"Besides the act of healing, everything else should be automated away in healthcare."

Q. Tell us a little about yourself and how you started Buoy Health.

Andrew: I am a doctor by training, and I started Buoy back when I was in medical school at Harvard. I was going to be a Neurosurgeon. Then, on my last rotation in the ER at MGH in Boston, I saw these patients who were Google-ing their symptoms or reading something online and just making a bad guess as to what kind of care they should be seeking. That led to a lot of bad outcomes. Here’s a real story — I saw a woman with a jammed finger, followed by a man who had ulcer in his foot from a history of poorly controlled diabetes that’d also become infected. We had to amputate it that night. When I told the lady she was fine to go home, she pulled out these printouts from the internet telling me why she thought the finger was broken and why she’d been waiting in the E.R. for six hours! I told the next patient, had he come earlier to the hospital, we could have saved his leg. He pulled out sheets of information from WebMD telling me why he had waited and didn’t think we should amputate.

Unfortunately, my dad got sick; he had a mini stroke but didn’t go the doctor. I have two younger sisters who are both doctors, and when I asked him why he didn’t call any of us for help especially since he had access to unlimited free telemedicine and he had in fact, paid for all this, albeit in a different way, he said – “you guys are working” and so, he Google-ed it. I don’t trust what I find at Google, so, for me that was just kind of this emotional tipping point.

Three months after graduating, I took a sabbatical from school and became obsessed with this idea that consumer-driven healthcare, shopping, and healthcare wasn’t real. It wasn’t possible because it’s predicated on this idea that a consumer or a patient or a member had to be clinically trained to figure out what the ailment was, what kind of treatment they’d have to pick, what doctor they should see to get the treatment, and where to get the outcome that they’re looking for. That is not part of our educational system.

So, we decided to build a product that could solve that knowledge gap, help people figure out what’s going on with their bodies, understand what treatment will lead to the right outcome for them. So, that’s the journey we’ve been on.

Q. You’re known as a company that is in the AI-enabled digital healthcare space. What’s your definition of AI and how did you apply that to starting Buoy Health and running it?

Andrew: AI in the most basic sense to me is the ability for a non-human entity — in this case, obviously a computer — to deduce something as if they were a sentient, intelligent being. So, all the definitions you threw out there that fall under that very broad umbrella. I think it’s an often-used buzzword today for statistics, data science, and the ability to turn data into insights. It’s as simple as that and an over-hyped, over-used term.

Our application of AI is as simple as communicating with a computer program that communicated back to you in a way that a clinician would. The net result of that communication which is like texting someone is that Buoy actually tells you what’s most likely going on. As I mentioned before, it shares what the best possible treatment is for what’s going on, helps you make a really educated self-diagnosis, enables self-triage, and self-navigation into the right care at the right time.

Q. So you use it primarily for triaging based on inputs that patients or consumers may put into the tool and match it up with data on the back end that throws up a set of potential recommendations or as used by a physician? I imagine it’s not used directly by a consumer.

Andrew: No, it’s used by the consumer. I very purposely did not say that we diagnose. We’re not trying to replace a doctor but we’re really replacing what today, is a very rudimentary system for narrowing down what’s going on with you. So, we have a search engine that narrows it down for a whole host of different things.

So, in this situation, you’re answering questions thrown at you by a computer program in real-time. The entire engagement takes 2-4 minutes at the end of which thousands of possible questions are getting re-ranked. Then, we show people three possible matches. They get to see the reasons for and against each match, which then helps them conclude and decide on the most logical match for them. Based on that their clinical situation, benefit design, insurance information, and if we’re working with that, then, their particular employer or payer – all these helps us show them the services that are in-network for them or subsidized by their payer or employer. And thus, we get them into that.

Q. That brings us to the fundamentals of the economic model of the business. The payer could be either the employer or a commercial or a Blue Cross-kind-of-a-payer, or a consumer. As a consumer, I’d need to download the app and pay to use it. Are these sources of revenue for the company?

Andrew: The main source of revenue from the company is from the self-insured employer and the payer. We don’t charge consumers for accessing Buoy. You can go on buoy.com right now and it’s totally free for you to use. If you get it through your employer or your payer also, it’s free to use. The employer or the payer is paying us to essentially configure Buoy to their particular network design, their set of point solutions or particular services that are in-network for them to then, drive them into that right care at the right time.

Q. I noticed that you didn’t mention providers; you’re going to the employers and the payers. Any particular reason why providers are not a target market for you?

Andrew: It’s a really good question, because that’s where we’re headed next. From an original kind of company perspective, we started out working with some health systems and when we saw the data coming from our deployments, the use case directed us toward helping consumers navigate a complex health system.

What we found was that when we’d ask people upfront what kind of care they were looking for and then we saw where they ended up going, we noticed we were de-escalating 50% of ER visits, 48% of urgent care and 42% of primary care. It was astounding how, if you removed uncertainty and fear from the equation, it often de-escalated peoples’ care. Health systems, in no fault of their own, are in a transition right now from fee-for-service to value-based care. They’re somewhere along that spectrum, let’s call it 80:20, so when you show someone that data of us actually potentially reducing the number of people that come in that 80:20 equation, the math starts to play out right.

Q. This is a classic conundrum for digital health solutions, and I’m curious — how long did it take you to figure out that providers are not going to be thrilled about this?

Andrew: I would say about a quarter. We had the benefit of having some investors on the payer side, who helped us know that that would be the eventual landing spot of where we would be very valuable if we were able to change behaviour and move people into the right care. So, it was one of those things where we were de-escalating care and a couple of potential prospects told us that that wasn’t interesting. So, it was an immediate shift for us — moving to self-insured employers and payers.

However, going into this year, as a business, we have 30 million consumers that come on to Buoy.com every year. We work with three of the largest payers and hundreds of self-insured employers and so, the next opportunity for us is to drive consumer-driven healthcare, make healthcare shoppable with our technology where the shopping decision is taken out of your hands or out of the domain of a doctor who shops on your behalf or a doctor who guides your shopping decision. It’s our chance to actually bring services directly onto providers, onto Buoy so as to enable this three-sided marketplace where the marketplace’s core function is to do a really complex match between that consumer and exactly what service they should be going to. The focus then, is less on health systems, more on digital health solutions.

The next stage of the business for us entails talking to, partnering with many of the companies from among 1900 digital health companies founded in the last two years, bringing them onto Buoy, and helping them find the right patient.

Q. Even though you’ve decided to move on from providers, you’ve said it’s 80:20. So, only 20% of healthcare is on some kind of a value-based model but that percentage is expected to grow. Do you think that ratio will change enough for you to approach health systems, again? If yes, is that a year or a quarter of a year or five years away?

Andrew: I think that with the success of digital health on the value-based side over the last couple of years, it’s a forcing function for the rest of healthcare to move in that direction. So, I don’t think that we are a decade away. But I will caveat and say we’re not a year away either. Healthcare moves at the pace that it moves but COVID was a massive accelerant for its digital version. There will be continued momentum in the direction of value-based care, but legacy, or let’s call it ways of making money, are hard to unwind.

Q. That’s a great segue to my next question. You mentioned forcing functions – so, one was the pandemic and now there’s an acute shortage of labour in healthcare. A report in this month’s American College of Healthcare Executives publication states this as the number one priority challenge for healthcare CEOs today. Is it the next forcing function for your business or any AI-enabled business that reduces the workload on caregivers, clinicians and, consumers and expedites the right decisions and treatments?

Andrew: Absolutely. It’s been an underlying and an unstated problem for many years but it’s quite acute now – this access to care for an average person is very hard. If you have a family member living in Boston, you’ll know the average wait time there is 49 days to see your primary care doctor. It was like this 5 years ago but I don’t know nor do I want to look up the number today. Access then, has always been a problem, and now is bigger due to this massive burnout of healthcare workers across the entire spectrum of different types of clinicians and workers. I mentioned my siblings in the healthcare field and many friends and former classmates of mine are here too and they feel a massive amount of strain which explains that shortage.

When I think about the future of our company and that of digital health, we must focus on the labor that exists out there today and what will emerge in the future. How do we make sure that they’re doing what they’re cut out to do – heal people? The catchphrase is “practice at the top of their license,” but the way I think about it is clinicians and humans specifically, are good at healing. So that pat on the back, the treatment rendered in a kind, compassionate way, is a job that’s tough to replace by anything automated. So, everything besides the act of healing should be automated away.

When I think about this, I like the fact that when we visit the doctor, they’re not just healers, they’re also our shopper. They offer us options – “A, B or C. What do you want to do?” If we can allow the clinician to be the healer to do what they do best the moment they actually need it and automate the amount of other work that fills their day — from the documentation, billing, post-care rundown perspectives — there’s a treasure trove of what should be automated by technology.

Q. There is a considerable interest in automation technologies – RPA, voice recognition etc. – and it will only increase. What are the biggest challenges that you have encountered as an entrepreneur in building this business from data aggregation, management, quality and analysis standpoints?

Andrew: I would say the biggest problem is around the silos of healthcare data. I don’t think my insight here will be unique or interesting but it’s real. Everyone sees the data that is really owned by the patient, as being theirs. And there’s a lunge to not want to share that in any form or fashion, in the guise of HIPAA and patient privacy. That is a real challenge.

Patient privacy and data ownership from a compliance perspective, makes a ton of sense and that’s correct. But, if a patient who owns their data consents to having their data moved across places for better care and an enhanced healthcare experience then, that should be made easy. It isn’t the case, today. Obviously, considerable digital health investment has gone into businesses to make healthcare more interoperable, liberate that data — clean it, make it more actionable, and drive more insights — so, I’m hopeful, over time, it gets easier for consumers to tangibly hold their data.

Q. Let’s talk about the flip side of that, too. Consumers must have access to their data but if it falls into the wrong hands, there can be all kinds of unintended consequences ranging from the mild to the severe. While data, AI and advanced analytics can make a difference in care, how does your company, undertaking data aggregation and analysis, address it?

Andrew: Our view — and I’ll come back to your point, because it’s an interesting counter to what I said — is that, at the end of the day it is the trust with the patient that matters. If we’re a company trying to drive better decision-making at a consumer level, empowering people to get the right care at the right time, making healthcare more efficient, and if the consumer doesn’t trust us with their decision, then, we must ask why do we exist? So, when it comes to how we treat their data, protect it, regulate access — any action, whether real, intended, or not — it’s that trust that’s crucial for us.

When it comes to secondary consequences – here’s the segue to your earlier point – we ask “what if the consumer doesn’t know how their data is being used?” And this is controversial. I’ll say, it’s been proven to be true across tech and industry where the products themselves are addictive and a means of gathering data and then, monetizing it in a way that may not be best for that person.

However, healthcare is different. People don’t use healthcare for purposes of selling vanity. The intent is to use it to go back to their baseline and get healthy, again. If it turns out that this company is not using their data correctly, then, there’s no way that that company will be able to exist for very much longer. There’s going to be a flight to quality. People won’t access the site that’s selling their data. So, it’s important to have a bit more trust in the consumer to not let that happen. The intent in the healthcare context is just different from other contexts where unfortunately, consumer data has been misused. So, that’s my optimistic hope.

Q. You do make an important comment about healthcare data being a little different. The bar is higher and there are serious consequences for misuse of the data and the breach of trust. So, as a start-up in digital health, what’s your advice as an entrepreneur for those who want to start their own companies here?

Andrew: There’s so much to learn when starting a company that can be applied from other industries. The piece of advice I’d give most often to people going into healthcare — into digital healthcare, specifically — is what’s different about healthcare, is that outside of direct-to-consumer services where someone is paying, these sales cycles here are so long, regardless of whether you’re selling to pharma, employers, payers, health systems etc. So, the learning is slow because by the time you get someone to say no — which in and of itself is a learning — it takes 12-18 months.

When you are raising capital and trying to prove something, it’s crazy how much you have to guess correctly in order to make it to the next stage. That is a reality which entrepreneurs have to embrace. In other words, the questions to be asked are — How can I speed up my learning in some innovative way? Do I have to raise enough money to last through 2-3 sales cycles? — It’s just a stark reality that I think is not talked about when trying to apply tech, how it works and how to start a tech company relative to healthcare in the digital health landscape.

I hope that doesn’t discourage anyone from getting into healthcare for we need the innovators, people who can dig in for the long haul and investors who will have the faith that eventually, it’s all going to work out. Andrew, it’s been a pleasure speaking with you. I wish you and your company the best and thank you again for being on the show.

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