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Manav Sevak:
Welcome to the Memora Health Care Delivery podcast. Through conversations with industry leaders and innovators, we uncover ways to simplify how patients and care teams navigate complex care delivery.
Matt Troup:
Hi, everyone! This is Matt from Memora Health, one of the medical directors and co-hosts of the Care Delivery podcast. I’m excited today to be joined by Gaurov Dayal. Gaurov, thank you so much for coming on the podcast today. Can you take a moment to introduce yourself to our listeners?
Gaurov Dayal:
Hi, Matt, it’s a pleasure. I know Memora really well, and I think you guys are doing great things. A pleasure to be here, and I’m glad we can make this happen. I’m, just quick background, Gaurov Dayal, I’m the CEO of Axia Women’s Health, and we’re one of the larger provider groups in the US for women’s health, and part of that have had about a decade-long history, mostly focused on clinic-based practices and value-based care, for example, in companies like …, so it’s a pleasure to be here, and look forward to our conversation, Matt.
Matt Troup:
Yeah, awesome. Yeah, I’m so excited to dig in today. I guess I’d like to start with what inspires you. You’ve been in healthcare most of your career. What keeps you in healthcare? What keeps you going day to day?
Gaurov Dayal:
Yeah, like yourself, I’m sure, and most people in healthcare, I think initially I was very intrigued by the ability to combine two things, especially as a young student; one was to help people and, especially when they’re in vulnerable moments of their life, and the second back then was to pursue my interest in science and technology, and I think medicine is a great way to do that. I ended up pursuing pediatrics, which I thought was a really good combination of both of those things. You really do help the most vulnerable members of society, and pediatric diseases are, mostly are not lifestyle-based, rather they’re based on a lot of genetic issues or infectious disease, and I found that very intriguing. So over time, my, while I remained passionate about that, I also got very inspired by the healthcare system and the ability to impact and improve that as a med student, as a resident, later on, as a working doc, there’s just a lot of collective frustration from providers around the system, and everybody gives up, puts up their arms and says, oh, it’s broken and don’t know what to do about this; and I really started getting intrigued by the delivery aspect, the financial aspect, the business aspect of what ails us as a country around healthcare. And now most of my time is spent around that, and I enjoy that, and I enjoy thinking about how to tweak it, how to slowly improve it, because the pace is not where I want it to be, but it really keeps me motivated, inspired and passionate about trying to make whatever contributions I can.
Matt Troup:
Yeah, we hear a lot that healthcare is broken. It seems like you hear that, and all over the place these days. Do you still feel that way now as much as ever, or where have you seen maybe some progress actually start to be made?
Gaurov Dayal:
I think that a quote that often is, I think, misattributed to Bill Gates that somebody else, who said that we overestimate change in the short term and underestimate change in the long term. I think we are making a lot of progress. I’ll give you some very relevant examples. Just this weekend, I was with my dad, who had knee replacement surgery two weeks ago, and he’s walking unassisted without a cane, he’s an 80-year-old guy, and he was out of the hospital the same day as his surgery, now he got very good care where he was. It also highlights some of the flaws in the system where the surgery went really well, but the post-surgical issues, he had some challenges with getting access and getting answers; the point being is that there is, when I was a med student, about a quarter century ago, these were complex surgeries, and they weren’t as reliable, and you definitely did not go home the next day, you went, typically you’re in the hospital for a few days, you went to rehab. That’s just one example, I could keep going. Remote medicine or virtual care, they’re a brand new concept. Of course, apart from technology, I think another area that we’re seeing significant changes is acknowledgement around what health really is. Behavioral health, I think when I was a med student or even a practicing doc was really thought to be peripheral to today medicine, for lack of a better word. I think there’s an acknowledgment that behavioral health is very much part of our health and that many of our issues are co-linked. A lot of the work happening around longevity research and the fact that our putting the last few years apart aside, the fact that lifespans do continue to increase globally, that we’ve, many challenges from an infectious disease perspective, childhood deaths, for example, across the world have declined dramatically in the last 20 years or so. So I think we are making a lot of progress, but it’s hard to see that progress on a daily basis. On a day-to-day basis, I think we’re just much more used to dealing with problems. And I think, to be fair, that’s probably how it is in every aspect of life. I think on a given day, I do have my own frustrations about healthcare, but when I step back, it’s cool to see like how much progress we are making and how much we’ll continue to make.
Matt Troup:
Yeah, I think it’s easy to look at how technology has moved other industries so quickly, and it’s, why isn’t healthcare moving that quick, but you’re right. There are significant gains that have been made a lot around direct patient care and optimization of surgeries. But you touched on something really interesting there, it’s, it was the post-discharge phase that was still maybe a little frustrating, or access was challenging. Why does that continue to be an issue? I know you have some background on population health. Why do we still have significant issues with access, and where do we need to make some changes?
Gaurov Dayal:
I think the system is just completely fragmented. Everybody, I’ll give you, again, my dad’s case. The surgery went fine, but the post-op care was being coordinated by yet a different provider group than the orthopedic group. You would think that, logically, it would make sense to have all under the same umbrella, and there was just a major disconnect there over a very minor issue. And I think that a lot of what ails us in this country around healthcare is this fragmentation which is driven by different reimbursement models, different payment models and payers, and lack of vertical integration. You could argue that because you have best-of-breed providers providing these services. From a customer perspective, though, it’s very difficult to understand, for example, my dad, who’s not in healthcare, to understand why this home health agency just can’t call this doctor immediately and figure out what’s going on and vice versa. So I think that, I would say that it stems from a very basic issue that we have in this healthcare system in this country, is that the customer is and the patient is not at the center of it. Everything is built around the provider convenience, either the hospital, the doctor, pharmacy, the home health agency, but a true model would have been built around the consumer and the person who actually needs the care rather than our convenience. And I think that, and we’re all complicit in this one way or the other, and it’s really no one’s fault, it’s just how the system has evolved over time. I do think that there’s acknowledgment of this, and there is at least conversations on how to change this versus, I could, 15 years ago, I don’t think this was even on the radar, linked to which I think is maybe the fact that social determinants of health play such a major role in your healthcare outcomes, which wasn’t even a thing, frankly. Of course, these issues existed, but nobody even acknowledged them or talked about them, and if you don’t have access to transportation, I could give you the best care in the world, but if you can’t get to it and I can’t get you there, it’s completely meaningless even if it’s available to you. So I think that as we, and now, of course, we have this very complicated large part of our economy, which is healthcare, and we’re trying to fix it, at the same time, we have to keep it operating, and I think those are challenges that are very complicated, and I think we’ll continue to make progress, but it’s, for that reason, it’s very slow.
Matt Troup:
Yeah, I completely agree. You mentioned about, previously, in your answer about identifying what health really is, you identified there that social determinants of health are finally being taken seriously as a part of quality care and ensuring that patients are getting what they need. As you’ve experienced different types of care models in your career, and we’ve seen this explosion of new care models since the COVID pandemic, what do you think is working well in those new models, and do you see any of those as the ideal approach?
Gaurov Dayal:
No, I think it’s a great question, Matt. I wish I could say that there is one delivery model that I believe is the best, but what, I’ll first give a more general answer. I think models that put people at the center of care delivery are, in my mind, are more effective and ones that, and also engage patients and people in their care better. I can give you probably two examples of that, both from my own experience. One is from Chenmed, which is fully capitated Medicare Advantage where, and Chenmed mostly focused on lower-income minority seniors, but much because the financial model is around full capitation, there is a natural incentive to highly engage with patients through the Medicare Advantage program, and I think that does lead to, if you look at patient satisfaction scores and outcome scores of models in fully capitated primary care clinics, you see a significant upward improvement in all kinds of metrics. And that is because the models drive that, it’s very, you would not be able to be profitable if you weren’t able to engage with your patients so that patient engagement is front and center, which leads to, I think, much better care outcomes. At the same time, I’m on the board of a company called MDVIP, which is country’s largest concierge medical practice, and that’s geared towards people who are paying a concierge fee, super high engagement, having NPS scores in the 90s, which is just unheard of and higher than companies like Tesla, and Netflix, and Apple, really good outcomes. From a financial perspective and from a payment perspective, they’re both different. One is very, is a capitated environment, and the other is a complete fee-for-service environment. But the outcomes, in many ways, are quite similar, and I think the common theme I see in both is the fact that the patient actually is in the center of the universe for both of these business models. So I think that financial incentives that drive putting patients at the center are, is what’s going to win in the long term. And as we make a pivot in this country towards consumer-centric, patient-centric care, I think that’s wise. And hopefully, over time, the savings comes from doing that by having people in a system where they’re not lost, where they’re not fragmented, where they themselves are activated to manage their own health, and also to engage with their healthcare provider in a very seamless fashion. So I think that overall high engagement care in my mind leads to better outcomes and lower costs, and you can deliver that in many ways. You can frankly deliver it in a behavioral health environment fully, virtually. You don’t have to have people come in, and we’ve seen that with COVID. But again, those are different examples of the same theme that, how do I engage, and how do I get people to interact with me on an ongoing basis, and how do I get to know them better, and they get to know me better.
Matt Troup:
Yeah, I’m glad you touched on the incentives there, especially as we think about how care teams and physicians are thinking about care models now. Are you starting to see any changes in how we incentivize clinicians and maybe remove some of the tasks from their plate so they don’t feel so burned out by patient care?
Gaurov Dayal:
I think that we have clinicians do way too many things that we don’t need them to do, and that’s just part of this fragmented system. And at the same time, there are only so many hours in a day, so if you’re spending two hours closing out your electronic health record every night, that’s, there’s no time left for you to actually follow up on patient calls and things like that and vice versa. Where I hope that, and I know there’s a lot of talk about generative AI and where we’re going with a lot of these automation tools, I do believe that there is an opportunity to do this right and use tools that truly, like they are in other industries, reducing work, low value-added work and letting that being automated so that folks can actually do, doctors, for example, nurses, pharmacists can focus on things that they truly are experts at, and that is not doing paperwork and extracting codes and filling out the same form for the 18th time just because it needs to happen. So automation, I think, is going to be a very early in the automation story. In fact, it … hasn’t even fully started, but I think that we’re going to see significant impact. The other thing that I think is reality is, a common question I get asked not just at my own company, but when I give talks, or I, or on companies that I advise or I’m being board on, is what do we do about this shortage of people? And for a variety of reasons, we’re always going to be in an environment where there will never be enough providers that we need. What we need to be doing differently is what other businesses and industries have done over time: use technology too, so that folks can do what only human beings can do and do very well.
Matt Troup:
Yeah, I appreciate that answer. I think a lot of the work that we’re attempting to do on Memora is really focused on trying to leverage automation and AI to remove a lot of these tasks from the plates of the care team and give time back to actually patient care and that human element. Where have you seen maybe good examples of technology being like a value-add to care delivery in your experiences, whether that’s at Chenmed or Axia? I know largely still like brick and mortar, has digital technology provided additional value? Is it delivering on some of the promises we’ve seen in other industries?
Gaurov Dayal:
I think that, as we all know, technology in healthcare is, just like the healthcare industry, is very fragmented, and it isn’t as seamlessly integrated into the day-to-day. That being said, I do, I think one area that I think has the ability to be, and has started to show significant transformation is virtual care. I think that during COVID, maybe the virtual story got ahead of itself a little bit for natural reasons, but I don’t think that means that it’s not going to be a major player. For example, if you just had a baby and you’re one of our patients at Axia, the last thing you want to do is go back to the doctor’s office a few days after going home for a postnatal visit, those are, that’s an example of something that can be done virtually. We, at Axia, we’re the company that is able to do home-based fetal monitoring where you basically put on a belt and you get wireless signal around how the fetal heart rate is doing. And those are things that, in the past, you could only do if you came to a clinician’s office. And there’s multiple examples of virtual care that happen and are happening again very early, some of it constrained by the reimbursement model itself, which requires either in-presence delivery, or there isn’t a quote-unquote-quote code for that at the moment. But technology will continue to push on the virtual side, I think that the ability to take care of people at home is, … at home, I think is going to be a major theme going forward. There’s, again, some reimbursement issues that have limited the growth of that sector because it’s a lot of Medicare beneficiaries, but I think that’s very early in its innings, and I think we’re going to see a lot more, nobody would be in the hospital. And also, if you look at end-of-life care, the same thing; most people want to die at home in the comfort of their home with support. And many of those things are, it’s just a combination of reimbursement, legal issues, and comfort issues with this new technology, so I’m very intrigued by that. I also think that while, at least in the short term, which I would define as maybe the next decade or so, in-person, hands-on care will still be the predominant modality. I think there’s a tremendous opportunity to start incorporating virtual things, virtual components of that. For example, at Axia, another area that we’re working on is, how do we incorporate virtual primary care into women’s health. So there’s a lot of, many women treat their OB-GYNs as their primary care providers; at times, a lot of the issues that they have are not related to reproductive health issues only, they could have high blood pressure, depression, high cholesterol, fill-in-the-blank. How do we incorporate primary care, for example, family practice and internal medicine into this more OB-GYN environment without creating yet one more fragmentation? So one way to do that, for example, is can you have a virtual care delivery model that manages the medical quote-unquote issues while at the same time, reproductive health issues are being managed in the confines of our clinic. And how do you integrate those things? So again, early stage, but it’s something that we’re really intrigued by. And then maybe finally, I also think there’s a tremendous opportunity for advancing payment modalities so that we can get better care. On the senior side, Medicare Advantage has been a major catalyst for growth and for moving people from into value-based care programs. I think the same will and should happen in Medicaid. 50% to 53% of babies born in this country are born to Medicaid beneficiaries, and we just don’t have that same milieu of value-based care programs, so we recently announced an initiative with a company called … that’s working to help some, with these some of these social determinant issues for Medicaid beneficiaries. And my hope is that over time, we start transforming part of our revenue model and business model into more of a risk-bearing Medicaid, or at least, becoming a Medicaid, larger Medicaid provider than we currently are. And I think that many of these things require two things to happen in parallel the payment model to change, and at the same time, the delivery model has to change to mimic the payment model across the healthcare system, where once there’s a change in payment modality, all of a sudden there’s a significant change in the delivery modality.
Matt Troup:
Yeah, exactly. At Memora, when we think about increasing access to care and how we partner with providers delivering in the women’s health space, oftentimes what comes up is how maternal health really hasn’t had significant clinical outcome improvements as much as we maybe would expect, and certainly in some demographics or socioeconomic statuses as well. How do you think about that? You mentioned ways you’re improving access within Axia, but I’m sure this must be top of mind for you. How does your, you and your team think about driving forward maternal health outcomes and really starting to tackle that specifically?
Gaurov Dayal:
Yeah, no, Matt, you hit it on the nail. Honestly, I think where we are as a nation is an embarrassment. You, probably you’ve seen these studies that have recently come out that we’re at a 40-year low for outcomes for Black women as it relates to prenatal death and mortality. We are not making progress in this country as it relates to women’s health. And look, this is a multifactorial issue, much of it, however, does relate to socioeconomic determinants of healthcare. If you look at poorer outcomes, they tend to be in poorer, people with fewer resources. You couple that to my prior point that majority of this country’s infants, babies are born to Medicaid beneficiaries, which again is a major social determinant and access issue. And I think you put these things together, and you’re creating a very fragile environment for the most vulnerable in the future parts of our society and also the future of this country. I think what really needs to happen is for us to make this a priority, and again, to have sustainable business models that support provision of care for Medicaid beneficiaries. Look, I’ll be honest. We can’t, as a company, survive at what, on the reimbursement that Medicaid provides for us, typically, in many markets. I think some of the forward-leaning plans are taking this seriously and are putting in either value-based care components or at least some level of parity with a typical payment modality. But from our end, we have to make a, and our doctors, and our staff, have to, and our business folks, have to make a very concerted decision as to where we are able to afford to provide care or not. And I think that as we’ve seen with the senior population, the right way to do this is to actually reimburse for care coordination, reimburse for outcomes, reimburse for access, which does require some level of investment, but does show a positive ROI, especially in this segment of our society, which is our babies and our future. So I think there’s a lot that we need to do, not to sit Axia, but as a country, and I think we’re slowly acknowledging at least what the problems are, I think we’re very far away from what the solutions are. As I mentioned earlier, we just, last, in the last four months announced an expansion into the Medicaid social determinant space with … We hope that’s a major catalyst for us to embrace those kind of care design modalities across multiple markets at Axia. But I think more importantly, as a society, we have to make a value decision as to how we value the future of this country, and this will require tradeoffs. We spend a lot of money towards the last few weeks of life in this care, where often, which is futile, and which is unnecessary, and frankly probably puts people through much more pain. How do we actually allocate resources to the future differently than currently is, I think, is a political discussion, and a resource allocation discussion that frankly, no company can determine, and I think it’s a societal issue. The optimism I see here is, from my earlier point around social determinants, being something that wasn’t even a conversation to something that’s becoming front and center of the conversation outcomes in many of our vulnerable populations, not just babies, not just moms, it’s even in seniors or working-class people, is exceptionally determined on where they stand in the pecking order and social status and resources. And that’s this question I think we have to ask ourselves as a country, are we willing to walk the walk, or are we just going to keep talking about this?
Matt Troup:
Yeah, everything you say is really inspiring to me. You’ve had such great experience in a variety of care delivery models, and I think that you’re right on with the ways in which we need to think about access and think about providing the best quality care possible so we can improve outcomes. As you think about the next 5 to 10 years of healthcare, is there 1 or 2 things you’re really focused on and thinking about, or hoping that we might actually move the needle on?
Gaurov Dayal:
Yeah, look, despite some of my pessimism, I’m a very optimistic person by design. Look, I think there’s a lot of good things happening, Matt. I mentioned AI, and again, I don’t want to say it because everybody else is just saying it, I truly believe it has the potential of being transformational, not just from how we operate as care providers, but from people’s understanding of their own health. It’s really, I think, going to be democratization of knowledge. So people can get better, it’s not, a lot of docs roll their eyes and say, Oh, don’t use doctor Google. This isn’t doctor Google. This is going to be a real doctor, or at least a real doctor resource, that folks can use in making very important decisions and being engaged in their own healthcare, and I think, as importantly, that clinicians can use in providing better care, so I think that’s going to accelerate. Technology grows exponentially, so I think next five years are going to be meaningfully different. We talked about virtual, I think we’re really early, and probably had a bit of a false start, where everything seemed like it was going to become virtual overnight, but it’s not staying out that way. That being said, I think it’s going to become much more embedded in the care delivery model. There hopefully will, we’re slowly moving towards this reimbursement model that promotes value. It’s definitely slow, we probably backslide it a little bit with COVID. That all being said, the numbers speak for themselves, and I don’t think there’s any path forward, but to continue to embrace that, and let’s see where we are with that. There’s a, for example, the new ACO Reach product I think is very interesting, I think it’s clever. I think it may push a lot more care coordination businesses and a lot more primary care businesses and practices into care coordination, I think is good. And then maybe lastly, I think one area that’s personal interest of mine, which I think is really at the cusp of taking off, is this whole longevity. How do you bring things together between nutrition, exercise, healthcare, biomarkers, to really give folks the tools to live life, to be, live lives, how they live lives to 100 or 105 or 97? Which 20 years ago would have seemed impossible but is looking very realistic. And I think it’s because of major breakthroughs that have happened in our understanding of this science.
Matt Troup:
Yeah, and to your point, as you mentioned earlier, better defining what health really is, which I think is critical. Yeah, and again, to your point, like really appreciating the areas in which we have made improvements such as social determinants of health being now front and center for most care providers as something we need to be mindful of, and triage, and break down barriers so that we can provide the best care possible. Gaurov, it’s been such a pleasure to be on this podcast with you today and to hear your stories and really have a moment to understand better where care delivery is currently. So I really appreciate the time.
Gaurov Dayal:
You’re a lot of fun, Matt. You guys are doing great work at Memora, and it’s always fun talking to like-minded folks. So thanks for the opportunity, and I look forward to talking next time.
Matt Troup:
Yeah, we get to connect again soon.
Gaurov Dayal:
Yeah, thanks.
Manav Sevak:
Thanks for listening to the Memora Health Care Delivery podcast. For more ideas on simplifying complex care for care teams and patients, visit MemoraHealth.com.
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