Delivering Seamless, Responsive Care at Home: Chris Altchek, Founder and CEO of Cadence

Shiv Gaglani: Hi, I'm Shivani Gaglani. We're going to learn about a company on today's show that sits at an intersection of three huge trends in U.S. healthcare: the unending growth in the number of people with chronic conditions, the advent of new virtual healthcare technologies, and moving more care into the home. 

Chris Altchek is founder and CEO of Cadence, a remote care management platform that helps physicians bring more responsive care to patients in the comfort of their own homes. He previously launched and sold an internet media company and worked at Goldman Sachs and the White House. And Chris and I go way back, actually, to the days of being undergraduates at Harvard where we were introduced by a gentleman named in Ryan Travia as part of the drug and alcohol peer advisor program. So Chris, it's great to connect with you and see all the great work you're doing with Cadence. 

Chris Altchek: Shiv, thank you and congrats on all your success. Excited to be here. 

Shiv: Well, thanks for joining us. And so, I know a lot about your background, having been friends with you for a number of years, but for our audience, do you mind giving us some of your career highlights? And as I mentioned, Cadence is not the first company you launched and ran, so you've become sort of a serial entrepreneur actually.

Chris: Yeah, I don't know about career highlights, but I'll tell you my story which is, I started my first company in 2011. It was a consumer internet company called Mic, a mission-driven company. I learned a lot through that experience. I think we were 23, 24 when we founded it. We ended up selling in 2018. I learned a lot through that experience, including that building a lasting company takes at least a decade, so you better be really excited about it. I also learned building mission-driven companies is a lot more fun and rewarding and meaningful and much better for attracting super high quality talent to your company. And then I learned a lot about management and business models through that experience. 

After Mic was over, I knew I wanted to build something else and take those lessons learned to a new space. I've been lucky. I grew up in a family of doctors, I'm married to a doctor, and a sibling is a doctor, and so healthcare has sort of always spoken to me and it very much felt like -- this is back in 2018 -- that if there was a place to spend the next fifteen or twenty years building, the intersection of technology and health care would be it. 

So I joined Thrive Capital, a venture firm in New York, as an Entrepreneur-in-Residence. That was an awesome experience. They've both funded and co-founded a number of successful health tech companies and have large and ongoing existing relationships with some very interesting progressive health systems. So I got to spend a couple years just learning as much as possible about both the business and the mechanics of health technology companies. In 2020, we launched Cadence. It has been a whirlwind journey since then and has just been so much fun and so rewarding and I'm just very grateful for these opportunities. 

Shiv: Yeah, absolutely. There's a couple of threads to pull on there. The ten-year time frame is interesting. It does seem like there's a pattern among great mission driven companies that took about ten years to reach fruition. There's this great quote, you may know of  which is people overestimate the impact of technology within the first year and underestimated its impact within ten years. Bill Gates has paraphrased it to say the same thing: you overestimate what you can accomplish within one year and underestimate what you can do in ten because of the power of compounding. You have no idea where things will take you, and that's certainly been our experience at Osmosis in terms of the growth we've had.

Chris: Yeah, that is exactly right. In any of these industries you have cycles that move fast and if you're going to build an enduring company, you're going to need to build something that survives and thrives both in the upswings and the downswings. And normally over ten years, you get at least a couple of those in the tech space.

Shiv: Absolutely. So going into Cadence, you launched it in 2020 -- a very interesting time for U.S. healthcare. Can you talk to us about the founding story and what makes Cadence different than other remote care at home companies?

Chris: So I was very passionate about how could we bring data from devices, wearables, and other sensors in the home and use that to help providers and health systems and hospitals deliver world-class care outside of the four walls of the hospital. That was the problem that I was most interested in and got lucky enough to get paired and introduced with our chief medical officer, Dr. Ted Feldman, who is a practicing cardiologist in South Florida. 

We started spending a lot of time on remote patient monitoring and you're both learning from many of the clinical successes that a lot of academic medical centers have proven over the last two decades, really showing that the connectivity of receiving patient vitals and symptoms from patients on a daily or weekly basis can provide very, very meaningful data for clinicians who are trying to manage patients towards guidelines for some of the most common chronic conditions in the U.S. 

The clinical studies and the clinical foundation for remote monitoring is really, really strong and now more than a decade old. But what we really want to spend time on is we know these programs can work and we know the science behind them is really sound and we know that in heart failure, if you can get a patient to follow GDMT (Guideline Directed Medical Therapy), you can have a very meaningful impact on both near-term and long-term health outcomes. We know similar trends exist for Type 2 diabetes, hypertension, and COPD. Despite that, there are very few remote monitoring platforms that have scaled beyond several hundred patients at some of the largest hospital systems in the country. 

So that was the problem we focused on: how do we take this new technology -- where the cost has come down and reimbursement has become more widespread -- and how do we make it something that's historically only scaled to a couple hundred or a thousand patients in some academic medical centers to tens or hundreds of thousands of patients who could really benefit from this level of connectivity and this level of responsive care the home? It felt like you're at the intersection of three big trends: One, how do we take care of patients at home because it's a better patient experience and ultimately lower cost; Two, what kind of technology do health systems and providers need to make this big transition?; And then three, how do we focus this effort on the four chronic conditions that are disproportionately having negative impacts on clinical outcomes, people's lives and the cost of healthcare in the U.S.? 

So that's what we focused on. We took a very first-principle approach to hospital system operations and clinic operations and really solving this problem end to end for our partners. We were lucky enough to partner with a progressive health system called LifePoint that's based in twenty-nine states and has over fifty hospitals, and really build a solution with and for them with the target of supporting 100,000 patients concurrently. It's been an incredible experience. We've got a whole another set of partners now that we're working with, but the spirit has stayed consistent which is delivering this everyday care to patients in the home in a way that's seamless, easy and truly responsive. 

Shiv: That's awesome. We're going to dive deeper into exactly what that looks like. Going back to that first comment I made after your intro about how things take longer than we expect, but once you stick it out and survive some of the downturns, you have a chance of building an enduring company. 

Similarly, there's this Gartner Hype Cycle, which I'm sure you've heard about, and digital health went through this. I remember being at TedMed in 2013 where we debuted something called The Smartphone Physical. We had all these devices then, including the AliveCor ECG. We had that company's founder, Dave Albert, on Raise the Line not long ago. I'm sure you know him. He's out in LA too. He's a cardiologist, and AliveCor is a patient monitoring success story, actually. 

But there was a lot of hype around these devices back then, almost a decade ago over. And then, we didn't hear much about them or telemedicine for a little bit. There's this Zone of Disillusionment. But then with the pandemic, and just kind of the natural cycle -- costs going down, patients being more willing, providers knowing that digital health is here to stay and that you got it cheap enough where it isn't just reaching the worried well, but the average consumer who has these chronic conditions -- it's really an exciting time to be in the remote patient monitoring space. Would you agree with that?

Chris: I would say it's really exciting because we believe remote monitoring and virtual care is going to become the standard of care for how you treat patients with these chronic conditions over the next five to ten years. I think you're exactly right. It's an intersection of all the trends you talked about as well as this hard work that a lot of clinical scientists and researchers have done to really prove the value of close monitoring and close medication management and close coaching of patients with these chronic conditions. 

We now have great therapeutics for a lot of these conditions if we can keep patients both prescribed and adhering to the best treatment plans. So that combination of everything you just discussed -- the uptick from providers being more interested, the uptick of patients being more amenable to this type of care, the cost coming down, the science really lining up. I would say that the last piece of really making this easy for both patients and providers is only now possible because of some of the technology advances. 

We really believe that technology is only as good as it is usable. We all in the health technology ecosystem need to stay focused on building efficient infrastructure that allows physicians to deliver much better care to a much larger number of people. If we stay very, very focused on that and then usability and ease of use and not creating more burden for clinicians and not designing complex patient experiences. It has to work for your average seventy-five-year-old patient in a community anywhere in the U.S. If they can't interface with your technology, it's probably not going to have as big of an impact as we would hope. So those are the types of themes that we really think about and hone in at Cadence, and I think that's allowed us to at least start to show that this really works. 

Shiv: That's awesome. Well, I would love to get into what that actual experience is like for patients and providers, if you can kind of walk through your new patient or provider on the Cadence platform.

Chris: So, on the patient side, these programs are integrated into their existing primary care and cardiology clinics and relationships. We've got a number of really successful clinics in North Carolina. If you're seeing your PCP that you've been seeing for a decade or two decades who you really trust and who you have a great relationship with, that PCP or office recommends that you join their new remote monitoring program. You can get your devices at home or in the clinic and they show up already configured to you. They're connected to yourself, so you don't need a smartphone and the data transmits automatically every time you take a reading. 

As a patient, you get taught that for less than thirty seconds a day, you can have peace of mind knowing that your care team is checking in on you and making sure that your vitals look good. The patient then gets communication from us via text message or phone, depending on what they prefer.  We've got various setups for virtual care where for some of our provider partners who need support, we've got fully-licensed teams of medical doctors, nurse practitioners, RNs and Medical Assistants who are supporting our clinician partners looking at alerts, engaging with patients, and even titrating medications according to protocols on an ongoing basis to make sure that the care of these patients receiving is world-class. 

If a patient is decompensating -- and this happens frequently because we've got a relatively sick patient population -- and we receive that in the vitals, we will make sure that we're escalating that to our clinician partners and following the appropriate escalation pathways that they want us to take. 

So, it's been really promising so far. We've been seeing that we've been able to help patients avoid costly ER visits and lengthy stays in the hospital. We've seen marked improvement in quality of life -- and we will be sharing a lot of this data shortly -- but the clinical outcomes are really, really promising so far. 

I want to stress that  this is tech that's optimized for seniors. Thirty percent of our patient population doesn't even have a cell phone, and a meaningful number have a flip phone not a smartphone. So the fact that these programs work and this connectivity is able to really get deployed at scale for this patient population is incredibly promising for the future of, hopefully, increasing access to care across the U.S.

Shiv: That's really key. We've had people talk about the silver tsunami that's coming. Alan Patricof is the founder of Greycroft, and now Primetime Partners. He was one of our major backers at Osmosis and he was on the podcast early on talking about investing in companies that are specifically designed around this use case. Certainly that's something Cadence is addressing.

One of the things I remember in the Zone of Disillusionment for remote patient monitoring back in the 2014 to 2017 era was many physicians don't know what to do with patient-generated health data. I think obviously that's changed a lot as we've gone to more value-based medicine, but can you talk to us about the experience for providers? Many in our audience will be your future providers who adopt Cadence and use Cadence with their patients. Why should they switch the Cadence? What's the experience like for them?

Chris: This is probably the area where we spend the most time. How do we make the provider experience truly seamless? If you're a primary care physician in a busy clinic, you might be seeing fifteen to twenty patients a day, sometimes even more. You've got a patient panel of 1,000 to 3,000 patients, and you're really, really busy.  Many times you end the day, and you've got 200 messages in your inbox. 

So, the sort of old school way of, "Hey, let's sign up a bunch of patients for remote monitoring, stick the data in the EMR and just have the physician and their Medical Assistant be responsible is not a realistic ask for overburdened clinicians who have a lot of work to do already. What we've tried to design is a model where we can be an extension of your clinical team and we can manage patients according to guidelines and protocols that you approve and you agree to and really only escalate the things that require your attention. The routine day-to-day stuff can be handled by us. 

That really empowers physicians to practice at the top of their license. That empowers them to use the time they have in person with patients on the most meaningful, difficult issues. If there's a hypertension patient who needs close monitoring and up-titration of their blood pressure medications, that can be handled remotely and virtually. The next time that patient comes into the clinic, the PCP can really address some of the root cause issues. That's the spirit of what we do. And so far, it's really worked. 

It's flexible. Every physician has different levels of comfort with care management teams, and so we've really designed this to help patients get this much more responsive personalized care every day without creating more burden. Actually, in many cases it's reducing burden on clinicians because a lot of the messages that they're currently getting from these patients in the off-hours and throughout the day are now being handled by the appropriate person on the care management team. So it's very much this evolution towards team-based care where we believe the PCP and the cardiologist and the endocrinologist should be at the center directing the care, but they should have a lot more resources to be able to deliver this, and that's both in terms of technology and clinical teams. 

Shiv: That's great. I think that viewing it as a physician extender, or clinician extenders is wonderful, and having that level of data and the extension is important. Elsevier released this great Clinician of the Future report, which I will make sure to send you. Over 8,000 clinicians across 150 countries were surveyed and the vast majority of them said digital health and remote patient monitoring are here to stay, just like telehealth. So I think there's definitely a more willing provider population that you guys are going after.  Plus, as the workforce ages and changes, you'll have a lot of these digital natives...people who are seeking experiences that are as seamless as what they have with Mint or Credit Karma or those kind of FinTech companies that have won over the past decade. So, that's great to hear. 

Chris: And on those points, I think what's important is physicians are really, really good at understanding how to manage chronic conditions. They know that small medication titrations can have a huge impact on a patient's outcomes. They know that close coaching on nutrition, or your health can have a really big impact. But, a lot of times they don't have the time or the connectivity to be able to do that on a regular basis. So intuitively, we found that physicians really get it and they want to do it and it's just a question of giving them the tools and resources to be successful at it because people understand, it's the right thing to do.

Shiv: Yeah, totally. And also, policy is now catching up because COVID forced remote patient monitoring and telehealth, as well. So speaking of COVID, what remote patient monitoring, value-based medicine, telehealth...these are all trends that have come out of COVID or been accelerated by COVID. Do you mind commenting on some of the other things that we could be doing to strengthen our healthcare system, or as we say at Osmosis, raise the line?

Chris: Our thesis is that health systems have largely been on the sidelines of the revolution in digital care over the last decade. We believe COVID threw them right in the middle of it, and that they are now taking a much more central role in driving digital care forward. And we think that's the right thing...that health systems, large hospital systems, and their providers should be the central players in the next evolution or revolution in digital care. 

But now we're seeing very widespread demand and adoption by health systems for solutions that allow them to deliver robust ongoing care remotely. Partially that's because there have been so many dynamics that have made it much more meaningful to these systems, but also, and I think most meaningfully, consumer and patient expectations around how healthcare is delivered have changed. I think there's no turning back the clock on this and we're excited to see providers who historically maybe have pushed back against this now really be the ones driving it forward. 

Shiv: Yeah, which is often the case...that the best advocates are the ones who previously were critics. As you know, Osmosis is a teaching company and we love to fill in knowledge gaps and create videos and courses. If you could snap your fingers and have a video or course for any population you care about -- whether that's the patients, their family members or the providers -- what topic would you like us to educate them on?

Chris: I think that the topic that would be most interesting is change change in healthcare and behavior change in healthcare. How do you align incentives between patients, providers, health systems, and payers? We all have so many good ideas for how health care innovation can move forward and what the future of healthcare is, but we really need to make sure those four groups are aligned. 

I was lucky somebody taught me some of those concepts early, and I come back to them often.  For us to truly be successful, we need to be adding value -- most importantly, to patients lives -- but equally importantly to providers lives and to their health systems and to payers in the total cost of care. So that alignment and then managing change through those four key stakeholders, I think is, one of the things that I am reminded of on a daily basis. For the next generation of physicians and healthcare leaders who are going to be building the future, I think that could be really valuable. 

Shiv: That's certainly some wise counsel. On that same topic, we have an audience of millions of current and future health care professionals who mostly skew towards the younger generation, as you know, just given our roots starting this when I was a medical student at Johns Hopkins. What's your advice to them about meeting the challenges of the COVID pandemic and beyond, and approaching their whole career in health care -- whether it's on the clinical side, or on the entrepreneurial side as you've done?

Chris: I will hesitate to give any advice on the clinical side. I think my wife or my sister would remind me that I have no idea what I'm talking about! But I think on the entrepreneurial side, I'd say that we've had the privilege of partnering with a large number of physicians, both as advisors and team members at Cadence.  We go  from very senior professors of Cardiology who've been practicing for 35 years, to one of our medical advisers who is actually a resident at John Hopkins and he's been gigantically valuable towards the development of our product.  I guess I would say for those clinicians who are interested in health technology, it's never too early to get involved in startups. Your voice really matters and your expertise is really deep and really meaningful to, in our case, to our software engineers, our product managers, and the people that are putting together the clinical team. These physicians, both young and old, had a very big impact on the company. 

Shiv: Absolutely. I would echo that. And the digital health space is big. There's a revolution here, so the people who are listening who are interested in that, folks like Chris are leading the way and it's good to get in touch with with them and find ways to add value to those companies because ultimately, they will be helping to shape the healthcare system that you practice in. 

I know we're at time, so my last question Chris is, is there anything else you want our audience to know about you, about Cadence, about the space, that you'd like to leave them with?

Chris: I think I'll say we're just in the very early days here. If you fast forward five to ten years, the types of devices and sensors we're going to have are going to be really, really interesting. I believe with the partnership of many of the people that are listening today, we're going to be able to use this data from patients at home across a very wide array of diseases and conditions and, hopefully, achieve this goal of making sure that everybody in the U.S. can receive the highest quality, world-class healthcare in whatever zip code they're in. I think we are really moving towards that future, and I don't think it's ten years out. I think it's closer to five years out, and I'm excited to hopefully partner with this next generation of physicians on this. 

Shiv: Those are some great words and a wonderful vision to strive toward. Hopefully it will be closer to that five instead of that ten given all that's going on. So with that Chris, thanks so much for taking the time to be with us today, and more importantly, for the work that you're doing to drive healthcare forward through Cadence.

Chris: Sure. I really appreciate it. Thank you so much.

Shiv: With that, I'm Shiv Gaglani. Thank you to our audience 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.