Healthcare Delivery Needs to Be More Like McDonald’s – Dr. Richard Park, CEO of Rendr Care Physicians

Shiv Gaglani: Hi, I'm Shiv Gaglani, and today in Raise the Line, I'm really happy to be joined by Dr. Richard Park, an emergency medicine physician who is one of the country's leading healthcare entrepreneurs and investors. He's perhaps best known for founding CityMD, which he grew from a single location in 2010 to nearly 150 sites, treating more than 4 million patients in New York and New Jersey. He's also co-founder of the private equity partnership Ascend Partners and CEO of Rendr Care Physicians, which is a multi-specialty physician group catering to a hundred thousand underserved patients in 30 locations in New York City. 

He also has a rich background as a medical educator, so we certainly have a lot can discuss with him today. And before we get started, I'd like to thank our friend and adviser, Peter Frishauf, who is the one who actually connected Dr. Park and me for this podcast today. So, Dr. Park, thanks so much for taking the time to join us. 

Dr. Richard Park: Well, thank you, Shiv. I'm honored to be part of this. And I echo the shout out to Peter. 

Shiv Gaglani: So, we'd like to get started by hearing about your journey into health care and medicine, specifically emergency medicine, do you mind giving our audience a bit of background?

Dr. Richard Park: Sure, absolutely. So listen. I'm an ER doctor by training, and I practiced in the ER for about 10 years. What attracted me, and the romance of emergency medicine for me -- which I love literally every day of -- was the fact that we cared for anyone that walked through those doors without paying attention to social class and status. There was something very democratic about it. Emergency medicine finds you; you don't actually find it. And so I enjoyed every minute of it and would do it all over again. 

Shiv Gaglani: That's great to hear. We've had a number of emergency physicians on our podcast including Joe Habboushe who started MDCalc, as well as John Dayton who started MedForums. I think there's something to be said for how emergency medicine provides not just democratic access to patients, but also kind of the shift work that allows you to work on other things. There seem to be a lot of entrepreneurs and people who pursue other careers within emergency medicine. So, clearly, you've done the same as both entrepreneur and investor. Do you mind giving us a bit of background on what led you to start CityMD? 

Dr. Richard Park: I think so much of what we do is not a decision, it's something that happens to us. We think it's our decision. Growing up as a Korean-American leading an immigrant-like life here in Flushing, New York, what Koreans in our generation did was we opened stores and we operated retail stores. So we were no different. I remember as a child following my dad around Broadway in Manhattan, and we owned a bunch of restaurants and stores. Unfortunately or fortunately, open and closed them. There was a lot of hardship around every one of those store closures.

But after high school, I ended up not going to college. I ended up opening a 1-hour photo store because that's what we did, you open up stores. It's amazing that all these years later, we're doing "1-hour photo" with a medical degree. That's what CityMD is. It's one-hour retail medicine, in a certain sense. Even as a child walking down 86th Street in Manhattan where the three largest photofinishing companies were -- photofinishing was a term, back then -- I remember thinking, "One day, I'm going to have a photo store on 86th Street." Sure enough, decades later in 2010, the first CityMD was on 86th Street between 1st and 2nd Avenue. 

So again, a lot of these things conspire to make us do things and we feel like it's our decision, but so many times it's not. If I can add one more thing...our backgrounds, our traditions and our cultures change who we are and make us do things. And so, dinner table conversation was always about, "Son, look at all the garbage outside that restaurant. Do you know what that means? No garbage outside the restaurant means they're not going to last long." 

That sort of sensitivity -- even as a 10-year-old, 12-year-old, 14-year-old -- about opening up your own store...having the sort of chutzpah to open a one-hour primary care/ urgent care...there's a thread that goes through it that transcends us as people. It's about our backgrounds and our cultures and our upbringing.

Shiv Gaglani: I love that. I mean, it reminds me a lot of one of my favorite podcast guests, Christopher Chen who I'm sure you've overlapped with or know. There is a somewhat similar story about what he's done with Chen Med and his own family's experience facing poverty and financial hardship and then trying to create something that anyone could afford...a model that works for underserved patients as you've done now, not once, but at least twice. 

Dr. Richard Park: So much of what we decided is not really us. 

Shiv Gaglani: Yes, the ancestral roots that come into that. I definitely can relate to that being an Indian immigrant, but the son of immigrants, myself. So you've obviously learned a lot in the healthcare delivery space over the years, scaling from one site on 86th Street to now over 150 locations and millions of patients with CityMD. What are some of the core lessons you've learned in that process? And then, we'll obviously get into COVID and how that's affected everything.

Dr. Richard Park: At the end of 2019, I left management at CityMD when it merged with Summit Medical Group in New Jersey. They are a 100-year-old institution with every specialty, and merged with CityMD, which was 100 months old. It's now being led by the very capable and very charismatic Dr. Jeff Le Benger. I left management and sit on the board.

I've learned two main things in the two years subsequent to that that I didn't fully appreciate. We've seen 16 million-plus visits from 5 million-plus unique patients. Number one -- I didn't fully grasp how difficult it was to provide access for the patients we acquired at an incredible scale. I took it for granted. So that's one, that's another discussion. But more germane to what we're doing today in health care and what we invest behind and operate behind is, how do you get physicians aligned to work in mass together? That requires a standardization of workflow and alignment of everything from financial to mission to vision. Because physicians, like all professionals -- whether you're a lawyer or architect or social worker -- every licensed professional...we tend to be creatures of partnerships. We do things similarly, we stand close together, but we don't do things the same. And you can't repeat, you can't therefore scale, and you can't make a process predictable unless you make everything as similar as possible. 

So, standardization and workflow leading to a maniacal focus on outlier management around patient satisfaction scores, patients per hour, wait times, and quality scores. Decreasing variation and getting doctors to work repeatedly, scalably, predictably is something we learned at CityMD. And I took that for granted too. I thought that was what everyone did, and I don't think quite everyone did do that. 

Shiv Gaglani: So, are those some of the lessons that you've been applying at Rendr Care as well? Can you tell our audience a bit about this next chapter leading Rendr Care?

Dr. Richard Park: Yes. Rendr Care is a conglomeration of 17 practices and 80 providers serving the Chinese-American and Asian community in 36 locations. So, by definition, the majority of our patients in New York that are represented by these ethnic communities are the elderly and the poor. They are Medicare and Medicaid patients, and the needs of government-sponsored plans require data. It requires a hive-like approach to physician behavior. A colony of ants or hive of bees. And in this world of Medicare/Medicaid, organization and standardization is a premium and is very important and valuable, as opposed to the world where I came from, which was mostly commercial. The commercial world feels different. The needs are different. 

In the world of Medicare Medicaid, where information and standardization are really important, that's the area -- with these ethnic physician groups and their ethnic patients -- where time, attention, and capital have least been deployed. It's been least deployed in the area where it needs it the most. So we're taking those lessons learned at CityMD. Many of my co-founders are here together with us, now. How do you apply that standardization of data, information, structure to standardize behavior? We find it very powerful and important work. 

Render is actually a Chinese word for dignity and kindness, so it's a play on words. Our mission is to render world-class care for hardworking immigrants. And less sexy than that, the way we do it is getting everyone aligned, coordinating physician behavior through clear metrics and standardized workflows. Not sexy but it has to be done.

Shiv Gaglani: Yes, it's really interesting. I mean, this challenge you've been able to solve, first the CityMD, and now we're applying to Rendr. It's something we've heard a bunch of about over the course of the last year of having this podcast. We've had people like Marcus Osborne, who runs Walmart Health. I mentioned Chris Chen but also Rushika Fernandopulle at Iora. There are so many interesting models that are emerging for frontline primary care and urgent care delivery. I'm curious, how do you see the next 10 years? I mean, CityMD has turned 10 last year during COVID. What do the next 10 years look like? Especially with all the lessons from COVID, are all these models going to succeed? Is one model going to come out as being the dominant force? Where do you see it going?

Dr. Richard Park: Well, Shiv, I don't know. That's a tough question. I can't prognosticate and my opinion would be really poorly informed. But I would say this: I like integrated delivery networks, not point solutions because they are a more holistic approach to cost and care. Integrated delivery networks that incorporate primary care, specialty, at-home or whatever type of care at their risk. I think that makes sense for the country. 

I think what we're doing, the solutions we have, -- whether you're Iora, or Chen Med, or Oak Street, or all the others...there are so many great companies -- the question is, are we going fast enough, better enough to make a difference? Are we being outpaced by the inefficiencies? I suspect we're not getting better fast enough and a lot of these models are slow-growing because it's hard, right? It's de novo approaches. Is there another approach where an acquisition partnership can move faster to get people aligned? 

At CityMD, it was a different thing. We were a de novo model. Everything we opened had the same systems in place. It's quite different to partner with a new group that's been in practice for 20 years and have them adjust to your ways. It's harder to tear down the house and build a house than just to build a house from scratch. So, with all these models, are they going to be able to acquire, grow quickly enough, to become of any significance? I don't know. When the market is trillions of dollars, we all need to go faster. 

Shiv Gaglani: Speaking of going faster, obviously we've heard that COVID has accelerated a lot of trends that people have been talking about for a long time. Telehealth had very little adoption, relatively, until COVID forced telehealth adoption. A core lesson. The reason we call this raising the line is how do we move forward past COVID? Obviously, we are nowhere close to being past COVID, especially in other countries. But once we hopefully get to that point, what are some of the things that we could be doing and should continue pushing and accelerating to raise the line and strengthen the health care system? We'd love your specific thoughts, as specific as you can be, on things that the healthcare system should be considering to improve quality as well as access. 

Dr. Richard Park: As to what did COVID do, I'm sure this has been discussed by many more intelligent people than I, including yourself. Telemedicine works well in integrated delivery networks. But what I do think it has accelerated is the feasibility, the importance of, and the necessity of the care-at-home model. We've always had people at home, but now it's gotten a lot of attention whether it's the primary care at-home market, the urgent care-at home, ER at-home, hospice at-home, SNF at-home, whatever at-home model. I think there's a lot of amazing companies doing point solutions to it that are very exciting, whether it's Dispatch, Contessa, or Remedy, Ambulance. There's a ton of them. I think the X type of care -- the hospital care at-home model is fascinating. I think it's beneficial to patients and to payers. 

Shiv Gaglani: Yes. We've seen a lot of movement in that space. We've developed a CNA training course largely because of the demand of skilled nursing facilities, but also home health agencies. We're working with several at this point for some of that curricular delivery. Wearing your investor hat at Ascend Partners, what are some of the things you're most excited about coming out of this? This has obviously been a great year for digital health and many of the companies that we've been following for years, like Oscar and 23andMe, are going public this year or they already have. So, maybe you can tell our audience a bit about what excites you most wearing your investor healthcare hat? 

Dr. Richard Park: It's probably not very sexy. It's not technology or AI-related. It's about fundamentals. I would say my experience in primary care, in Medicaid/Medicare here in New York just reinforced to me the importance of basic fundamentals. Standardization. I'll give you an example. When I walk into a lot of these primary care doctors' offices, most of them ethnic here in New York, they all want to take advanced levels of risk. The payers are dangling in front of them...Level 2 risk, upside and downside risk. They're eager to embrace it because all of us think we can do it. When you walk into the office and you see 5 brands of computers and you don't know the password to this one because every password is different for every one of these, and then you open it up and it's Windows 95 -- that's an exaggeration -- but the sophistication, the technology, the workflow, the methodology required to standardize, to create a dashboard and structure against it at scale doesn't exist. So before AI, before all these fancy layered things on top, we need to focus on fundamentals. 

I don't know which football coach it is, but I remember one football coach inviting people to come and look. "Come to training camp. There's no secret here. We are running drills, fundamental drills. I don't care if you watch. There is nothing special here, but we do the basics." And I think in the Medicare/Medicaid World in government payer world, that fundamental standardization is step number 1, 2, 3, 4, and 5, and people jump into 6 and 7. So the exciting part is, people have cured smallpox with carbon paper, and I think we have to take a carbon paper approach to healthcare before you add on anything fancier. So again, that's what excites me. It's probably not a sexy answer. It doesn't give you the multiples. But in the long run, that will win. 

Shiv Gaglani: Yes, that's fascinating. I mean, behavior change of physicians and other providers is difficult. At Osmosis, we mostly interact with the next generation of clinicians, right? People who are not yet stuck in their ways, with regards to how to do things. So, you have an opportunity to help them. This is one reason we have the podcast, to expose them to thought leaders and visionaries and entrepreneurs, like yourself, so that they can hopefully choose to go work for a Rendr Care, or an integrated delivery network that's doing it right as opposed to getting burned out in some other model that doesn't have great workflows and has 80% of the time being spent with documentation as opposed to patient care. In your experience, what is the secret factual behavior change? Either helping reprogram existing clinicians to get in these workflows? Or just hiring new ones? And what should we be training our learners so that there are more malleable or more able to do the basics well? 

Dr. Richard Park: Health care needs an army of coordinated team members -- physicians, extenders, front desk people, nurses, home health aides, call center. Everyone needs to work in a coordinated fashion. So how do we do that? Instead of trying to create these Michelin star rated, one-off restaurants that are not reproducible, we should be studying McDonald's. Every physician who wants to be a leader and wants to have an impact on the future of our care, to make a difference en masse, just study how do you scale and repeat anything predictably. There are very few examples in health care. They should look at McDonald's, and see the pros and cons. We need physician leaders that know how to do a McDonald's. 

Shiv Gaglani: I'm sure you're familiar with the potatoes ...how they get standardized French fry recipes across all these McDonald's?

Dr. Richard Park: No, I think I did watch the Netflix show. Was it in there?

Shiv Gaglani: I think there was probably some allusion to it. But I was just amazed at how precise they are with where they source their potatoes in Idaho, and in terms of the climate and other factors. And obviously, climate change is actually something that McDonald's has been paying a lot of attention to because it's going to change the quality of the ingredients going into their fries, as an example. 

Dr. Richard Park: My chief medical officers -- David Shih and Frank Illuzi at different times -- said something to me that I initially ignored and kind of blew off. They said, "Dr. Richard Park, you guys have to realize that quality is variance control." He said that very simple, profound statement, and I just blew it off and I went on to the next conversation. But only later did I realize, as he gave us examples of this, what that means. 

In a world where there's a lot of variation, step number one is to decrease variance. As an example, at CityMD at one point, one of our duties was to avoid unnecessary ER visits. Nobody's served by that, right? We had doctors sending patients to the ER .7%percent of the time. Other doctors sending patients 25% of the time. It's insane. So I don't understand. I can't comprehend how we have doctors sending 1 out of every 4 patients that came into urgent care to the ER. 

Now, there's mean. You work on the edges. 25% is clearly too much, right? Because other doctors that work in the same office, different profiles, it should be more like three-and-a-half to four. Maybe three. Under five. On the other hand, if you only send .5 or .8, you're dangerous, you're doing something wrong too. So step number one of quality is to get it within reason. And until you get everyone within a plus or minus from 2 to 10, don't introduce anything new. It's not a time for AI. There's no automation to be done. Variance control.

Once you get the potatoes to a similar size, that is more valuable than doing the incremental next profound thing. Once you get that under control...once you do your homework, you can go get ice cream. We have so much work to do on variance, which is for all intents and purposes, step number one, two, and three for quality. Until we get past that, until we have Windows 2000 at least on all our computers, you can't get compliance. You can't get cybersecurity. There's no dashboard. There's nothing. There's no conversation to be had until most of the healthcare has basic infrastructure. You're asking people to take risks and do things that they're not equipped to. They can't handle a fastball.

Shiv Gaglani: That's fascinating. I love that. Those are great analogies, and certainly a message worth our audience of prospective or existing young clinicians to hear. We're coming up on time. I had 2 other questions for you. One is, I'm Indian-American. You're Asian-American. Rendr Care specializes in Asian-American care. This last year has been a very challenging time for diversity, equity, and inclusion, all around and specifically this year with the Asian-American community. Is there anything you'd like to share with our audience about the way Rendr Care is approaching it? I want to give you the space to share anything. 

Dr. Richard Park: That is a very charged question. Let me answer it in a way that at least I view it recently. First of all, as a human being, as Richard Park, I have to do the very best that I can do. So as an individual, I have my own responsibility to myself, to my family, and to my partners, and to my country. God-Country-Family is sort of the hierarchy that has been instilled in me as a child. Not that it's not my problem, but it takes a second seat to God-Country-Family...this entire race relationship. So, what is best for the country? It may not necessarily what's ideal or perfect for each individual, but everyone rises together. 

If everyone got whatever they wanted, this thing would fall apart. If everyone had an advantage, where would you be? It's the same problem with physicians. How do we get everyone to lead? So, to answer your question, there's a balance between dignity and our self-right, and our right to self-preservation relative to the greater good. I hope we don't lose sight of that. Sometimes, losing means you win. That may not be a very popular answer to help people, and I hope they don't misinterpret that. 

If I were to liken it to the physician world, how do you get doctors aligned? Because taking care of doctors is like feeding deer, I once heard. If you move too quickly, they're skittish, they scare away, they don't trust. Successful groups, successful physician leaders, or provider leaders, always sacrifice a little bit of themselves. They lead the way by self-sacrifice. I've seen this in physician groups. At Rendr Care, sure, we had some CityMD talent come in because of their "know-how." That's not why we succeeded. The chairman of the board and the board, they're leading by example because they sacrifice self-interest. They lose an arm to get everyone to trust and win. It needs leaders that are servant leaders, especially physicians. Same way with race relations. In any human interaction when everyone tries to win, we all lose. 

Shiv Gaglani: Yes. Total Game Theory. What advice would you give to our audience about pursuing a career in medicine or health care in general moving forward? 

Dr. Richard Park: There's not a one-size-fits-all, answer, right? Most doctors, most providers, most normal human beings shouldn't care about having to change the world. They should be caring about themselves. They should be trying to be better people. So, with that being said, I think very early on in medical school, particularly, you should get exposed to as many different flavors. Shiv, you know this because you've done it...be exposed to as many specialties as possible. Don't rule anything out. Be exposed to as many different types of physicians, not just clinical -- researchers to entrepreneurs to pharma companies -- and get exposed. I wish I had done that earlier. 

Shiv Gaglani: Great advice. Well, Dr. Park, I really want to thank you for taking the time to be with us on Raise the Line today, but more importantly, for the work that you've been doing for decades now, in terms of improving healthcare and providing more access, especially to underserved populations. 

Dr. Richard Park: Thank you for listening everyone. Thank you, Shiv, for your time. 

Shiv Gaglani: Well, to our audience, thank you for checking out today's show, and remember to do your part to flatten the curve and raise the line. We're all in this together. Take care.