Speaker 1: Pushkin. Think of everything everybody in the United States buys
Speaker 1: in a year, all the food, all the clothes, insurance, education, housing, travel, iPhones,
Speaker 1: everything of all the stuff we buy. Out of all
Speaker 1: the money we spend, around twenty percent, around one in
Speaker 1: five dollars, is spent on healthcare. This is extraordinary. It
Speaker 1: is completely out of line with what other people in
Speaker 1: other countries spend. It's about twice as much as what
Speaker 1: other rich countries spend relative to their GDPs on healthcare.
Speaker 1: And crucially, we in the US do not get better
Speaker 1: health outcomes, So we're spending lots of money without much
Speaker 1: to show for it. For a long time, people have
Speaker 1: looked at this problem and thought, what if instead of
Speaker 1: paying doctors and hospitals to treat us when we get sick,
Speaker 1: we could pay them to keep us healthy. Is there
Speaker 1: some way we could spend less on healthcare and get
Speaker 1: better results. I'm Jacob Goldstein, and this is what's your problem.
Speaker 1: My guest today is Farzad Mosta Shari. He's the co
Speaker 1: founder and CEO of a healthcare company called Alde. Farzod's
Speaker 1: problem is this, how can you pay doctors to keep
Speaker 1: us healthy rather than treating us after we get sick.
Speaker 1: People have been struggling to solve this problem for decades,
Speaker 1: but for a bunch of reasons you'll hear about on
Speaker 1: the show, Farzad and his fellow travelers may be the
Speaker 1: ones to finally solve them. Before he became an entrepreneur,
Speaker 1: Farzad went to medical school, but he told me that
Speaker 1: back in the mid nineties, when he was doing his
Speaker 1: clinical training, his residency and internal medicine, he started to
Speaker 1: question what he was and what he was not learning.
Speaker 1: I kept looking at stuff that was happening and being like,
Speaker 1: this doesn't make sense to me, Like why, like you're
Speaker 1: telling you're teaching me how to you know, treat someone
Speaker 1: who's coming in here with difficulty breeding in the emergency room.
Speaker 1: I get that, Like it's really important that that person
Speaker 1: get their treatment, their nebulizer so they can breathe again,
Speaker 1: that's really I get that. But why is this person
Speaker 1: coming in today? Why is it all of a sudden
Speaker 1: we're seeing people coming in with breeding problems. Why why
Speaker 1: is it that the people who tend to come in
Speaker 1: with breeding problems tend to be from these neighborhoods, not
Speaker 1: other neighborhoods. And it was those questions that were between
Speaker 1: medicine and public health and ibidemology that really grabbed me
Speaker 1: so far as Odd finished his residency and went into
Speaker 1: public health, and he had this this trait that at
Speaker 1: the time was kind of a superpower. He was really
Speaker 1: into computers. So I came of age at a time
Speaker 1: when in a way, you know, asking the question can
Speaker 1: you use a computer for that was was like, uh,
Speaker 1: you know, unlocked a lot of a lot of value.
Speaker 1: And so I joined the New York City Health Department
Speaker 1: and I said, oh, public health surveillance, can we use
Speaker 1: a computer for that? Right? So one of my first startup, Jacob,
Speaker 1: was a within the New York City Department of Health
Speaker 1: where I started. Was one of the group of people
Speaker 1: who started this national idea of why don't we why
Speaker 1: don't we track when when someone gets logged into the
Speaker 1: emergency room for just for their registering the patient in
Speaker 1: the emergency room, or when an ambulance gets dispatched, or
Speaker 1: when when when some item in the pharmacy goes beep
Speaker 1: across the scanner. Like before all those things were on paper.
Speaker 1: Now they're all electronic, which means I can get a
Speaker 1: copy and if I can get a copy, then I
Speaker 1: can tell you in real time that something's happening to
Speaker 1: the health of the city. Right that was That was
Speaker 1: like consumed me for five to ten years, and it
Speaker 1: was really really cool. It was really really fun, and
Speaker 1: that system TILT today is the system that we use,
Speaker 1: for example, during COVID to see that what was happening
Speaker 1: in the city. But then something fundamentally shifted in my life,
Speaker 1: which was Mike Bloomberg asked the Commissioner of Health at
Speaker 1: the time, who turned to me. I was like the
Speaker 1: data guy, and the question he asked was, don't worry
Speaker 1: about the politics, don't worry about the budget, don't worry
Speaker 1: about any of that. Your job is to answer the question.
Speaker 1: What's the question? And the question was what's the problem?
Speaker 1: What's your problem? As you might say, the question was, hey,
Speaker 1: how do we save the most lives? And I was
Speaker 1: like can I swear? Oh yeah? Fuck? That was like
Speaker 1: what am I doing? Like? What am I doing? Why
Speaker 1: am I not starting with that question? That is such
Speaker 1: the right question, how do we save the most lives?
Speaker 1: And it turned out that no one in like, we're
Speaker 1: spending three four trillion dollars, We're doing all this activity right,
Speaker 1: and no one was starting from that viewpoint. There were
Speaker 1: hundreds of thousands of research articles written about various things
Speaker 1: that we're doing, and no one was saying, what is
Speaker 1: this the scientific, evidence based answer to the question how
Speaker 1: do we save the most lives? And it turned out,
Speaker 1: in New York City in the year of Our Lord
Speaker 1: two thousand and two, the answer to that was smoking.
Speaker 1: The answer to that was we're going to attack smoking.
Speaker 1: So that meant that we were going to dedicate more
Speaker 1: of our living waking hours to how do we reduce
Speaker 1: smoking in New York City than we do to anything else.
Speaker 1: And within the time span of four years, we drove
Speaker 1: I was a small part of a big effort to
Speaker 1: drive teen smoking from fourteen to seven percent in New
Speaker 1: York City, to drive adult smoking from twenty two point
Speaker 1: eight percent to sixteen point eight percent. That saved more
Speaker 1: lives than anything else we could have possibly done. And
Speaker 1: then the next question was, Okay, that's public health. That's great,
Speaker 1: that's changing the environment within which people make decisions. But
Speaker 1: we know what we're spending all this money on healthcare?
Speaker 1: What can healthcare do to save the most lives? Just
Speaker 1: stay with that question. That's such a clarifying question that is,
Speaker 1: so that is my flaming sword, right, It's like, how
Speaker 1: can we save how can medicine? How can healthcare save
Speaker 1: the most lives? And again no one had the answer.
Speaker 1: So we published this paper, Randy analysis. Do you want
Speaker 1: to take a guess, Jacob, as to what thing in healthcare?
Speaker 1: If we you know, we have thousands of evidence based
Speaker 1: guidelines and protocols and quality measures, and like, what is
Speaker 1: the one thing? And then phrase the question, well that
Speaker 1: if you took the performance of the American healthcare system
Speaker 1: from where it is today to where the best American
Speaker 1: healthcare institutions can perform, would reduce the number of premature
Speaker 1: deaths by the greatest amount. Do not have any idea
Speaker 1: what that would be? Based on my preparation for this interview,
Speaker 1: I'm gonna guess lowering people's blood pressure. Yeah all right,
Speaker 1: see that's not fair because you've been listening. I did
Speaker 1: my homework. Homework, you did your homework. But the funny
Speaker 1: thing is that if you ask that question of you know,
Speaker 1: hospital CEOs, they'll say, like getting stroke patients to the
Speaker 1: hospital ten minutes faster something. Yeah. Yeah, they'll say, like,
Speaker 1: let's not kill people in the hospital through infections, they'll say, right, well,
Speaker 1: because it's not really traditionally a hospital CEO's job to
Speaker 1: keep people out of the hospital, which is what you
Speaker 1: want to do if you want people not to die,
Speaker 1: right exactly. But even if you if you talk to
Speaker 1: health planned people that they don't know right there, if
Speaker 1: you if you look at the number of quality measures
Speaker 1: that doctors are incentivized and measured against, right, like, there's
Speaker 1: not a there's not a ten x difference between the
Speaker 1: amount of importance placed on blood pressure control. Then there
Speaker 1: is the amount of importance placed on mamograms and colonoscopies
Speaker 1: and flu vaccines and all that other stuff. Right, it's
Speaker 1: all good stuff. And you're saying the evidence as the
Speaker 1: efficacy of lowering blood pressure means there should be a
Speaker 1: ten x difference between blood pressure and right, it's just
Speaker 1: gigantic and it's sable, right like, And it's just science
Speaker 1: of blow Like we know there's cheap, cheap, safe drugs,
Speaker 1: there's life like, we know how to lower people's blood pressure.
Speaker 1: And and then that was the that became my problem. Right,
Speaker 1: It's like, well, why aren't we why aren't we why
Speaker 1: aren't we controlling blood pressure, and I came to the
Speaker 1: wrong answer. And the reason I came to the wrong
Speaker 1: answer was because I tended to be the kind of
Speaker 1: person who said, can use a computer for that. You
Speaker 1: saw the computer as it was, It was your hammer.
Speaker 1: So every problem looked like a nail that could be
Speaker 1: hit with the computer. And look, there was some truth
Speaker 1: to it, right, Like the truth to it was, you
Speaker 1: can't improve blood pressure control if you can't even know
Speaker 1: what blood pressure control rates are, right, Because you actually
Speaker 1: couldn't tell what blood pressure control rates were in any
Speaker 1: given practice, any given population, because the data was trapped
Speaker 1: in deadwood that there were you would write it down,
Speaker 1: You would write down the person's bloodressure control. How would
Speaker 1: I even know, if I'm a doctor what percent of
Speaker 1: my patients had their blood pressure control? I literally couldn't,
Speaker 1: with a room full of paper charts, answer that question.
Speaker 1: I couldn't have quality improvement. I couldn't have decisions support
Speaker 1: that would prompt me when I'm seeing a patient. I
Speaker 1: couldn't have a registry that made a list of the
Speaker 1: patients to say, can you use a computer for that? Right?
Speaker 1: As your friend that problem with the computer, yeah, so
Speaker 1: then so then we and we had a big concern
Speaker 1: around around what was now called health equity. So we
Speaker 1: went around to the doctors in New York City's poorest neighborhoods,
Speaker 1: in Harlem, in the South Bronx, in Central Brooklyn, bed Stye,
Speaker 1: and we said, hey, guess what you've been Medicine has
Speaker 1: been using paper and pen for thousands of years. We're
Speaker 1: going to give you a free electronic health record with
Speaker 1: all of these functionalities built into it. And we spent
Speaker 1: the next year and a half building into the h
Speaker 1: ARE the functionality electronic health record, the functionality that we
Speaker 1: thought should exist in those electronic health records, and then
Speaker 1: we did that. We rolled it out to half of
Speaker 1: all those primary care docs in New York cities poorest neighborhoods.
Speaker 1: So mission accomplished. But you know, you want to guess
Speaker 1: what happened to blood pressure control rates? They did not improve.
Speaker 1: They did not improve, And the number of strokes and
Speaker 1: the number of heart attacks and the number of kidney
Speaker 1: failures from that continued just as much. And so that
Speaker 1: was my continued frustrating He said, what was your frustration.
Speaker 1: That's my frustration is, um, I didn't feel like I
Speaker 1: felt like we'd done all this work, and at the
Speaker 1: end of the day, the reason we'd done all that
Speaker 1: work hadn't hadn't been accomplished. And I reluctantly, you know,
Speaker 1: for twenty years, Jacob, I had like I was a
Speaker 1: public health guy, I was a government person, like like
Speaker 1: I was not a private sector person. And in fact,
Speaker 1: I kind of thought that the profit motive was the
Speaker 1: problem in many cases. And that's right, and it's wrong.
Speaker 1: And what I reluctantly came to see is that the
Speaker 1: financial incentives are the water we swimming and and and
Speaker 1: that sometimes we and even see it likes it shapes
Speaker 1: the force of everything around us, the gravity that pulls
Speaker 1: on us or not right, like everything around us is
Speaker 1: there's this invisible thing which is the financial incentives of
Speaker 1: the system. And I was trying to ignore them. I
Speaker 1: was trying to pretend like they didn't exist. And in fact,
Speaker 1: the financial incentives of the healthcare system are to treat strokes.
Speaker 1: They are not to No one makes billions of dollars
Speaker 1: preventing strokes. No one makes you make money waiting until
Speaker 1: literally waiting until someone's kidney fails, and then there's billions
Speaker 1: of dollars available to you. For treatment of like taking
Speaker 1: someone's blood out of their body, running it through a
Speaker 1: machine and returning it to them. There's a lot of
Speaker 1: money in that, not needing that. There's not a lot
Speaker 1: of money doing that. You're talking about strokes and kidney
Speaker 1: fail because we know that lowering blood pressure, which is
Speaker 1: relatively cheap to do, lowers the risk of strokes and
Speaker 1: kidney failure. But you're saying we don't lower blood pressure,
Speaker 1: and that happens because that's literally the money in healthcare flows,
Speaker 1: because doctors and hospitals get money for treating strokes and
Speaker 1: kidney failure and not for lowering blood pressure. Yeah. I
Speaker 1: mean there's one the one part of the healthcare system
Speaker 1: that is supposed to be in charge of the controlling
Speaker 1: the blood pressure, which is primary care. Right, it's the
Speaker 1: primary care part. And guess what part of our healthcare
Speaker 1: system makes the least money, makes the you know, has
Speaker 1: the least prestige in in where I trained, right, it's
Speaker 1: it's Oh, those those people who you know they talk
Speaker 1: to patients, they don't they don't you know, they don't
Speaker 1: cut the patients, they don't do procedures on them, they
Speaker 1: don't do expensive scans on them, right, They sit in
Speaker 1: a little room and they talk to the patient about
Speaker 1: why they should take their medicine. Right. Oh, those those
Speaker 1: those poor, those poor little primary care doctors. We spend
Speaker 1: five percent of healthcare costs on primary care, five percent.
Speaker 1: We spend as much on ICUs as we do on
Speaker 1: primary and even primary care doctors traditionally do not get
Speaker 1: more money when their patients stay healthy. Right. And I
Speaker 1: know primary care doctors are not motivated by money explicitly,
Speaker 1: but but still the incentives don't push primary care doctors
Speaker 1: to reduce their patient's blood pressure though they I'm sure
Speaker 1: they want to, they don't get paid more if they do. Traditionally,
Speaker 1: until twenty twelve, big moment, big narrative moment happening, big moment,
Speaker 1: say healthcare economics, Cliffhanger. We'll get to that big moment
Speaker 1: and to how it led Farza to start his company
Speaker 1: in just a minute. Okay, now back to the show
Speaker 1: to find out what exactly happened in twenty twelve. In
Speaker 1: twenty twelves, the rules for accountable care are published by
Speaker 1: the Center for Medicare and Medicaid Services. That basically says,
Speaker 1: if you get a group of primary care dots together,
Speaker 1: and you gain accountability for the total cost of care
Speaker 1: for the patients they care for. If those costs come down,
Speaker 1: we will give you half of that those savings. And
Speaker 1: it was like it was like the heavens had opened up, right,
Speaker 1: And I was like, oh my god. And I was like,
Speaker 1: primary care docs don't realize the power they have in
Speaker 1: this new world. And the only problem, right was that
Speaker 1: if you're if you're an independent, small primary care practice,
Speaker 1: you don't really have the scale to to band together
Speaker 1: with one hundred other groups to pool your patients, to
Speaker 1: take that actuarial risk, to understand the regulations, to have
Speaker 1: the data systems to know what the playbook is to
Speaker 1: actually reduce costs, right. And I was like, yeah, but
Speaker 1: that's easy. That's the easy stop you for that. You
Speaker 1: can use the computer for that. Someone's good. I was like,
Speaker 1: someone's gonna build a business doing this. So I just
Speaker 1: want to I just want to make sure that we're
Speaker 1: really clear about what rules are actually changing here, right Yeah,
Speaker 1: So okay, so um so the traditional way that almost everybody,
Speaker 1: including medicare, the federal program that pays for old people's healthcare.
Speaker 1: It's but probably the most important sort of payer and
Speaker 1: healthcare in this country. Right, they pay doctors fee for service.
Speaker 1: You do your doctor, you do something for a patient,
Speaker 1: you get money. And so what's happening in two thousand
Speaker 1: twelve is the government is saying Medicare is offering doctors,
Speaker 1: primary care doctors in particular, a different way to get paid, right,
Speaker 1: and they call it accountable care, Like, what exactly does
Speaker 1: that mean? So that means that if you submit an
Speaker 1: application to the government, your primary care doctor, you and
Speaker 1: your friends submit an application to the government, and the
Speaker 1: government says, oh, you care for these named human beings, right,
Speaker 1: you're the primary care doctor for these Medicare beneficiaries. So
Speaker 1: if you have ten thousand Medicare beneficiaries who are getting
Speaker 1: primary care from you, the Medicare actuaries, that's their job.
Speaker 1: They look to see who are those people, what have
Speaker 1: their costs been in the past, how sick are they?
Speaker 1: And they're going to say, ah, next year, we think
Speaker 1: those ten thousand lives are going to cost us a
Speaker 1: hundred million dollars. Now, if the actual costs, once all
Speaker 1: the claims are submitted and all the costs are counted up,
Speaker 1: all of the hospitalizations, all the specialist visits, all the
Speaker 1: medications and scans and everything else that gets done to
Speaker 1: the patient. If that actual cost comes in not at
Speaker 1: one hundred million, which was our budget, but at ninety million,
Speaker 1: there's ten million dollars of savings, and we will share
Speaker 1: those savings with these docs. We will give say half
Speaker 1: of those savings to the docks. So of that ten
Speaker 1: million dollars of savings, the government gets to keep five
Speaker 1: million they spent less, and the docks get five million.
Speaker 1: And you have to prove that you actually improved quality
Speaker 1: while you reduced cost of care. It's a fundamental rewriting
Speaker 1: of the incentive structure of American healthcare. So you see
Speaker 1: this new thing in the world, and what do you think.
Speaker 1: I think, Who's someone's going to build this business that
Speaker 1: does this? And I went to the Brookings Institute where
Speaker 1: they had done a lot of the foundational work on
Speaker 1: this idea, and I created a learning network to teach
Speaker 1: other people how to do it, and we published a
Speaker 1: tool kit, and we had a learning collaborative. And I
Speaker 1: kept waiting for nine months. I kept waiting for I
Speaker 1: was like literally every morning I'd wake up and I'd
Speaker 1: be like, Who's Who's starting a company to do this.
Speaker 1: Where where is that come? It's such an obvious idea,
Speaker 1: I thought to myself, it is like and the obvious
Speaker 1: thing for me was, well, I ain't going to be
Speaker 1: the hospitals, right, the most powerful people in healthcare today
Speaker 1: are hospitals and health systems under one incentive structure. But
Speaker 1: getting those people, the incumbents, the ones who are powerful
Speaker 1: in the current system, the goliaths, getting them to change
Speaker 1: their economic model, well, that's never going to happen. Whereas
Speaker 1: you go to a you know, we got a group
Speaker 1: of primary care dogs, You're like, hey, you got nothing
Speaker 1: to lose but your chains. Yeah, they already don't like
Speaker 1: the system. Right with primary care dots. If you're starting
Speaker 1: with people who are disgruntled as a as a general rule,
Speaker 1: are appropriately pissed off of the current system, doesn't help
Speaker 1: them take the care of their patients that they believe
Speaker 1: their patients should be getting. So okay, every day you're
Speaker 1: looking for somebody to start this obvious company doesn't happen.
Speaker 1: And so I went for a walk with the VC
Speaker 1: and that metaphor or literal did you actually go literal
Speaker 1: without Yes? Yes I did, Yes I did. They got
Speaker 1: it right, away, and they were, you know, they saw
Speaker 1: the long term opportunity for combining information and incentives in
Speaker 1: a new way and creating a new business model, and
Speaker 1: so they like, literally we had one one pitch meeting
Speaker 1: after that, and they they they gave us the money
Speaker 1: to start the company. To to my co founder and
Speaker 1: I to Guvees who had never started business before. Were
Speaker 1: there moments as your getting the company going, as it's growing,
Speaker 1: when there were things that were harder than you expected,
Speaker 1: things that didn't work that you thought would work. I mean,
Speaker 1: is this obvious idea to you? Yeah? Was it obvious
Speaker 1: to everybody else? Well, obviously not. And I think the
Speaker 1: biggest thing that didn't make sense to people was the
Speaker 1: going after these independent practices community docs as opposed to
Speaker 1: the big, gleaming health centers. But the thing that really
Speaker 1: shook us was we we went out and we signed
Speaker 1: up our first groups of doctors in four states, and
Speaker 1: it felt just charmed. Everything was magic, And we built
Speaker 1: our software system and we started analyzing the data and
Speaker 1: we started doing the stuff that we knew was the
Speaker 1: right things to do for patients, and wholly commole hospitalization
Speaker 1: rates came down measurably within that first year seven percent.
Speaker 1: It worked. It worked, and it was like and it
Speaker 1: was you know a lot of elbow grease and grit
Speaker 1: and whatever, but just just churning the focus of these
Speaker 1: primary care docs on reducing r visits, reducing hospitalizations was working.
Speaker 1: And I was like, oh my god, charmed life, right, Like,
Speaker 1: this thing is, this thing is gonna work, gonna totally
Speaker 1: take off. And then we got the results from our
Speaker 1: first year's performance, and sure enough, total hospitalizations went down
Speaker 1: by seven percent, the biggest source of suffering in American healthcare.
Speaker 1: Quality went up and costs did not come down. Huh
Speaker 1: So it didn't work. It seemed like it was working,
Speaker 1: but the core bottom line things, they didn't come down,
Speaker 1: and we only get paid. Like we had done all
Speaker 1: this work, burned all this cash, hired all these people,
Speaker 1: gotten all the hopes of these doctors up right, and
Speaker 1: and we and these investors and we told them, hey,
Speaker 1: it's working. We're gonna get paid. And you don't get
Speaker 1: paid for improving quality or reducing hospitalizations. You get paid
Speaker 1: if total cost of care comes down. And when we
Speaker 1: looked into it and we actually published a paper, you're like,
Speaker 1: this sucked. Let's tell the world, how much pain we're
Speaker 1: in and what happened? And so what we learned was
Speaker 1: that the hospitals, when faced with a decrease in utilization,
Speaker 1: changed their coding so they got paid more for admission.
Speaker 1: And to be clear, changing their coding means changing the
Speaker 1: way they bill, so they're billing so that they get more.
Speaker 1: There are fewer patients coming to the hospital, they're billing
Speaker 1: more for each patient. For each patient. Yeah, so okay,
Speaker 1: so so far you're not making any money, right because
Speaker 1: you make money by saving money. What do you how
Speaker 1: do you respond? Well, we had also in the in
Speaker 1: the intim we had, we had massively expanded, So not
Speaker 1: only were we waiting to see if we were going
Speaker 1: to get paid, but we went out there and on
Speaker 1: the success of the vision and the mission and the
Speaker 1: tools we built and the early results we got, we
Speaker 1: signed up a hundred practices in five new states and
Speaker 1: we had to make it work. So we went to
Speaker 1: five states and fortunately in that first year with this
Speaker 1: new batch, one out of five states the docs got paid.
Speaker 1: If the initial problem is that, as the doctors you're
Speaker 1: working with, our lowering admission rates to hospitals, hospitals are
Speaker 1: effectively charging more for each admission. How do you solve that?
Speaker 1: How do you how do you fix that? There's only
Speaker 1: a limit to how much you can play those games,
Speaker 1: how much the hospitals can play those games? Yeah? Yeah, yeah,
Speaker 1: so you so you just drive down admissions even more,
Speaker 1: even more. Yeah, And were you able to do that? Yeah? Yeah,
Speaker 1: So we're now down seventeen percent. Hospitalizations are down seventeen
Speaker 1: percent in for our patients compared to what they would
Speaker 1: be if they were just like everybody else in their communities.
Speaker 1: So that's gigantic. So you're saying, same kind of patients
Speaker 1: you match the you know, big batch of patients, thousands
Speaker 1: of patients, if they're working with the doctors you work with,
Speaker 1: they're seventeen percent less likely to be admitted to the hospital. Correct?
Speaker 1: Is that at all a function of selection bias? The
Speaker 1: fact that docs who sign up with you already have
Speaker 1: a lower admission rate among their patients because that's what
Speaker 1: they're into. I mean, that's such a big effect. It is,
Speaker 1: And this is compared to themselves, So it's it's it's
Speaker 1: comparing our practices compared to themselves before, compared to non
Speaker 1: practices compared to themselves before right. So it's the same docs,
Speaker 1: the same doctors, the patients get admitted to the hospital
Speaker 1: seventeen percent less often once they sign up with you. Then, yeah,
Speaker 1: how how do you do that? I mean, I understand
Speaker 1: that incentives are powerful. Is it just the money? No,
Speaker 1: can use a computer for that. Um, it's it's actually
Speaker 1: creating data to target the right people for the right interventions.
Speaker 1: It's doing the basics better. So the fundamental thing that
Speaker 1: we're doing is we're increasing more access to primary care.
Speaker 1: So we get thirty four percent more visits to primary
Speaker 1: care doctors for the patients in particular who need it
Speaker 1: the most. And I just want it. There's there was
Speaker 1: a phrase you used in there that I just want
Speaker 1: to grab for a second. It was not just that
Speaker 1: it's easier to see the doctor. It's easier to see
Speaker 1: the doctor for the patients that need it the most.
Speaker 1: That's right. It seems like that's a really important phase
Speaker 1: is figuring out who those patients that actually need to
Speaker 1: see their price marycare doctor or seeing them when they
Speaker 1: need to be seen like that seems hard, Yeah, and
Speaker 1: that is where the technology comes in. My father in
Speaker 1: law was CEO of a health plan and before that
Speaker 1: he had started one of the health insurance company health
Speaker 1: insurance company, and before that he had started one of
Speaker 1: the first HMOs in the country. And he said to me,
Speaker 1: as far as how's this different than what we did
Speaker 1: fifty years ago? And I showed him our our technology
Speaker 1: and he was like, Okay, that's what's different. So how
Speaker 1: does it actually work? So how does it work that
Speaker 1: a doctor knows what patients they actually need to see
Speaker 1: or need to be available for. Yeah, so nine of
Speaker 1: our practices use our platform, our software platform every day. Yesterday,
Speaker 1: our practices were in the tool and what they do.
Speaker 1: When you log into the tool, the first thing you
Speaker 1: see is you had three patients who went to the
Speaker 1: emergency room yesterday, and we think that within forty eight
Speaker 1: hours you should call them. And here's here's the tool
Speaker 1: that helps you call them and you can now send
Speaker 1: them a text message. And just to be clear, like
Speaker 1: most doctors when their patient goes to the emergency room,
Speaker 1: how do they find out or that they don't They don't.
Speaker 1: They don't they don't because how would they be right?
Speaker 1: It's just like how would the doctor is over here
Speaker 1: in some clinic and then the patient is just driving
Speaker 1: to the emergency room or whatever getting driven to the
Speaker 1: emergency room, and they're like separate islands exactly, even when
Speaker 1: even when the doctor's part of the same system as
Speaker 1: the emergency room, there's no system to inform them, there's
Speaker 1: no system to call the patient. There's no system for that.
Speaker 1: Why because there's no incentive to do that. Yeah, nobody
Speaker 1: gets paid more to if they do that, And now
Speaker 1: there is, and now there is. Right, So that's that's
Speaker 1: one of the things you'll see. The other thing you'll
Speaker 1: see is you'll see it that says, hey, you know what,
Speaker 1: here's a list of patients who you haven't seen in
Speaker 1: a while, who you know they might need your help.
Speaker 1: They're pretty got pretty complex conditions, or their last blood
Speaker 1: pressure was pretty high or whatever. Right, here's a list.
Speaker 1: But you don't need to worry about that. Here's a
Speaker 1: list of patients for your scheduling person, the front desk
Speaker 1: person between patients. When she's got a few minutes, she
Speaker 1: should call these patients and make an appointment for them
Speaker 1: to come back into primary care. Right, So that's the
Speaker 1: wellness work Listen, when they come in once a year,
Speaker 1: like let's have a visit. That's not based on you
Speaker 1: reaching out to me because you've got something wrong with you.
Speaker 1: But once a year, let's have a visit where we
Speaker 1: can just sit and we can talk, and we can
Speaker 1: see how do we keep you healthy? What are the
Speaker 1: things that are going to be problems for you and
Speaker 1: prevent them? And you've found that it's profitable under this
Speaker 1: new system to do that. The practices make about fifty
Speaker 1: percent more per Medicare patient who's in these models fifty
Speaker 1: percent more, and they're they're like scrapping and begging for
Speaker 1: like a two or three or four percent rate increase,
Speaker 1: and they're getting a fifty percent increase through this model.
Speaker 1: And is allidate's business model to take some chunk of
Speaker 1: the additional Medicare pay basically that the doctors get. Is
Speaker 1: that the model, that's the model. The model is we
Speaker 1: only get paid when the practices get rewarded and the
Speaker 1: government saves money. Are the practices on the hook if
Speaker 1: their patients wind up costing medicare more than expected? Great question.
Speaker 1: So we do start with what's called one sided models,
Speaker 1: where it's it's it's like reward only, but then we
Speaker 1: move pretty quickly to two sided models and we backstop
Speaker 1: that risk for the practices. So so you take the
Speaker 1: you're on the hook and the practice is not on
Speaker 1: the hook. Correct. So I feel like I where you
Speaker 1: came from and where you are now, and I'm curious
Speaker 1: where you're going next, and in particular, you know, what
Speaker 1: are the things you're trying to figure out that you
Speaker 1: haven't yet cracked. We're in this in order to reduce
Speaker 1: hospitalizations and complications and bad stuff happening to patients, and
Speaker 1: we need to continue and there's so much every day
Speaker 1: I see the opportunity that we're leaving behind. Tell me
Speaker 1: more about that, I mean, and specifically when you talk
Speaker 1: about seeing opportunities that you're leaving on the table, Like,
Speaker 1: what's a specific example of a thing there you look
Speaker 1: at you're like, oh my god, we can help people
Speaker 1: and we're not doing it. What's an example of that? Kidney?
Speaker 1: Let me talk about kidney. So when someone's kidneys fail,
Speaker 1: it's a terrible thing, right where your blood is no
Speaker 1: longer being cleaned. They oftentimes it happens unexpectedly and the
Speaker 1: so called crash into needing dialysis, they get hospitalized. There's
Speaker 1: actually a big mortality rate for that when people actually
Speaker 1: die during that and never get a chance right to
Speaker 1: make it to the next stage. We can predict who's
Speaker 1: going to crash into dioss with pretty good accuracy. So
Speaker 1: because we have all of this information on the patient
Speaker 1: before upstream of when that happens in the earlier stages
Speaker 1: of kidney impairment, we can do a really good job
Speaker 1: using machine learning AI models of predicting who's going to
Speaker 1: crash into diosis. We can steer those patients because we
Speaker 1: have the primary care relationship with them. We can do
Speaker 1: a handoff from primary care to kidney specialists and kidney
Speaker 1: educators and work with the patients. And what we're seeing
Speaker 1: is at twenty four percent lower rate of hospitalizations twenty
Speaker 1: four percent for patients who've got that handoff into the
Speaker 1: kidney care management program to dialysis. And when that happens,
Speaker 1: presumably hospitalization goes down. Does mortality even go down? People
Speaker 1: die less if you do this. I haven't proven that yet,
Speaker 1: but I think it does well. So are you doing
Speaker 1: that already or is that a thing you think you
Speaker 1: can do but that you're not quite doing yet. So
Speaker 1: we have a unit that does these tests, these experiments,
Speaker 1: and then when they work, we scale them. So this
Speaker 1: is literally hot off the presses. We got the results
Speaker 1: from the pilot. It seems promising, and we're going to
Speaker 1: scale it and you can imagine like you can imagine
Speaker 1: that same sort of rinse and repeat right for a
Speaker 1: whole host of other of other things of just finding
Speaker 1: ways to be smarter about figuring out who is about
Speaker 1: to get really sick essentially, that's right exactly, and intervening
Speaker 1: either ideally to prevent them from getting really sick or
Speaker 1: at least to reduce the bad outcomes associated with getting
Speaker 1: really sick. You got it. We'll be back in a
Speaker 1: minute with the lightning round. Now back to the show. Okay,
Speaker 1: let's close with the lightning round. Okay, Um, what you
Speaker 1: ran health? I t for the Obama administration. So what
Speaker 1: is the least glamorous thing about working in the White House? Um?
Speaker 1: We had to pay for our own water like literally,
Speaker 1: what's yeah? Why? Literally we had a we had because
Speaker 1: the government is I mean, you really learn frugality. People
Speaker 1: have no idea Like in the government, we had a
Speaker 1: water club and you had to put in twenty bucks
Speaker 1: for to have the privilege of drinking from you know,
Speaker 1: the filtered water from from the water cooler. Uh, that
Speaker 1: is what you're That is the spirit of frugality that
Speaker 1: people don't understand. The government agencies have. What's why? Piece
Speaker 1: of advice you'd give to someone trying to solve a
Speaker 1: hard problem. Spend a lot of time asking yourself, what's
Speaker 1: the question? What's the what's the heart of the problem? Um,
Speaker 1: and I think you should change the name of your
Speaker 1: podcast to what's part of the problem? What do you
Speaker 1: think I should change it to to to what's the
Speaker 1: heart of the problem? Huh, you don't like it? I
Speaker 1: like I wonder about the problem framing at all, frankly
Speaker 1: as a as a as a name for the podcast
Speaker 1: I've come. I love it. I love it. I love it.
Speaker 1: That's why. That's that's that's why I love your podcast.
Speaker 1: I think it's the most important thing is to be
Speaker 1: working on the most important thing, and and we don't.
Speaker 1: We don't work on the most important thing. It goes
Speaker 1: back to that question you were talking about at the beginning,
Speaker 1: how can we save the most lives? That is that's
Speaker 1: my question, right, that's the that's that's that's the problem
Speaker 1: that I'm trying to solve. But for every every entrepreneur,
Speaker 1: what's the heart of the problem you're trying to solve
Speaker 1: and how can you how can you get to that?
Speaker 1: And what I found is people don't really don't really
Speaker 1: ask themselves and iterate enough on do I have it right?
Speaker 1: Is that really the heart of the problem is that
Speaker 1: the question what was the last hike you went on? Ah?
Speaker 1: I love hiking, and I walk on the Capitol Crescent
Speaker 1: Trail and the Ciano Canal all day. Like some days
Speaker 1: I'll walk eight hours during the workday with my phone
Speaker 1: and my tablet and my backup battery. So the last
Speaker 1: hike I did, was it a long hike on the
Speaker 1: Ciano Canal towpath? And was it, in fact a workday
Speaker 1: where you just walk in for eight hours and running
Speaker 1: your company? Yeah, that's a nice move. That's a very
Speaker 1: strong move. If everything goes well, What problem will you
Speaker 1: be trying to solve in five years hospitals? I think
Speaker 1: we've we've started where it's easier, where the incentive alignment
Speaker 1: is easier with independent primary care, and now we're adding
Speaker 1: on people around that. But particularly in rural areas, we're
Speaker 1: going to need to solve the rural hospital problem and
Speaker 1: maybe maybe maybe we can help flip them to a
Speaker 1: different model. Farzad Mosta Shari is the co founder and
Speaker 1: CEO of Allidate. Today's show was produced by Edith Russlo,
Speaker 1: edited by Robert Smith, and engineered by Amanda k Wong.
Speaker 1: I'd love to get your suggestions for who else I
Speaker 1: should talk to for the show. You can email us
Speaker 1: at problem at Pushkin dot fm, or you can find
Speaker 1: me at Twitter at Jacob Goldstein. I am Jacob Goldstein
Speaker 1: and we will be back next week with another episode
Speaker 1: of What's Your Problem.