WEBVTT - How to Save the Most Lives 0:00:15.316 --> 0:00:24.316 Pushkin. Think of everything everybody in the United States buys 0:00:24.636 --> 0:00:31.276 in a year, all the food, all the clothes, insurance, education, housing, travel, iPhones, 0:00:31.916 --> 0:00:36.396 everything of all the stuff we buy. Out of all 0:00:36.436 --> 0:00:40.996 the money we spend, around twenty percent, around one in 0:00:41.236 --> 0:00:46.516 five dollars, is spent on healthcare. This is extraordinary. It 0:00:46.676 --> 0:00:49.836 is completely out of line with what other people in 0:00:49.916 --> 0:00:52.836 other countries spend. It's about twice as much as what 0:00:52.956 --> 0:00:56.396 other rich countries spend relative to their GDPs on healthcare. 0:00:56.876 --> 0:01:00.436 And crucially, we in the US do not get better 0:01:00.516 --> 0:01:04.836 health outcomes, So we're spending lots of money without much 0:01:04.876 --> 0:01:08.316 to show for it. For a long time, people have 0:01:08.396 --> 0:01:10.836 looked at this problem and thought, what if instead of 0:01:10.876 --> 0:01:13.836 paying doctors and hospitals to treat us when we get sick, 0:01:14.276 --> 0:01:17.596 we could pay them to keep us healthy. Is there 0:01:17.676 --> 0:01:21.196 some way we could spend less on healthcare and get 0:01:21.236 --> 0:01:29.276 better results. I'm Jacob Goldstein, and this is what's your problem. 0:01:29.276 --> 0:01:32.356 My guest today is Farzad Mosta Shari. He's the co 0:01:32.516 --> 0:01:36.956 founder and CEO of a healthcare company called Alde. Farzod's 0:01:36.956 --> 0:01:39.956 problem is this, how can you pay doctors to keep 0:01:40.036 --> 0:01:43.036 us healthy rather than treating us after we get sick. 0:01:44.236 --> 0:01:46.796 People have been struggling to solve this problem for decades, 0:01:47.156 --> 0:01:49.196 but for a bunch of reasons you'll hear about on 0:01:49.196 --> 0:01:52.316 the show, Farzad and his fellow travelers may be the 0:01:52.356 --> 0:01:58.276 ones to finally solve them. Before he became an entrepreneur, 0:01:58.316 --> 0:02:01.476 Farzad went to medical school, but he told me that 0:02:01.716 --> 0:02:03.956 back in the mid nineties, when he was doing his 0:02:04.036 --> 0:02:08.036 clinical training, his residency and internal medicine, he started to 0:02:08.116 --> 0:02:10.996 question what he was and what he was not learning. 0:02:11.756 --> 0:02:15.836 I kept looking at stuff that was happening and being like, 0:02:15.876 --> 0:02:19.236 this doesn't make sense to me, Like why, like you're 0:02:19.276 --> 0:02:22.076 telling you're teaching me how to you know, treat someone 0:02:22.116 --> 0:02:24.876 who's coming in here with difficulty breeding in the emergency room. 0:02:24.916 --> 0:02:26.996 I get that, Like it's really important that that person 0:02:27.076 --> 0:02:30.036 get their treatment, their nebulizer so they can breathe again, 0:02:30.356 --> 0:02:33.796 that's really I get that. But why is this person 0:02:33.916 --> 0:02:37.836 coming in today? Why is it all of a sudden 0:02:38.076 --> 0:02:42.036 we're seeing people coming in with breeding problems. Why why 0:02:42.116 --> 0:02:43.796 is it that the people who tend to come in 0:02:44.076 --> 0:02:46.596 with breeding problems tend to be from these neighborhoods, not 0:02:46.636 --> 0:02:51.956 other neighborhoods. And it was those questions that were between 0:02:52.356 --> 0:02:55.956 medicine and public health and ibidemology that really grabbed me 0:02:56.796 --> 0:02:59.236 so far as Odd finished his residency and went into 0:02:59.236 --> 0:03:02.756 public health, and he had this this trait that at 0:03:02.756 --> 0:03:05.676 the time was kind of a superpower. He was really 0:03:05.716 --> 0:03:09.836 into computers. So I came of age at a time 0:03:09.836 --> 0:03:14.276 when in a way, you know, asking the question can 0:03:14.436 --> 0:03:20.076 you use a computer for that was was like, uh, 0:03:20.436 --> 0:03:23.076 you know, unlocked a lot of a lot of value. 0:03:23.316 --> 0:03:25.436 And so I joined the New York City Health Department 0:03:25.436 --> 0:03:28.396 and I said, oh, public health surveillance, can we use 0:03:28.396 --> 0:03:33.196 a computer for that? Right? So one of my first startup, Jacob, 0:03:33.676 --> 0:03:36.316 was a within the New York City Department of Health 0:03:36.436 --> 0:03:38.956 where I started. Was one of the group of people 0:03:38.956 --> 0:03:43.476 who started this national idea of why don't we why 0:03:43.476 --> 0:03:46.956 don't we track when when someone gets logged into the 0:03:46.996 --> 0:03:50.476 emergency room for just for their registering the patient in 0:03:50.516 --> 0:03:53.636 the emergency room, or when an ambulance gets dispatched, or 0:03:53.676 --> 0:03:56.636 when when when some item in the pharmacy goes beep 0:03:56.716 --> 0:04:00.596 across the scanner. Like before all those things were on paper. 0:04:00.916 --> 0:04:03.316 Now they're all electronic, which means I can get a 0:04:03.316 --> 0:04:06.196 copy and if I can get a copy, then I 0:04:06.236 --> 0:04:10.516 can tell you in real time that something's happening to 0:04:10.556 --> 0:04:14.076 the health of the city. Right that was That was 0:04:14.076 --> 0:04:17.276 like consumed me for five to ten years, and it 0:04:17.316 --> 0:04:19.756 was really really cool. It was really really fun, and 0:04:19.836 --> 0:04:23.596 that system TILT today is the system that we use, 0:04:23.676 --> 0:04:27.196 for example, during COVID to see that what was happening 0:04:27.196 --> 0:04:31.116 in the city. But then something fundamentally shifted in my life, 0:04:31.556 --> 0:04:35.876 which was Mike Bloomberg asked the Commissioner of Health at 0:04:35.876 --> 0:04:39.196 the time, who turned to me. I was like the 0:04:39.276 --> 0:04:43.996 data guy, and the question he asked was, don't worry 0:04:44.036 --> 0:04:46.636 about the politics, don't worry about the budget, don't worry 0:04:46.636 --> 0:04:49.156 about any of that. Your job is to answer the question. 0:04:49.276 --> 0:04:52.716 What's the question? And the question was what's the problem? 0:04:52.756 --> 0:04:57.636 What's your problem? As you might say, the question was, hey, 0:04:57.756 --> 0:05:01.396 how do we save the most lives? And I was 0:05:01.436 --> 0:05:08.716 like can I swear? Oh yeah? Fuck? That was like 0:05:09.356 --> 0:05:13.476 what am I doing? Like? What am I doing? Why 0:05:13.476 --> 0:05:17.796 am I not starting with that question? That is such 0:05:17.876 --> 0:05:20.196 the right question, how do we save the most lives? 0:05:20.676 --> 0:05:24.716 And it turned out that no one in like, we're 0:05:24.756 --> 0:05:28.316 spending three four trillion dollars, We're doing all this activity right, 0:05:28.556 --> 0:05:31.476 and no one was starting from that viewpoint. There were 0:05:31.556 --> 0:05:35.796 hundreds of thousands of research articles written about various things 0:05:35.836 --> 0:05:39.396 that we're doing, and no one was saying, what is 0:05:39.436 --> 0:05:43.276 this the scientific, evidence based answer to the question how 0:05:43.316 --> 0:05:45.116 do we save the most lives? And it turned out, 0:05:45.116 --> 0:05:47.036 in New York City in the year of Our Lord 0:05:47.076 --> 0:05:49.516 two thousand and two, the answer to that was smoking. 0:05:50.756 --> 0:05:53.436 The answer to that was we're going to attack smoking. 0:05:53.916 --> 0:05:57.756 So that meant that we were going to dedicate more 0:05:57.756 --> 0:06:01.356 of our living waking hours to how do we reduce 0:06:01.396 --> 0:06:03.596 smoking in New York City than we do to anything else. 0:06:04.516 --> 0:06:08.596 And within the time span of four years, we drove 0:06:09.276 --> 0:06:11.796 I was a small part of a big effort to 0:06:11.876 --> 0:06:14.556 drive teen smoking from fourteen to seven percent in New 0:06:14.636 --> 0:06:17.596 York City, to drive adult smoking from twenty two point 0:06:17.636 --> 0:06:21.236 eight percent to sixteen point eight percent. That saved more 0:06:21.276 --> 0:06:24.756 lives than anything else we could have possibly done. And 0:06:24.796 --> 0:06:29.316 then the next question was, Okay, that's public health. That's great, 0:06:29.596 --> 0:06:32.716 that's changing the environment within which people make decisions. But 0:06:32.796 --> 0:06:34.716 we know what we're spending all this money on healthcare? 0:06:35.076 --> 0:06:38.236 What can healthcare do to save the most lives? Just 0:06:38.476 --> 0:06:41.796 stay with that question. That's such a clarifying question that is, 0:06:41.876 --> 0:06:47.156 so that is my flaming sword, right, It's like, how 0:06:47.196 --> 0:06:50.716 can we save how can medicine? How can healthcare save 0:06:50.756 --> 0:06:54.516 the most lives? And again no one had the answer. 0:06:54.596 --> 0:06:58.636 So we published this paper, Randy analysis. Do you want 0:06:58.676 --> 0:07:01.996 to take a guess, Jacob, as to what thing in healthcare? 0:07:02.236 --> 0:07:05.556 If we you know, we have thousands of evidence based 0:07:06.596 --> 0:07:10.116 guidelines and protocols and quality measures, and like, what is 0:07:10.116 --> 0:07:13.116 the one thing? And then phrase the question, well that 0:07:13.196 --> 0:07:15.836 if you took the performance of the American healthcare system 0:07:15.876 --> 0:07:18.036 from where it is today to where the best American 0:07:18.076 --> 0:07:22.436 healthcare institutions can perform, would reduce the number of premature 0:07:22.476 --> 0:07:25.276 deaths by the greatest amount. Do not have any idea 0:07:25.356 --> 0:07:29.956 what that would be? Based on my preparation for this interview, 0:07:30.316 --> 0:07:35.316 I'm gonna guess lowering people's blood pressure. Yeah all right, 0:07:35.356 --> 0:07:39.836 see that's not fair because you've been listening. I did 0:07:39.876 --> 0:07:44.436 my homework. Homework, you did your homework. But the funny 0:07:44.476 --> 0:07:47.236 thing is that if you ask that question of you know, 0:07:47.436 --> 0:07:51.756 hospital CEOs, they'll say, like getting stroke patients to the 0:07:51.796 --> 0:07:55.316 hospital ten minutes faster something. Yeah. Yeah, they'll say, like, 0:07:55.396 --> 0:07:59.036 let's not kill people in the hospital through infections, they'll say, right, well, 0:07:59.036 --> 0:08:02.796 because it's not really traditionally a hospital CEO's job to 0:08:03.316 --> 0:08:05.276 keep people out of the hospital, which is what you 0:08:05.276 --> 0:08:06.956 want to do if you want people not to die, 0:08:07.116 --> 0:08:09.036 right exactly. But even if you if you talk to 0:08:09.156 --> 0:08:12.756 health planned people that they don't know right there, if 0:08:12.796 --> 0:08:15.316 you if you look at the number of quality measures 0:08:15.356 --> 0:08:19.996 that doctors are incentivized and measured against, right, like, there's 0:08:20.036 --> 0:08:23.076 not a there's not a ten x difference between the 0:08:23.036 --> 0:08:25.636 amount of importance placed on blood pressure control. Then there 0:08:25.716 --> 0:08:29.236 is the amount of importance placed on mamograms and colonoscopies 0:08:29.236 --> 0:08:31.436 and flu vaccines and all that other stuff. Right, it's 0:08:31.436 --> 0:08:33.596 all good stuff. And you're saying the evidence as the 0:08:33.676 --> 0:08:36.556 efficacy of lowering blood pressure means there should be a 0:08:36.596 --> 0:08:39.636 ten x difference between blood pressure and right, it's just 0:08:39.796 --> 0:08:43.316 gigantic and it's sable, right like, And it's just science 0:08:43.436 --> 0:08:46.756 of blow Like we know there's cheap, cheap, safe drugs, 0:08:46.836 --> 0:08:50.036 there's life like, we know how to lower people's blood pressure. 0:08:50.356 --> 0:08:53.556 And and then that was the that became my problem. Right, 0:08:53.596 --> 0:08:56.276 It's like, well, why aren't we why aren't we why 0:08:56.316 --> 0:09:00.436 aren't we controlling blood pressure, and I came to the 0:09:00.476 --> 0:09:04.236 wrong answer. And the reason I came to the wrong 0:09:04.276 --> 0:09:07.516 answer was because I tended to be the kind of 0:09:07.556 --> 0:09:11.476 person who said, can use a computer for that. You 0:09:11.516 --> 0:09:15.196 saw the computer as it was, It was your hammer. 0:09:15.236 --> 0:09:18.156 So every problem looked like a nail that could be 0:09:18.236 --> 0:09:21.316 hit with the computer. And look, there was some truth 0:09:21.356 --> 0:09:24.396 to it, right, Like the truth to it was, you 0:09:24.436 --> 0:09:30.596 can't improve blood pressure control if you can't even know 0:09:30.676 --> 0:09:33.996 what blood pressure control rates are, right, Because you actually 0:09:34.156 --> 0:09:36.996 couldn't tell what blood pressure control rates were in any 0:09:37.036 --> 0:09:42.676 given practice, any given population, because the data was trapped 0:09:42.916 --> 0:09:45.716 in deadwood that there were you would write it down, 0:09:45.716 --> 0:09:47.836 You would write down the person's bloodressure control. How would 0:09:47.836 --> 0:09:50.316 I even know, if I'm a doctor what percent of 0:09:50.356 --> 0:09:53.636 my patients had their blood pressure control? I literally couldn't, 0:09:53.676 --> 0:09:55.876 with a room full of paper charts, answer that question. 0:09:56.276 --> 0:09:59.716 I couldn't have quality improvement. I couldn't have decisions support 0:09:59.756 --> 0:10:02.556 that would prompt me when I'm seeing a patient. I 0:10:02.556 --> 0:10:04.596 couldn't have a registry that made a list of the 0:10:04.596 --> 0:10:08.596 patients to say, can you use a computer for that? Right? 0:10:08.636 --> 0:10:13.676 As your friend that problem with the computer, yeah, so 0:10:13.156 --> 0:10:16.356 then so then we and we had a big concern 0:10:16.396 --> 0:10:19.276 around around what was now called health equity. So we 0:10:19.316 --> 0:10:24.116 went around to the doctors in New York City's poorest neighborhoods, 0:10:24.516 --> 0:10:29.756 in Harlem, in the South Bronx, in Central Brooklyn, bed Stye, 0:10:30.156 --> 0:10:32.436 and we said, hey, guess what you've been Medicine has 0:10:32.476 --> 0:10:35.676 been using paper and pen for thousands of years. We're 0:10:35.716 --> 0:10:38.196 going to give you a free electronic health record with 0:10:38.356 --> 0:10:40.716 all of these functionalities built into it. And we spent 0:10:40.716 --> 0:10:43.076 the next year and a half building into the h 0:10:43.156 --> 0:10:46.716 ARE the functionality electronic health record, the functionality that we 0:10:46.796 --> 0:10:51.076 thought should exist in those electronic health records, and then 0:10:51.196 --> 0:10:53.556 we did that. We rolled it out to half of 0:10:53.596 --> 0:10:56.996 all those primary care docs in New York cities poorest neighborhoods. 0:10:57.036 --> 0:11:01.116 So mission accomplished. But you know, you want to guess 0:11:01.156 --> 0:11:05.436 what happened to blood pressure control rates? They did not improve. 0:11:06.876 --> 0:11:09.876 They did not improve, And the number of strokes and 0:11:09.956 --> 0:11:12.036 the number of heart attacks and the number of kidney 0:11:12.036 --> 0:11:16.236 failures from that continued just as much. And so that 0:11:16.476 --> 0:11:20.196 was my continued frustrating He said, what was your frustration. 0:11:20.556 --> 0:11:26.276 That's my frustration is, um, I didn't feel like I 0:11:26.316 --> 0:11:29.716 felt like we'd done all this work, and at the 0:11:29.836 --> 0:11:31.836 end of the day, the reason we'd done all that 0:11:31.916 --> 0:11:36.956 work hadn't hadn't been accomplished. And I reluctantly, you know, 0:11:36.996 --> 0:11:39.436 for twenty years, Jacob, I had like I was a 0:11:39.436 --> 0:11:43.436 public health guy, I was a government person, like like 0:11:43.716 --> 0:11:46.876 I was not a private sector person. And in fact, 0:11:46.996 --> 0:11:50.196 I kind of thought that the profit motive was the 0:11:50.276 --> 0:11:56.116 problem in many cases. And that's right, and it's wrong. 0:11:56.796 --> 0:12:02.516 And what I reluctantly came to see is that the 0:12:02.596 --> 0:12:08.236 financial incentives are the water we swimming and and and 0:12:08.316 --> 0:12:11.476 that sometimes we and even see it likes it shapes 0:12:12.276 --> 0:12:16.116 the force of everything around us, the gravity that pulls 0:12:16.156 --> 0:12:20.396 on us or not right, like everything around us is 0:12:20.476 --> 0:12:23.716 there's this invisible thing which is the financial incentives of 0:12:23.756 --> 0:12:27.556 the system. And I was trying to ignore them. I 0:12:27.596 --> 0:12:30.916 was trying to pretend like they didn't exist. And in fact, 0:12:31.276 --> 0:12:36.396 the financial incentives of the healthcare system are to treat strokes. 0:12:37.276 --> 0:12:39.876 They are not to No one makes billions of dollars 0:12:40.156 --> 0:12:45.636 preventing strokes. No one makes you make money waiting until 0:12:45.836 --> 0:12:51.116 literally waiting until someone's kidney fails, and then there's billions 0:12:51.116 --> 0:12:55.996 of dollars available to you. For treatment of like taking 0:12:56.036 --> 0:12:58.276 someone's blood out of their body, running it through a 0:12:58.316 --> 0:13:00.636 machine and returning it to them. There's a lot of 0:13:00.676 --> 0:13:04.316 money in that, not needing that. There's not a lot 0:13:04.316 --> 0:13:08.876 of money doing that. You're talking about strokes and kidney 0:13:08.876 --> 0:13:14.156 fail because we know that lowering blood pressure, which is 0:13:14.996 --> 0:13:18.756 relatively cheap to do, lowers the risk of strokes and 0:13:18.876 --> 0:13:21.796 kidney failure. But you're saying we don't lower blood pressure, 0:13:21.836 --> 0:13:27.236 and that happens because that's literally the money in healthcare flows, 0:13:27.436 --> 0:13:31.636 because doctors and hospitals get money for treating strokes and 0:13:32.076 --> 0:13:35.796 kidney failure and not for lowering blood pressure. Yeah. I 0:13:35.836 --> 0:13:39.636 mean there's one the one part of the healthcare system 0:13:39.676 --> 0:13:42.196 that is supposed to be in charge of the controlling 0:13:42.236 --> 0:13:44.636 the blood pressure, which is primary care. Right, it's the 0:13:44.836 --> 0:13:48.676 primary care part. And guess what part of our healthcare 0:13:48.756 --> 0:13:52.356 system makes the least money, makes the you know, has 0:13:52.396 --> 0:13:56.836 the least prestige in in where I trained, right, it's 0:13:56.956 --> 0:13:59.676 it's Oh, those those people who you know they talk 0:13:59.716 --> 0:14:01.996 to patients, they don't they don't you know, they don't 0:14:01.996 --> 0:14:04.796 cut the patients, they don't do procedures on them, they 0:14:04.796 --> 0:14:08.076 don't do expensive scans on them, right, They sit in 0:14:08.116 --> 0:14:10.316 a little room and they talk to the patient about 0:14:10.356 --> 0:14:13.476 why they should take their medicine. Right. Oh, those those 0:14:13.636 --> 0:14:17.476 those poor, those poor little primary care doctors. We spend 0:14:17.516 --> 0:14:21.156 five percent of healthcare costs on primary care, five percent. 0:14:21.316 --> 0:14:23.396 We spend as much on ICUs as we do on 0:14:23.396 --> 0:14:28.316 primary and even primary care doctors traditionally do not get 0:14:28.356 --> 0:14:31.556 more money when their patients stay healthy. Right. And I 0:14:31.636 --> 0:14:36.116 know primary care doctors are not motivated by money explicitly, 0:14:36.276 --> 0:14:40.796 but but still the incentives don't push primary care doctors 0:14:40.836 --> 0:14:44.196 to reduce their patient's blood pressure though they I'm sure 0:14:44.276 --> 0:14:47.396 they want to, they don't get paid more if they do. Traditionally, 0:14:49.236 --> 0:14:55.396 until twenty twelve, big moment, big narrative moment happening, big moment, 0:14:59.876 --> 0:15:04.316 say healthcare economics, Cliffhanger. We'll get to that big moment 0:15:04.596 --> 0:15:07.076 and to how it led Farza to start his company 0:15:07.556 --> 0:15:15.476 in just a minute. Okay, now back to the show 0:15:15.636 --> 0:15:19.596 to find out what exactly happened in twenty twelve. In 0:15:19.636 --> 0:15:25.916 twenty twelves, the rules for accountable care are published by 0:15:26.116 --> 0:15:28.916 the Center for Medicare and Medicaid Services. That basically says, 0:15:29.396 --> 0:15:31.956 if you get a group of primary care dots together, 0:15:32.756 --> 0:15:37.196 and you gain accountability for the total cost of care 0:15:37.356 --> 0:15:40.516 for the patients they care for. If those costs come down, 0:15:41.396 --> 0:15:45.596 we will give you half of that those savings. And 0:15:45.676 --> 0:15:48.836 it was like it was like the heavens had opened up, right, 0:15:49.196 --> 0:15:51.356 And I was like, oh my god. And I was like, 0:15:51.876 --> 0:15:54.996 primary care docs don't realize the power they have in 0:15:55.036 --> 0:16:00.756 this new world. And the only problem, right was that 0:16:00.796 --> 0:16:05.636 if you're if you're an independent, small primary care practice, 0:16:06.476 --> 0:16:10.476 you don't really have the scale to to band together 0:16:10.556 --> 0:16:13.196 with one hundred other groups to pool your patients, to 0:16:13.316 --> 0:16:16.876 take that actuarial risk, to understand the regulations, to have 0:16:16.916 --> 0:16:19.556 the data systems to know what the playbook is to 0:16:19.636 --> 0:16:23.196 actually reduce costs, right. And I was like, yeah, but 0:16:23.876 --> 0:16:28.116 that's easy. That's the easy stop you for that. You 0:16:28.116 --> 0:16:31.836 can use the computer for that. Someone's good. I was like, 0:16:32.196 --> 0:16:37.036 someone's gonna build a business doing this. So I just 0:16:37.116 --> 0:16:40.036 want to I just want to make sure that we're 0:16:40.076 --> 0:16:45.356 really clear about what rules are actually changing here, right Yeah, 0:16:45.436 --> 0:16:52.356 So okay, so um so the traditional way that almost everybody, 0:16:52.596 --> 0:16:57.636 including medicare, the federal program that pays for old people's healthcare. 0:16:57.676 --> 0:17:00.196 It's but probably the most important sort of payer and 0:17:00.236 --> 0:17:04.316 healthcare in this country. Right, they pay doctors fee for service. 0:17:04.356 --> 0:17:06.276 You do your doctor, you do something for a patient, 0:17:06.396 --> 0:17:09.036 you get money. And so what's happening in two thousand 0:17:09.236 --> 0:17:15.076 twelve is the government is saying Medicare is offering doctors, 0:17:15.196 --> 0:17:19.076 primary care doctors in particular, a different way to get paid, right, 0:17:19.556 --> 0:17:22.796 and they call it accountable care, Like, what exactly does 0:17:22.876 --> 0:17:27.716 that mean? So that means that if you submit an 0:17:27.756 --> 0:17:30.916 application to the government, your primary care doctor, you and 0:17:30.956 --> 0:17:34.076 your friends submit an application to the government, and the 0:17:34.116 --> 0:17:39.476 government says, oh, you care for these named human beings, right, 0:17:39.556 --> 0:17:43.956 you're the primary care doctor for these Medicare beneficiaries. So 0:17:43.996 --> 0:17:48.516 if you have ten thousand Medicare beneficiaries who are getting 0:17:48.556 --> 0:17:52.636 primary care from you, the Medicare actuaries, that's their job. 0:17:53.116 --> 0:17:56.076 They look to see who are those people, what have 0:17:56.116 --> 0:17:58.716 their costs been in the past, how sick are they? 0:17:58.796 --> 0:18:01.636 And they're going to say, ah, next year, we think 0:18:01.676 --> 0:18:05.956 those ten thousand lives are going to cost us a 0:18:06.156 --> 0:18:11.596 hundred million dollars. Now, if the actual costs, once all 0:18:11.596 --> 0:18:14.036 the claims are submitted and all the costs are counted up, 0:18:14.316 --> 0:18:16.996 all of the hospitalizations, all the specialist visits, all the 0:18:17.036 --> 0:18:20.196 medications and scans and everything else that gets done to 0:18:20.276 --> 0:18:23.196 the patient. If that actual cost comes in not at 0:18:23.236 --> 0:18:26.156 one hundred million, which was our budget, but at ninety million, 0:18:26.356 --> 0:18:30.356 there's ten million dollars of savings, and we will share 0:18:30.636 --> 0:18:34.676 those savings with these docs. We will give say half 0:18:34.996 --> 0:18:37.796 of those savings to the docks. So of that ten 0:18:37.796 --> 0:18:40.556 million dollars of savings, the government gets to keep five 0:18:40.636 --> 0:18:45.396 million they spent less, and the docks get five million. 0:18:45.796 --> 0:18:49.516 And you have to prove that you actually improved quality 0:18:49.596 --> 0:18:53.836 while you reduced cost of care. It's a fundamental rewriting 0:18:53.836 --> 0:18:57.556 of the incentive structure of American healthcare. So you see 0:18:57.596 --> 0:19:00.716 this new thing in the world, and what do you think. 0:19:02.236 --> 0:19:05.636 I think, Who's someone's going to build this business that 0:19:06.156 --> 0:19:08.956 does this? And I went to the Brookings Institute where 0:19:08.996 --> 0:19:10.756 they had done a lot of the foundational work on 0:19:10.796 --> 0:19:13.876 this idea, and I created a learning network to teach 0:19:13.876 --> 0:19:15.676 other people how to do it, and we published a 0:19:15.716 --> 0:19:18.356 tool kit, and we had a learning collaborative. And I 0:19:18.436 --> 0:19:21.716 kept waiting for nine months. I kept waiting for I 0:19:21.836 --> 0:19:24.396 was like literally every morning I'd wake up and I'd 0:19:24.396 --> 0:19:27.756 be like, Who's Who's starting a company to do this. 0:19:27.956 --> 0:19:30.796 Where where is that come? It's such an obvious idea, 0:19:30.916 --> 0:19:33.556 I thought to myself, it is like and the obvious 0:19:33.596 --> 0:19:35.636 thing for me was, well, I ain't going to be 0:19:35.636 --> 0:19:40.836 the hospitals, right, the most powerful people in healthcare today 0:19:41.116 --> 0:19:45.756 are hospitals and health systems under one incentive structure. But 0:19:46.036 --> 0:19:50.796 getting those people, the incumbents, the ones who are powerful 0:19:50.836 --> 0:19:54.036 in the current system, the goliaths, getting them to change 0:19:54.076 --> 0:19:56.996 their economic model, well, that's never going to happen. Whereas 0:19:57.276 --> 0:19:58.996 you go to a you know, we got a group 0:19:59.036 --> 0:20:01.436 of primary care dogs, You're like, hey, you got nothing 0:20:01.436 --> 0:20:05.396 to lose but your chains. Yeah, they already don't like 0:20:05.516 --> 0:20:07.876 the system. Right with primary care dots. If you're starting 0:20:07.916 --> 0:20:11.716 with people who are disgruntled as a as a general rule, 0:20:12.076 --> 0:20:14.836 are appropriately pissed off of the current system, doesn't help 0:20:14.876 --> 0:20:16.716 them take the care of their patients that they believe 0:20:16.996 --> 0:20:20.076 their patients should be getting. So okay, every day you're 0:20:20.116 --> 0:20:24.156 looking for somebody to start this obvious company doesn't happen. 0:20:24.876 --> 0:20:29.116 And so I went for a walk with the VC 0:20:30.316 --> 0:20:37.316 and that metaphor or literal did you actually go literal 0:20:35.676 --> 0:20:40.636 without Yes? Yes I did, Yes I did. They got 0:20:40.676 --> 0:20:43.316 it right, away, and they were, you know, they saw 0:20:43.356 --> 0:20:49.076 the long term opportunity for combining information and incentives in 0:20:49.116 --> 0:20:51.236 a new way and creating a new business model, and 0:20:51.276 --> 0:20:54.916 so they like, literally we had one one pitch meeting 0:20:55.276 --> 0:20:58.996 after that, and they they they gave us the money 0:20:59.036 --> 0:21:01.876 to start the company. To to my co founder and 0:21:01.916 --> 0:21:06.556 I to Guvees who had never started business before. Were 0:21:06.596 --> 0:21:11.156 there moments as your getting the company going, as it's growing, 0:21:11.556 --> 0:21:14.956 when there were things that were harder than you expected, 0:21:15.076 --> 0:21:17.556 things that didn't work that you thought would work. I mean, 0:21:17.676 --> 0:21:21.436 is this obvious idea to you? Yeah? Was it obvious 0:21:21.436 --> 0:21:28.916 to everybody else? Well, obviously not. And I think the 0:21:30.116 --> 0:21:32.996 biggest thing that didn't make sense to people was the 0:21:33.436 --> 0:21:40.916 going after these independent practices community docs as opposed to 0:21:40.996 --> 0:21:47.716 the big, gleaming health centers. But the thing that really 0:21:48.916 --> 0:21:53.636 shook us was we we went out and we signed 0:21:53.676 --> 0:21:58.916 up our first groups of doctors in four states, and 0:21:59.876 --> 0:22:03.236 it felt just charmed. Everything was magic, And we built 0:22:03.236 --> 0:22:06.676 our software system and we started analyzing the data and 0:22:06.716 --> 0:22:08.916 we started doing the stuff that we knew was the 0:22:09.156 --> 0:22:14.556 right things to do for patients, and wholly commole hospitalization 0:22:14.716 --> 0:22:19.396 rates came down measurably within that first year seven percent. 0:22:20.316 --> 0:22:23.196 It worked. It worked, and it was like and it 0:22:23.276 --> 0:22:24.836 was you know a lot of elbow grease and grit 0:22:24.916 --> 0:22:28.876 and whatever, but just just churning the focus of these 0:22:28.916 --> 0:22:34.236 primary care docs on reducing r visits, reducing hospitalizations was working. 0:22:35.036 --> 0:22:38.436 And I was like, oh my god, charmed life, right, Like, 0:22:38.476 --> 0:22:40.956 this thing is, this thing is gonna work, gonna totally 0:22:40.956 --> 0:22:44.916 take off. And then we got the results from our 0:22:44.996 --> 0:22:51.156 first year's performance, and sure enough, total hospitalizations went down 0:22:51.196 --> 0:22:55.036 by seven percent, the biggest source of suffering in American healthcare. 0:22:55.116 --> 0:23:00.116 Quality went up and costs did not come down. Huh 0:23:00.156 --> 0:23:02.636 So it didn't work. It seemed like it was working, 0:23:02.676 --> 0:23:06.916 but the core bottom line things, they didn't come down, 0:23:07.436 --> 0:23:09.996 and we only get paid. Like we had done all 0:23:09.996 --> 0:23:13.876 this work, burned all this cash, hired all these people, 0:23:13.956 --> 0:23:17.036 gotten all the hopes of these doctors up right, and 0:23:17.276 --> 0:23:21.116 and we and these investors and we told them, hey, 0:23:21.116 --> 0:23:24.116 it's working. We're gonna get paid. And you don't get 0:23:24.116 --> 0:23:27.356 paid for improving quality or reducing hospitalizations. You get paid 0:23:27.356 --> 0:23:30.036 if total cost of care comes down. And when we 0:23:30.196 --> 0:23:33.236 looked into it and we actually published a paper, you're like, 0:23:33.796 --> 0:23:36.596 this sucked. Let's tell the world, how much pain we're 0:23:36.596 --> 0:23:39.956 in and what happened? And so what we learned was 0:23:40.476 --> 0:23:45.156 that the hospitals, when faced with a decrease in utilization, 0:23:45.996 --> 0:23:50.596 changed their coding so they got paid more for admission. 0:23:50.996 --> 0:23:53.996 And to be clear, changing their coding means changing the 0:23:53.996 --> 0:23:56.916 way they bill, so they're billing so that they get more. 0:23:57.316 --> 0:23:59.476 There are fewer patients coming to the hospital, they're billing 0:23:59.516 --> 0:24:04.116 more for each patient. For each patient. Yeah, so okay, 0:24:04.156 --> 0:24:06.516 so so far you're not making any money, right because 0:24:06.556 --> 0:24:09.876 you make money by saving money. What do you how 0:24:09.876 --> 0:24:13.116 do you respond? Well, we had also in the in 0:24:13.196 --> 0:24:17.956 the intim we had, we had massively expanded, So not 0:24:18.036 --> 0:24:20.476 only were we waiting to see if we were going 0:24:20.556 --> 0:24:22.036 to get paid, but we went out there and on 0:24:22.076 --> 0:24:25.156 the success of the vision and the mission and the 0:24:25.196 --> 0:24:28.036 tools we built and the early results we got, we 0:24:28.076 --> 0:24:32.676 signed up a hundred practices in five new states and 0:24:33.276 --> 0:24:36.516 we had to make it work. So we went to 0:24:36.596 --> 0:24:40.476 five states and fortunately in that first year with this 0:24:40.596 --> 0:24:43.876 new batch, one out of five states the docs got paid. 0:24:44.276 --> 0:24:48.596 If the initial problem is that, as the doctors you're 0:24:48.596 --> 0:24:52.276 working with, our lowering admission rates to hospitals, hospitals are 0:24:52.276 --> 0:24:56.076 effectively charging more for each admission. How do you solve that? 0:24:56.836 --> 0:24:59.516 How do you how do you fix that? There's only 0:24:59.516 --> 0:25:01.516 a limit to how much you can play those games, 0:25:01.676 --> 0:25:05.036 how much the hospitals can play those games? Yeah? Yeah, yeah, 0:25:05.076 --> 0:25:07.916 so you so you just drive down admissions even more, 0:25:08.356 --> 0:25:11.996 even more. Yeah, And were you able to do that? Yeah? Yeah, 0:25:11.996 --> 0:25:18.116 So we're now down seventeen percent. Hospitalizations are down seventeen 0:25:18.196 --> 0:25:23.556 percent in for our patients compared to what they would 0:25:23.596 --> 0:25:27.476 be if they were just like everybody else in their communities. 0:25:27.476 --> 0:25:30.596