic workup. 

Mark: Right.

James: So, you know, let's only go to the genetic workup when it's become clear that you need to go deeper and there's something, you know, holding up. So first of all, "Do it in the right place," I think, is the first thing.

And, look, you know, predictive P4 medicine, Predictive, Preventative, Personalised, and Participatory, it's cool. It's a great concept, and I use it in my book to, like, help doctors understand this. But the truth is, you know, it's an aspirational, it's an aspiration, P4 medicine, right? There's no system out there that teaches you…

Mark: Right.

James: …to do P4 medicine, and that's why we chose the word functional, because functional medicine is an operating system. It is a system that everyone uses and does things the same. It prioritises intervention. So I think, you know, the way in which personalised, predictive, preventative is going to be delivered is through functional medicine. 

Mark: Right.

James: I feel like functional medicine is the operating system for P4 medicine. You know, but like the words, P4, those words, they're aspirational, they're not a real thing. There's no doctors who are like doing P4 medicine now and calling it that. And if they are, they're not doing it the same as the P4 medicine guy down the road. 

Mark: Yep.

James: That’s how you create scale. You have to have people doing it the same way. And so, ultimately, that's why we bet on functional medicine. I think there's other people that are trying to, like, facilitate it, and simplify it, and organise it better. But, you know, we're getting there, and I think that we are seeing a time where that kind of medical system is possible. But in order to make it affordable for more people, we just have to do things in the right order.

Mark: And that's where functional medicine steps in to say, "Here's the operating system." Like an operating system, the logic of it is you move in at this point at low-cost, wide availability, and then as needed you move along that line so that you may end up looking at the genetics of a person, say, with cardiovascular risks, you may look at particular things, but generally you can deliver prediction, prevention early on just by a good family history, by a good medical history, by a good physical examination. You can see things going on, but you can't easily do it in a 10-minute or 15-minute consultation.

So there is a time issue here, and I'm interested in how you see that breaking down. A doctor is a limited resource, only, you know, maybe 10 hours of work in a day at the most. They have to be used efficiently for what they're good at. How do you distribute that workload to other people in your team to do that predictive part? Do you do questionnaires? Do you do health coaching? Do you get into other areas? What's your mechanism for getting the most information and the most prediction and prevention without involving doctors at high cost?

James: Yeah. I mean, ultimately, just want to be talking about all the way along here is you've got to use different providers. 

Mark: Yep.

James: You know, you've got to use the power of community and coaching, and you've got the doctor... Like, in my opinion, the doctor should be really there for only those people who need to go deeper…

Mark: Right.

James: …who are on multiple medications, whose case couldn't really be managed by someone without medical training where there's the potential of acute issue. So, you know, I think that's an important part. We need to use the doctors where they're necessary.

And, yeah, functional medicine is an operating system for getting to the root cause of chronic conditions, but the ideas of, you know, using the least possible intervention to try and get the most effect, that's actually a concept from naturopathic medicine. That's called the therapeutic order.

Mark: Right.

James: And all I've done in the last 13 years is like looked around and seen what was valuable. I see that functional medicine is useful because it's a way that everyone can operate the same to get to the root cause and have sort of a common language. But, like, that idea from naturopathic medicine of the therapeutic order of using the least costly, least invasive methods first and then working your way up to the most costly, most invasive, that's just an idea whose time has come. I don't think it matters who came up with it, but ultimately, whether you're accountant, or whether you're a patient, or whether you're just someone who cares about the reversal of chronic disease, starting always with drugs and surgery is definitely proving to be a costly error…

Mark: Yeah.

James: …in how we're delivering medicine, and we need to fix that as soon as possible.

Mark: Again, you may not know this, but Medicare is the taxpayer-subsidised system in Australia. It has one of its definitions, there are a few exceptions, but Medicare pays only for the treatment of established disease and disorder. There are a few little side things. In 40 to 45-year-olds, you can do prevention, you can do Pap smears, you can do a few things which would be considered predictive and preventative, but it specifically excludes everything that I think you would regard as functional medicine, predictive, preventive. The entire area is left to, "Well, that's your responsibility, but when you fall over we'll pay the much higher price of medicine at the end," and that has disabled Australia, when it comes to doing something powerful in prevention, it's really difficult to shift that mindset that medicine works best when it's treating an established disease in a 15-minute consultation. Changing the mindset has proven incredibly difficult over 30 years here. I don't know if you've ever run into that problem, but it is actually cheaper to get sick here than it is to stay well.

James: No. Yeah. I'm 100% aware of it. 

Mark: Right.

James: So, like, yeah, 100%.

Mark: How do you break that? How do you break that in a population?

James: Ultimately, if we're sitting, waiting for someone else to give us permission to do things in the way that we know they should be done…

Mark: Right.

James: …we are going to be waiting a long time, right? We are going to be waiting a long time for the powers that be, with all of their vested interests, to give us a shot. And if they do give us a shot, it'll be on their terms and it'll be a mess.

Mark: Okay.

James: Australia has a little bit more, you know, has its own things going on, but like, in America… So ultimately, you know, why I'm doing what I'm doing right now, driving in a bus around America to launch this alternative to health insurance, is because what I see is available to America at this exact moment is for us to start a whole new, separate ecosystem in healthcare where we make the rules, and we do primary prevention, and we come up with whatever plan it is, and we showcase the power of this medicine and these concepts to be able to keep the population healthy. 

Mark: Right.

James: And this is a big project that I'm going after. But that issue that you raise where these people think mammograms is, you know, is predictive, preventative health, it's not at all. 

Mark: Yeah.

James: You know, predictive, preventive health is like eating well, exercising, sleeping well, and all those kinds of things, and we know that, and it's so obvious, but why aren't people doing it? Because, you know, because there are structures impediment into the system. And, ultimately, I'm bored of waiting for like, Congress to pass a law, or for doctors to get it when they've been literally conditioned in a bootcamp, which is medical school, to be against all of these things, right?

I'm not going to wait for these guys to get it. We're going to build a new system. There's enough doctors now that want it. We're going to create demand for the doctors that want to practice it, we're going to employ the health coaches, and we're going to create a new system that makes the existing system obsolete. And I'm not going to apologise for it, and we're just going to do it.

Mark: That's a great way of moving.

James: Yeah. Everything that you're saying, you just got to do it. And like there's not the opportunity to do this in England, right? 

Mark: Right.

James: Coming up with your own crazy alternative to health insurance is not a good idea when everyone else has got socialised medicine, because no one's going to buy it. The way that I think that this will roll out in England is with a public-private partnership, because the issues are the same in every country. If you treat chronic disease the way you treat acute disease, you run out of money very quickly, and everyone's facing it. 

Mark: Yeah.

James: Australia’s facing it, UK is facing it, America's facing it, Canada's facing it, every advanced nation is facing it. So my feeling is that, you know, we need to find ways to showcase the power of this medicine, when done in an efficient way, to reduce the cost of care and to keep people healthy. And in America today, could you imagine a more fertile ground for this revolution? You've got 7% of people who trust their health insurance company. That's a lower rate than Congress. You know, you've got a 86% of healthcare costs being driven by lifestyle-driven chronic disease, which is totally, you know, preventable and reversible. 

Mark: Yeah.

James: And you've got this like absolute mess of a healthcare system with the ACA, the prices going up, and deductibles going up, where most people are ending up having to pay cash for health services. You have a complete lack of trust in the system. And we think that this is the opportunity, the best opportunity on the planet right now…

Mark: Right.

James: …to be able to do something transformative, to bring this type of medicine to the front, and that is Knew Health. It's knew with a K, knewhealth.com, we're launching an alternative to health insurance where functional medicine is the operating system of care. And we're going to keep everyone out of the health system that's so expensive. And if we do go into the health system, we're going to negotiate every bill down for the cash rate. 

Mark: Aha.

James: And that's why it builds on an operation of health cost sharing, and it's been proved out by a million Christians who use it. And now our goal is to take it from a weird thing that a few Christians use to a natural extension of the sharing economy, which is happening in every other sector of American health…

Mark: Right.

James: …or in American society. And that's what we're doing. And it's in response to exactly what you said, is that there are just things that people don't get, and that it's like they're paid not to get them, and if we're waiting around for them to get them, it's going to be a long wait and it's going to be super frustrating. So we're going to just build a new system.

Mark: So are you working with the insurers and the health maintenance organisations? Are they partners or are they involved in this, because they seem to have a vested interest in keeping costs under control?

James: No, they don't. That's the fraud. They do not have that. So maybe in Australia they do, but let me just share this with you now. I think it's pretty obvious to everyone that hospitals and pharma do better when they sell more of their thing…

Mark: Right.

James: …fill beds in a hospital better, more drugs better. Now, what you think is that insurance has the opposite of incentives where they want to control costs, because what's your experience with them? Oh, they denied one of your claims. So it must be that, like, they want to control costs by not paying out. In fact, the opposite is true.

And the fact is that in America, and this is maybe not the same with Australia, but in America, as a result of the Affordable Care Act, essentially, the business model of health insurance companies reverted to something very similar to cost plus, where they could only make 20% of the premium as profit. And, therefore, you know, what they want, is they realise that 20% of $100 a month and 20% of $1,000 a month is a different number. 

Mark: Right.

James: And so, ultimately, their goal is to actually get the insurance premiums to be as high as possible, and that's why you see double-digit growth in health insurance premiums every year, and in some cases triple-digit growth. It went up by 110% last year in Arizona, health insurance premiums went up. So there's nothing controlling the costs.

And, you know, I've wanted to point out this scam to people for eight years, but five years ago I decided I was going to wait until I'd built a better system. So just pointing out the scam and saying, "Hey, this is a scam," now I can say, "Hey, this is a scam. Here's an affordable alternative." That's the journey. That's what we're doing. And, ultimately, people need to understand the economics behind the system. Because if you don't understand it, then you make assumptions about it that would help you assume, "Oh, someone must have this worked out, someone must have it together."

So, no, we're not in business with the insurance companies, and I hope that in the next three years we end up making a dent in their business, and whether we do or not remains to be seen.

Mark: So what's the commercial model? How do you make money by making healthcare cheaper? Is it just the drive comes from your desire to do good, or there still has to be a business model? A friend of mine once said, you know, "Ben Franklin got it right in America. If you don't have a business, well, if you can't make a profit, you will die in a commercial field." How do you make money in functional medicine?

James: We found the first business model, where we, actually, where people stay in the business when they get better.

Mark: Right.

James: Which is one of the biggest problems with cash or any of these models, where it's like once people get better they go out and then you don't make money from them. 

Mark: Right.

James: But you don't capture the value of the service that you provide, because as soon as they're well, they're off and they're just spending their money on Starbucks again, right?

Mark: Right.

James: So, you know, so that's been a problem. So our model is essentially community health cost sharing, where a community of people decide how they're going to share their health costs. And, you know, ultimately, it's a system that's like insurance except you never pay the high insurance rates, you just pay the cash rate. 

Mark: Okay.

James: And, ultimately, inbuilt to our prices is the health coaching services. And, essentially, if you're well and you don't use those health coaching services, you know, we have a certain amount in the price that's built-in for those services. And so, if people don't use those services, we're making money for people not using services they're paying for. And why don't they just quit paying? Because we're providing a service for them…

Mark: Right.

James: …which is covering them in the case of an emergency, and they don't want to uncouple from those services, and our services are way cheaper than health insurance.

Mark: Yeah.

James: And so they don't want to leave to go back to health insurance because they'd have to pay more. So I found the perfect business model for the delivery of care, and it ultimately is a fully contained ecosystem that includes insurance-type products and care. And ultimately, you know, that's what I've been waiting for. And that's what this industry needs, is the business model where everyone is incentivised to create health, right?

Mark: Right.

James: The patient is there and is inspired and incentivised to get healthy and stay healthy. And then if you get healthy and stay healthy, the more independent you become, where you know exactly what to do to keep yourself healthy and you have a whole range of, you know, things under your belt to know what to do when this happens or what to do with that happens, the more independent and self-reliant that people become, the less that it costs for them.

And then if they then want to help their fellow man get healthy, so if they're now participating in the community structures and whatever, if they help other people stay well too, then it reduces the total cost of the pool. 

Mark: Right.

James: And, ultimately, here's the thing that has never been done, is that if you work hard to get healthy and help other people stay healthy, you know, you are now financially benefited from that process. And that's, you know, that's why health cost sharing, a transparent health cost sharing system has to be the wave of the future, because now everyone's incentivised not just to keep themselves well, but to help their fellow man.

Mark: Okay.

James: And that is an evolutionary priority that has not been part of our system for healthcare in the modern era.

Mark: Yeah. It’s transformative, but as you would know better than anybody, medicine has a kind of inertia about it that makes change very difficult, to put it mildly. When you come in with a new system like that, that threatens a financial model that runs to the trillions of dollars, do you expect pushback? I'm guessing you already have had pushback. Can you sustain yourself against the, in a sense, the might of my own profession, that it likes things to be very, very profitable, very, very simple, very, very proximate in causes? Can you change the mindset of the public, or are they changing anyway and you're just there to accept them as the kind of new realisation about health?

James: Well, we're going to accelerate that realisation. We're going to give them a product that is better than what they already have. And, you know, whether or not they get it in the medium term, we'll see.

Mark: Okay.

James: And whether or not, you know, if we make a big enough impact. Here's the thing. In my system, doctors get paid cash at time of delivery. Don't you think doctors prefer that to insurance, or do you think they want to do insurance? 

Mark: No.

James: No, they prefer cash. So like, you know, we've created this system from the doctor's perspective. We spent the last five years building the doctor network, so I know intimately how, you know, how to make it work for the doctors. And, ultimately, you know, we've created something that we think works for the payer, works for the patient, and works for the doctor.

Mark: Okay.

James: And we're excited to see where it'll go.

Mark: Now, if you just project forward, say five more years, I mean, we're maybe a bit further away from that here, but in five years time, a person coming to see a doctor within your model of Knew Health, a person comes sick, or do you go out looking for healthy people to keep them healthy? Is it a presentation, opportunistic, or are you marketing to the public to say, "Here's our model for keeping your health?"

James: Yeah, like, we will, you know, at the beginning of this, in five years... Like, right now, you know, our first product is going to be solely for people who have insurance through the individual insurance market. You know, in five years' time, we'll have products for people who qualify for Medicare and people who are in larger medical systems. And, you know, we'll have taken a chunk out of the market as far as like, you know, facilitating people's health. So that's where we're going.

Mark: So our listeners are largely practitioners for this podcast. I imagine they're thinking what I'm thinking, "How do I join in this system? How do I become part of a coordinated health care delivery system rather than a kind of fragmented disease care system of passing on referrals when you run out of ideas?" Can you bring this to Australia? Do you think this is something that you have got like, a decade in America to work through before you deliver it to England, Australia, or other areas, or is this doable soon?

James: No, this is happening. So I would say, you know, give us two years to turn the sort of hodgepodge delivery of care between doctors and coaches into a super streamlined app. And then with that app we'll be able to then go for business and work with, in this case, like the Australian government directly, go to the Australian government and say, "Hey, you know, you’re already spending, on these 10,000 Crohn's patients, you're spending $100 million a year, and we think that we can get better results for only $75 million. 

Mark: Right.

James: Give us $75 million and we'll take care of them." And then we will use our system of education, and groups, and coaching, and functional medicine to be able to get all those people where I'll get a large per cent of them off medication and, you know, have a business there.

Mark: All right, so you build the evidence for prevention. So you're effectively saying, "We'll build the evidence." And in doing what you are doing in, say, Knew Medicine, I'm hoping that you're gathering all the data to demonstrate the effectiveness. In fact, I'm sure you will be, because you're an economist and you use the technology. So that gathering of your information is a critical part of what you do to project into the future.

James: Yeah, no one's tracking their outcomes, no doctors. If there's doctors who are listening to this in Australia who've been tracking their outcomes, I'd love to speak to them. I don't see anyone tracking their outcomes. 

Mark: Right.

James: It’s a big problem for our profession. And so, yeah, we're going to do it the right way because we're going to control it, because we're going to be employing the doctors, employing the coaches…

Mark: Right.

James: …giving them the protocols, and we'll build the evidence base across tens of thousands of patients.

Mark: Don't doctors in America, don't they love their freedom? Like, when you say, "Employ the doctors," it brings up, in my mind, the kind of British NHS system of you become just cogs in a machine, and the very thing that drives doctors to wanting to be individual is also their weakest point. How do you herd cats?

James: You know, those doctors that really value freedom above everything else can have their freedom and build a private practice doing whatever they want. 

Mark: Right.

James: I think, my feeling is that if you have doctors who are employed, who also are every day reversing chronic disease, holding people accountable, and building and delivering the kind of health care that they believe in, I think freedom is not the most important thing. I think congruence with their values is the most important thing.

Mark: Right.

James: It's just in order to have congruence with your values you had to have freedom, because you couldn't work inside the system doing this, so we've got to build a new system. That's it.

Mark: James, thanks so much for joining us today in FX Omics. It's been a real pleasure and a delightful introduction to what is, I guess, the future of medicine and functional medicine in our country as well.

James: All right. Thanks so much. I appreciate it.


Other podcasts with James include


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James Maskell

James Maskell is the creator of Functional Forum, the world’s largest integrative medicine conference. He lectures internationally, and has been featured on TEDMED, Huffpost Live, TEDx and more, and is a contributor to many major news outlets. His organization and book of the same name "The Evolution of Medicine" prepares doctors for the next era of predictive, preventive, personalized and participatory medicine.