First 2021 post in our series of B2B thought leadership interviews with visionary digital health entrepreneurs working to improve care of chronic conditions. In keeping with our mission, we particularly care about chronic immunoinflammatory disorders (CIIDs), e.g., autoimmune and autoinflammatory diseases. Bonnie and Ellen were happy to finally interview digital health thought leader and busy CEO of Oshi Health, Sam Holliday. Sam has been a digital health pioneer since 2013. He was a senior executive at Greenway Health and Everyday Health. More recently, he was COO of Cecelia Health, a digital chronic disease management company, then CEO of Emelie Scientific, a clinical trials recruitment platform. All before taking the helm at Oshi Health , a virtual-first GI care clinic revolutionizing management of digestive health conditions through a technology-enabled, patient-centered, value-based care delivery model. He brings his deep perspective to the accelerating digital health landscape and Oshi Health’s place in it.
Ellen: The COVID-19 pandemic drove an unprecedented increase in telemedicine and remote patient monitoring. What’s your view on the likely long-term post-COVID changes to digital healthcare and the opportunities it offers Oshi Health?
Accelerated traction for telehealth beyond urgent care
Sam: Historically, meaning pre-pandemic, telehealth was gaining traction around urgent care scenarios where an immediate response was essential. It didn’t matter so much which physician you saw, as long as you could get a trustworthy one quickly. So companies in the early wave of telehealth built around those needs. Yet there were a lot of arguments before March, 2020, that telehealth wouldn’t work for other types of care. Also, there were regulatory and payment barriers, many of which still exist. But I think one of the biggest barriers was inertia, believing that telehealth couldn’t deliver the same quality of care.
The pandemic response forced all healthcare stakeholders to adopt, pay for and use telehealth digital solutions. Out of necessity, the counter-arguments, regulatory and payment barriers melted away. Therefore, most care providers and patients tried it, and largely found it could deliver a quality care experience.
Moreover, people found they LIKED many aspects of not going to in-person care. Like not having to travel, not having to park, not having to sit in a waiting room. COVID really forced us to try out telemedicine at scale. That made people realize that most of those arguments against telehealth were pretty artificial. Through direct experience, many people realized care delivery, the patient and provider experience were as good, even better, done virtually.
Like virtual work, telehealth is here to stay
Sam: I think telehealth is here to stay. Just as the pandemic forced so many people to work from home, employers are going to continue work from home as part of their mix going forward. If more of life is virtual, at least as a regular part of things, then telehealth and virtual care fits well, too.
Virtual care now has much clearer demand plus more openness to reimbursement by payers and employers. Obviously a lot of capital has poured into scaling virtual care companies and enabling technologies. We’re seeing big mergers, too. All this has fueled more investments into care at home in general. Look beyond virtual care and telehealth. Home delivery of prescriptions has taken off in a big way. More at-home diagnostics are available than ever before. There are more home visit providers available. All these capabilities mean going to practices in person will become a smaller piece of the healthcare experience every year.
First virtual primary care, then specialties like GI
Sam: I think we’ll see huge growth in virtual primary care in the coming years. We’re seeing a lot of companies step into it. It makes perfect sense for primary to lead with virtual. Their PCPs can schedule in-person visits if they are truly needed to follow up on issues identified in telehealth visits. The next wave, which we are part of at Oshi Health, is virtualization of specialty care, like our focus on GI. I believe virtualization of specialty care will advance in the wake of the wave of primary care telehealth adoption. That is, once people try it and like it, as they did with the COVID-fueled wave of telehealth.
Will telehealth keep all its COVID-19 gains?
Bonnie: Some of the conversations around JP Morgan 2021 expressed a contrarian view. When real visits come back, there will be more telehealth than before COVID, but not as much as we might like or expect. What’s your thinking around that perspective?
Sam: I’m not surprised to hear that people believe that. I’ve heard it in my conversations with gastroenterologists, the specialty we focus on. Many of them believe they are going to snap back to in-person care. Some of that is driven by the fee-for-service (FFS) machine, an installed base that had been running smoothly, or at least predictably, for a long time. It’s tough for any established medical practice to go virtual-first while running a profitable business. It’s particularly hard to make that pivot for GI practices. These, as procedure-focused businesses, have a big anchor in fee-for-service, visit-based medicine.
Digital primary care as the patient journey front door
Bonnie: New primary care delivery models such as Firefly, Maven, 98point6, Teladoc, and others position themselves as digital front doors for patient care. Does this change your view of the market and Oshi Healthi’s strategy? That is, if digital front doors start in primary rather than specialty care?
Primary care creates demand for specialty care
Sam: It doesn’t really change our strategy. Primary care is often the beginning of the patient journey for someone experiencing any symptoms, including GI symptoms. I think patients starting with virtual primary care will be MORE likely to value virtual-first providers when they need specialty care. Digital primary care creates demand for specialty care to move towards digital as well. Like Oshi Health. We’re building a virtual GI care experience from the ground up. We want referrals from virtual primary care to our virtual GI care and, of course, from us back to them.
Virtual primary care as the doorway into patient-first digital health ecosystem
Sam: As some in the industry have noted, many existing digital health companies are pivoting into virtual primary care. Companies with established employer-sponsored businesses, like telehealth urgent care, navigation services or on-site clinics, are repositioning into virtual primary care. As you mentioned, there is also a growing group of virtual care companies built for specific populations. Examples include women’s health (Maven, Tia) or Folxhealth, the LGTBQ+ clinic. They offer tailored primary care experiences built intentionally around the needs of target populations.
Furthermore, traditional telehealth and chronic care management companies are expanding which conditions they support. They are enhancing telehealth offerings to cover more of their customers’ populations. Some are building new solutions, others use acquisitions to build broader platforms. Traditional diabetes and weight-loss focused companies are adding adjacent offerings like mental health, heart health, even MSK (musculoskeletal). There are companies, like us, focused on particular specialties.
Our hope is that all these companies will become referral partners for Oshi Health and our virtual GI clinic. Digestive conditions are typically complex to diagnose and manage. Thus, we believe the best outcomes at the most efficient cost can be achieved by providers that see GI patients within an integrated care team approach.
Emerging hybrid models: virtual care + in-person visits
Bonnie: Some of the other buzz at JP Morgan was around hybrid models, combinations of virtual care with brick and mortar or monthly fee programs that also include services covered by insurance. Examples include One Medical and on the functional side, Parsley Health. Where do you see Oshi Health sitting among hybrid models?
All models have hybrid elements, even colonoscopy
Sam: I think in each condition area, we can tease apart needs that can be met virtually from those that can be virtual much of the time, but some virtual encounters lead to in-person visits. I mean, we’re never going to do virtual colonoscopies. Well, maybe I shouldn’t say that because there is a lot of interesting technology being developed: capsule endoscopy and colonoscopy, for example. One of our gastroenterologists did the first-ever pill endoscopy at home, monitoring a patient on video, rather like we are now, reviewing the images through his computer. It’s pretty amazing and potentially disruptive technology, but for now colonoscopies are still an in-person procedure.
So, I think each specialty will have to sort care procedures into these buckets. Then design a better, more efficient experience for patient-consumers when they do need in-person care. Given our approach at Oshi Health, we need to know where to route patients in the local markets where we provide care. So we’re building up more partnerships with endoscopy centers and local gastroenterologists. Because if we’re handling remote monitoring, coaching, diet and psychology support, even lower-acuity GI needs, through telehealth and then find the patient does need a procedure, we can immediately refer them.
Partnering with local practices, avoiding redundant visits
Sam: Importantly, patients won’t have to go through repeat in-person workups. That is a challenge for us today because practice partners want to do their own workups. From their perspective, they ask, “Who is Oshi Health?” Can they trust we’ve correctly determined the need for this procedure? Even if we hand them the patient record seamlessly, because of liability, fee-for-service and other reasons, they may want to do their own in-person consultation before the patient goes to procedure. Even though that’s inefficient for the patient.
It’s also inefficient from a payment perspective, but it’s also the reality of trust and liability. So we’re working to make it more seamless. The more we can partner with brick-and-mortar providers in local markets over time, the more seamless that can be. We’ll talk about value-based care later, but I think over time we want to create direct contract relationships in these markets with endoscopy centers and GI practices.
The future of mass colorectal cancer screening in a digital health landscape
Ellen: Before we leave the subject of colonoscopy, Sam, what do you think is the future of mass colorectal cancer screening? Is there is a looming disruption, a black swan, as Dr. Kosinski (Sonar MD) mentioned to us? The technologies you just referred to, pill colonoscopy and remote imaging, means that cancer screening doesn’t always have to be done by scopes.
Sam: There’s a book, Scope Forward, which talks about this. From an economic perspective, gastroenterology has been procedure-driven. However, alternatives to colonoscopy are available today (and new ones being developed) for certain patients. Here’s the challenge. If you are well, the new US colon cancer screening guidelines recommend starting at age 45. We want everybody to be screened. There’s no doubt about that. How do we do it in the most cost-efficient way? One that takes the patient’s perspective into account? How do we enable shared decision-making?
Helping patients choose between colonoscopy and alternative screening modalities
Today for screening, your PCP refers you to a gastroenterologist or an endoscopy center. Do most PCPs counsel patients about alternatives like FIT (fecal immunochemical testing) or at-home versions like Cologuard? Probably not, because the economic incentives are to perform the gold standard test by default. Colonoscopy is the gold standard for good reason. It IS the most accurate at detecting early-stage bowel cancer. But what if your PCP said to you, “We’ve assessed you as low risk, here are alternatives that you could do at home or at a local lab.”? I think there’s going to be increasing movement towards those other modalities.
In our conversations with payers, they are focused on this, but they also realize someone needs to help the patient navigate through the choices. Another cost aspect is that a colonoscopy in an academic medical center hospital costs significantly more than that same colonoscopy in an outpatient center. For lower-risk colorectal cancer screening, if you’re paying for that procedure, where do you want them to go? If quality is similar, why not go to the outpatient center?
Sharing the patient perspective, two anecdotes
Sam: Just to share, I had a personal experience where the decision was presented as my call. Here are your choices. You can come to our outpatient clinic and here are these inconvenient times that are available or you can go to the hospital and we’ll get you in exactly at the time you want. It was a four times cost difference between the two options, which they did not mention. They framed the choice to steer me to the more expensive and profitable procedure. Let’s not forget, hospitals are businesses. And I have great employer-sponsored coverage and was not paying for the procedure, so, obviously, you know where I went, but I’ll get off my soap box.
Ellen: A soap box I happen to share. In my case it was paying a $1000 co-pay for my second colonoscopy at the same endoscopy center because they chose full anesthesia rather than sedation. I was happy with sedation the first time, but no one gave me a choice. I just got a big unexpected bill because my payer didn’t cover full anesthesia. I’m sure there were financial incentives in play. It soured me on that practice and on the procedure. This sort of thing just annoys patients to no benefit.
Part 2: Coordinating primary with specialty care, redesigning virtual GI care around patients
Contact Dr Bonnie 360
We approach these interviews, as we do all our work, from two different multi-lens perspectives:
- DrBonnie360: clinical dentist, Wall Street analyst, patient advocate, and digital health consultant.
- Ellen M Martin: evolutionary life science, finance & investor relations, marketing, communications and writing/editing.
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