On the Health Record - Interview with the Former CEO of Heal, Nick Desai
We recently spoke with Nick Desai, the former CEO of Heal, to learn more about his experience starting Heal with his wife Dr. Renee Dua, his thoughts on value-based care, healthcare inequality and so much more. We transcribed some highlights from the conversation here, but we highly encourage you to listen to the whole episode here.
You co-founded Heal with your wife, Dr. Renee Dua; can you tell us about her background and why you decided to start a company together?
Renee and I got married about 13 years ago. We have three wonderful little kids together, and her background is in nephrology. She was board certified in hypertension, nephrology and internal medicine. She taught medicine at UCLA. She was chief of medicine at two of the largest hospitals in Southern California. When we had our first kid, we had very bad experiences trying to get care for our son who was six or seven months old. He ended up in the ER when he didn’t need to be and didn’t get the care we felt he needed. One night after sitting in an ER for seven hours, we were driving home in an Uber, and we thought that there just has to be a better way.
If we can have Uber that brings a driver to your location, why can’t there be an app to bring your doctor to you? That’s what kicked off the idea. We wanted to build a company that would change healthcare with technology, and what two better people to do it than a doctor and an engineer? I think about technology. She thinks about quality healthcare. We decided to start together.
Honestly the six and a half years I spent building Heal with Renee were the best of my professional career. Not just because of what Heal is, but because Heal became what it is due largely to her perspective as a physician, her insights into what real patients need and what real doctors need. Having a trusted, equally hardworking, if not more hardworking, partner was just an incredible marriage, literally and figuratively, for us.
Can you talk about the product you did build at first and, and how that seed idea might’ve grown in those six and a half years.
The concept of Heal was extremely easy to get people excited about. How would you like an app that brings a doctor to your house, and it’s covered by your insurance? People were like, “Where do I sign up?” It was not hard to raise the initial money. It was not hard to get early customers. It was not hard to get early providers because one of the things that we knew from day one is we had to reinvent. You can’t fix medicine for patients without fixing it for doctors. This technology could remove the pain points for doctors and patients alike. Basically, early traction came easily, and there is still so much excitement around the idea to this day.
That translated into our investors who run the gamut from major institutional funds like Fidelity and Briar Capital to celebrities like Lionel Richie to business tycoons like the former CEO of IBM and our chairman, Paul Jacobs. Whether you’re the richest person in the world or the least advantaged in the world, you want better access to timely, quality healthcare, so that was the initial idea.
What it grew into was the understanding that Heal could be very successful in the value-based care segment. We focused especially on people over 65 who use technologies like remote monitoring and telehealth, which we pioneered to be working in conjunction with house calls. We also worked with Medicare to get them to change the rules to allow house calls for people over 65 broadly in the first place. That happened in January, 2019. The point of all of that is that what we built together was something that grew from fee for service. Anyone can use it, which we still do now. However, we’ve given more focus to value and outcomes based care, especially for seniors with Medicare Advantage plans, which is what drove the interest from Humana and ultimately the investment that made the company last fall.
How have healthcare and value-based care changed and grown over the last decade?
The most important, fundamental aspect of this is that in the fee-for-service world, doctors are compensated based on the volume of patients rather than the value of care they deliver. That is counter to what is best for healthcare, what is best for patients, for providers and payers alike.
If I have a sore throat, I can do a transactional telehealth call with a provider, and they would tell me what it might be, or that I should drink some tea with honey and call back in a few days. Instead, if a doctor came to my house, saw my home environment and learned about my behaviors, they could develop a much fuller understanding of what could be affecting me.
The goal is giving a doctor the ability to find out the complete context of their patient’s life and the context of the likely root causes across the horizontal spectrum of a patient’s care, rather than a point solution around the vertical disease state. Humans are not disease states. Humans are complex interconnected beings. It’s easy to just say, “This person’s diabetic,” but you know what? They are also a 78 year old, retired grandparent of six grandchildren who likes to take walks, and they have diabetes.
By allowing that longitudinal view of a patient and integrating social determinants of health, which can only be seen in the home, we at Heal enabled a much better quality of care. Isn’t that what value-based care is fundamentally all about? It’s about looking at a patient broadly and generating more value. Each patient interaction is longer, and a doctor is seeing less patients per day. However, they’re providing a much more comprehensive care plan that can result in improved outcomes, lower costs and the patient spending more time being well and less time getting well.
This also ultimately saves money for the healthcare system. I think one of the things that’s happening in the value-based care industry is that many plans are looking at how to make money from the value-based care system while still providing the least amount of care. How can I code the HCC correctly even if the patient is not necessarily achieving better outcomes? The patient’s not necessarily happier or living a better, healthier life. Costs aren’t necessarily down, but the reimbursement for Medicare is higher because a person’s RAF score went up. I think that is a problem we have to fine tune. The whole entire healthcare industry has to fine tune these models, so that the incentives are truly aligned rather than perceptually aligned.
After six and a half years at Heal, you’ve said publicly that you want to tackle problems of a new scale. What kind of problems are you talking about?
This is what I know. In 2020, in the middle of this pandemic, 85% of people using telehealth in the United States had a household income over $150,000 a year, which means that the people who really need it didn’t use it. We have not solved health equality and health equity, and without equality in healthcare, there’s no equality anywhere. If by virtue of where you were born, you are destined to live less long than somebody else, your life is inherently unequal. End of discussion. We know right now that different zip codes in Manhattan, New York, which is only nine miles long, have life expectancies differing by five years. We know that U.S. life expectancy before the pandemic went down for the first time.
We know that there’s a digital divide, an education divide, an income divide and a socio-demographic divide. Healthcare has to be the foundational piece of solving that divide, and technology has to be the foundational method by which we solve that divide for healthcare. How exactly we will accomplish that, I have no idea, but as everyone who knows me well says, “Nick has gotta be cooking up something soon enough.” I’m excited to try to tackle this question, but first, I’m just going to enjoy spending some time with my family.
Can you talk about the scale of the problem of health equity?
Fundamentally, here’s the problem. If you are on a Medicaid or Medi-Cal lower income program, you technically have insurance, but you don’t have access. There are often no doctors that work in your neighborhood, or there are no doctors who want to take your insurance because the reimbursement rates are cartoonishly low. Maybe it’s just unsafe to go out, or you can’t get time off work. That’s one problem.
The second huge problem is that there are parts of the United States where no matter what insurance you have, there just aren’t providers available. Moreover, it’s often unclear how to find the options that are available to you. Do you know that your insurance plan covers X, Y or Z?
My father-in-law was in the hospital for back surgery. My father-in-law is a physician, my mother-in-law’s a physician, my brother-in-law is an orthopedic surgeon, my wife is a physician, and yet we needed to fight to make sure he got the care he needed at one of the best hospitals in America. Thankfully, my father in-law got the care he needed and is doing well, but it took a ferocious commitment to advocating for the patient to make sure that care was coordinated. We had to make sure the physical therapist, the occupational therapist, the rheumatologist and everyone else all knew what was going on and what the other one was doing, and thankfully we were in a position to do that. We have access, we know people, we’ve got a family full of doctors, and I know how to go in and talk to people.
However, imagine that you don’t. Imagine that you’re an immigrant, or even that you’re not an immigrant but you have a fourth grade reading level, which is what the average average person in America over 65 has. You have no idea how to advocate for yourself, and you have no one to advocate for you. That’s why we need solutions that naturally integrate care, drive advocacy, enable you to know what’s available and make it as easy as possible for you to get the best care that may already be available to you and may already be paid for. That’s a critical part of what we have to solve for.
For the full episode, listen here.