This week I am talking to Ankit Rohatagi, MD, Chief Clinical Officer, AssureCare (@AssureCareLLC) an innovative, patient-centered, connected care platform that is trying to increase access to care while reducing cost.
We dive into Ankit’s background traversing multiple clinical systems and countries providing him with useful and important insights into what works for healthcare and what could be applied to the system in the United States. Ankit applies system-based thinking and this experience to change the practice of medicine by improving the incentives and allowing clinicians to practice good medicine
Listen in to hear us talk about the current fee-for-service environment we work and what could be changed to make improvements including some interesting approaches to treatment pioneered by Kaiser that includes prescribing food to their patients as part of a treatment plan
Listen live at 4:00 AM, 12:00 Noon, or 8:00 PM ET, Monday through Friday for the next week at HealthcareNOW Radio. After that, you can listen on demand (See podcast information below.) Join the conversation on Twitter at #TheIncrementalist.
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Raw Transcript
Nick van Terheyden
And today I’m delighted to be joined by Dr. Ankhit Rohatagi. He is the Chief Clinical Officer for a Assurcare. Thank you. Thanks for joining me today.
Ankit Rohatagi
Thanks for having me, Nick,
Nick van Terheyden
as I do always, and it’s always a pleasure when I meet a fellow clinician who’s branched out into other areas, I like to get a little bit of the background, I think it helps in terms of setting the context for the episode. Tell us your journey and how you arrived here if you weren’t
Ankit Rohatagi
sure, Nick. So my background training is an internal medicine and er, I was born and raised in India, where I did my medicine training from Mumbai. After that, I moved to UK where I trained in emergency medicine and trauma and experienced NHS healthcare. I was there for close to five years and I was practicing er, in 2008, I came to us I did my training in internal medicine, followed by an MBA that I did from Fuqua School of Business Duke University. Over the past years, I worked in multiple care settings, both as an internist and as an ER physician, both as a clinician as a as an executive healthcare professional. I was involved in founding and directing multiple physicians group sharing, medicine and hospital setting, as well as system utilization review committees. I have supervise large group of clinicians, I’ve reviewed hospital and group metrics, as well as developed and led organization strategies, both for the Hospital and Healthcare Organizations. Over the years, I have directly been involved in implementation of various EHRs to large health system. During the roles that have been practicing for so many years, I have encountered multiple pitfalls throughout the continuum of patients journey for right from the ambulatory setting, to the hospital, and then nursing homes, including transition of carers, medication reconciliation errors, SDOH influences and lack of proper tools to assist clinicians to realize better ways and opportunities to address them. So I want to make a pivot, mostly from clinical care to system based thinking, and to help improve the way healthcare is delivered. Which led me to a short career, where I joined as a Chief Clinical Officer last year, just a brief about a short career in one line, assured care, it provides extensive population health management solutions, which I oversee research and development of clinical based best practices, workflows, and provide them with clinical subject matter, opinions and expertise.
Nick van Terheyden
So before we get into that, tell us a little bit about your journey from clinician to business thinker, and specifically system based thinking, because that’s not the traditional pathway. You’ve qualified essentially in three countries to practice medicine, that’s almost like going to medical school three times, although maybe there was a little bit of reciprocity between India and England. I I’m not sure about that. But I know between England and the US, you you went back and studied again. So you’ve done a lot of studying. I’m kind of curious a about that journey and be about your comparisons between those systems.
Ankit Rohatagi
Yeah, that’s thanks that you’re asking me this question. So having experienced different countries and health systems and payment models, including India, which is mainly a fee for service, NHS, which we all know is a socialized medicine, will mainly single payer systems, they do have some private insurance, but majority of the patients they don’t use it as often. And then us payer system, which right now is mainly fee for service. So it intrigued me when I initially came to us in 2008. While I was doing my residency, I had an effect, because we were following the gold standard of investigation and diagnosis. But at the same time, the way the medicine was practiced, I did see we were almost over utilizing our tools while I was working in emergency medicine. To give you an example, a patient comes with a headache, and I’m seeing physicians are doing a CAT scan, which kind of didn’t equate to the way I had practiced in NHS. So I saw that other things I saw, you know, patients going to primary care providers PCPs are focusing on point of care tests and focusing on really acute care episodes. In NHS It was absolutely different in NHS you know, when you go to a primary care physician, the focus This is really, really on preventative health. There’s a dialogue, there’s a discussion with a patient that engages patients to talk to primary care physicians, tell them about their background, their history, their social factors and reasons, and primary care physician really know, a patient as a whole. So seeing those differences, you know, we all know that you’ve spent so much money in healthcare. But if I see the mortality and overall outcomes, there’s not much difference in the outcomes that UK has versus us. So the question that came in my mind, what are we doing different in us, we are spending so much money in healthcare, why our outcomes not do not equate to the amount of efforts that we are spending. What I realized that, you know, every healthcare system has its own pros and cons, but utilization and care management in the US have become highly fragmented, this lot of information and data scattered throughout various systems, which decreases the efficiencies to pre patient. So keeping in mind, all of these factors and the way the medicine was practiced, I really wanted to understand how the healthcare works in us. So that motivated me to do MBA from Duke. I also did my concentration in health sector management, kind of to learn about how the insurance works, how the payer and billing system works, etc. So that’s my journey. I’ve always had some intrapreneurship. skills in me, I also started a hospitalist management group in Massachusetts few years ago, we had contracted with different hospitals and long term acute care facilities. So keeping in mind, all of those factors, I always have been intrigued, and how do I change the practice of medicine at a system level?
Nick van Terheyden
Yeah, so thanks for that. I mean, I think, you know, interesting journey fee for service single payer, I would say essentially fee for service in the US. So you’ve been in a similar systems. Albeit, let’s be clear, the Indian system is quite different, but has many similarities, certainly to the US. But substantially lower costs. Let’s be clear, which is part of the reason that we see all this flow of medical tourism. I think you are being overgenerous in your description of over investigation in the emergency room? I would, I would go a significant step further and say there is far more investigation than necessary. I think, from a clinical standpoint, I’d been, you know, fully outspoken about this. And, you know, there are multiple causes. I don’t I don’t sort of attribute this to this as clinicians misbehaving, I start with the premise that, you know, everybody comes in with the best intentions, but the system is pushing them towards behavior. And, you know, some of that is litigation. To be clear, there’s a great fear of it much less than the United Kingdom, although that’s rising, you know, perhaps less than in India. But, you know, we have major challenges with the basis of this system. You’ve now been through this. I mean, I think I wouldn’t be tried and say which is best? Because I think that’s just a ridiculous question. I think what’s a better question is, what can we pick and learn from those experiences? And importantly, based on your system thinking, that would start to sort of tilt the US system, which pays gargantuan amounts of money, but does not get value for money? Can you pick out some learnings that you’ve had along the way? Because your experience is relatively unique in that sense?
Ankit Rohatagi
Sure, Nick, as you rightly said, I would like to re emphasize on that statement. In a lot of the providers, including myself who work in er, in high stress environment, we are mainly practicing defensive medicine. I know there are a lot of investigations with patient or don’t need, but there’s a there’s a stress that’s hanging on my head, what if, what if I miss this diagnosis? I’ve seen a lot of my colleagues, a lot of my surgeon surgeon friends who have had malpractice suits. And if you challenge them, you know, seeing from the providers eyes, they probably were right in the management but the ways the system has said you’re practicing inferior. Moving on to the question that you said. One of the key differences that I have seen in NHS versus us is we think that access to health care equates to good health in us which which I think is not really a true statement. We are focusing too Increase access to health care. But I think the big part what we are missing is we can provide multiple hospitals and clinics to the patients. But what’s more important is we need to see what are the barriers that are being faced by the patient to have a follow up to that excess of care. And to give you an example, I see in my practice as an internist, I see a patient who comes with chest pain, ruled out 40 years old, young female, who walks in, I admit the patient for a night I do telemetry, I do EKG. Next, a patient has an echocardiogram. We rule out proponents. So we need to keep patient in for an eye for an observation to rule out chest pain. And then we do a series of tests, including lipid panels even see, then we look at nice patients have some risks, risk factors. Maybe they’re pre diabetic, and then we do the workup and we send patient discharged patients. But what we think that by doing the whole workup, we have taken care of patients LS, but what we’re missing is how strong is our follow up? Do I do I know whether a patient has a primary care to follow up? I’ve diagnosed a condition. But what control do I have to make sure that the patient follow ups with a provider to ensure the care is given to the patient. I can prescribe a medication insulin, but we all know in the US the cost of insulin is so high, that even if I write medications for the patients, patients may be not able to afford those medications. So as a clinician, I’m doing my part, but I’m not aware of the other factors which are going in the background. So a lot of loose ends that I see in the US the intent is good, but a lot of other factors outside of the medical intervention that I think we need to focus on.
Nick van Terheyden
Yeah, I mean, you bring up lots of points in there. And you know, they’re all valid, I think you’re entirely right. I think we’re both in agreement, I always start out with the notion that everybody comes in with the best intentions. You know, that’s true across the throughout the industry. But if you incent behavior, through various means, even unintentionally, this happens, we see over investigation, we see it from a litigation standpoint. And, you know, partly the insurance system is driving people to the short term behavior that you see in the emergency department where I can get care, potentially, I don’t want to say free because nothing is ever free to be clear, but I don’t pay out of pocket. And you know, it’s not connected to the back end, because I don’t have a back end. We’re crippling people as a result of, you know, this failure in delivering a concerted health care system. I’m sorry, but I just have to make one comment about diabetes and insulin. It’s just an outrage to me that it costs 700 to $1,500 for a patent that was given for $1 a piece by the inventors who felt that it was you know, inappropriate for the medical profession to make money where you could save lives. I think, most of if not all the medical profession concur with that, but we’ve lost our way. That’s a real struggle for me. So I think you know, huge numbers of problems. For those of you just joining, I’m Dr. Nick the incrementalist today, I’m talking to Dr. Ancheta, Ro Tagi. He is the Chief Clinical Officer for a shore care, we were just talking about the challenges of systems, you know, and kids extended experience growing up in an original system, fee for service moving to essentially single payer and then ultimately into the US system, the struggles and you know, some of the learning points, I think, you know, most people that have had those experiences, and I certainly have recognized that you can’t take the single payer system, right? That’s what we should have in the US. It’s just never going to work, you’re not going to impose that. You know, there’s a fundamental resistance. But you know, you you talked a little bit about some of the challenges of tying things back. And I think it’s important to get to that, because that’s some of the areas that I think you’ve really focused on, which is, you know, how do you identify these problems? So, you talked about seeing this patient, you start to see some of the indicators and you know, we could have a whole show, in fact, I’m, I’m certainly going to have a whole show talking about whether we’ve got decent screening for some of these things. But at least if we have that, how do we then tie that back in other solutions in place that can help for this?
Ankit Rohatagi
Yeah, that’s a great question. And I would like to talk a bit about diabetes. So we know that the global prevalence of type two diabetes has sharply increased over the four decades. And it’s projected to increase further cardiovascular disease risk, cardiovascular disease remains the leading cause of death and disability in patients with diabetes. There’s a lot of recommendations by societies such as American Heart Association, who do give some recommendations on how to manage the risk factors for these type two diabetes, including lifestyle intervention, screening methods, doing a one C and lipid profile. I think the best opportunity for better outcomes for these diabetes patients are and other chronic diseases, so to say, is in effectively leveraging the data. And what I mean by that, you know, right now, if I do have a patient who I diagnosed with diabetes, I do the evensi screening, things just don’t stop there. The CPT code, or the or the condition of pre diabetes, or diabetes, along with some SDOH data should ideally generate a clinical pathway, which should, which should lead to utilizing interprofessional teams. Modifying initial risk factors such as weight loss management programs, or programs to help with physical and activities. There have been some drives going on in US VA introduced similar programs such as Move, which is a weight management program, which is offering services as one of the preventative strategies. So not only these patients will need medication, but they will need a whole array of services a to educate them on diabetes, we need to identify modifiable factors, I see a lot of patients you know, who are pre diabetic, but they don’t have means or access to healthy food or healthy diet because of socio economical reason. They just can’t afford those expensive food. So then once we identify those risk factors, we can provide some education and we can support those socio economic people, whether we provide them Meals on Wheels, we provide them vouchers, we provide them transport so they are able to go to their follow ups and have routine screening for other complications that arises from diabetes, etc.
Nick van Terheyden
So I mean, I think, fundamentally, I agree with you. But in practice, I don’t, in part because I’ve seen lots of instances of these programs. And I’ve experienced it through my own family. People living in food deserts have no options. And it doesn’t even matter if you had the money, and they don’t. And if they had the money, they wouldn’t live in these places, quite frankly, but they can’t access healthy food, if any food at all. I mean, in in a particular example that I have personal experience of there was maybe a corner shop with who knows what kind of junk predominantly alcohol that was for sale? How do we solve for these problems so we can identify them? I think that’s entirely right. We understand that weight management. But we as a human humanity are programmed to go for both the most unhealthy because, you know, we’ve programmed from this feast or famine, but ultimately, it’s what’s available. How are you seeing the solutions around that?
Ankit Rohatagi
So I would like to give some examples of what’s happening. So Kaiser Permanente, we know about Kaiser Permanente. So they launched an initiative, they used Thrive tool, which is tools for health and resilience in vulnerable environment, which was introduced by Prevention Institute. So they have been used in Thrive tools. It has some key questions that we ask the patients where you live, do you have a shelter? Do you have access to food? Can you afford to pay your medications? Do you have any troubles getting transportation or to medical appointments? Do you have a caretaker responsibility, or are you unemployed or looking for job? So what they did yesterday? really assess the patient’s physical, mental and social conditions and match the needs related to appropriate services, they were able to determine that more than 60% of Northern California members had at least one unmet social needs. So what they did, they took the data, and they introduced local Thrive programs. And they created close to 5000, affordable housing units, to provide services to help with access food and support with healthy relationships. There are examples what BMC is doing. If a patient goes to a provider, and the provider has the tools while they are assessing the patient while they’re writing a prescription? There’s a question Do you have access to food? Or, you know, other other utilities? And if the answer is no, the provider is literally able to prescribe for groceries from the food pantry that BMC has, which includes very disease specific diets and health programs and options to cover for the patient and families. So these are just few examples. And I know this this, this won’t solve the epidemic of diabetes, but at least it’s a start.
Nick van Terheyden
No, I agree with you. I think it’s important to sort of highlight the programs where they’ve been successful. And you know, Kaiser certainly familiar with but the other one that you mentioned BMC. Who you Washington Medical Center, Boston Medical Center. Okay. Sorry, I wasn’t sure who precisely but, you know, let’s pick on Kaiser, because they’re a slightly different health insurer. I mean, they’re still a health insurance. But they essentially I mean, I’m, I know, I’m going to get into trouble, but I’m going to call a capitated care of some description. And for the most part single payer system, which says, you know, they’re incentivized, and therefore doing the right things. And actually, you know, you describe some fantastic programs, imagine that prescribing food, you know, almost unheard of. So, I think some, you know, great examples, and some lessons in there that potentially say, we should be tilting further to that we haven’t seen a lot of, I mean, I think ACOs are still fundamentally stuck at about a third of the rate of insured people. We need to move further to that, do you have other examples of this that you’ve seen that are working?
Ankit Rohatagi
So one of the other example again, I’m very close to be MC. So Boston Medical Center, they also started the week here program, in which they were able to, again, assess the needs and necessities for food for the patients, they implemented the program. And the the accessibility to food and employment increased from 80 to eight to 70%. So there have been very noticeable changes.
Nick van Terheyden
I just want to be sure I get that eight to 78
Ankit Rohatagi
to 70%. Wow. So significant improvement. Again, I think it depends on what’s the mission and vision of the healthcare organization. So coming back to different peer groups payer system, I think, rightly, as we are seeing the shift is there towards value based care. And I think that needs to happen once the physicians are properly aligned, once they have the right incentives, and pots to provide the endpoint for the patients. I think that’s where that’s how the journey needs to start. And that’s the direction I think, which we are going. It’s a slow move. But I think slowly, but surely we hopefully get there.
Nick van Terheyden
And as you think about the sort of inputs to all of this, obviously, to track it, and to demonstrate the value propositions, do we have enough data that helps us guide this program? And importantly, demonstrate the value proposition? Because ultimately, it has to otherwise people are not going to pay for it, right?
Ankit Rohatagi
Yeah, no, you’re absolutely right, Nick. long question. We can spend a lot of time answering that. But in briefly, I would say, I think there is a drive towards that. People are the lot of companies and firms who have recognized the challenges. We are working on interoperability. We are working on technology platforms, which which are EHR, agnostics, who can collect the data. But more than collecting the data, we need to ensure that it’s a meaningful data, how that data can be used for the providers to give very clear endpoints and interventions. So I think if we can do all of those, it may take time, but by by analyzing those meaningful data and giving it to patients, to providers, and to transition teams, I think maybe that’s where we see some impact.
Nick van Terheyden
Fantastic. Well, unfortunately, as we have each and every week, we’ve run out of time, so it just remains for me Two thank you for joining me on the show uncut thanks for joining me
Ankit Rohatagi
thanks a lot Nick
