A New Model for Primary Care - Tim Barry, Co-Founder and CEO of VillageMD

Welcome to Raise the Line with osmosis.org, seeking solutions with leading experts on how to increase healthcare capacity so people can get the care they need during the COVID-19 crisis and beyond.

SHIV GAGLANI:

Hi, I'm Shiv Gaglani and today on Raise the Line, I'm really happy to be joined by Tim Barry. Tim is the co-founder and CEO of VillageMD, which provides thousands of primary care physicians with technology, staffing, and other support to help them provide better patient care. The company has also developed primary care clinics of its own and announced, over the summer, that Walgreens is investing over a billion dollars to build hundreds of VillageMD clinics next to its pharmacies over the next five years. I'm really looking forward to asking Tim about his vision for transforming primary care and what the Walgreens partnership signals about how healthcare delivery in the US is changing. Tim, thanks so much for being with us today.

TIM BARRY:

Shiv, thanks for having me. I really appreciate it.

SHIV GAGLANI:

So you have a really impressive background across all types of healthcare, including running a Medicare Advantage program. I'd love to hear a bit more about your own background in your personal words and how you got into the healthcare space.

TIM BARRY:

By way of background, I’m a technology entrepreneur, which is always funny to our tech team, but I have started a few different technology companies earlier in my career. I'm actually incredibly fortunate to be working in healthcare today, in that I had a college roommate, frankly, who was starting his own consulting practice. And he convinced me after I had sold one of the technology companies to go do some work at Blue Shield of California. And to be perfectly honest with you, Shiv, I was not all that excited about it at first, I thought, here I am this kind of tech guy, or I thought of myself as a tech guy, and here was this sort of non-profit health insurance company. It didn't sound all that sexy or fun.

TIM BARRY:

And so my college roommate, I think, knew better and he convinced me to come give it a shot, and I fell in love with the industry. And I've always been a bit of a math nerd by background. I think caring about people and making a difference in the community matters. And so when I got into the healthcare space, I realized that this is really an industry, right -- some would say a business – that is really all about trying to change the trajectory in lives of others, and so it became a natural fit.

SHIV GAGLANI:

That's fantastic. And so can you talk to us a bit about some of the seminal or milestone events in your life and kind of what types of things you ran before founding VillageMD, and then obviously, we'd love to hear that founding story.

TIM BARRY:

It's interesting because all of the technology companies that I was involved in were really tied to education and human development, and I'll never forget, this is a funny story, it was sort of mid-1990s, and I was living in Chicago and walking on Michigan Avenue. I was out shopping with some friends and we walked into the Nike store and there was a poster of Lisa Leslie, who was a women's professional basketball player at the time. And the sign said, "You just can't fake love, man." And I thought that was so cool. It was so impressionable for me in that the things that I've done professionally, I always felt the need to be very passionate about it. And I worked at consulting very early in my career and worked for a blanking and stamping plant, which was a third tier supplier to an automotive company and that body of work was intellectually interesting for about a day.

But for me, it was really about what are the things that really excite me. I'm from a small town in Northeast Wisconsin, and the idea of seeing people improve and their lives improve is something that always just really motivated me. And so the companies that I started prior to getting to healthcare were all really focused on that. My health care journey was somewhat interesting in that when I came into Blue Shield, I came in at a time that was in the early 2000s. And one of the big events that happened in my time at Blue Shield of California is that the Medicare Modernization Act was signed into law in December 2003. And it was a hotly contested piece of legislation, but it gave birth to what we now call the Medicare Advantage industry.

Back then, it was called Medicare+Choice, and it was run very differently prior to that. I was falling in love with the healthcare industry, and so I read the legislation kind of cover to cover. One of the things that really fascinated me was that in the course of this legislation, it introduced the idea of acuity adjustment, which to most people, what is that? And it was a way of the government paying insurance companies based upon the acuity of the people they were caring for. So you think about all other insurance -- property casualty, life insurance, car insurance -- there's really not this idea of acuity adjustment, where you get paid more for someone who's of higher risk, unless they get to individually underwrite as an insurance company.

But to have an insurance program that did that, to me, was kind of a sentinel event that said, "We're going to start to move down a pathway in the healthcare system where the companies that take risk, the health insurers, are going to have to work much differently with the healthcare providers than what they have historically. Because the people who are highest risk are people who have chronic disease, they have COPD, they have CHF, they have these heart conditions, and we have to do a better job of providing care to them such that they don't need to go to the emergency room in the hospital, et cetera, as often as they do.

And so, to me, that was a sentinel event that kind of helped send me down a pathway to also realize that either health insurers have to work very differently with providers, or health insurers have to start becoming providers. Like in California, Kaiser has always been there, but more and more around the country, we see health insurance companies now acting as providers. And the other phenomenon is provider organizations who are willing to take risk. And so to be fully accountable for all of the total quality outcomes and the medical spend that their patients have.

And frankly, as I read this, and thought -- and I went out and talked to different physician groups across California where I was at the time -- my bet was on the doctors because at the end of the day, the physicians are the people that have built the greatest amount of trust with their patients. And if we're going to change outcomes in this country, it has to come from a really trusted source. And it has to come from people who are the ones day in, day out caring for patients. And so my bet was on the provider.

Long-winded context to some of the sentinel events, but there's some things from a legislative front, some things in talking to doctors and realizing what they were missing as it related to the way that they could best deliver healthcare, all kind of led me down a path to say, "I wanted to pursue my career and focus the energy of my career in organizing primary care doctors and helping them deliver the best care they possibly can."

SHIV GAGLANI:

That's fantastic. We've had a lot of pretty amazing guests on the podcast, including just recently, we had Dr. Sachin Jain who I'm sure you know from CareMore, now SCAN, and then in a few weeks, we'll have Dr. Vivian Lee who runs Verily at Google, but also just wrote a book called The Long Fix, which I've been reading in preparation for the interview, and I feel like your explanation there perfectly encapsulated some of the things that I read in that book. So you've made a bet on the primary care docs, given that Osmosis reaches millions of current and future physicians, I'm sure our audience likes to hear that. Can you talk about how you actually materialized that bet and you started VillageMD, what the trajectory has been, and then let's move that into the discussion around your major Walgreens contract and where you see it going.

TIM BARRY:

Absolutely, Shiv. I think, just one other contextual item is that if you look at the U.S. healthcare system, we spend $4 trillion per year on healthcare, right? And that number is going up and to the right, at a pretty significant pace. And yet we have quality of care outcomes that are, frankly, a little bit better on a population basis than many third world countries. So we have this sort of interesting perspective where we have the cost of healthcare continuing to skyrocket, and yet as much as we're spending on healthcare, the quality of outcomes don't improve. Lots of people have heard that. No big statement there. The thing that I find most fascinating though, is that when you peel back the layers of the onion a little bit, you're going to find that less than 20% of the population is accountable for 85% of that $4 trillion.

And that happens to be people who have chronic disease, right? And so when you think about the clinical professionals in this world who are, frankly, best trained to take care of those who have multiple chronic conditions, it's the primary care doc. And so, unfortunately what's happened in our medical system, both from a medical education standpoint, as well as where most doctors go to practice, they're not focused on, "How are we delivering the best outcome to chronic patients." Right? People aren't saying, "How do we invest as much as we possibly can into primary care so that the outcomes that these patients have, are best." So that in the ideal scenario in the healthcare space, we would have an intense focus and energy on those who currently have chronic disease and then we would work really hard to prevent the continued exacerbation of chronic disease with others. Right?

And so if you just sort of think about that from a macro economic standpoint, it all leads you to primary care has to be the answer. But primary care can't be the answer in the way in which the training currently works today, as well as where most of the primary care doctors work, which is unfortunately in hospital systems. And it's also in a spot where the primary care doctors are resource-constrained. They don't have access to technology. They don't have a longitudinal view to know what's going on with their patients. They don't have the ability to send someone to the home. They don't have the ability to have someone coordinating care across different specialties. And so we said, let's build a primary care system that moves beyond the traditional clinic space into one that's thinking holistically about this 10-foot bubble that wraps around the doctor and the patient.

And if we acknowledge the fact that people who have chronic disease are living with it 24/7, as opposed to the 15 minutes, every 90 days they go in and see the primary care doctor, we would create a different kind of healthcare system. We'd have more resources, we'd have nurses, we'd have social workers to deal with behavioral health conditions. We'd have pharmacists who are integrating the chemical aspects of care improvement, tied to the physical aspects that the doctors are bringing to bear. There's all these things that we would do differently, and so that's the journey we've been on. It's seven and a half years. We started with one physician group in Houston, Texas. There were 14 doctors that we started with, we're just about 3,000 doctors today. And as you've referenced earlier, we're on a pretty aggressive path to continue to scale this model into so many other markets.

You can't scale without great technology, and so thankfully, and that's a huge part of what we do, you can't scale and give doctors this better care model to practice in unless you have data and technology and resources that you can bring to bear. But the thing that I'm most encouraged by is that at the end of the day, primary care physicians, they want to do the best thing they can for their patients. They went into this specific family practice, geriatric, internal medicine, pediatric specialties, because they want the best outcomes for the people they care for. And thankfully, we're able to show, quantifiably, that we can do that.

SHIV GAGLANI:

That's incredible. I mean, the level of scale over seven and a half years is pretty amazing. And so what are some of the outcome metrics that you can share as you've scaled, and specific examples of support, is it everything ranging from electronic health record implementation to remote patient monitoring? We'd love to hear some of those specifics of your model that make you different than some other primary care models that are out there.

TIM BARRY:

Thankfully, I could go on for hours about that, but I'll try to summarize a few different ways, right? So as a primary care provider, part of the beauty of our model and uniqueness of our model is that we care for all patient populations. And so it's Medicare, it's commercial -- those who get their insurance largely through their employer -- as well as Medicaid. And so you have these different populations or payers that you're contracting with. With the Medicare Advantage insurers like Humana and United Healthcare and the Blues, et cetera, what you'll find is that there's a star rating that's used in Medicare Advantage, and we're four and a half to five stars across the plans that we work with. That's the highest level of quality you can achieve. We contract directly with CMS, the federal government, in a model called the Next Gen ACO Model, we’re fully at risk with Medicare fee for service patients. And our quality scores are 99%, right? Sort of the top decile of performance and quality.

In the commercial carriers that we contract with, you'll find the exact same thing where we're consistently being given data by the payers that say, "You are a top decile." So across the board, quantifiably, we can show the quality of care has improved. We have net promoter scores in our clinics that are in the 90s. And so the patients are voting and saying, "We like this experience because it's a primary care model. It's not just reactive, but it's proactive, it's high-touch, it's coordinated and continuous." And then the last thing is the ability to demonstrate a reduction in the total cost of healthcare. And that if you look at our performance across those different populations, again, you're going to find that we're saving a couple thousand dollars per Medicare beneficiary in Medicare Advantage, we're saving almost $1,000 dollars per Medicare beneficiary in Medicare fee for service. We're saving sort of $400 to $600 for the commercial population.

Those are very real, tangible savings that are measured in the tens and hundreds of millions of dollars all through a model that patients are saying they love and the quality of care is improving. So to us, at the end of the day, when people talk about results, those are the things that we are most excited about. We make that happen because as I said, we move the primary care practice and model from just reacting to whoever happens to show up that day into a model where we're proactively scheduling the patients who need to be there based upon what the data and technology are telling us, in terms of who's most at risk of various kinds of bad events.

And then from there, we're available to patients 24/7. The way we do that is through Telehealth, the way we do that is through remote patient monitoring, the way we do that is by seeing patients in the home. We see patients in the hospital, we see them in the skilled nursing facility. And so we're embedding ourselves into the lives of the patient and those who really need the additional touch points tied to the patient care. So I could go chapter and verse, Shiv and bore you to tears on this, but it's really about thinking about the outcome in mind and knowing what's possible and driving better results, and then investing resources to actually help make it happen.

SHIV GAGLANI:

Not boring at all. I mean, that's wonderful to hear. The quality scores -- for our audience's context -- I think, most people have experience with Apple products, those are in the 60s or 70s as an NPS, and to have a 90 plus for something that inherently people don't want to go to their doctors, right? Because every time they go, maybe they'll get a test that they don't want or things like that. So that's pretty incredible results. We've talked about COVID a lot on this podcast. This is the reason we even started the podcast to “raise the line”, increase healthcare capacity, and strengthen the healthcare system during COVID and beyond. We would love to hear how… you've been working on VillageMD for six and a half years before COVID hit, COVID hit in March in a big way here in the US. How has it affected VillageMD's business positively or negatively. And what are some of the lasting changes do you think COVID will have on not only VillageMD, but the healthcare system as a whole?

TIM BARRY:

When I think about the threat of COVID, frankly, come into the U.S. shores, I'm incredibly grateful to our Chief Medical Officer, Dr. Clive Fields, who during the span of one of our executive meetings said, "Hey, let's stop the presses. We need to sort of spend several hours planning and getting prepared for the thought or threat of this pandemic coming to the U.S. and what's going to happen when it gets into the communities where we have clinics." And so to his credit and the credit of the rest of the leadership team, I think we got out in front of it a lot earlier than many others.

And part of it was a strategy that said that as a primary care provider in the community, we feel we have an obligation to keep our doors open, right? Just because COVID's hit, it doesn't mean COPD magically goes away, right? That our patients still need care, they still need us, and we've got to make sure that we're creating a level of accessibility for them so that they can be seen and be seen appropriately in the way that drives the best outcome for them. Right? From that standpoint, we got out in front of it and we were able to keep the vast majority of our clinics open during a time where many others were just sort of shutting their doors to say, "Okay, let's just move to a pure Telehealth model." And while that's all well and good -- and as an industry, I'm quite proud of how people responded during this event -- but there's a reality that still many patients need to be seen physically. Right?

So, we, like many others, we did see a significant reduction in the number of patients who came to see us. Our reduction was about 50% less than what most others did and that's because frankly, I think we had the benefit of six weeks of planning. In the February timeframe, we were planning for this eventual event that sort of manifested itself in the mid-March timeframe. So we had this ability to kind of get in front of it. We did see a reduction, that was negative to us. We did see, frankly, as you can imagine as things got a little more comfortable, more hospitals were admitting folks -- and maybe not appropriately -- but they were admitting people to the hospital. They were also sort of suggesting there were COVID symptoms, even though there weren't COVID tests being done. And so there was some negative impacts associated with that, both for the patients, as well as for us as an organization.

The really positive things though, I would tell you is that the level of engagement that we have with patients via Telehealth has significantly improved. And not necessarily in the way that I think many have described it in the past. A lot of folks are thinking about Telehealth just from the standpoint of "How do I create an access point where someone doesn't have to come into the clinic but they can be seen." That's an obvious use case that everyone can apply. And frankly, I mean, it requires a little bit of work, but it doesn't require that much for that to happen. The more important thing we thought was the way that we care for our chronic patients. And so, for us, it's allowed us to increase the number of touch points that we have with our chronic patients and see them on a more frequent basis. So that if you're looking to titrate medication, which is a common thing for chronic patients, we're able to do that leveraging Telehealth in ways that maybe we hadn't historically.

I'm sure many people say Telehealth will be a key part of the U.S. health care system on a go forward basis. I agree. I'd argue COVID is just a little bit of an accelerant toward that versus a wholesale shift toward it. It was naturally occurring anyway, and so it was a bit of an accelerant. I think that remote patient monitoring is another way in terms of the ability for COPD, CHF patients, as an example, to kind of correspond with you as the provider on a regular basis. We're seeing that happen as well. But again, that was sort of, it was bound to happen anyway. So maybe it accelerated it by a year or so, but in a healthcare industry that is notorious for taking 20 or 30 years to adopt innovation and change, I think that we're seeing that it'll accelerate some of this by a little bit.

I do think a potential negative with Telehealth, just to be blunt with you, Shiv, is that today as an American public, we're not always the most discerning around knowing what is good health care and what's not. And there've been a lot of forces that have tried to prevent quality data from being brought to bear into the American public, right? There's contracts between payers and hospital systems that don't even allow for some of that quality data to be shared broadly with the public. I love what's happening, frankly, with the current CMS orientation towards promoting a level of transparency, it's something that we need as an American public. And I think we need it, especially in the context of more advanced technology being brought to bear, right?

So that if option A for you as a sick individual is, "Do I just see someone who can see me today, even though they know nothing about me and my illness, or I can see someone who actually knows something about me and my history and more about what's going on with me as a person?" I think everyone would agree they'd rather have the latter versus the former scenario. We've got to find ways that this advanced technology that's being rolled out doesn't further fragment our healthcare system, but finds a way to weave it thoughtfully to drive a better outcome for patients. And everyone, frankly -- I'm a huge proponent of this -- as healthcare providers, we should all be measured on the outcomes that we provide. People shouldn't stand back and hide from outcomes. They should be proudly displayed. And if you're not doing great, then you better turn it around. Right?

SHIV GAGLANI:

Totally. Couldn't agree more. And the fragmentation is something that is a very interesting point you brought up because on some end, it's really great. We had Eric Topol on this podcast and he wrote the book, The Patient Will See You Now, which I'm sure you've seen or read. And it's about the consumerization of healthcare, which we're seeing massive news announcements this year especially. They were planned before COVID, but more of them are coming out because of COVID. Ranging from Walmart really scaling out their health clinics and making partnerships, trying to make a $40 adult primary care appointment versus the national average of $106. And so I know you guys made a major announcement with Walgreens, and we've had the opportunity at Osmosis to get to meet a number of those folks like Giovanni, Matt and Greg.

And actually seven years ago, I was at TEDMED and did something called the Smartphone physical, which was a harbinger for a lot of remote patient monitoring that was very popular. And I met a gentleman there at Walgreens named Igor, who I'm sure you know him too. And I'm being very impressed with how innovative they seem to be as an org. So when I saw that partnership with VillageMD, I wasn't surprised, but if you could give us some context on what you're hoping to achieve in the coming years with Walgreens and maybe any other partnerships that you have that you're willing to share.

TIM BARRY:

Thank you for asking about that. I will say that the Walgreens team has been, so far, just an absolute joy to work with. And part of what excites us about the nature of the relationship, frankly, it goes back to one of my opening comments Shiv, which is that "If we're going to change what happens in the U.S. healthcare system, we have to do a better job of taking care of people who have chronic disease." And though I'll continue to argue ‘til the day I die that the primary care doctor is most important in terms of driving to a better outcome for patients who have chronic disease, the next most important is the pharmacist, right? And so medication adherence, medication education, in some ways we say them as if they're simple and yet, to know and understand these patients is to know how unbelievably complex that formula is in the context of the U.S. healthcare system, both from a reimbursement standpoint, a cost standpoint, an access standpoint, how it makes you feel, contra indications of medications.

And so the reality is bringing the primary care doctor and the pharmacist into a common location, physically through these clinics, but also doing it in a way that's done digitally so that in the context of our care model -- I talked about how we use Telehealth for patients that have chronic disease -- they need their pharmacist engaged. Just period, end of sentence. And I don't think any one of the listeners would disagree, and I know that the thousands of doctors that we work with and many others would also agree. And so why don't we have that in the US healthcare system today, right? Why is that missing? And the reality is it shouldn't be.

And so what we're trying to do through the context of this partnership is make it happen, and make it happen in a really easy, convenient, accessible location. And these are not your kind of typical minute clinic, walk-in clinics, where you got to walk past the greeting card aisle, and in between the contact solution and the toothpaste is a doctor or nurse practitioner in a 200-square-foot room. These are 3000-square-feet, nine exam rooms, two overflow Telehealth rooms. And so it's a really incredible physical experience, but there's also a digital component to the nature of our partnership that I think both parties are just really excited about.

SHIV GAGLANI:

That's incredible. Congratulations again on that scale, it'd be great to see, given how many people live near Walgreens, how you all scale that. I know we're coming up on time so I want to be respectful of your time...

TIM BARRY:

One thing I would say Shiv, just on that front by the way is the doctors that are working in these clinics, the feedback that we're getting is just very strong, right? It was something that as we rolled this innovation out, I think one of the questions that lots of people had was, "Is this just another doc in a box, are these a walk-in clinic that doesn't feel very good?" There's a level of privacy, there's a level of professionalism, there's a level of privilege associated both from a patient standpoint, as well as from a physician standpoint, that makes it a really nice experience. And based upon the net promoter scores I talked about, people are actually quite thrilled about being able to have their doctor, in their community, and the docs are quite thrilled about having these. Frankly, they're quite nice. These are very nice clinics for them to practice in. It's also convenient for them, and their patients seem to be happier because they didn't have to park in a garage and walk 600 yards to see them. So it's ending up being a very nice experience for both docs and patients.

SHIV GAGLANI:

That's great. I mean, we all know about the statistics around burnout among our clinicians and how that may even be exacerbated because of COVID. So it's great to hear that net promoter scores of the providers are increasing too. One of the last questions I had was just basically, given that we have so many healthcare professionals, current and future, in our audience at Osmosis, what advice would you give to somebody right now considering a career in healthcare?

TIM BARRY:

I thought about this question a lot, right? And there's two things that I would just strongly... they're recommendations and they're frankly, pleas. And first is dive into the data. There's so much data that is out there, and available, and anyone who works in healthcare, the data is at your fingertips. And just bring a level of intellectual curiosity and hunger around the data. And for the docs who are out there, demand the data, and get the data, and really understand what's happening with your patients and patient populations. So that's the first thing, right? You don't have to become a data scientist, but really, analytically, let's make sure we're generating insight as both individuals and then continually as a system.

The second thing I'd say is -- and this is sort of tied to the first one – is that the fee for service healthcare system that we're living in is the wrong system. It is a 100% the wrong system, no one in their right mind will argue and say, it's a good system, right? We spend two and a half times that of other industrialized nations on healthcare, but yet we have horrible and worse outcomes. It's great healthcare if you can really afford it. But for the vast majority of Americans, we're failing as a healthcare system. And so I think everyone who can rush into and demand a change in their organizations, that we're not proliferating a fee for service healthcare system, that rewards people when they get more hospitalizations, that's the wrong way to be thinking about our healthcare system. And so if you're inside of an organization that's focused on fee for service, I would demand change. If you're not seeing change, find organizations who are on the right side of change, because we're doing the right thing for patients, we're doing the right thing for the healthcare system.

Personally, I think this is an unbelievable opportunity for anyone who's 22 or someone who's 68, for us to spend the rest of our careers, for those of us who work in healthcare, really pushing and promoting a better healthcare system, and one that's focused on value. I use the word risk a fair amount, but risk and value are interchangeable because all of the risk models in contracting today are tied to quality of care. And so data and value, I think, are the places where I would encourage everyone to, frankly, rush to.

SHIV GAGLANI:

That's fantastic feedback and really appreciate you being able to share that. I really encourage our audience to look at VillageMD as an innovative model, because many of our audience will be going into primary care. We've had several of the leaders behind the DO associations and MD associations, and they all speak to the need of primary care. And what you're doing is certainly innovative and hopefully will be a model for all of them to look into.

TIM BARRY:

Anyone who's thinking about primary care, we would love to talk with them. That's just short reality of the world. This is a growing movement in the healthcare system, and I view my job, frankly, Shiv, as the CEO of the company as a non-clinician, just to remove every barrier I can to allow the docs to be the ones who drive this system for the kind of results that we're talking about.

SHIV GAGLANI:

That's fantastic. So with that, Tim, thanks for taking time out of your busy schedule to be with us today.

TIM BARRY:

Really appreciate it. And Shiv, again, congratulations on just an incredible amount of success through Osmosis.

SHIV GAGLANI:

Really appreciate that. And with that, I'm Shiv Gaglani, thanks to our audience for checking out today's show and remember to do your part to flatten the curve and raise line since we're all in this together.

OUTRO:

For more information on how you can help raise the line and flatten the curve, go to osmosis.org/COVID-19. If you like this podcast, please share it on your social channels. You can also subscribe to the series and check out all of our podcasts at osmosis.org/raisethelinepodcast.