Solving the Hard Problems in Healthcare - Dr. Ami Parekh, Chief Medical Officer at Grand Rounds Health

SHIV GAGLANI: Hi, I'm Shiv Gaglani and today on Raise the Line, I'm really happy to be joined by Dr. Ami Parekh, who's the Chief Medical Officer at Grand Rounds Health which is a company that acts as a personal healthcare assistant, connecting patients to high quality doctors and top-rated medical facilities in their insurance network. Dr. Parekh leads clinical and provider strategies to accelerate the company's leadership and employee health navigation. She's passionate about using her skills and knowledge base to help as many people as possible facing difficult health care decisions. Dr. Parekh is also an Associate Professor in Internal Medicine at UCSF. Dr. Parekh, thanks so much for taking the time to be with us today.

DR AMI PAREKH: Thanks for having me.

SHIV GAGLANI: Can you start by telling us a bit about your background and what led to your interest in pursuing a career in medicine?

DR AMI PAREKH: Yes, absolutely. I was not necessarily going to be a doctor when I went to college; I thought I was going to be a poet, actually. But I went to a liberal arts college and was exposed to a lot, loved science, always, but really felt like my passion was bringing science to people. So, really early in my career I decided I would learn as much as I could both about the sciences like biology, but also about the political sciences, about how do we communicate effectively? How do we make systemic change? That prompted me to pursue, I would say, a non-traditional track, which is that after college I went to McKinsey & Company, again with the idea of, how do we solve hard problems? Because I think when you want to solve hard problems like in healthcare, you really need a breadth of problem solving capabilities. No single discipline is going to give us all of the tools in the toolbox to make change.

While I was at McKinsey, I got exposed to new ways of approaching problems, really understood the economics behind healthcare, and then went to medical school and law school at Yale. What really pushed me into that direction was, I knew I wanted to be a doctor. September 11th happened while I was at McKinsey in New York. I knew I had to have a profession where I got some gratification that I was doing something inherently good. One of those things is being a doctor. But the law school is sort of continuation of the theme that I had learned in college, which is, if we're going to solve hard problems, it's not only going to come from clinicians. It's going to come from this cooperation between people across disciplines. So that's how I ended up with a slightly different track than most people as they are building their medical professions. But it's one that I found really fulfilling because I still learn something new every single day about healthcare.

SHIV GAGLANI: Absolutely. Your background reminds me a bit of one of our closest advisors and one of my mentors, who also appeared on the Raise the Line podcast, her name is Lois Nora. She ran the American Board of Medical Specialties, was the Dean of several med schools, but also has an MD, JD, MBA. Given your experience at McKinsey, which, all my friends who've gone to McKinsey say it's like a mini MBA program, it sounds like you have all of that training. You joined Grand Rounds in 2018, correct?

DR AMI PAREKH: That's right.

SHIV GAGLANI: Can you tell us a bit more about the company and what inspired you to join them?

DR AMI PAREKH: Yes. Grand Rounds is a national technology company that's trying to raise the standard of healthcare for everyone everywhere. As a clinician, I had already had this past experience at UCSF where I was the chief medical officer for population health and critical aggression. I had worked at places like Brigham and Women's in Boston, and I knew I had to be a part of a mission-driven organization. I realized, it was time to start working with a technology company to learn yet another language of how we can solve healthcare problems. I needed to find a company where I was aligned with the mission first and foremost. Everyone I talked to at Grand Rounds was a hundred percent there because they believe healthcare as we do it today in America is broken, and they believe we can use technology to make it better.

The first thing I would say, when you're switching a job or what you do, make sure it's mission-aligned with your values. So that was the first and foremost. I think the second is, in my past roles, I would sit with clinicians or clinician leaders and everyone would complain that technology wasn't changing healthcare the way it was changing every other aspect of their life. As a working mom, technology has, I would say, enabled me to be a working mom, especially right now in COVID. I mean, you can do almost everything on your phone or through your computer. We're doing a digitally-based podcast right now, teaching the world about things. These are things that we couldn't do when I was in medical school.

Yet healthcare felt so old-school, for lack of a better word. We still would make our patients wait in waiting rooms, we'd still make them drive to see us. People would get frustrated with bills; they'd get them in the mail, they wouldn't understand what they meant. And we just complained about it. It just felt like it was time for me to stop complaining about it and do something about it, and to go to a technology company where maybe I could bring the expertise of the healthcare system and how we think about things on the ground and match it with really, really smart folks who know how to engage members digitally, who know how to use data in new and innovative ways to make us more precise in our recommendations, to really move that needle. So that's why I made the jump from the traditional healthcare system to a healthcare startup.

SHIV GAGLANI: That's awesome. I mean, it's hardly a startup now given what I've learned about how big of a reach you all have. For our audience, a lot of them are early stage healthcare professionals. I know you all are hiring healthcare professionals as well. Do you mind giving them a sense of your size and scope? If you close your eyes and imagine Grand Rounds in five years, what are you hoping to achieve at Grand Rounds?

DR AMI PAREKH: Yes. Let me tell you a little bit about what Grand Rounds actually does, as opposed to why I joined. We really do three main things. We deliver expert medical opinions to over 6 million Americans across the country. What that means is, if you have a diagnosis or you're on a treatment plan and you don't know if it's the right one, we'll connect you with a true expert in that disease area to say, “Let's get this person the right diagnosis and let's get them on the right treatment path.” I think it's a sad state of the world, but we change diagnoses about 10% of the time and we change treatment paths about 50% of the time. So, there's a lot of non-evidence based care being practiced in the United States, and so it's really democratizing access to that expertise.

About a year before I joined Grand Rounds, we launched healthcare navigation, because we realized that, wouldn't we rather live in a world where we didn't have to change diagnoses 10% of the time, and we didn't have to change treatment plans 50% of the time? Just get people started on the right track first. So we invested a lot in data science to say, how do we help people find in the first place, the highest quality doctor in their network for them? This launching navigation where we're helping patients find the highest quality care, getting rid of the friction of healthcare, helping them with their financial bills and their administrative problems to make it easier for patients to navigate the healthcare system that we sadly made quite complex in the United States, was really the second phase of Grand Rounds growth. With that, we serve I think over 140 customers, over 6 million lives, and have really I think changed the trajectory of care for populations, as opposed to just individuals at this point.

Our third phase, which is really exciting and we launched this in 2020, is virtual care. We're now providing actual medical care across all 50 states for patients who can't access care. We recently received funding to go from providing more comprehensive urgent care to true virtual primary care. As I think about the next two to five years of this company, that's really where we're going to be focused. How do we get the synergies from expertise plus navigation plus virtual care so that we can truly improve outcomes and decrease the total cost of care for populations? In terms of numbers, we're about 700 people. We have three locations, San Francisco, Reno, and Maine, and about 30% of our staff is remote. And so we have clinicians in all states who work for us, and we use a lot of technology to make that happen.

SHIV GAGLANI: Yes, that's pretty incredible scale. I'm sure this plan was coming even before COVID, and we'll get into COVID in a second, but there are a lot of very innovative primary care models coming out. We've had a number of them on the podcast, including Iora Health, and ChenMed, and Carbon Health, and we'll have Oscar in a couple of weeks joining us. What are some of the key differentiating factors do you think? I mean, obviously in your UCSF role, you have a tremendous amount of experience in population health data, which I'm sure has contributed to the capitated models that you're looking at. What do you think will make Grand Rounds a bit different as far as its offering?

DR AMI PAREKH: I think the first thing is, one thing I've been really impressed with at Grand Rounds is we learn from patients. So, we both use the evidence. We all know patients that are in medical homes have much better outcomes than what I would say traditional fee-for-service based primary care had. Truly team-based care makes a difference. So, we're going to do all those things because everyone should, if you're developing primary care models. But also, we are talking to patients and learning that members often don't even know what primary care is. It's sad because I think everyone in healthcare knows what primary care is and knows that it's the thing that can truly change outcomes for patients. But if you're a person, you might not actually know what it means to have a primary care doctor and how that's different from having an urgent care doctor. So, I think there's a lot of really understanding the end user that has to happen as we think about primary care and how do we get primary care to more people. So that's, I think first and foremost, what I've loved about Grand Rounds, it's this continued focus on the end user, which is in our case, a number of our patients.

The second is, make it easy, it has to be so easy. If it's something that you want patients to engage in, which I think we all want patients to engage in primary care, it has to be multichannel, everywhere, the easiest thing, all hours of the day. It cannot be scheduled around the provider, it has to be around the patient. So we're 24/7. You can do it from your phone, you can do it by chat, you can do it from video. You can do it the way you want to do it so that it's really easy for the patient.

Then the third is, the patient has to derive value from it. That has to be value that the patient feels, not the people who get excited about the A1C reduction which I'm definitely in that camp. But a lot of patients don't see value in dropping their A1C. So how do we make primary care something that the patients actually value and see the value of engaging with? I think COVID was a great opportunity for us, because you see, patients suddenly realized they need a primary care doctor, because when this urgent thing came up, they didn't know who to turn to. I think educating patients on why having a primary care doctor can make their lives better and easier to manage will go a long way.

I think the big differentiator for Grand Rounds is that we're coming from navigation. I've been in clinic before and someone will ask you, "Okay, Doc, how much is this going to cost me?” My patients used to call me Dr. Ami. "Dr. Ami, you're asking me to get this lab test. Do you know how much it's going to cost me?" And I sadly couldn't tell them, back in my old clinic days. At Grand Rounds, because we have navigation, we'll be able to actually educate around the cost and the value of that cost and see if there's a way to help the patient decrease that cost of care if we think it's really productive.

The other is this idea that virtual-first care will make it so much easier for patients, but there will always need to be in-person care. So, how do we use all the data that we've already accumulated? All the quality information we already have on brick and mortar care in any network to say, "Okay, now Shiv, you need a cardiologist. And I'm going to make sure that you see the highest quality cardiologist in your network, because that's going to then improve all of your outcomes.” I don't think any of the other models out there have that clear connection with quality-based navigation that we have inherently because that's our starting point. So I think those are probably the main differentiators for Grand Rounds as we enter into this new space.

SHIV GAGLANI: Yes, that's very exciting. We recently had Vivian Lee, who's the president of Verily and she used to run University of Utah Health System, you probably know her. She wrote the book The Long Fix, and one of the chapters was, how do you go from being just a caregiver to a co-producer of health? So your first point about how Grand Rounds learns from patients and empowers them to get in the process reminds me of what she really advocates as well.

DR AMI PAREKH: That's a great book, I recommend it.

SHIV GAGLANI: Totally. So let's go to COVID. We launched this podcast Raise the Line in the midst of COVID last year, and the whole point was, how we can interview leaders like yourself to talk about how we're going to adapt to COVID? Then coming out of COVID, what are some of the lasting changes we think will be in the healthcare system?  You've touched upon virtual care as being omnichannel care, but we'd love to hear, even on the micro basis, you as a provider, how the COVID story has played out for you, and also from Grand Rounds' experience, how COVID has played out.

DR AMI PAREKH: Yes. Why don't I start with the Grand Rounds experience. I think COVID taught us how to scale at ridiculously fast speed. When COVID became a known entity, which is about this time last year, we predicted that this was going to be a big deal, but actually there were a lot of people who were like, "No, it's going to be gone by the summer. We're going to be fine." That's appropriate because people were hopeful. But trying to quickly say, "Nope, the volumes are going to come, people are going to get sick and we're going to have to respond and be available for them when they need us most," was a good challenge for us at Grand Rounds. I think it really taught us that we're going from, let's say, 1X volume that we were running in January, February, to 10, 15, 20X that volume over the summer, and it continues to be very high volumes today, and then just being nimble.

Every week we learn something new about both the disease and now about the treatments and the vaccinations and quickly understanding how to manage new content and get knowledge to our front lines as quickly as possible has been a goal of ours. I think we've really changed how we do that in light of COVID. On a personal level, I feel like healthcare is always humbling. I really do learn something new about healthcare every day, but COVID is about as humbling as it can get. We could have all the greatest ideas on how to fix things, and when a new unknown unknown shows up, it shows how fragile our healthcare system really is.

I don't think COVID showed us any new problems none of us knew about. I mean, we always knew about the disparities in healthcare. We always knew that we have a very fragmented system that's not nationally coordinated. COVID just exposed those cracks with a bright light. It highlighted that we had these cracks and when left unattended, they're going to cause really big problems. That's what we sort of saw this year.

SHIV GAGLANI: Yes, I couldn't agree more. I'm glad to hear that you all have been nimble when COVID was starting to become big here in the US. One quote I often cited, especially in the early episodes of the Raise the Line podcast was actually from a surprising source, Lenin, who said, "There are decades where nothing happens, and there are weeks where decades happen." Clearly I imagine that you guys probably felt that at Grand Rounds and accelerated some of the initiatives that you were planning already to meet the demand.

DR AMI PAREKH: I'm definitely going to borrow that quote.

SHIV GAGLANI: Yes, it's a great quote. Another one that I've often cited is that—you probably know this one too—Andy Grove from Intel who said, "Bad companies are destroyed by crisis, good companies survive crisis, but great companies are improved by them."

DR AMI PAREKH: Yes. I think we hopefully are in that latter category. We've been very lucky in 2020 to grow faster than we could have imagined, and help people get through this crisis.

SHIV GAGLANI: Totally. Being a 24/7 provider is unique and I think obviously patient-centric. I know we're coming up on time, so two more questions. The first is, what advice would you give to people right now considering careers in healthcare or early on in their career in healthcare, about meeting the demands and challenges of COVID and beyond?

DR AMI PAREKH: Well, one, if you're considering healthcare, thank you. I think one of the lasting impacts of COVID, hopefully, will be this reenergizing of people interested in healthcare. In all honesty, when I decided to go to med school, a few people were pushing me the other way. They were like, "Look, you have this business experience, why don't you just go and be a businessperson or go join the tech world?" I still decided to go to med school and then do my residency. There were moments where I wasn't sure if that was the right call, but it is so fulfilling. So if you're considering it, thank you. I feel really privileged every day that I have the skillset where I can actually help patients. So consider it and consider it strongly.

In terms of what we need in our future clinicians and our future leaders in healthcare, I do think it's this openness and curiosity about different ways to solve problems. We go into these schools and we learn one way of thinking. If we're going to solve these intractable problems that have been exposed by COVID or existed before, we're really going to need people who can lead across disciplines. One thing I would encourage is, if you're in medical school or if you are in residency, reaching out to colleagues in business schools or law schools or engineering schools and not just being the clinician, SME, the subject matter expert, or being the person who brings up the clinical stuff, but really trying to lead in those multidisciplinary organizations to make measurable change, would go a long way. I think we'll see a better healthcare system if we open up our thinking, as folks in healthcare, if we can do that.

The other piece I'll say is, even within healthcare, we have to be integrated. I think COVID exposed how much behavioral health need there is, and I think the stylization of behavioral health and physical health needs to go away. We treat people. Nobody treats an organ; the organ belongs to a person. So I think pushing all of us in healthcare to treat the person. You might have an area of expertise, but thinking about how that area affects everything else that the person is going through, I think can really push us to do better.

SHIV GAGLANI: That's some very good advice. On that last point, one thing I'll mention is that we obviously we train healthcare professionals, medical, nursing, PA, at Osmosis, and language matters. One thing we're actively doing and hopefully other training groups will do this as well, is seeing people as people. Even the language that you say in question stems to prepare for exams, where instead of a diabetic patient or a homeless patient, a person experiencing homelessness, a person with diabetes, that stuff. When you're looking at it once, it probably doesn't make a difference, but if you're looking at it again and again for years, and start just looking at them as a pancreas, as opposed to a person with a pancreas that has diabetes. So, I'm glad you mentioned that.

DR AMI PAREKH: Yes. I mean, healthcare will always be human. I know there are people out there that think you can get rid of the human aspect of healthcare. I'm not in that camp. I think the future of healthcare is definitely more technology and technology enabled, but this is a person-to-person endeavor. What happens when you're talking to your doctor is what happens when you're talking to a person. The doctor's a person, or the nurse is a person, or the PA is a person, and the patient a person. It's that therapeutic relationship that really brings the better outcome.

SHIV GAGLANI: Totally. Well, I know we're out of time, but my last question is, is there anything else you'd like our audience to know about you, about Grand Rounds, about getting involved? Whatever else you'd like to be able to share with them.

DR AMI PAREKH: Yes. I would just say for everyone who's listening, keep an open mind on where the opportunities are to change healthcare. If you want to change healthcare, it's not going to be a linear path. If you look at companies like Grand Rounds that are trying to change healthcare, there's a lot of opportunity to make things better, both in the traditional systems and outside. So make sure you're keeping an open mind, being continuously curious, and thank you for trying to fix healthcare.

SHIV GAGLANI: Thank you Dr. Parekh. I really appreciate you taking the time to be with us and more importantly, the work that you do at Grand Rounds and as a provider yourself to raise the line.

DR AMI PAREKH:Thank you.

SHIV GAGLANI: 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.