WEBVTT - Medicare’s Hospital-at-Home and Other Reforms 0:00:11.760 --> 0:00:14.079 Hello, and welcome to another episode of the Votes and 0:00:14.200 --> 0:00:18.680 Verdicts podcast, which examines the intersection of business policy and law. 0:00:19.920 --> 0:00:22.480 My name is Duwayne Wright, and I'm a senior healthcare 0:00:22.560 --> 0:00:26.760 policy analyst at Bloomberg Intelligence, the in house research arm 0:00:26.760 --> 0:00:31.120 of Bloomberg LP. I'm looking forward to this discussion today 0:00:31.200 --> 0:00:35.959 because we'll focus on healthcare delivery system reform, specifically the 0:00:36.000 --> 0:00:38.960 hospital at home program, which took off dramatically during the 0:00:39.000 --> 0:00:42.920 COVID nineteen pandemic. To walk us through this, and we 0:00:42.960 --> 0:00:46.000 have Mark Braither, a leader at the forefront of change 0:00:46.000 --> 0:00:49.440 in the healthcare system. Mark is the co founder and 0:00:49.520 --> 0:00:53.559 executive chairman of Dispatch Health and has a deep background 0:00:53.640 --> 0:00:57.960 in business and hands on healthcare delivery. Mark, welcome to 0:00:58.000 --> 0:00:58.680 the podcast. 0:00:59.160 --> 0:01:00.040 Thanks for having me to. 0:01:01.520 --> 0:01:04.440 Now, before we dive into this topic, can you give 0:01:04.480 --> 0:01:07.720 us some background on Dispatch Health, which, as I said earlier, 0:01:07.760 --> 0:01:08.440 you co founded. 0:01:09.280 --> 0:01:14.559 Yeah, so, Dispatch Health has been around for almost a decade. 0:01:15.319 --> 0:01:18.840 At its simplest, it's a system of care that allows 0:01:18.880 --> 0:01:22.200 for the safe and effective provision of high acuity care 0:01:22.200 --> 0:01:24.960 in the home. So that's care that substitutes for an 0:01:24.959 --> 0:01:29.360 emergency department, substitutes for a hospital award admission or a 0:01:29.400 --> 0:01:34.200 skilled nursing facility admission. We can also bring in laboratory 0:01:34.560 --> 0:01:37.920 capabilities as well as X ray and ultrasound to your home. 0:01:39.120 --> 0:01:41.640 We've served I think over the last decade, more than 0:01:41.680 --> 0:01:47.040 a million patients and we do that across thirty states 0:01:47.280 --> 0:01:51.200 and during that time, the way that we've structured our 0:01:51.320 --> 0:01:53.720 care is that we do it in a way that's 0:01:54.240 --> 0:01:57.600 more cost effective than the building. So we've delivered almost 0:01:57.600 --> 0:01:59.960 a billion and a half dollars of medical cost savings. 0:02:01.000 --> 0:02:04.680 And so not just the co founder and executive chairman 0:02:05.080 --> 0:02:09.520 of a company, you have a deep healthcare background in 0:02:09.560 --> 0:02:15.480 your board certified emergency specialists, So what was the spark 0:02:16.080 --> 0:02:20.720 that led you to create a company focused on delivery 0:02:20.720 --> 0:02:24.160 system reformat in how we provide healthcare? 0:02:24.600 --> 0:02:28.840 Yeah, what's an old er doctor doing delivering house calls? 0:02:28.919 --> 0:02:29.079 Right? 0:02:30.880 --> 0:02:33.760 So you know, I spent I don't know two and 0:02:33.760 --> 0:02:37.440 a half decades at the bedside as an emergency medicine 0:02:37.440 --> 0:02:42.160 specialist and fantastic run. Enjoyed every moment of it, but 0:02:42.440 --> 0:02:45.600 was ultimately sort of drawn into the business side of 0:02:45.680 --> 0:02:50.120 healthcare and towards the end of my career helped create 0:02:50.680 --> 0:02:55.280 the largest clinically clinician owned staffing company in the country. 0:02:55.360 --> 0:03:00.760 So that's a company that provides er specialist hospital and 0:03:00.919 --> 0:03:06.200 extensivest people who staff skilled nursing facilities to hospitals. And 0:03:06.240 --> 0:03:09.520 so I learned a lot during that run. Ended up 0:03:10.040 --> 0:03:13.040 managing the West and for us that was about sixty 0:03:13.080 --> 0:03:19.000 four hospitals, somewhere close to fifteen hundred clinicians. But a 0:03:19.000 --> 0:03:22.040 few things started to concern me. And again this is 0:03:22.120 --> 0:03:26.360 probably twenty eleven or so. The first thing I noticed 0:03:26.560 --> 0:03:30.399 was we were so far off of our healthcare consumer, 0:03:30.680 --> 0:03:34.600 our patients expectations when it come when it came to pricing. 0:03:34.760 --> 0:03:38.440 So I was the recipient of a lot of complaints 0:03:38.520 --> 0:03:40.600 on my desk about the cost of care and the 0:03:40.680 --> 0:03:43.840 time with the clinician. And that had changed dramatically since 0:03:44.320 --> 0:03:46.960 I was a young resident in the nineties, and so 0:03:47.240 --> 0:03:48.960 I wasn't sure what I was going to do about that, 0:03:49.080 --> 0:03:54.120 but I wanted to do something that improved that issue. Secondly, 0:03:54.400 --> 0:03:58.000 was the concept of value based care. So in twenty eleven, 0:03:58.040 --> 0:04:01.320 we were still debating whether this was a a thing right, 0:04:01.360 --> 0:04:03.320 whether this was going to happen again. I was there 0:04:03.320 --> 0:04:06.040 in the early nineties when we tried it, but the 0:04:06.160 --> 0:04:08.840 second round, to me, looked like it could actually work. 0:04:08.920 --> 0:04:11.200 And if it did work, you'd have more and more 0:04:11.320 --> 0:04:15.000 patients in paneled to these smart primary care docs who 0:04:15.040 --> 0:04:18.159 would try to navigate patients to the appropriate side of care. 0:04:18.320 --> 0:04:20.599 And I knew that there was a ton of patients 0:04:20.640 --> 0:04:22.880 that I treated on a daily basis that could be 0:04:22.880 --> 0:04:25.599 treated elsewhere. And I think the thing that really moved 0:04:25.600 --> 0:04:29.159 me forward was that I had some family members and 0:04:29.320 --> 0:04:33.200 elderly family members that went through hospitalization a post acute 0:04:33.200 --> 0:04:36.160 stay that did not go well. They went really poorly, 0:04:36.720 --> 0:04:39.880 and I just saw the other side of that, and 0:04:39.960 --> 0:04:42.520 I think I had a little existential moment where I said, 0:04:42.760 --> 0:04:45.440 have I been doing that? Have I been putting patients 0:04:45.560 --> 0:04:51.240 in the hospital and maybe to their detriment? And the answer, 0:04:51.320 --> 0:04:53.400 if I was honest, was yes. And so I began 0:04:53.600 --> 0:04:56.480 looking for an alternative, and I wasn't sure what it was, 0:04:57.120 --> 0:05:00.279 but I reached out to some people who began publicishing 0:05:00.320 --> 0:05:03.440 this concept of hospital at home in the nineties, a 0:05:03.440 --> 0:05:06.119 guy like Bruce lef out of Hopkins and al Sioue 0:05:06.200 --> 0:05:09.360 out of pen These were Maverick geriatricians who were doing 0:05:09.400 --> 0:05:12.720 something different. I was also being done in other countries, 0:05:12.720 --> 0:05:15.480 but they were sort of the leaders in publishing in 0:05:15.960 --> 0:05:18.440 the States, and it looked really compelling to me. It 0:05:18.480 --> 0:05:21.880 looked like we could get lower costs and patient satisfaction. 0:05:21.960 --> 0:05:24.520 But importantly, there was something about it that looked like 0:05:24.560 --> 0:05:28.560 we could get more efficacy, we could get better clinical outcomes. So, 0:05:29.080 --> 0:05:34.000 like most naive folks when you're first starting out, I thought, well, too, 0:05:34.720 --> 0:05:39.159 I've managed ers, I've managed hospitals, I've managed post acute facilities. 0:05:39.160 --> 0:05:42.360 I could just do this in the home. So it's 0:05:42.400 --> 0:05:44.839 been much more of a daunting task than that. But 0:05:45.560 --> 0:05:48.320 that's the premise of dispatch, is that we would take 0:05:48.600 --> 0:05:51.080 what we could out of the emergency department, out of 0:05:51.120 --> 0:05:54.000 the hospital, ward, out of the post acute facility, delivered 0:05:54.120 --> 0:05:57.839 in the home for lower cost, better outcomes, and better satisfaction. 0:05:59.279 --> 0:06:02.800 And you mentioned and you're in thirty states. Now, how 0:06:02.800 --> 0:06:06.640 did that start? Was there an anchor and then you 0:06:06.800 --> 0:06:07.680 grew from there? 0:06:08.000 --> 0:06:12.280 Absolutely, it's a great question. So I practiced in Denver, 0:06:13.440 --> 0:06:16.200 and I was also an EMS medical director in Denver. 0:06:16.680 --> 0:06:19.479 And the reason that that's important is at about that 0:06:19.640 --> 0:06:23.240 time there was a concept growing up called paramedicine, where 0:06:23.279 --> 0:06:26.440 the paramedics would practice it the top of their scope 0:06:26.440 --> 0:06:30.200 of license and that's still going today. And so we 0:06:30.240 --> 0:06:33.720 started one of those early programs. But I said, during 0:06:33.760 --> 0:06:35.960 this whole journey, in the back of my head, could 0:06:36.000 --> 0:06:38.719 we not create a mobile er? Could we not do 0:06:38.800 --> 0:06:41.080 that respond to the nine one one phone call and 0:06:41.120 --> 0:06:44.279 treat a patient in place? And so that really was 0:06:44.360 --> 0:06:47.679 the beginning of it. We created a very forward thinking 0:06:48.040 --> 0:06:51.719 fire chief named Rick Lewis and I and a few 0:06:51.720 --> 0:06:55.560 other folks built this mobile er and started treating patients 0:06:55.600 --> 0:06:58.720 in lieu of a transport to the hospital. We did 0:06:58.760 --> 0:07:01.520 that for two years. In the data it was extremely compelling, 0:07:02.400 --> 0:07:04.719 and so we took that to our first payer partner 0:07:04.960 --> 0:07:07.200 and said would you pay for this? And they said yes, 0:07:07.320 --> 0:07:08.679 And that was the beginning. 0:07:10.760 --> 0:07:14.960 And so you had mentioned earlier as you were starting 0:07:14.960 --> 0:07:18.560 this company some of the conversations you had with folks 0:07:18.560 --> 0:07:22.440 who have focused on hospital at home for a while. 0:07:22.600 --> 0:07:25.840 So it's not a new concept, but it might be 0:07:25.960 --> 0:07:29.880 new for people who haven't been paying attention. Can you 0:07:30.200 --> 0:07:32.320 kind of give us some of the history here, and 0:07:32.360 --> 0:07:35.880 then when we think about hospital at home, what kind 0:07:35.920 --> 0:07:40.920 of services are we talking about? And if you look 0:07:40.920 --> 0:07:44.920 at a hospital at home program in one state or 0:07:44.960 --> 0:07:48.960 one geography, is it the same as another geography in 0:07:49.000 --> 0:07:52.880 a different state. Walk us through how the concept has 0:07:53.920 --> 0:07:56.720 started or how it's evolved, and where we are now. 0:07:57.960 --> 0:08:00.040 And the first thing I would say is that a 0:08:00.840 --> 0:08:05.840 hospital at home Moniker is a bit of a misnomer, right, honestly, 0:08:05.880 --> 0:08:08.400 doesn't necessarily have anything to do with the hospital. It's 0:08:08.480 --> 0:08:12.000 part of a macro trend that we've had since the seventies, 0:08:12.040 --> 0:08:16.880 really where we've moved care that is in that higher acuity, 0:08:16.960 --> 0:08:21.280 higher cost setting into the ambulatory setting. And you know, 0:08:21.360 --> 0:08:24.200 I would give you the example of the ambulatory surgery center, 0:08:24.360 --> 0:08:26.920 right that started back in the seventies. And I remember 0:08:27.480 --> 0:08:30.240 even in the nineties when I was training, lots of 0:08:30.320 --> 0:08:33.600 us were very concerned about these ambulatory surgery centers where 0:08:33.640 --> 0:08:37.200 they good quality? Could you safely do it? And you know, 0:08:37.679 --> 0:08:40.440 very similar situation that we find ourselves in today. But 0:08:40.800 --> 0:08:44.000 today there's fifty three hundred surgery centers across the country. 0:08:44.360 --> 0:08:48.840 They're performing twenty million procedures annually, and it's estimated that 0:08:48.880 --> 0:08:51.880 they are saving you know, call it forty billion dollars annually. 0:08:52.760 --> 0:08:57.200 I often use another really tangible example from my history. 0:08:57.320 --> 0:09:01.240 So over the time that I practice, the standard of 0:09:01.320 --> 0:09:05.240 care changed, right, And if we talked about let's say 0:09:05.240 --> 0:09:07.200 a blood clot in your leg, you came and saw 0:09:07.240 --> 0:09:11.319 me in the emergency room, we made that diagnosis. Call 0:09:11.360 --> 0:09:14.520 it fifteen years ago. The treatment at that time would 0:09:14.520 --> 0:09:17.200 have been to admit you to the hospital on bed 0:09:17.280 --> 0:09:21.079 rest on an ivy medication called hepron. Now let's fast 0:09:21.080 --> 0:09:23.720 forward to today, and if you went to the emergency 0:09:23.760 --> 0:09:27.600 room had that diagnosis, what would happen. You'd go home 0:09:27.640 --> 0:09:30.319 in an hour on a medication, you know, a shot 0:09:30.360 --> 0:09:34.360 that you gave yourself for a pill. It's pretty interesting 0:09:34.440 --> 0:09:37.320 how we've evolved. And that's exactly what this whole hospital 0:09:37.320 --> 0:09:41.679 at home concept really is. So when people hear it today, 0:09:42.200 --> 0:09:45.200 they often equate it to the concept of the waiver, 0:09:46.520 --> 0:09:49.480 which is really a payment mechanism. It's not this delivery 0:09:49.480 --> 0:09:54.640 of the service. But during the pandemic, there was an 0:09:54.679 --> 0:09:58.280 initiative called the Acute Hospital Care at Home Initiative, And 0:09:58.320 --> 0:10:01.840 I remember getting a call from the administration one night 0:10:01.960 --> 0:10:04.760 and thinking, whoa good am? I in trouble. But I 0:10:04.800 --> 0:10:07.440 showed up the next morning and it was all of 0:10:07.520 --> 0:10:09.960 us in the community who were delivering this type of care, 0:10:10.400 --> 0:10:12.840 and they were very worried that the hospital beds were 0:10:12.840 --> 0:10:15.320 going to fill up and that they weren't going to 0:10:15.320 --> 0:10:17.520 be able to service all of the sick patients. And 0:10:17.600 --> 0:10:20.840 so I think very thoughtfully they said, well, can we 0:10:20.920 --> 0:10:24.319 take the reimbursement mechanism that we use for the hospital 0:10:24.920 --> 0:10:28.200 and just transferred to the home right and we'll use 0:10:28.240 --> 0:10:31.400 you experts to tell us what a good program looks like, 0:10:31.880 --> 0:10:34.360 and then that'll be the standard. And that really was 0:10:34.400 --> 0:10:38.120 a nice catalyst to get hospitals thinking that way, although 0:10:38.160 --> 0:10:41.000 you know, there were obviously hospitals doing it at that time, 0:10:41.559 --> 0:10:44.760 and so that was really the beginning of, you know, 0:10:45.200 --> 0:10:48.280 I think the popularization of the concept of hospital at home. 0:10:49.880 --> 0:10:52.280 So when you mentioned, you know, is it the same everywhere? 0:10:52.320 --> 0:10:54.560 So there are some standards that we put in place, 0:10:55.600 --> 0:10:59.360 you know, our program essentially, when you're admitted into the 0:11:00.000 --> 0:11:05.679 dispatch program, you are monitored continuously, you have access to 0:11:05.760 --> 0:11:08.520 our nurses and doctors twenty four to seven. You have 0:11:08.840 --> 0:11:11.720 you know, on demand rescue therapy, which would be either 0:11:11.800 --> 0:11:15.960 our mobile er units or ems UH, and then we 0:11:16.040 --> 0:11:19.199 provide all of the services that you would receive typically 0:11:19.280 --> 0:11:22.600 in your hospital stay. That could be physical therapy, that 0:11:22.640 --> 0:11:27.000 could be you know, oxygen, that could be help with 0:11:27.040 --> 0:11:29.680 activities of daily living. We bring all of that into 0:11:29.720 --> 0:11:33.520 the home and then I think importantly, our model continues 0:11:33.600 --> 0:11:36.040 for thirty days. So as you know, we have a 0:11:36.040 --> 0:11:38.640 problem in this country where we'll treat you in the 0:11:38.679 --> 0:11:41.080 hospital for call it three and a half days, discharge you, 0:11:41.640 --> 0:11:43.920 and one in four one in five times you'll come 0:11:43.960 --> 0:11:46.920 back to the hospital. So we continue to keep you 0:11:47.000 --> 0:11:50.680 on our service for thirty days, all the while integrating 0:11:50.720 --> 0:11:54.079 you back with your primary care doctor and ensuring that 0:11:54.080 --> 0:11:56.960 that care plan is continued throughout the thirty days. And 0:11:57.000 --> 0:11:59.600 so at the end about our readmit rates about half 0:11:59.600 --> 0:12:03.280 of what you get inside the hospital. And then you know, 0:12:03.400 --> 0:12:06.679 can you do this throughout the country anywhere? Well, I 0:12:06.679 --> 0:12:09.600 would tell you that it's being done in a lot 0:12:09.640 --> 0:12:12.960 of geographies today. We do this, you know, like I mentioned, 0:12:13.000 --> 0:12:15.640 I think we're in thirty states, but forty markets where 0:12:15.679 --> 0:12:19.679 we provide that on demand er substitute of care imaging. 0:12:20.600 --> 0:12:24.080 And then we have fourteen markets where we provide that 0:12:25.120 --> 0:12:28.320 ability to you know, quote unquote hospitalize in the home 0:12:28.440 --> 0:12:31.480 or recover in the home. And those are very disparate 0:12:31.520 --> 0:12:34.520 markets throughout the country, and so far we haven't encountered 0:12:34.559 --> 0:12:36.720 a situation where we couldn't provide that care. 0:12:38.640 --> 0:12:42.360 And so in this this sounds great in terms of 0:12:42.400 --> 0:12:47.440 an opportunity to rethink how we're delivering care that's not 0:12:47.559 --> 0:12:50.360 just good for the patient but good for the system. 0:12:50.400 --> 0:12:52.760 Good for the patient because they're getting good quality care, 0:12:52.800 --> 0:12:57.040 good for the system because maybe we're seeing this care 0:12:57.080 --> 0:13:00.280 done in a cheaper setting, we're a lower cost sitting. 0:13:00.440 --> 0:13:05.120 We're seeing care that doesn't lead to re admissions, which 0:13:05.160 --> 0:13:11.680 is good overall, but it takes a lot to actually 0:13:11.760 --> 0:13:15.480 make that successful. So, you know, when we think about 0:13:15.520 --> 0:13:18.480 what happened during the pandemic, this was also a time 0:13:18.600 --> 0:13:24.720 when the digital aspects of healthcare kind of blew up 0:13:24.720 --> 0:13:28.720 as well. So can you walk me through what the 0:13:28.920 --> 0:13:33.439 infrastructure is like or is needed to make it successful? 0:13:33.760 --> 0:13:37.720 Yeah, you're spot on. So I'll start with the care teams. 0:13:38.960 --> 0:13:41.000 You know, when I first started, I thought, well, I 0:13:41.000 --> 0:13:43.440 could just take my er care team and bring them 0:13:43.480 --> 0:13:46.880 into the home. And yes, some of the skills translate, 0:13:46.960 --> 0:13:49.240 but there's a there's a different approach, and there are 0:13:49.240 --> 0:13:51.200 different things that they need to be aware of, and 0:13:51.280 --> 0:13:55.160 so I think number one, having adaptable care teams, having 0:13:55.800 --> 0:13:59.880 you know, a quality education program I think is important. 0:14:00.160 --> 0:14:03.760 Number Two, you mentioned technology, This is key, This can't 0:14:03.760 --> 0:14:07.920 be done without it. So we use remote monitoring, we 0:14:08.120 --> 0:14:11.040 use telehealth. We've had to build a lot of our 0:14:11.120 --> 0:14:14.880 own capabilities because you know, every EMR in the world 0:14:15.040 --> 0:14:18.440 is built around the concept of a building where everybody 0:14:18.520 --> 0:14:21.200 is in the building. And for us, you know, the 0:14:21.280 --> 0:14:24.480 patients in a building, but everybody else is driving around, 0:14:24.560 --> 0:14:28.360 right the physical therapist, the pharmacists, the everything, And so 0:14:28.480 --> 0:14:32.400 we've had to become logistics experts. We literally had the 0:14:32.440 --> 0:14:36.040 team that built early Uber come in and build our 0:14:36.120 --> 0:14:40.560 logistics model. And that's a logistics model that's clinically informed, 0:14:40.640 --> 0:14:43.960 meaning you know, is to something need to be happened 0:14:44.000 --> 0:14:46.920 faster because of the clinical acuity of that patient. So 0:14:47.440 --> 0:14:49.480 those are things that we've had to build over the 0:14:49.560 --> 0:14:52.840 decade that I think, are you know different. And then 0:14:53.280 --> 0:14:56.720 to me, you know, I'm an old hospital doc that 0:14:56.800 --> 0:15:00.600 manage lots of other docs and clinical quality is super important. 0:15:00.920 --> 0:15:03.360 So the foundation here really is built on what we 0:15:03.480 --> 0:15:07.040 used to do back inside the hospital. So a patient 0:15:07.120 --> 0:15:11.080 center to focus that is you know, highly focused on 0:15:11.160 --> 0:15:13.240 clinical quality and consistency. 0:15:14.680 --> 0:15:19.600 And so you talk about the care teams that you 0:15:19.640 --> 0:15:22.600 bring to the table. Dispatch Health brings to the table 0:15:23.200 --> 0:15:28.000 the remote monitoring, the technology, and the capabilities that you 0:15:28.280 --> 0:15:32.000 have built to make this work. So help me think 0:15:32.000 --> 0:15:37.160 about how a hospital or a health system would work 0:15:37.320 --> 0:15:40.960 with you, Like how does that conversation start? And then 0:15:41.000 --> 0:15:44.000 when you think about what it is that you do, 0:15:44.080 --> 0:15:48.680 what makes you, what makes Dispatch Health unique from some 0:15:48.720 --> 0:15:50.240 of the other players in the system. 0:15:50.600 --> 0:15:53.880 Yeah, so I'm going to start with the second half 0:15:53.920 --> 0:15:56.120 of that first because I think it'll help us answer 0:15:56.120 --> 0:16:00.360 the first. And when I originally looked at these hospital 0:16:00.400 --> 0:16:03.200 at home models, the first thing that struck me was 0:16:03.200 --> 0:16:06.600 how few admissions there were actually work right. Why hadn't 0:16:06.600 --> 0:16:09.320 this scaled? Why hadn't we done more of it? And 0:16:09.400 --> 0:16:11.880 I would ask some of the folks who were doing this, 0:16:12.040 --> 0:16:14.520 and they mentioned things like, well, it's hard to get 0:16:14.520 --> 0:16:17.120 oxygen to the bedside, or it's hard to get reimbursed, 0:16:17.160 --> 0:16:20.120 and you know, in my head, those are all things 0:16:20.160 --> 0:16:23.320 that we could solve. I thought that the fundamental problem 0:16:23.360 --> 0:16:26.960 that we had in scaling this was the site of origination, 0:16:27.400 --> 0:16:31.960 meaning we were starting the care after the patient had 0:16:32.000 --> 0:16:35.680 already arrived in the emergency department. And as an old 0:16:35.880 --> 0:16:37.880 er doc, I can tell you there's so many people 0:16:37.920 --> 0:16:40.440 that once the patient gets there, they really don't want 0:16:40.480 --> 0:16:43.480 them to leave, right. It's a hassle for the er 0:16:43.520 --> 0:16:46.840 doc to keep that patient longer than is needed and 0:16:46.920 --> 0:16:49.360 work on getting them back home. That's a lot of work. 0:16:50.120 --> 0:16:52.560 If you think of then about the hospitalist. You know, 0:16:53.000 --> 0:16:55.200 is it easier to arrange all this stuff in the 0:16:55.200 --> 0:16:58.000 home or is it easier just to admit them upstairs? 0:16:58.080 --> 0:17:02.120 And frankly, there are some incentives and their pay that 0:17:02.160 --> 0:17:05.119 would you know, make them maybe want to admit the patient. 0:17:05.200 --> 0:17:07.439 And then you know, if I'm the CFO of a hospital, 0:17:07.480 --> 0:17:09.760 it's very hard for me to send the patient out 0:17:10.040 --> 0:17:12.000 if I could have kept them in. And there's the 0:17:12.040 --> 0:17:15.200 whole idea of like, let's keep the lower acuity stuff 0:17:15.240 --> 0:17:18.320 out and just do you know the higher acuity stuff 0:17:18.320 --> 0:17:20.399 in the building. But in the moment, I think that's hard. 0:17:20.680 --> 0:17:24.520 And so with dispatch, what we said was, let's create 0:17:24.960 --> 0:17:27.639 a system in the home. Let's be able to bring 0:17:28.400 --> 0:17:32.640 an er to the bedside and diagnose and treat somebody 0:17:32.760 --> 0:17:35.080 just like I would have in the er. Now, short 0:17:35.080 --> 0:17:37.400 of a cat skin. But everything else I can do, 0:17:37.960 --> 0:17:40.800 and that's really important because you have to risk stratify 0:17:40.880 --> 0:17:44.359 the patient in terms of their clinical condition. So you 0:17:44.440 --> 0:17:46.679 have to have a moderate complexity lab, you have to 0:17:46.680 --> 0:17:49.600 have EKG, you have to have X ray, ULTRASOUM, all 0:17:49.640 --> 0:17:52.760 those things, but we do, and then we can do 0:17:52.800 --> 0:17:56.160 that work up at the home and admit directly to home. 0:17:56.320 --> 0:18:01.399 Patient never leaves their h never leaves the bedside, So 0:18:01.480 --> 0:18:04.440 that's really the difference. And we're one of a handful 0:18:04.440 --> 0:18:06.600 of programs that can actually do that in the country 0:18:06.600 --> 0:18:09.760 because of all the infrastructure that's required to do that 0:18:10.400 --> 0:18:13.359 now hospital systems and we partner with many of them 0:18:13.400 --> 0:18:16.560 across the country. We're better together than a part and 0:18:16.600 --> 0:18:19.679 they understand that we built infrastructure that other people haven't, 0:18:19.720 --> 0:18:22.639 we have technology that other people haven't, and so we 0:18:22.680 --> 0:18:27.960 can integrate with them help them deliver this care. They 0:18:27.960 --> 0:18:29.840 may want to use some of their own staff, they 0:18:29.840 --> 0:18:32.080 may want to use some of our staff, but we 0:18:32.119 --> 0:18:35.520 can work together to decide how to do that as 0:18:35.560 --> 0:18:37.840 long as the clinical quality meets our standards. 0:18:38.920 --> 0:18:42.640 And I think you raised a fundamental component of as 0:18:42.680 --> 0:18:48.840 you raised earlier, the desire to shift to value based healthcare, 0:18:48.880 --> 0:18:54.960 which is focus on not creating that episode of care, 0:18:55.920 --> 0:18:58.119 which is keeping them out of the hospital. And it 0:18:58.119 --> 0:19:01.439 seems like you all are focused on that, and maybe 0:19:01.840 --> 0:19:04.720 the follow up question there is like how do you 0:19:04.800 --> 0:19:08.679 identify those patients so they don't go to the hospital 0:19:08.840 --> 0:19:11.760 and what kinds of patients or what types of patients 0:19:12.440 --> 0:19:19.000 do you regularly see in terms of primary diagnosis. 0:19:18.520 --> 0:19:22.399 Yep, and overall need. So, you know, I and we 0:19:22.440 --> 0:19:24.960 can treat just about anyone, but I say our sweet 0:19:25.000 --> 0:19:27.680 spot are the high medical needs, high social needs patients. 0:19:27.920 --> 0:19:30.520 And just so happens that many of those folks are 0:19:30.520 --> 0:19:33.720 in value based arrangements, and so we spend a lot 0:19:33.800 --> 0:19:39.479 of our time working on educating and catching folks before 0:19:39.480 --> 0:19:42.399 they end up, you know, in the wrong setting. And 0:19:42.440 --> 0:19:45.320 that could be through you know, just their own physicians. 0:19:45.480 --> 0:19:49.160 They're talking to their physician. Use my mom as an example. 0:19:49.240 --> 0:19:52.600 Let's say she has emphysema and let's say she's on 0:19:52.640 --> 0:19:55.320 the phone with her doctors saying, I'm really struggling breathing 0:19:55.440 --> 0:19:58.240 and I think I've had a fever and a cough. Well, 0:19:58.240 --> 0:20:01.000 that's a pretty sick patient potential, especially if she's you know, 0:20:01.080 --> 0:20:05.240 eighty years old. And the work up. You know, doing 0:20:05.280 --> 0:20:09.040 all of that inside a primary care office is almost impossible, 0:20:09.119 --> 0:20:12.560 so typically that patient we get sent to the er. Instead, 0:20:12.680 --> 0:20:15.679 that doc could say, oh, you know what, I have 0:20:15.760 --> 0:20:19.919 a partner, and we do function as an extension of 0:20:19.960 --> 0:20:22.360 a primary care doc. We don't impanel our own patients, 0:20:22.960 --> 0:20:25.040 and so they can say, I have a partner that'll 0:20:25.040 --> 0:20:30.919 come and evaluate you that you know, emphysema, COPD, congestive 0:20:30.960 --> 0:20:36.640 heart failure, pneumonia, complex UTI. The classic medical admission diagnoses 0:20:36.720 --> 0:20:38.240 are our bread and butter and right. 0:20:38.200 --> 0:20:42.840 Up our alley. And so maybe we can talk about 0:20:42.880 --> 0:20:47.400 how it's working right now. You know, there's a couple 0:20:47.480 --> 0:20:51.160 of things that's always needed when and we'll jump into 0:20:51.200 --> 0:20:54.920 this further when we end the conversation, which is the 0:20:55.240 --> 0:20:59.919 policy outlook, because you mentioned the waiver that was initiated 0:21:00.080 --> 0:21:02.080 or in the pandemic and it needs to be extended. 0:21:02.119 --> 0:21:05.440 We'll talk about that. But there's a lot of conversations 0:21:05.440 --> 0:21:08.440 about whether the data is showing that this is successful 0:21:08.760 --> 0:21:14.680 and there's concern or maybe making sure we focus on 0:21:15.600 --> 0:21:22.119 how this is equitable for everybody in terms of you know, 0:21:22.200 --> 0:21:27.240 people this program works for people in certain geographies versus 0:21:27.320 --> 0:21:30.800 it doesn't work well in others making sure that everybody 0:21:30.880 --> 0:21:34.480 has access regardless of where they live, regardless of demographics. 0:21:35.040 --> 0:21:38.159 And so I want to get into kind of the 0:21:39.000 --> 0:21:43.960 data and the health equity and racial disparities discussion that 0:21:43.960 --> 0:21:47.080 it's going to be probably a conversation when Congress looks 0:21:47.119 --> 0:21:50.240 into whether they should be extended or not. And so, 0:21:50.960 --> 0:21:53.159 you know, you said, you know this can work in 0:21:53.240 --> 0:21:57.679 various geographies, but how do kin of some of the 0:21:57.800 --> 0:22:02.879 demographic factors play in to how this can work and 0:22:03.040 --> 0:22:08.320 whether it works? And you know, for example, somebody living 0:22:08.560 --> 0:22:12.399 with a couple of different generations in the same household. 0:22:12.800 --> 0:22:15.000 I guess where I'm trying to go is how do 0:22:15.040 --> 0:22:18.800 we ensure that as many diverse patients as possible benefit 0:22:18.840 --> 0:22:19.760 from the program? 0:22:20.000 --> 0:22:24.600 Yeah, yeah, and we're we're fully in support of that. 0:22:24.600 --> 0:22:27.400 That's exactly you know, back to my comment about high 0:22:27.400 --> 0:22:29.800 medical needs, high social needs patients. That's where we want 0:22:29.800 --> 0:22:33.840 to be. And you know, interesting the way we've approached 0:22:33.840 --> 0:22:38.360 this again, like the waiver. We like the idea. We'll 0:22:38.359 --> 0:22:42.000 talk about that later, but when we get reimbursed, we're 0:22:42.040 --> 0:22:45.800 partnering with managed care plans and some of our earliest 0:22:45.840 --> 0:22:50.320 partners were in Denver and they were managed Medicaid plans, 0:22:50.800 --> 0:22:54.320 and they were pace programs, so dual eligible folks who 0:22:54.359 --> 0:23:00.280 were who were Medicare age but then met criteria for Medicaid. 0:23:00.880 --> 0:23:05.359 And so we've been in you know, homes that aren't 0:23:05.520 --> 0:23:09.560 you know, the fancy suburban home since we started. And 0:23:10.320 --> 0:23:13.520 when we think about is a patient safe for admission? 0:23:14.680 --> 0:23:17.600 We have obviously our clinical checklist, but we also have 0:23:17.720 --> 0:23:20.440 you know, a social checklist. But you'd be surprised how 0:23:21.080 --> 0:23:25.920 short that is. Is the electricity on, is the water 0:23:26.080 --> 0:23:29.720 running right? And if those basic things are there for 0:23:29.760 --> 0:23:34.240 the most part, we can generally deliver care. So I 0:23:34.280 --> 0:23:37.560 would agree with you. I think that's very important that 0:23:37.720 --> 0:23:41.200 we keep this as equitable as possible. I also understand 0:23:41.200 --> 0:23:44.480 the concerns. When I first read about hospital at home. 0:23:45.200 --> 0:23:48.080 You know, I was a bit of a snobby doctor 0:23:48.119 --> 0:23:51.040 who trained in the nineties at UCLA and thought, well, 0:23:51.080 --> 0:23:54.439 only you know, real medical care can happen inside that building. 0:23:55.119 --> 0:23:58.240 I've come to change my tune quite a bit over time, 0:23:58.280 --> 0:24:02.200 but I understand the reticence. I do think it's important 0:24:02.200 --> 0:24:06.200 that as we broaden this, that we are measuring safety 0:24:06.440 --> 0:24:10.600