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Community Health: Aristotle Mannan
27 Plays5 years ago
Season 1, Episode 8: Aristotle Mannan is a healthcare innovator from Boston, MA. Listen to Aristotle talk about community based organizations, Medicaid and how his company bosWell is using data to optimize healthcare
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Transcript
Introduction to The Wound Dresser Podcast
00:00:09
Speaker
You're listening to The Wound Dresser, a podcast that uncovers the human side of healthcare. I'm your host, Jon Neri.
Aristotle's Career Transition
00:00:23
Speaker
Aristotle worked as a cancer research associate at the Broad Institute of MIT in Harvard before becoming a community health worker in the greater Boston area. Ultimately, he founded Boswell, a company that deploys a free web-based application to help community-based organizations with record keeping. Aristotle, thanks for joining the show. Thanks for having me, John.
00:00:45
Speaker
Yeah, so first I wanted to just maybe go back in time a little bit and hear about the leap you took from doing cancer research to community health. I imagine working at MIT in Harvard was a great experience, but then to go directly into community health, if you could just talk about that sort of thought process, maybe kickback you might have gotten from other people. Sure. So a lot of the reasoning for jumping from cancer research to community health worker
00:01:15
Speaker
Tides are just leaving my comfort zone, getting out of my bubble and doing something different. For the most part of my career and just my childhood, I'd grown up in research labs. So my father has like a PhD in biochemistry. My parents always worked in the pharmaceutical industry. So my college summer internships and then, you know, the work I did right after school was very much the biotech pharma space. I also had this background in molecular biology when I came out of Michigan.
00:01:43
Speaker
as an undergrad. So I had this orientation towards doing a PhD and being on that biomedical sciences pathway. But I felt like I was really interested in bench to bedside at the time and I had seen a lot of the bench in the laboratory setting. I never really understood what it's like to work directly with people and that's something I wanted to get more experience about.
Community Health Engagement
00:02:05
Speaker
So I considered a lot of options in the spring of 2014 after about three years in the cancer research setting. But then
00:02:13
Speaker
found this opportunity to work with community-based organizations and opted towards that direction. OK, excellent. So were there other people around you who were kind of encouraging or discouraging you from taking that leap? I imagine, even from a financial perspective, that might have looked differently from being a cancer researcher to a community health worker. You're definitely dealing, I'd imagine, you're surrounding yourself with different types of people in those two settings.
00:02:42
Speaker
Did you, what were kind of people around you influencing you? Sure. Yeah. And I did a lot of outreach to mentors and advisors and just trying to get a sense of what to do next. But a lot of people basically said, look, you're 24 years old. You don't have a lot to lose. It's good to get out there and get new experiences and try new things and sometimes see if you might be able to carve out a new niche.
00:03:08
Speaker
You don't know what you don't know until you go out there and experience it for yourself. So, I mean, that was kind of some of the feedback I'd gotten. Before I left research altogether, I had considered things like consulting in the biotech world. During my time at the Broad Institute, I was also working kind of on the down low for a small cancer diagnostic startup company, and was just kind of interested in that startup world.
00:03:38
Speaker
And it was just something different. And then it's probably, I probably didn't mention it to you earlier, but even after I left cancer research, while I was working as a community health worker, I continued to do some part-time biotech business development roles to kind of keep myself in the game. So I was interested in also the biotech space with the business end of things. But again, I felt like, you know, there was something that was compelling me to work more directly with people and do something different and completely different, right? So, I mean, I was living in Cambridge,
00:04:08
Speaker
in Porter Square, working in Kendall Square, you know, it's eight minutes on the T, point A to point B. You don't really see a lot outside of you, outside of that bubble. So I really wanted to just completely do a 180 and try something different and see how I respond and
Experiences in Boston Neighborhoods
00:04:24
Speaker
react to it. And so I had met along the way people that worked with mobile health clinics, and that's kind of, that was my foray into the community-based organization world.
00:04:34
Speaker
Okay. And you cited one of the reasons also for the jump was going out of your comfort zone. What was the work like as a community health worker and how did it push you out of your comfort zone? Sure. So, I mean, you know, Boston is an interesting city because it's pretty much segmented in terms of like, you know, where opportunity exists and where poverty is and
00:05:02
Speaker
In some ways it's just highly gentrified, right? You have to have these very fortified areas where you don't see a lot of poverty and then you move a couple blocks over and all of a sudden things look very different. But if you're within, you know, the former and that kind of gentrified area, you don't often see things, you don't have a conception of what things might be like. And so, you know, living in Cambridge, people would always say, you know, don't ever go to Dorchester, Roxbury. It's dangerous down there. Things are different down there. Or same thing with East Boston or Chelsea, right?
00:05:32
Speaker
And so, you know, I kind of went into those neighborhoods with this conception that, you know, something's going to happen to me or I shouldn't be in those places in the first place. And so part of that was like, all right, you know, addressing those concerns or what people had said to me, but more of it was just, it was kind of shocking to me how many missed opportunities that were out in these neighborhoods. You know, I had no conception of the fact that you could be out in East Boston
00:06:01
Speaker
Thursday evening at a mobile health clinic in a neighborhood with one of the highest liquor store to grocery store ratios in all of Massachusetts. And you'd see people just showing up to get food, toiletries, and clothing, but also drinking Listerine, which is 21% alcohol, and wearing green hospital gums and going in and out of Boston Medical Center emergency departments 100 times a year. And that was just kind of like, in terms of the biggest thing I had to adapt to was just kind of how shocking a lot of this was to me. I had no
00:06:31
Speaker
I couldn't even imagine that some of these things were occurring out there just a few miles from where I was living. So this was kind of a very eye-opening experience, to say the least. Sure, yeah. I can definitely see what you're saying about I lived a summer in Boston and worked in Brookline and went through Roxbury on my way to work and going from the back bay to Roxbury, two different scenes for sure.
Role in Mobile Health Clinics
00:07:02
Speaker
I wanted to ask you also about, so you said you kind of got into this and with a person, as a person who didn't really have more of a, you said more of a biomolecular science background, what roles were you able to play with these mobile health clinics and community-based organizations? Yes, I mean, my main role is observer. And I think actually a research background
00:07:28
Speaker
we think about like scientific method. The first thing you do is make observations, and then you kind of make deductions from there. And so for about 18 months from the spring of 2014, really about May of 2014 through 2015, I was very much in observation mode. I was working with these churches, food pantries, mobile clinics, needle exchanges, kind of spectrum of touch points out there, serving those in need. And just try to understand, you know, what it is that they're doing, why is it that they're doing it in certain ways,
00:07:58
Speaker
But one of the things that became apparent to me was that these organizations are under-resourced nonprofits. They're not technology enabled. And the constant theme was that they were using pen and paper for record keeping, which it just kind of blew my mind because I'm coming from this kind of tech-oriented background in a cancer research setting. We're doing drug discovery and screening novel therapeutics for cancer.
00:08:26
Speaker
And here I am out there in East Boston or Dorchester at a mobile clinic or drop-in center doing intake on pen and paper, but on individuals who are frequent flyers to the hospital. And, you know, there are a lot of missed opportunities to coordinate care. So yeah, in terms of skill set, I mean, I was just kind of observing and then piecing together information. And then that's how I kind of took my next step.
00:08:52
Speaker
So as a, were you employed by these organizations or you're more just of a volunteer? What was, did you have kind of an official title with them or? There were a handful where I was actually employed with and they weren't paying me anything. So I mean, I guess technically volunteer, but I was kind of, I had a role with the organization. One of them was the family van, which is a mobile health clinic through Harvard medical school started in the early 1990s. And so they do a lot of work in some of these neighborhoods through their mobile health clinic.
00:09:20
Speaker
And then there were a handful of others that I just got to know and build relationships and for some reason I felt drawn to go out there and work with them and continue to get this exposure and experience. And so you keep saying community-based organizations, are these
00:09:40
Speaker
When I hear that term, it almost seems like they wear a lot of hats and kind of the lines get blurred with what their function is in a community. What different things do they do? Healthcare, I imagine, provide some support of healthcare to individuals, but you've also said, you know, toiletries, food. What are the different things that people depend on these organizations for?
Community Organizations as Safety Nets
00:10:05
Speaker
Sure, there's a vast array of community-based organizations out there. You have the homeless shelters, the food pantries, churches are kind of multifaceted, do a lot of different things. There's mobile health clinics that are deployed to different sites, and syringe service programs for those that are dealing with opioid addictions. And the list goes on. But ultimately, they're all kind of an embodiment of the safety net. So in many ways, there are social services that
00:10:33
Speaker
people can access. And then there are certain welfare benefits that give people some ability to get to the next point in their lives. But these community-based organizations are kind of like this informal safety net that exists in any zip code that you go to. And in many ways, they fly under the radar because people don't really know about them until they really have to access them. But they're always kind of in these longstanding touch points that have existed
00:11:04
Speaker
in any given community. And yeah, I mean, they do kind of informal care management. It's not always healthcare oriented, but they address the socioeconomic risk factors that are critical to someone's health and help people stay in the game. So yeah, there's really the neighborhood touch points. And I think people have become more aware of them as the middle classes continue to shrink and people continue to become more vulnerable
00:11:33
Speaker
and are increasingly dependent on these organizations. So how would you say is the main mechanism for these community-based organizations to stay alive? Is it government funding? Faith-based organizations, I imagine, wouldn't have as much of that. So maybe private donation. Could you just speak to who's really keeping these things alive? Yeah, it's a great question. And I would say that.
00:12:01
Speaker
maybe 75 to 80% of these community-based organizations are kind of these small mom and pop nonprofits that are just, you know, maybe they're funded through a congregation, local donations. Sometimes there might be a thrift shop that, you know, they sell some goods or items and they use that to bootstrap the organization or the service center that they're running. You know, I've come across food pantries like in South Boston, there's a church that serves a number of neighborhoods and they do it on a $5,000 budget.
00:12:31
Speaker
that's what their food pantry operates on. It's just donations, and it's just the goodness of what the neighborhood has to offer in terms of supporting that organization. So as you can imagine, they're pretty cash-strapped and resource-limited. Then you have some of these organizations, like the larger shelters. In Boston, you might have something like Pine Street Inn or Woods Mullen. And shelters are actually federally funded. They get funding through housing and urban development.
00:12:59
Speaker
and they have to generate data called Homeless Management Information System data, HMIS data, that's conveyed to HUD so that they can get funding allocated to them based on the number of heads in their beds. Then you have syringe service programs and mobile health clinics that might get some state and federal dollars. But ultimately, the majority of these organizations, even the ones that are seemingly well-funded,
00:13:28
Speaker
have very few resources given the amount of work that they have to do and the growing demand. And so that's what's kind of created this technology gap and has pushed a lot of organizations to be dependent on pen and paper. So the individuals who are utilizing the community-based organizations, could you just paint a better picture of who they are? I imagine they,
00:13:57
Speaker
would be predominantly people of color. They would be, I don't know what their employment status would be. Could you just paint a picture for who's kind of utilizing these organizations?
Challenges Faced by Community Service Users
00:14:14
Speaker
Sure. Yeah. I mean, this is something I'm continuing to learn about and, you know, discover more about what this population looks like. So, you know, when I first went out to the neighborhoods like East Boston and Dorchester,
00:14:27
Speaker
especially kind of as we were doing some of this outreach work, there was a focus on the homeless population. That's kind of who we associate with poverty and kind of individuals that are slipping through the cracks of the healthcare system. And around that time, I was also shadowing some of the folks at Boston Healthcare for the Homeless. And so I was just very interested in the homeless population and some of the individuals like the ones I'd mentioned, the ones drinking Listerine and wearing the green hospital gowns and in the emergency department, they were very much homeless.
00:14:57
Speaker
But it turns out that on any given night in the United States, there might be 600,000 people that check into a homeless shelter. And cumulatively throughout the course of the year, maybe a few million, three to four million that are considered homeless. And so it turns out that the majority of individuals that are checking into these organizations are actually kind of the working poor or just marginalized populations that are struggling to make ends meet.
00:15:26
Speaker
And in many ways they're invisible because they're not necessarily homeless. Even within the homeless population, 80% of people that show up in a shelter show up one night in a year, right? And all beds drop as to where they go after that. Another 10% are episodically homeless. They check into shelters or social service organizations periodically throughout the year. But again, we don't know where they go. And it's actually 10% of that homeless population that's truly chronically homeless. The ones that, you know,
00:15:54
Speaker
we associate with that street corner and the panhandler and we can actually put a face to an individual and consistently see them out there. But then in terms of all the rest of those individuals, I'd say that they're housing and secure. And just because they have a, you know, some sort of roof above their heads, it doesn't necessarily mean they're in a much better situation. They might have a sectionate housing voucher. It might be another unfavorable living situation, maybe doubled up.
00:16:20
Speaker
A lot of people sleep in cars. It's really hard to keep track of where individuals are and how they get by. There's actually an interesting book. It came out a couple years ago by an author named Matthew Desmond. It was actually now based in Jersey and it's called Evicted. And he talks about how when he was in Milwaukee in 2009 at the height of the housing crisis and beginning of the recession, something like one out of eight renters in Milwaukee was evicted.
00:16:48
Speaker
These are folks that are not necessarily homeless, but they're kind of just out there struggling to get by. And as you can imagine, the working poor, that population is growing because the middle class is effectively shrinking. There's some blurred lines there. With regards to kind of demographic information, yeah, I mean, it disproportionately affects people of color, but it turns out that there's also a lot of white poverty, which is something that I hadn't had much exposure to, but early on,
00:17:17
Speaker
as I was working on Boswell, I spent some time out in Colorado Springs, and there are far more rural areas in this country than there are urban areas, or maybe actually they might be even, right? And so again, there's another population out there that it's relatively invisible, but they're very much struggling to make ends meet. And the community-based organizations are the first place to go to in times of need.
Founding Boswell: A New Approach
00:17:44
Speaker
So when you were doing all this observing, and you identified the need for sort of better record keeping strategies, when did you make the jump to start Boswell? And how did you initiate funding and things like that? Sure. So, you know, I was working out in the neighborhood organization starting in May of 2014. And very early on, this idea of addressing record keeping was something that
00:18:13
Speaker
was very interesting to me. And probably in the summer of 2014, I reached out to engineers I knew in the greater Boston area, including people like Mike Neary, right? And my neighbor, Will Leonard, we may have met as well. And I actually hosted a little event in my apartment in Cambridge called Pizzas and Beers for Software Engineers, because I was really interested in getting some insight on
00:18:39
Speaker
you know, what to do about this and how to go about building something to address record keeping at the neighborhood level. So actually my neighbor Will at the time in Porter Square, he offered to help me and we built kind of the Boswell 1.0 kind of record keeping application. And for some context, Boswell is an old English word that means companion and record keeping assistant. So if you're Sherlock Holmes and I'm Watson, you might say, you know, I'm lost about my Boswell.
00:19:08
Speaker
somewhere on YouTube, there's a clip where he actually says that. And so the idea of Boswell is it's actually like, you know, we want to be that companion record keeping assistant. So yeah, by the fall of 2014, will it help build out this like prototype, minimal viable product application for community based organizations. And at the time it was like a native Android application and the data was stored locally on a tablet and we did our best to encrypt it.
00:19:37
Speaker
But we just put it out there in the hands of a few organizations and we said, look, go ahead and use this. And on my end, I was actually working at some of these organizations and I thought it beneficial to get off a pen and paper and to use something more digital. The feedback that we got early on was that no one was going to pay for it. And that was the reason we didn't have SOF in the first place. Salesforce and things like that are way too complicated. Even if they had to find a contractor to build some sort of
00:20:04
Speaker
customizable solution, you know, they couldn't pay for that either. So they said, we're not going to pay you a dime for this, because you can't afford it. So we said fine. But we just started to kind of put this out in the hands of organizations. And we just want to test if it actually could be used, if it addressed the pain point of, you know, client intake, data reporting, if it could improve efficiency in some sort of way. And then, yeah, more organizations started coming to us. And
00:20:34
Speaker
We said, all right, wait a second. We don't actually know what this is right now. We're not even incorporated as anything. It was kind of very much nonprofit minded the way we were building it. But we figured, all right, for this to be a tech solution and to be scalable, we might have to find a value chain. And we can't simply just be a nonprofit and try to go get donations to build this out. There might be a value chain to tap into.
00:20:59
Speaker
And that's probably tied to the data layer that's being generated through these organizations on a population that's very vulnerable and costly to the healthcare system. So when you first started putting Boswell out, was it hard to get, especially some of these mom and pop organizations to get on board with it in terms of just the tech gap?
00:21:26
Speaker
Yeah, well, I think the hardest part is that at the community-based level and the safety net, everything is relationship-driven, right? And so, I mean, people show up at these organizations because they are trusted touchpoints. They have relationships with people that work at these organizations and, you know, they look like one another and they can relate to one another and they have shared experiences. And so the notion of like, you know, some Cambridge tech-oriented guy going to Dorchester or going to East Boston
00:21:55
Speaker
saying to an organization, knocking on their door and saying, hey, we have the software application you should use. It can be a bit off-putting, right? And so certainly when I was kind of cold contacting organizations, they're like, who's this guy? What does he know? Why is he coming to us? There's always a bit of suspicion in that sense. But earlier on, some of the organizations that had already been working with, we'd kind of built that relationship. They knew who I was. We were very much co-developing it with them.
00:22:23
Speaker
And so they were kind of our early adopters. And as we continue to grow, we leverage those relationships so they could speak on our behalf and kind of convey our message. So you started Boswell in 2015, correct? I technically started working on it in the spring of 2014 and actually incorporated the company in 2015. So,
00:22:50
Speaker
who knows what the actual start date is. And then I started working a full time in 2016. So it's just kind of incremental. Yeah. Can you just talk to more of the evolution of Boswell and how you sort of alluded to where you started out, but how has the company changed? Have you taken on more people and then sort of how the record keeping service has evolved to where it is today? Sure. Okay. So a lot of points. I guess that's, you know, try to summarize six years as well as I can.
00:23:20
Speaker
So if we go from where we started in the spring of 2014 and the fall of 2014, we put out this 1.0 iteration of Boswell. And it's this native Android application. We're purchasing these tablets. And we allow people to do the data entry. And then it's information stored locally. But at least it's helping them build these longitudinal profiles of the folks that they're serving. And by the time we probably had four or five test kitchen
00:23:50
Speaker
organizations around Boston that were working with us. So then it became apparent that for this to be scalable, it should probably be a web-based application and not like a native application. And so I said, all right, well, where am I going to find a web developer? And so serendipitously, I reconnect with another friend of mine who had just finished a launch academy coding bootcamp for Ruby on Rails developers.
00:24:19
Speaker
He's a good guy. He was looking for more experience. He was interested in what we were doing. So then he kind of started to build out the Boswell 2.0, where we built this web-based application that can be used on a phone, tablet, or PC. It's mobile responsive, all hosted on AWS. And we continue to kind of scale the application that way. But still from a value chain standpoint, I had mentioned earlier that
00:24:48
Speaker
I had the sense that this couldn't be a nonprofit. It had to be something different. It had to scale. And that had to be tied to the data layer. And so I started to recognize that a lot of the folks that were visiting these organizations, and particularly the vulnerable individuals, were frequent flyers to the emergency departments.
Addressing Health Insurance Gaps
00:25:06
Speaker
So in the winter of 2015, I started shadowing in some of the hospital EDs. So like at the Brigham, Mass General, Boston Medical Center, found some, you know,
00:25:18
Speaker
physicians who are kind enough to let me just kind of come through and shadow. And it's interesting, I mean, you see people go there Friday night, any given Friday night at one of these hospitals, there's kind of, it's predictable. And it's like clockwork, how people show up, right? I mean, you have people early in the evening that show up for, you know, whatever, you know, common ailments, then just kind of a wave of people that show up to car accidents and so forth. But there's continuously individuals
00:25:47
Speaker
that are showing up through these social risk factors, right? I mean, housing insecurity, a lack of access to food, something else that's driving an underlying health condition, but it's a preventable upstream social health determinant. And so I went to the emergency departments after that, mostly like on the directors or the people that are more financially oriented. And I said, look, you know,
00:26:13
Speaker
You must care a lot about your frequent fires at the hospital because they do consume resources. We have information on those individuals because they visit community-based organizations using Boswell. Why not build a bridge together? And long story short, there's kind of a health economics catch-22 with hospitals and emergency departments in the sense that prior to Medicaid expansion, a lot of the folks that were visiting emergency departments were uninsured.
00:26:42
Speaker
And so the care is uncompensated care, which becomes a right up to hospitals and it's very burdensome financially. But, you know, post affordable care act and Medicaid expansion, a lot of these members are now insured, despite the fact there's plenty of uninsured individuals in any given expansion state. But a lot of these members are insured and the hospital would rather see them than not see them, if that makes any sense. You know, a Medicaid reimbursement might be, you know, 70% of commercial insurance.
00:27:12
Speaker
but you'd rather see that guy a hundred times than not see him at all, right? And so that's, it's a bit of a catch to me too. And it does affect like, you know, some of these shifts towards value-based care because the incentive along the way, right? So we were kind of spinning our wheels talking to hospitals and for about a year I was actually just kind of talking to hospitals, emergency departments and trying to get a sense of what they cared about because we were positioning ourselves as a mechanism to help
00:27:42
Speaker
reduce frequent flyers in the healthcare system because we know that they were showing up at community-based organizations and someone ought to care about them. So then the next pivot was actually to move further up the value chain to health insurance plans. And just to kind of give you an overview of like Medicaid and some additional context, you know, Medicaid is the nation's largest healthcare program, 75 million Americans, costs exceed $600 billion a year, started 1965,
00:28:10
Speaker
through the Lyndon B. Johnson administration. And the way it operates is that it's half funded by state and half funded by federal dollars. So in Massachusetts, for example, just around 2 million people who have that Medicaid is a little over a quarter of the population on mass health as a $17 billion program. Half that comes from the state taxpayers, half that comes from federal dollars. And states over the last 20 to 30 years
00:28:40
Speaker
in order to kind of be mindful of their budgets, they've actually outsourced the risk of managing Medicaid members to these organizations that are literally called managed organizations, MCOs. And so across the country, you have things like United, and Aetna, and Molina, and Santin, and New Jersey, and Ewing, New Jersey, you have Horizon Health, Blue Cross, and New Jersey. And basically, they're given a set amount of money per member that they cover,
00:29:09
Speaker
and it's their job to manage that risk. But anytime some of those folks crash in the system, they have to foot the bill, right? So we eventually shifted our focus from hospitals to health insurance plans, probably like in 2015. And then, again, you know, over the next couple of years, there were some pivots and actual value proposition we'd be presenting to hospitals or to health insurance plans with the data layer that we were generating.
00:29:38
Speaker
And initially, the focus was that we could identify the highest risk individuals that are on the health insurance plan roles and figure out ways to predict risk of hospitalization. Long story short, although I'm happy to go into details, the burden of proof of that is very high. And we didn't have the data layer or the algorithms or the clinical claims data to work with in the health plans to do that.
00:30:05
Speaker
you know, through that experience, talking to health insurance plans, I may have alluded to earlier, I went to other markets, I left Boston for a little bit, I went to Colorado, then I went to Philadelphia, Wilmington, Delaware, Pittsburgh, I mean, all sorts of different places. And we made another pivot, which was that we recognize that health insurance plans, as much as they care about identifying their highest risk and costliest members, there's another population
00:30:36
Speaker
that's also known as kind of Medicaid's MIA, the unreachable Medicaid members. So if you're a health insurance plan again, like, I don't know, Blue Cross, New Jersey, and maybe you have 900,000 members, it turns out that a third of them are completely missing in the system. They don't have an address, they don't have a phone number, they don't show up in primary care, there's no breadcrumb trail on them. And so despite all this work to provide coverage to individuals, people have coverage but it doesn't necessitate access to care.
00:31:05
Speaker
And as a health insurance plan, you care about that because you have to be compliant with state Medicaid contracts to screen and engage members. And then also many of these individuals that are on your enrollment files but not accessing service are kind of check engine lights and you're concerned about them because they're rising risk. So this is all to say that over the last few years, we've done our best to do like domain understanding and value chain discovery
00:31:33
Speaker
And we've shifted our focus to helping health insurance plans reach their unreachable members. I think it's really cool that at the beginning, you know, you really could just start out as a nonprofit, but you decided to find some, you know, commercial value in your data.
00:31:52
Speaker
From what I gathered, you started looking at emergency departments, but then it became clear the target was the insurance companies. Could you elaborate a little more on that reason again, why it was in the insurance companies? It's because they were footing these bills for the patients who went MIA. Yeah, exactly. That's the top of the value chain. I guess one of the lessons earlier on, and something we try to keep in mind moving forward, is that everything is tied to the value chain.
00:32:21
Speaker
We were starting out by understanding the base of that value chain, which is the fact that there's an individual who struggles with access care. He or she visits a community-based organization. That's great. And the next wrong in that value chain is going to the hospital. And so the hospital, the emergency department, they see an individual. If it's an uninsured individual, they have to put the bill. And they take on the risk and responsibility of that individual. But for those that are insured,
00:32:52
Speaker
Again, you have to go further up the value chain and look at these Medicaid managed care organizations, right? And so, and just as a little exercise, I mean, if you're a health insurance plan in the Medicaid space and you have 100,000 members, you're getting about $6,000 per person per year from whatever state that you're in. And so think about yourself having like $600 million in payments from a state Medicaid agency to cover 100,000 members, right?
00:33:20
Speaker
And then as you break down that population, 5,000 of them are your super utilizers that'll drive 50% of costs. So 5,000 individuals are going to cost you $300 million in expenditures. They're frequent flyers. They have unchecked chronic illnesses, mental health and or substance abuse issues. They're a pretty complex population. Then you have maybe 60% of individuals who are kind of relatively stable and engaged in care. And then you have 35% or maybe 35,000 members that you have
00:33:50
Speaker
absolutely no idea about them. They have a phone number with limited minutes, their address has changed quite a bit, oftentimes due to eviction or housing insecurity, and they don't show up at the doctor's office. So you don't have a paper trail on them. All you have is like their name, date of birth, gender, and $6,000 from the state Medicaid agency. And so for that population in particular,
00:34:14
Speaker
This is where we've wanted to focus. It's kind of a literal and figurative blind spot for the health insurance plans. And they're holding their breath in that population. And they represent in many ways the check engine lights in Medicaid because arguably the next wave of frequent flyers is coming from this pool of individuals. So you said only about 2 million of the 75 million
00:34:41
Speaker
on Medicaid are in Massachusetts. So did you, were there challenges in sort of growing Boswell out of that just 2 million population to the 75 million where sort of the problems with Medicaid and insurance weren't necessarily homogeneous throughout the country? Yeah, I mean, we've hardly even scratched the surface of the 2 million in Massachusetts. And honestly, to get to the 75 million, I mean, this is,
00:35:11
Speaker
We're five to six years in, but this is like another 10 to 15 year roadmap. We really had to like get across the country. And I think a lot, you know, with these early stage endeavors is building the blueprint and iterating and creating the best operational strategy that can be, you know, set in other markets and, you know, launched accordingly. But, you know, you bring up a good point in the sense that Medicaid is state run. So,
00:35:41
Speaker
there are actually 51 Medicaid programs across the country to include DC for those 75 million Americans. And of those 51 states, I think only about 37 or 38 of them have actually expanded Medicaid in the sense that they raised the eligibility so that people with certain incomes could actually access Medicaid whereas they couldn't before. One of the challenges with health insurance is that
00:36:09
Speaker
you know, for many years, and I guess in many markets today, you have individuals that are too poor to obtain their own commercial insurance, right? And a lot of insurance is tied to employers. So they might not have an employer that can sponsor their health insurance plan, but they're somewhat, you know, too wealthy in the sense that they're not poor enough to be eligible for, you know, government subsidized insurance like Medicaid. And so you have this kind of population that's stuck in the middle, right? And when,
00:36:38
Speaker
the Affordable Care Act was rolled out and now it's at 37, 38 states. It created insurance eligibility for another 15 to 20 million Americans who were kind of stuck in the middle. But there are other states like Texas and Florida, which have not expanded Medicaid and arguably have many more eligible members out there. So yeah, it's kind of a process to kind of
00:37:05
Speaker
go state by state and understand the Medicaid programs. And there's a lot of nuances of them too, right? I mean, you have some Medicaid programs, like I would say Connecticut and Oklahoma are kind of these dinosaur Medicaid programs where the state still runs everything, right? You don't actually have health insurance plans that sit in the middle. The state covers the bill directly to hospitals and providers. And then you have markets like Pennsylvania where you have
00:37:33
Speaker
you know, dozens of health insurance plans that can be Medicaid managed organizations. And then in New England, you have Rhode Island in Massachusetts, where you not only have health insurance plans, but you have these provider networks that have created kind of network, kind of alliances called accountable care organizations. And they share some of the risk and the upside in the Medicaid population. So yeah, I mean, it's still a relatively similar value chain wherever you go.
Medicaid and Socio-Economic Factors
00:38:02
Speaker
but there's a lot of nuances which affects the customer segments that we want to talk to moving forward. So keeping it on the idea of Medicaid though, what do you see as valuable in Medicaid and what do you think needs to be scrapped and fixed? Sure. So you think what works with Medicaid and what doesn't in a way? Correct.
00:38:31
Speaker
Yeah, I mean, I think there's any number of ways to go with this and any number of polarizing statements I could make, depending on what your audience sounds like and looks like, but who cares? I think that what works with Medicaid is the fact that people need to have coverage, right? It's almost a non-starter sometimes for people to even access healthcare if they don't have coverage, right? But still we're starting to realize that
00:39:01
Speaker
as we roll out coverage, it doesn't necessarily mean access for everyone, right? And we have to stratify that population of who's accessing versus who's not accessing and understand the intricacies and vulnerabilities across those populations. I think another thing that's challenging with Medicaid, and it's kind of become the double edged sword, is the reimbursement rates for Medicaid are lower than commercial insurance. And earlier on with the Affordable Care Act, as they rolled that out, they tried to actually boost the reimbursement rates
00:39:31
Speaker
to incentivize providers to take on Medicaid patients, but you still see it being like two thirds or three quarters of what commercial insurance pays. And so what that actually creates is another access bottleneck because if you're a provider and you exclusively see Medicaid members, odds are you're gonna go out of business, right? And there have been some studies and reports that kind of talk about that in particular. And so in any given place,
00:39:58
Speaker
Interesting enough, I mean, so when I turned 26, I lost my mother's health insurance coverage, which was like some fancy Blue Cross program through the employer that offers it to her, right? So there was a time when I could go to Mass General Hospital in Boston, if you can imagine, it's a nice place to get primary care, right? And that was my quote unquote medical home, right? The four walls of that clinic and that care management team.
00:40:24
Speaker
And then for some time, like when I had some income earlier on when I was kind of bootstrapping the company with these business development, whatever gigs I had, I could pay for my own insurance in the marketplace. And the marketplace is another complexity because not enough insurance plans can keep the marketplace. And so there's nothing to really drive down prices and drive up quality. Not a lot of incentives there, but still, I mean,
00:40:51
Speaker
I might not have been able to go to Mass General, but I could still go to other providers and there were a lot of options. Interestingly enough, and ironically, later on in my Basel experience, I became Medicaid eligible myself, technically falling at that poverty line threshold. And so then I had Medicaid. And the first thing I realized is that as someone even who just spends a lot of time trying to learn about health insurance and health systems,
00:41:19
Speaker
I couldn't understand the Medicaid enrollment process myself. It's not straightforward. So leave alone someone that might have multiple jobs, might have housing insecurity, struggles to access food, any number of issues to deal with. If I couldn't understand how to enroll in the Medicaid, that's troublesome. The other thing was that it severely limits the types of providers I can go to and where I can access care, which I can imagine
00:41:46
Speaker
As it is, it's not trivial to access the healthcare system, but like now we're limiting it and curtailing it because most providers don't want to see Medicaid members. So I think like, you know, it's good to expand coverage, but you know, one caveat is that the reimbursement rates are lower. A lot of providers are not incentivized to see individuals in the space. And the other thing is like, you know, someone describes it as like Maslow's hierarchy of needs. If I'm out there,
00:42:14
Speaker
take the scenario where I have a couple of jobs and my income hasn't increased over the last couple of years, but the cost of my rent has, right? And I struggled to access food and maybe I have a couple of kids at home, who knows what, this is just like pick a scenario in America. Accessing healthcare is not my number one priority, right? Arguably, I have other things to deal with to survive. And so the question is, all right, well, what can we do to
00:42:44
Speaker
you know, bring health care to the forefront or to address those other socioeconomic risk factors I might have so that my health care, you know, doesn't go, you know, without any attention, right? So that's something I think about as well is that, you know, Medicaid covers costs of care, but it doesn't cover all the costs of everything else that people go through, which eventually when they become, you know, too burdensome, that's when individuals are crashing the health care system.
00:43:14
Speaker
Yeah, I mean, I think it's a step in the right direction. I think it also takes a village. Any number of moving parts that are involved with this, right? And so, yeah, it's pretty, I think people spend generations trying to understand that.
00:43:34
Speaker
Yeah, I think you've touched on a lot of things I've been hearing recently with regards to the accessibility of health care is obviously a big issue, the shortage of primary care providers. And then you throw in sort of the limited compensation from Medicaid. It's just kind of like a can be a raw deal at times for both sides. And not to say that Medicaid isn't doing some great things, but certainly some changes
00:44:04
Speaker
are kind of seemingly needed. But then I guess that kind of brings us to the holy grail question of like the 2020 election cycle, right?
Global Healthcare Models and U.S. Reform
00:44:12
Speaker
Where like, would this just all like, would, would it blow up if we kind of just went single player, would it be fixed? Well, yeah, well, this brings you back to, you know, polarizing statements, I could say, your audience. Well, I can tell you, we have a virtually non-existent audience. So you're, you're free. You know, I'm,
00:44:35
Speaker
You know, I have faith your audience will continue to grow. But, so let me, I mean, in terms of like 2020 and the single payer, I mean, one of the interesting books, and I don't read a lot of books, I have to admit that. I quoted Matthew Desmond in Evicted. But another book that's really interesting is a book called The Healing of America, written by a former columnist for the Washington Post and TR Read. And, you know, I recommend reading it.
00:45:04
Speaker
So basically he breaks down all of the global healthcare systems into four different categories, right? So you have what he calls the Bismarck model, which is like in Germany and Japan. And I think in Germany, back in the day, there was a guy, Otto von Bismarck, who kind of mandated that everyone has some sort of health insurance. But in the sense that like you go to Germany, you go to Japan, everyone has insurance, but it's like a private health insurance, right?
00:45:31
Speaker
And but there's hundreds if not thousands of options in those kinds of markets, right? So what that does, it kind of, it drives competition and probably improves quality, but brings down prices, right? And I think that was the idea of like the marketplace earlier on over here. But what happened is that a lot of these plans kind of drew lines in the sand and weren't really competing with one another. And they can monopolize the little mini markets and drive prices accordingly. You have another model, which is,
00:46:02
Speaker
but basically like the NHS model in the UK, National Health Service, right? So basically everything is government run, the facilities are government run, the payer is the government, you go in and out of the doctor's office and there's really no bill, right? You just kind of walk in, you walk out and like, that's it, right? And that's actually pretty similar to what we have with the VA and Indian healthcare services in this country, right? So you're a veteran, you just show up, present your card and they just walk right out of there, right?
00:46:32
Speaker
And there are drawbacks there, too, in the sense that the government can deny any number of procedures and services because they're also trying to control costs as well. And then you have this other model, which is basically out of pocket, fee for service. I'd say a lot of the developing world looks like that. You don't have insurance. You go to the doctor when you have to, and then you pay whatever you can afford. And then that's just about it.
00:47:02
Speaker
you know, 80, 90 years ago, right? Maybe your grandparents' generation, they might not have had a concept of health insurance, right? They would just kind of go to the doctor and they'd pay a little bit of money and they keep moving, right? And that's kind of what it's like to be uninsured in this country, right? There are some sliding scale payment schemes out there. Then finally, you have this kind of Medicare, Medicaid concept, right? So, I mean, Canada, everything is called Medicare, right?
00:47:33
Speaker
basically government subsidized insurance for private facilities. And so you can kind of go wherever you want and then the government, you know, puts the bill. And again, like, you know, their drawbacks and questions about that as well. So I bring this up to say that like every other country in the world has one of those systems, one of those four types of systems. You can categorize any country's healthcare system into one of those four categories. The United States, we have all four, right?
00:48:03
Speaker
We have Medicaid and Medicare for the low income and for the elderly and or disabled. We have people that are uninsured and they pay out of pocket. We have private health insurance plans, which is primarily driven through employer sponsored health insurance. And then another portion of which is through the marketplace. And then we have this kind of government oriented system like the VA and IHS. And so it makes healthcare reform, I think, very complicated.
00:48:33
Speaker
And you have to think about the fact that when you do reform, you're basically moving all four of those parts at once, right? So the notion of basically saying, we're just gonna have a sweeping thing and flip the switch. I mean, that's a great idea. I support anything that improves cost, quality and access in the healthcare system. But I personally, I might not be well-informed enough to know what the ramifications are of like unplugging all four things at once.
00:49:02
Speaker
and then try to plug in one thing and see if it moves forward. I mean, just think about it. And then the other part of that is that even in Vermont, they tried to have a single payer strategy. And I mentioned Vermont because some of these ideas come from places like Vermont. And I would encourage people listening on the podcast to read about what happened in Vermont.
00:49:29
Speaker
what happened with like a single payer sort of model in that state because it didn't actually materialize into, you know, what's being pitched as what could happen around this country, right? And so, and then the other thing I'd mentioned is that a lot of health insurance plans are for profit and they're very large corporations, right? And I mentioned like United, the same team, Molina, Aetna, which is now part of CVS, which is another kind of giant, right? I mean, in the last couple of decades,
00:49:58
Speaker
a lot of little health insurance plans have actually merged and become like these, you know, super power ranger, transformer kind of health insurance plans, right? They're massive entities, right? Hundreds of billions of dollars, sometimes even touching trillions of dollars, right? And they're all in the fortune 50. And another thing that dictates policy in this country are lobbies. And, you know, it's not often who has the largest voice or the biggest supporters
00:50:26
Speaker
It's who has the strongest lobby, right? I mean, if lobbies were not an issue, gun control would be so streamlined. Tobacco laws would be so streamlined, right? But it's not the case, right? And that's the same with health insurance plans as well. They hold incredibly strong lobbies. And that's not to hate on them. I think health insurance plans also, I mean, for as many horror stories about denied claims and everything that goes on. I mean, they also have to take on a lot of risk and responsibility
00:50:57
Speaker
I'm not justifying their salaries and their payrolls and whatever, but they hold a lot of weight, right? And they can influence a lot of decision makers. And so I think like, yeah, it's a great concept to say everyone should have free and affordable and accessible healthcare, but there's a lot of moving parts to get there. And
Socio-Economic Factors in Healthcare Policy
00:51:19
Speaker
I'd also say the other piece of this, which I think is actually the major thing I think about is that just giving everyone healthcare doesn't eradicate
00:51:27
Speaker
poverty. And I think poverty is a huge driver in this country for why people slip with the cracks. And so, and we've already demonstrated that even people that have access to services and access to coverage, they might not utilize it because they have other things to deal with. And the middle class is shrinking. For the last three years in this country, the life expectancy has gone down. Dollar General is the number one store in America, right? I mean, that's the writings on the wall, right? And so like, just because we're throwing
00:51:56
Speaker
uh, insurance covers everybody. I don't, I'm not certain that, uh, that solves everything, but I'm certain that it ruffles a lot of feathers to say things like that. So, but that's how it is. Well, I'll make sure to check out healing for, you said healing for America. The healing of America. The healing of America. Okay. Sounds like a good balance book. Um, and, and like all these political tensions.
00:52:22
Speaker
And he wrote it in 08, so it was before the Affordable Care Act, but he kind of anticipated a lot of things. And there's just so many moving parts. And I think in some ways we have to do the best that we have and work with it, and also kind of wake up and start to see the things that are the real drivers. People don't want to always acknowledge poverty. The most progressive ideologies are coming from places like the Bay Area.
00:52:50
Speaker
but the deepest levels of poverty are also in those places too. So, you know, let's acknowledge what's actually going on and then see how that can fit into our frameworks for the thinking. Good stuff. All right, we'll finish up with a couple of fast-paced questions to learn more about you. So you walk into a bar, bartender says, what do you have, you say? Well, it depends on the season, but lately, you know, in the winter months,
00:53:19
Speaker
a milk stout, you know, maybe it's like a Guinness, something Irish, but I like like the left-hand milk stout, especially those nitro stouts, something like that. Maybe whiskey too, depends on who I'm with. Warm me up, right? Yeah, exactly. Boston or Ann Arbor? Ah, that's tough. Probably Boston. I mean, I love Ann Arbor and for everything it is, but like, um, it's hard to describe what formative years are.
00:53:49
Speaker
A lot of people say it's like their childhood or even when they're in college, but I think my 20s have very much been my formative years and I've shaped a lot of how I think about things and what I care about and who I care about, right? And so that's all happened in Boston. So I really appreciate this time. I heard you lived in Lyme, Connecticut. Have you ever had Lyme? Yeah. Well, I lived in East Lyme, Connecticut back in the day, which is East of where Lyme disease was found. Is that right? So does everybody get Lyme disease there?
00:54:20
Speaker
You know, it's actually like surprising. I mean, a fair amount of people do, but I think a lot of people get Lyme disease in a lot of places. But when I was out there, when we first moved out there, my mom was like so paranoid that I would get Lyme disease and ticks and whatever. We were living in the woods, right? And so she would actually send me out
00:54:40
Speaker
like wearing my socks rolled over my pants, if you can visualize that, right? And so that was my look in the late 90s, into the early 2000s, when I was out and about, especially like, you know, camping and things like that, just the socks rolled over the pants, white socks, khaki pants, right? Just kind of a broken down Harbaugh look, right? So, yeah.
00:55:05
Speaker
And lastly, I don't know if you can answer this quickly, but the biggest change you'd like to see in healthcare? I would like to see a lot more awareness of the drivers of healthcare expenditures and costs and missed opportunities. And when I say cost, it's not just the dollar, it's actually like the cost of life and the cost of society. And so, yeah, I mean, I'd like people to just kind of
00:55:34
Speaker
or whoever it is that is involved with these things to pay more attention to these things that are not just tied to healthcare as we know, it's actually like a lot of these socioeconomic risk factors, social health determinants, whatever you wanna call them. And then also leveraging that to address policy issues which are upstream of this. So that's a couple of different things in one, but I myself, I'm still trying to formulate this
00:56:01
Speaker
get a clear understanding. It's still very early in the game for me. And so I'm also just trying to observe and continue to learn about the space. Well, you sound very informed. I can tell you that much. Aristotle, thanks for joining the show. Yeah, thanks for having me, John. Great to chat with you.
00:56:28
Speaker
Thanks for listening to The Wound Dresser. Until next time, I'm your host John Neery. Be well.