"Competition in the market is forcing more collaboration between healthcare providers and payers"

Q. Tell us about Wellframe and how you got funding for the company?

Jacob: Wellframe is a company that is partnering with healthcare organizations to drive digital transformation of experiences for members and patients. Primarily, we work with health plans and help them modernize the delivery of services and their members’ experiences. We started by digitally modernizing clinical support services for high-risk members and have expanded to help plans drive toward a more integrated and holistic service model. Think: a concierge or advocacy type of service that really transforms members’ experiences and positions plans to help people better understand their health and how best to navigate the healthcare system.

The company was founded in late 2011-early 2012 by a diverse group – an Epidemiologist by training together with a Primary Care Physician, a Computer Scientist, and a Data Scientist. What really drove us was the huge gap between the day-to-day needs of people — especially those living with chronic conditions or multiple chronic conditions — and all that people had to do to manage their health at home. We noted the pressure people were under to make good decisions about the levels of care, their increased stress, isolation and uncertainty and saw a well-endowed health care system struggling to comprehend how to help them — conveniently and on a bigger scale. At that time, some technology enablers – mobile phones and the Machine Learning techniques — were relatively new but they presented huge opportunities to better organize the resources of the health care system around the needs of people outside of the four walls of care delivery, the home and the community.

Motivated to make an impact, we brought our collective skills and expertise together to bridge that gap with technology while focusing on extending relationships and helping people feel supported and cared for during periods of need.

Q. Let’s talk about the macro-environment. What has the pandemic meant for your company and your consumers? How have the past 18 months been for the competitive landscape you operate in?

Jacob: This is a huge topic deserving time but here are a few highlights. Pre-COVID, there were some pretty significant temporal trends governing the market and consumer that were driving demand for what we were doing. Consumers looked to access care and support through digital channels — the mobile — while every other part of life started to take hold for large healthcare organizations. Those who purchased insurance or care, employers or state agencies, expected more from health plans — a more modern service model and experience for their constituents – and that increased the urgency for plans that could enable investments to digitally modernize their services.

Covid had a far-reaching impact — it bared some of the challenges inherent to traditional modes of communication and engagement. One was the absence of ways to communicate policy changes, offer support, guide people or even recommend action to them. These deficiencies became more glaring in light of minimal investment in modern channels to reach a lot of people.

Then, there was the acceleration of Telemedicine. Here, incentives were aligned among consumers or patients, providers, health plans and regulators. That was kind of a perfect storm to massively accelerate its adoption. It challenged a lot of the traditional paradigms that had kept virtual channels as a bit of a sidecar to the health care system. Not a lot of people get care or support through the digital media. And a lot of fairly risk-averse health care organizations had been pretty skeptical about value here. But Telemedicine elevated the stature of some of the things that we were doing. It hit the priority list of more and more health plans, leadership boards and expedited some expansions with our customers. It definitely put us on the radar of more and more plans that recognized that if now wasn’t the time to invest here, then, I don’t know when that could be.

Q. Who pays for your technology and services? Your clients are health plans, so how do they justify an investment in a platform like yours and by extension, any other digital health plan?

Jacob: Our target customer is any organization that’s holding some sort of risk around outcomes and investing resources in supporting and engaging people to improve outcomes to mitigate that risk. Historically, that’s largely been health plans. So, that constitutes the majority of our customers, today.

But the growing prevalence of risk-bearing providers that are hitting scale and investing in these types of services are all relevant for us, as well. So, the kind of business case or value for them is they’re spending money on services, today, that are trying to support and engage their members largely through telephonic interaction and home visits, etc. And the mobile presents a more intimate but scalable channel through which to extend these relationships of therapeutic support, very high touch and convenient manner as to reach more people in need. The aim is to be effective in delivery of services and support to enable people to manage their health at home and be aware of the choices they make about their care. That ultimately leads to higher quality and lower cost and a more competitive plan product. So, our motives are aligned with our health plan customers to deliver a better member experience, a more competitively priced plan product, innovate and differentiate in a market where there’s a growing amount of disruption from startup health plans or a third-party service provider and the expectations around how plans invest to engage and support their members.

We provide the technology and partner-up to catalyze modernization and transformation of these services to help our customers compete and meet their members and stakeholders’ needs.

Q. Messages and outreach campaigns from the provider and health plans both target the same thing — better health behavior and efficient management of chronic conditions. Who do I engage with first? What are you seeing and how does that dynamic play out in the way you position your platform with your services?

Jacob: We see that as an exciting opportunity on the horizon. As we’ve evolved from digitally modernizing care management to helping our customers deliver more holistic support, our first objective was helping break down some of the silos within the health plans to offer more integrated services, holistic support and focus on the needs of the member, first.

From there, we see considerable opportunities to help our customers facilitate greater collaboration between plan and provider as it relates to the provision of support. For the individual patient, remember, it’s not that I’m talking to the plan but I’m talking to the provider and there’s no crosstalk in between. So, digital channels and workflows that can be built around those present an exciting opportunity to facilitate greater collaboration and crosstalk between plan and provider.

That goes along with a growing trend toward vertical integration, value-based care arrangements, more collaboration from a financing and a risk-sharing perspective that creates incentives for this to happen across geographies and markets. We appreciate that.

 There’s no silver bullet and it’s not easy, but we have the building blocks — active strategies with all our plan partners around how to drive more provider collaboration and move more of what we’re doing closer to point of care — to enable this.

Q. Historically, providers and payers haven’t been great at collaboration. When will that change? Where do the opportunity areas to drive these collaborations and create value for the consumer/member/patients?

Jacob: I think that competition in the market will force more collaboration. Large plans that are vertically integrating with providers very aggressively, startup health plans engaging in joint ventures or close collaborations with provider systems are signs that your plan products are getting out there. They will have tight collaboration with providers and there will be benefits to consumers/members, and benefits from an efficiency perspective that can be derived from there. 

That will force everybody to rethink some of the traditional paradigms and relationships that may have been more contentious, historically. Now, we’ll have to figure out how to work collaboratively to deliver the best possible solutions to consumers at the highest value and the best experience. People that aren’t thinking that way will struggle to succeed and compete because the market will pass them by.

Q. Where does a firm like yours play in that equation to bring about this collaboration — Will you straddle both sectors? Will you be working with providers eventually and perhaps integrate both?

Jacob: We also work with providers and have been deployed in the provider context for over 7 years. There are many plans – some provider-owned and some they have partnered or have some sort of value-based care relationship with — that are actively deploying. These offer great learning, proof points and insights into how that model can be scaled across payment arrangements, geographies, lines of business and types of plans.

There are opportunities to work directly with providers that take the risk and hit a scale where they start to invest in their own services. There’re also the regulations around data interoperability and integration that are enabling consumers to share their data seamlessly and creating forcing functions for organizations to open up APIs to allow this data to flow.

So, the idea that we’d help facilitate the exchange of clinical and claims data on behalf of an individual that is both, a patient, and a member, in the coming years seems more possible now than five years ago. The government regulations are encouraging of this type of interoperability, and it plays into the strategy of our customers and what we’re doing, well.

Q. –Let’s talk about the competitive landscape. There are providers who’re doing what you do. Perhaps in very fragmented ways. There are many innovative solution providers, too. But the clients are struggling to make informed choices. On the flip side, the startups, in a bid to stand out are adopting different strategies to stay relevant. What’s your take from the perspective of either increasing surface area or enhancing your impact and going deeper or broader?

Jacob: There’s been a massive influx of investment capital into this space, which is enabling thousands of blossoms to bloom. This is catalyzing innovation in exciting ways to open new care models, solutions and offer a plethora of options to incumbents in terms of either disruptive or enabling forces.

The challenge with that is you run the risk of actually adding to fragmentation as opposed to countering it. There’re lots of point solutions that, for example, offer virtual care for diabetes, behavioral health, maternity and cardiac, which is great! But a lot of the people that have serious need don’t have one condition. They have four, five or six. So, how do you manage that?

We see that health plans are in a pretty unique position where they manage a network of all types of providers. And they capture data that, while not to the clinical depth, looks holistically across the care people are getting, often among multiple providers. And there’s an opportunity for health plans to facilitate integrations that allow people to access the resources they seek and help them navigate to the ones optimal for them.

We’re partnering with plans to help them establish a proactive relationship with their members by identifying their needs and helping them access high-value resources. This could imply finding the right person in customer service or care management on the planet, get them the right provider and network — whether that’s brick and mortar or virtual care – or zero-in on the right solution or third-party benefit that’s offered to them through the plan or employer.

If the plans invest in establishing more modern relationships with members, organize and curate this plethora of solutions, help evaluate the impact of these solutions and then, optimize their routing to connect people with what they seek, then, there’s tremendous opportunity.

What we’re doing can be meaningful in enabling that strategy. And then, as it relates to the provider-side of things, in a world where payments are evolving and risk is shifting, there’s certainly ambiguity in some situations about who’s responsible for what. Whereas historically, the risk was that a lot of people would have fallen between in the cracks, with neither their provider nor the plan paying attention to them, today, there may be situations where they’re being paid too much attention. That’s not ideal but it’s a swing in the right direction. More collaboration between plan and provider can help work that out.

There’s no simple solution – technology isn’t the only one — but there’s an earnest effort among our customers to work collaboratively between plan and provider to sort that out, increase communication and collaboration. That’s not easy nor simple but will pay off over the coming years.

Q. With regard to health care management and chronic conditions, you mention the comorbidities that the most intense cases represent. You’ve also talked about expanding into clinical areas. Are you heading toward becoming a one-stop shop as a company?

Jacob: That’s a critical part of our foundation. For instance, I’ll start with a condition and then, I’ll recognize existence of multiple conditions, and so, I’ll stack these – conditions and specific solutions — and try to cobble them together.

We purpose-built our platform from the start to enable holistic clinical support for people with multimorbidity and clinical complexity across both physical and behavioral health domains, recognizing that it’s the person managing multiple conditions and social drivers of health that tends to be the highest risk and among those, who are targeted for care management programs.

All our programs are modular. So, if there’s an individual with complicated Type 2 Diabetes, stage 2 heart failure and mild depression, they will need help with nutrition and finding a doctor. We can bring those modules together to offer holistic support to that individual in the context of an integrated care team that would include a nurse, a coach, a social worker, an expert peer, and a customer service representative. That’s really been the crux of our strategy from the start. It’s enabled us to help our customers target some of the most complex members that need nurse-led clinical services.

While many of the interventions that are framing themselves as care management are non-clinical coaching services, which can be incredibly valuable, there’s a different scope in terms of what they’re able to tackle and who they’re able to help. For health plans, for instance, while there’s been varying levels of appetite to in-source or out-source some of the less clinically intensive services, most plans have continued to own nurse-led care and case management throughout. 

Q. When it comes to the tech landscape, there are the Big Tech firms — some larger healthcare-focused tech firms and the digital health startups – with more emerging every day. What’s your advice to the newcomers and the VCs who like to invest in them?

Jacob: There’s a lot of money coming into this space. So, the concern or the skepticism is that we’re over-funding ahead of the market. However, there’s also evidence that the market is being disruptive and there are huge pockets of need and opportunity that are conducive to significant change. That change is probably not going to be driven entirely by incumbents. It’s going to be delivered through disruptive forces that push incumbents to change or companies like us that are enabling incumbents to modernize more quickly than they’d be able to do on their own. Given the huge need for improvement in the way care is delivered — the convenience, quality, accessibility, and cost — it’s hard to say that we’re putting too much money into the space.

In fact, even if some of this money is like “wasted,” it helps accelerate the improvements in care and helps expedite better outcomes, and improve quality of lives. There’s a long way to go to make care work for people in the way we all imagine it would.

So, money is coming into the space for a reason and some people will be successful. But that’s the venture model. For entrepreneurs coming in, I’d say, you really need to be passionate about the impact you’re making because nothing happens that quickly in healthcare, it does require significant persistence. But now is a good time to be part of that change. Things possible today wouldn’t have been imaginable 10 years ago.

Q. A couple of the mature big tech firms with deep pockets have recently scaled back their investments in the healthcare market. What does it mean for the appetite in the marketplace for disruptive technology-led innovation models? Is that just a blip or is there a broader message?

Jacob: It’s such a big space and there are so many opportunities that the large tech and retail players will continue to invest here. The idea that their pulling-back signals failure isn’t correct. Large organizations must be encouraged to invest, innovate, and take risks. When one does that, one takes risks to try do something new, and it doesn’t always work exactly the way one thought. So, you must pivot and adjust and its laudable what these players are doing that. I’d be very reticent to criticize such organizations for seeming to pull back or change their strategy. If you’re a startup, you’ll do that 10 times over before you hit your stride. So, I applaud them doing it to make an impact in such an important space.

Between the healthcare incumbents who have the appetite to improve and the commercial pressure that’s pushing the disruptive large tech and retail players and the venture- and private equity-backed startups, hopefully, all of them will meet in the middle and sort themselves out. That’s good for consumers and we’re privileged to be a part of that, but it doesn’t mean you’ll always win. If you can help move the ball forward and make things better for people, then that’s a goal worth working toward.

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Disclaimer: This Q&A has been derived from the podcast transcript and has been edited for readability and clarity