He's Here, He's There... Virtual Care Everywhere

Brian Urban:                                           
Yes, this is the Healthcare Rethink Podcast. I'm your host, Brian Urban, and today we're going to virtual care models yet again. We're excited to have the Chief Commercial Officer Randy Forman from Oshi Health joining us today. Randy, thanks for being on our show.

Randy Forman:                                          
Really appreciate you having me.

Brian Urban:                                           
This is going to be a lot of fun, Randy. We've gotten to know each other a little bit before the recording here, so shared a few lasts and a couple of stories and we're definitely going to get into that. And with every episode we have, we'd love to have our audience get to know our guests and become more familiar with yourself and your background and your organization, of course. So let's go back before the C-suite executive title. Let's go back to Randy Forman. What's your background? How did you get into virtual healthcare? Take us up to speed here.

Randy Forman:                                          
Yeah, so I won't go all the way back, but I did grow up in the Southwest New Mexico and Texas and just through a fortunate series of events and luck, ended up finding myself going to Yale University to play baseball. So truly life changing, altered my trajectory. I graduated in 2000, so right in the tech boom, right before the tech burst. I decided to chase that and went into technology at an early stage company.

And then the bubble burst and my CEO at the time just noted that while I was a network engineer and consultant, I had a knack for building relationships with our clients and said, "We've got to get you into sales someday." And so that got the wheels turning. When I decided that I was going to move on from that company, just through my network found a healthcare company that was making neck braces and back braces with foam and plastic. I'd gone to college with... The guy I went to college with whose father was running the company.

And that's what took me to Chicago and that's how I got into healthcare and started selling neck braces and back braces into the bowels of these healthcare systems, hospitals. Old Cook County Hospital was one of the first places I ever walked into. I remember thinking like, is this what I signed up for? It looked more like a prison than a hospital at the time. Just as my career progressed, started getting into more technology driven solutions and really getting closer and closer to the patient themselves.

And in 2013, just again through personal network, a friend of mine who had built a business with a serial entrepreneur and leader in our healthcare system, Glen Tullman, he was about to start his venture fund, 7wireVentures. And they brought me in and introduced me to a couple of the concepts that they were thinking about hatching, launching, and one that they had invested in, which was a diabetes company, and that's where I went. That became Livongo Health. And so I was the first commercial employee at Livongo.

I never sold into the employer health benefits space before and none of us had. We had all spent most of our career in health systems. And so we were kind of learning. It was early on in the digital health in the employer space, and so we were figuring it out as we went. Obviously we built a great company, created access for hundreds of thousands of members and created a ton of shareholder value, took it public, and then ultimately required by Teladoc in the pandemic as telemedicine, telehealth companies were spiking.

Had that exit at the peak of the company. And then, yeah, long story short, joined Oshi Health earlier this year. Kind of wanted to try to do it all over again, but in an area that was a little more personal for me. So I live with six autoimmune diseases, which are even harder to get to the root of than most of the common GI issues, a very similar patient experience. And there's a lot of correlation between autoimmune and GI for some people and me in particular.

I learned about this model ironically through another college connection. One of the early investors in Oshi Health brought me and introduced me to the leadership team. Yeah, so joined here at the beginning of this year.

Brian Urban:
And thank you for sharing that, Randy. A few things I wasn't aware of there, but it shows that there's a deep-seated connection between yourself and the work that you've been involved in for a long time, especially right now with Oshi. A couple of things to react to. Solid name-drop there with Glen. I remember Glen's face was painted everywhere when Livongo was starting to get traction in the tech space and healthcare tech space in particular pre-Teladoc acquisition. So I remember how hot that was and how much excitement there was and who could be the future suitors.

I remember there's a great relationship struck with Cigna. And actually going back, I didn't know you were a Yale ball player. I think of Yale baseball, I immediately think of old President Bush had played Yale baseball it so happens. I didn't mean to do this. I wore my lone pine green Darvish shirt today, but neither one of us are touching a diamond these days. But just such a dynamic background. Love the stories and it shows your fluidity in terms of where you went into healthcare.

And we talked about a couple personal stories around Oshi. I want to get into the model a little bit more here, Randy. So virtual healthcare seems to be filling a lot of needed gaps, not only for patient engagement, but provider engagement and interaction, and also really provider assistance in terms of having really good outcomes, not just invasive surgery based outcomes and procedures like that. So I want to talk about the model of Oshi because you all are quite young still. So take me through the model a little bit and then we can go a little bit deeper.

Randy Forman:
Well, before I even get into the model, even just taking a step back like, why digestive health? I think it's really interesting. We're at an interesting point in time, both as it relates to coming out of COVID, how we live as a society, like the level of anxiety and stress and the connection to a lot of the physical issues that we're starting to see develop, issues around the food that we eat, all of this is culminating. We're seeing this tidal wave of all these different chronic conditions, but in particular, we're seeing a spike around digestive or gastroenterology related issues.

Not to say that they haven't already been here before this, but we're starting to talk about it more. Stigma is lifting the same way 10 years ago, you might not be as open about mental health issues as you might be today. You have celebrities starting to come out and talk about their mental health issues. Two weeks ago, price on news about Drake stepping away from working for a year to focus on digestive health issues, something that you wouldn't have seen a celebrity talk about before.

And the other thing that's interesting is the economic burden of digestive diseases in our country has been grossly misunderstood for a variety of reasons. When we look at the macro US data, we see GI as a broad category, usually in the number three spot in terms of total economic impact. But when employers or health plans start to look at the solutions or interventions that they want to focus on in the market, they look at their top cost drivers and GI wasn't showing up.

And why is that? There's a whole bunch of reasons largely due to the maze that is our billing coding system, a lot of misdiagnosis, or there's a variety of reasons why things don't get coded the right way, and then how the actuaries look at this data. The long story short is we've done all this work to find all these hidden claims and realize that yes, it is in fact having this impact. Getting that word out, employers are starting to wake up to it. The benefits consultants who support these employers are seeing this is...

It's not just that the wave is coming, it's already here. We're just starting to better understand it. Now, for our model, I'd love to say that we're doing something exceptionally innovative, but the reality is we are taking a proven care model that the evidence has supported for years and it's been delivered effectively in some of the leading academic medical centers in this country. But unfortunately, that model has not been scaled because these specialized clinicians are in short supply.

Telemedicine, of course, unlocks scale, not just from a people and efficiency perspective, but from a zip code perspective. And so we've taken this proven model, which is fully integrated multidisciplinary care, and we've created a virtual first clinic or center of excellence to deliver this proven model and scale access to that to the masses. And so the model simply, it is a team that works closely together.

It's a GI doc, so our GI physicians, APPs, nurse practitioners, GI specialized dieticians, GI specialized behavioral health experts, also working with a care coordinator because while virtual health can serve a huge piece of a member or patient's needs, there are also in-person needs, testing, labs, procedures. We need to be integrated with their primary care.

And so basically we're pulling together this combination of the work that we do virtually, which can lead most of a member's care, but also thinking about the broader healthcare ecosystem and really trying to push forward this concept of hybrid collaborative care, which is I think the future of how care will be delivered.

Brian Urban:                                           
That sentiment right there is I think the most intriguing forward-looking thing that a lot of our audience can start to tangibly understand is that integrated model that's upstream to have deeper engagement, education, and then coordination downstream in terms of shared decision-making. So that is extremely helpful. And it's interesting that you said that.
                                                       
It's going way back to your earlier comments and mentioning celebrities being a lot of leaders in trying to open the door, break the ice around a lot of stigma related to some particular diseases or conditions that have really been taboo or in fear to discuss. And I think if that's the way it has to be, that's the way it has to be at least in the Western culture. But the gist of health in particular, Randy, we were talking about this, and I find it so funny because when I first met you, we were talking about just these obvious things in my personal story around having digestive issues in my late 20s, mid 20s.
                                                       
I was a big partier and they were like, "You know what? You're partying too much. Hydrate more." That didn't work. Then they were like, "You know what, we got to take that gallbladder out. I think that's the issue here." After I had a lot of upper GI scans, lower GI scans, colonoscopies, they were like, "It's the gallbladder." I took a different route that was not recommended by the surgical team or even my primary care physician, and I went and saw a dietician, saw registered dieticians, and changed my whole diet.
                                                       
It took some time, but the behavior change, the support and repetitions I had with changing my diet offset a lot of unnecessary spend, unnecessary procedures and treatments that I would've had to have gone through. So that kind of care team didn't exist. I had to figure that out on my own and do my own investigation. So that was rough, that was horrible. It's probably a lot of common, I guess, scenarios that a lot of patients and members that you serve probably experience.

Randy Forman:                                          
Absolutely. That is the journey to date for most people. These specialists in these interventions do exist, but rarely in this integrated way. They all don't sit in one office together. For people that end up finding the answers, like you were fortunate to be able to, whether its because of your knowledge or your resourcefulness or your just unwillingness to accept that this extreme path is the way that I have to go, the reality is there's these conservative treatments that can help most people get better, but most people don't have access.
                                                       
A lot of this stuff that really works isn't reimbursed by insurance. A lot of these GI specific interventions isn't reimbursed by insurance. Put yourself in the mind of the GI practice down the street, right? You're running a business. You're obviously ultimately trying to deliver patient care. But if you're not going to get reimbursed for these clinicians and you get reimbursed really well for procedures, colonoscopy, endoscopy, you own the imaging center down the street, the incentives are really what are driving a lot of the behavior and the lack of access to these specialists.
                                                       
It's just these tools have not been made available to our GI clinicians. The incentives haven't forced them, or shouldn't say forced, allowed them to be able to deliver this model at scale. And primary care is not equipped to treat these complex GI issues. The ER certainly isn't. And what we see very often is this bouncing around between... They start in primary care. They get referred to at GI. It can take months to get access to see that GI doc. They're using the tools that they have at their disposal.
                                                       
So they're going to image you. They might do a colonoscopy or endoscopy, which can rule some things out like cancer for instance, but they don't have these conservative treatments available, these low cost treatments available. And most patients end up leaving that visit not necessarily feeling like they have answers, and then they start escalating and popping up in various different care settings, driving a lot of costs. Our chief medical officer, I think one of the most profound things that he taught me was that in GI, the patients drive all the utilization.
                                                       
With something like diabetes, you may not feel your symptoms every day. When you have these severe GI issues, you feel them every day and you are desperate for relief. There's some really powerful stats. Patients with IBS report lower quality of life scores than that of a patient on dialysis. IBD patients would be willing to trade 15 years of their life for a cure today. So you put yourself in that mindset and you think like, what lengths would you be willing to go to find answers?
                                                       
And then you think about the broader healthcare system who is set up to do things that are expensive and take your money, especially when you're willing to pay anything for that kind of relief. Unfortunately, you're one of the lucky few who has been able to piece it together, potentially paying out of pocket, finding the right specialist and piecing together this concept of a multidisciplinary care.

Brian Urban:                                           
And it's just so funny, as you were describing this, Randy, I am thinking about how the model of healthcare has evolved and it hasn't. We've gotten great with science disease detection. We've gotten better with coordination. But in terms of a really integrated whole model that goes beyond medical science and layers in nutrition, gut brain health, all types of things underneath that, it's just not there yet. And it's funny as you're describing that, I was also thinking about a very big trend.
                                                       
Food is medicine as a title for a lot of executive leaders at health plans. A lot of them are MDs, which I think is funny because a lot of MDs aren't trained in dietetics, nutrition, bioenergetics. They're trained in medical sciences and physiology to a certain depth. So I find that interesting and there's lots of great authors out there now, some were starting to support on our show. But this emerging trend, I mean, I feel like it's going to benefit Oshi in the long run or even in the short term now.
                                                       
Are you starting to see there's a lot of big connection or hunger for having a digestive health integrated model for members, for patients to be able to be plugged into? Are you starting to see that because all these trends are emerging in this gut-brain health new phase we're going into in healthcare, at least awareness in healthcare, is that starting to happen for you all?

Randy Forman:                                          
Yeah, I think so. Absolutely. I mean, I think the time is right. And again, I think it's a confluence of factors. It is that we're talking about this. Again, these are things that as an employee I probably wouldn't talk about with my colleagues or my HR benefits team. We're seeing increase in prevalence. Again, we're seeing the way... It's not all dietary, right? So that's one of the big misperceptions about these GI issues. It may not actually be the food you're eating. It may be a food related anxiety because you got really sick when you had broccoli five years ago.
                                                       
And now every time you're going to have broccoli, you're associating that. And again, there's signaling between the gut and the brain. If you think about it before, you probably don't get nervous anymore doing these podcasts, but if you're going to go speak in front of 500 people, you step on stage, you feel a little pit in your stomach, that is signaling between the gut and the brain. And so sometimes that gets dysregulated in some way, and then the anxiety reinforces that signaling.
                                                       
So over time, it may actually be that it's the anxiety about the food that is causing these physical manifestations. Again, it's been proven that dietary is at least one of the critical interventions. For many members it is. It's dietary. It could be behavioral. There's certainly a role for medications. There's certainly a role for procedures. It's the bringing together of all of these pieces and a team that actually works together, talks to each other. Again, this fully integrated model. That's just what hasn't existed and for all the reasons we talked about.
                                                       
And again, I think we're at this perfect moment in time where if all these trends happening, we... What are some of the positive things that came out of COVID? We realized we can deliver a lot of this care virtually in a way that is more convenient for patients. And by the way, there's also now plenty of evidence that shows that GI patients in particular prefer virtual care. And why is that? Well, I mean, if you have IBS, one of the most anxiety inducing things might be leaving your house and not knowing where all the bathrooms are on the way to where you're going.
                                                       
And so yeah, patients love this model, not just because of the convenience, but it actually makes it so that we can have visits. Our members have visits every two weeks. I just spoke to a friend who joined Oshi about at the end of September, was really struggling, and we got this person access and I lost track of things. I forgot that I had even helped this person out, reached back out the other day, see how things were going. Seven visits between, whatever, September I think 27th was when they started in the program and three days ago.
                                                       
So seven visits, APP, behavioral health, dietician, again, all working together and most important thing, feeling better, symptoms are under control, got access to a specialist that they said was a year wait. We had them in two weeks. Yeah, it's pretty amazing what can happen when you unlock a model like this.

Brian Urban:                                           
I'm glad you said that term actually, unlock, because you're unlocking nudges for the patient, but also for the providers that are more downstream too that are being integrated and part of this and primary care that's having this information shared back with them and care managers or health coaches is a part of a health plan that will be able to see these types of interactions or progress. I can definitely attest to myself not wanting to wait four weeks to see someone that specialized in upper GI.
                                                       
That just didn't make any sense. So you had to be in pain or struggling or uncomfortable for an initial month to see someone in person. And literally you're going to have a maybe five-minute evaluation and your whole end-to-end could be a couple hours going to, waiting, and then going back home. The convenience side, it just makes sense. I wish this would've existed honestly like 50 years ago. Can you imagine the economic shift that we would've had in healthcare and better experiences?
                                                       
But now just on the edge of this, I'm so excited for this, Randy. So let's look at the horizon here for a second. I'm curious, as you continue to see just this amazing growth building evidence, more intimate relationships and connections with individuals back into their providers and back to the health plans as well, what do you think is your greatest contribution to the healthcare ecosystem here or to healthcare as the model focusing on digestive health?
                                                       
What's that going to be in the next five years? What do you think Oshi is going to really give to the ecosystem, and what are you going to turn into I guess?

Randy Forman:                                          
Yeah. I think a couple of things. So one is, again, this concept of virtual first multidisciplinary care, but not living in a silo, actually building into the ecosystem. I think when we launched, there are people that think that there might be contention between us and traditional brick and mortar GI. The reality is it's exactly the opposite. In fact, the ACEG and the AGA both invested in our series B.
                                                       
So two of the medical bodies. Because one, they believe in this model of care. They know that they're not incentivized or equipped to scale this. And also, a model like ours decompresses their practice. Again, the average, you touched on this before, five minutes. I'll give credit where credit's due, the average GI appointment visit is 19 minutes.

Brian Urban:                                           
Okay, a little bit longer.

Randy Forman:                                          
Years of history isolate down to a trauma 15 years ago that may have coincided with the onset of your symptoms. But so integrating with brick and mortar care, with primary care, and then frankly, building it on the rails that exist today to how care should be reimbursed, which is through our health plans, the health insurers. And so what we've seen is this trend over the last 10, 15 years.
                                                       
Sometimes as we talk about this, I have to apologize because Livongo also helped to accelerate this shift to carving out. If the health plans weren't solving these issues, the employers who own the risk are saying, "We'll just buy our own thing." And so they started buying the Livongo's and the Omada's and all these different companies. But when you're delivering medical care, we don't have to do that, provided that we can actually overcome some of the legacy billing constraints and also move more towards value, not just in how we deliver care, but how we're actually getting paid for that care.
                                                       
So I think one is creating more awareness and starting to open up this model of virtual first hybrid collaborative care, and the other piece is just creating a shift towards value. We actually with a large national payer, one of I think the first value-based GI contract that had ever been done. So just starting to reorient around outcomes versus volume towards preventative care versus acute care. And frankly, giving patients time. If your time is money as a doc and you get paid a lot of money to do certain things, but the reality is patient needs time, that's a huge unlock.
                                                       
So again, this is where designing our clinic and our operating system, if you will, and aligning the incentives in the right way. Our first clinical visit with our members is 45 minutes. And I actually think this is probably one of the biggest keys to why we're having so much success, and we see this feedback all the time. Our members fill out CSAT... It's optional, by the way. They can fill out a CSAT survey after every visit. And so many of our members do. And by the way, they can click one to five and move on with their day. They don't.
                                                       
They go and they write in these overwhelming testimonials. But what we hear every time is, "This is the first time I've felt hope that I'm going to get to an answer. This is the first time I've felt listened to. We talked about things that no doc has ever asked me about. And I feel like this is the first step on a path towards real answers." And that's not where all the real magic happens.
                                                       
But I actually think that is in some ways the reason that we're able to ultimately impact the member, because then they lean into the next three, six months of more intensive care, meeting with our clinicians every couple of weeks. Somebody asked me recently like, "What's the most innovative thing that you do?"
                                                       
And I said, honestly, it's just you spend time with patients and we talk to them, we listen, we validate, and we show them that there is a path with a little bit of work to get to relief, get to an understanding about why this is happening, which by the way, go to the ends of the earth to figure out why my body does the crazy things it does. I still don't have answers. But for these digestive health issues, we can get the answers with just a little bit of work. So spending time both creates this feeling of hope. It also allows us to get information that helps us get to the ultimate answer and the outcome.

Brian Urban:                                           
And the best thing is your model and everything I've heard and learning is complimentary to the existing healthcare model. You're just affording more time for a lot of GI physicians to be able to go deeper and your model goes deeper upfront for them. And it's so funny, it just shows you have to nail the basics, the fundamentals. I think so many different niche healthcare startups, everyone always wants this overly complicated statement of how innovative and creative they are.
                                                       
But just as you said, Randy, we have more time, we get more time, we get deep with the patients and allow them to share everything that they're challenged with related to digestive health. The one thing I think I'll make a prediction for where Oshi is going in the next few years, you're tackling the tip of the spear now, but I believe you're going to continue to tackle more and more biosocial psychological elements related to digestive health, which you already are, but I think you're going deeper and you're going to just completely surround all the degrees of challenges someone has where the center of it is the outcome of poor digestive health or digestive malfunctioning.
                                                       
And you come back to the why and you investigate through having this different very thoughtful model. So I think for me, I wish it would've existed 10, 12 years ago when I was experiencing my challenges. But now going forward, you're going to help so many people avoid those types of experiences. So I'm so thankful that Oshi is here and you're at the helm leading with a lot of other great leaders there.

Randy Forman:                                          
Yep, no. I appreciate you saying that. This care model and democratizing it is important, because ultimately how we get people better is what really matters. But then we're on a path in our healthcare system of a trend that is unsustainable. And the reality is so much of what happens to these patients is avoidable. And again, you were able to force your way down this path and avoid some unnecessary, expensive stuff that might've otherwise happened to you. But yeah, there's so much of that in GI.
                                                       
It's how we're able to drive, I mean, almost hard to believe, cost savings in a short term just by reducing some of this avoidable utilization. And again, it's the tools that a lot of our docs, the ER docs and the GI docs, have available to them. And so those are the tools that they use. But what if we drove out a lot of this unnecessary or avoidable utilization and freed up those practices to spend all their time on the patients that do need those procedures? And I think that's a win for them. It's a win for the patients.
                                                       
And ultimately from an economic perspective, it's a win for the payers, which are the health insurers and the employers, the federal government, ultimately all of us. And so no, I'm really excited about the economic impact that we can drive with models like this and the number of people that we can just have a truly life altering impact on the trajectory of their health and frankly, how they live, how they work. And so yeah, the future is bright. We just have a lot of work to do.
                                                       
And frankly, we need the health insurers to lean in and try to make it easier. We need the employers to listen and look at this data that we've proved out and lean in with us to help scale this kind of a model.

Brian Urban:                                           
I wouldn't see why otherwise, Randy. I mean, the evidence is building and the momentum is moving. The economic trickle-down effect that you have is so positive. I'm just so excited to continue to see how big Oshi impacts healthcare with digestive health. It's going to be so exciting. And Randy, thank you so much for joining our little show here today. I feel a follow-up episode coming on. Would love to get you on one of our round tables with a good group of executives talking about next generation healthcare. But until then, I'm so thankful that you were able to give us some time today.

Randy Forman:                                          
Appreciate you reaching out and investing time and energy into helping to spread the word about what we're doing. If one person who is struggling realizes that there is a potential path that listens to this and gets care, how powerful is that? We just need to keep spreading the word.

Brian Urban:                                           
That is powerful. And for more exciting insights and excerpts, please visit us at finthrive.com.