TECH: WorldDoc CEO Rahul Singal transcript

This is the transcript from my recent podcast with WorldDoc CEO Rahul Singal transcript.

Matthew Holt: Hi. It's Matthew Holt, at The Health Care Blog, and we're back with another podcast. This time, I'm talking with the C.E.O. of a very interesting company, which has its fingers in multiple pieces of the health-care system. I'm talking today to Rahul Singal, M.D., who is the president and C.E.O. of WorldDoc. Rahul, how are you today?

Rahul Singal: Doing fine. Thanks, Matt. Good afternoon.

Matthew: WorldDoc is based in Las Vegas, just to let the people listening know. I saw Rahul there at a conference a week or so ago. I'd kept tabs on WorldDoc a little bit in the last couple of years, but I wanted to find out a bit more about what was going on. But a number of interesting health care stories are coming out of Las Vegas. I suspect that both those stories and the roles of WorldDoc are not so well known. Anybody going to your website would see that you're involved in a bunch of different things: strategy analysis, software, personal health records, pharmacy benefits management. To tell the people listening, what does WorldDoc do and what are your main lines of business?

Rahul: WorldDoc is in its seventh year of operations. We started with 14 board certified specialists. We now have 20. We have the single vision of trying to educate and empower consumer end users about their health before seeing a doctor. So we created a web based software system that helps people understand their acute care problems, things like a cough or red eye or stomach pain, "What's wrong with me? What can I do to make myself better?" Acute care is one of the things. Preventive health. "Hey, I just turned 40 years old. What tests do I need? How can I maintain a healthy lifestyle? Am I at risk for a heart attack?" Then chronic conditions, things like when you know you have high blood pressure or diabetes or high cholesterol. We teach people about their goals, how to talk to their doctors, how to get to their goal.

We do this all in a software based system, created by the 20 board certified specialists.

Matthew: That's one part of your business. As you know, there have been plenty of companies over the last decade or so who have created software programs to do some parts of some of that, but you guys seem to have made a real business of it. So what have you been selling, who are your customers, and what kind of services are you selling?

Rahul: Our core customers are self insured employers and their payers. The self insured employers are the true purchasers of health care. Their payers are independent third party administrators or regional health plans, which market to these entities, and then their consumers and end users use them.

Our core web based system comes with a 24 hour nurse line. One of the things that we've been able to do is import pharmacy and medical claims into our care engine, so that the pharmacy claims can be done within 24 hours of a claim fill. That means that, if I have diabetes and you have high blood pressure, and we each fill a prescription, then, the next day, the WorldDoc system might message you and say "Hey, for your high blood pressure, do you know what your goals are? Here's the medication. You may want to talk to your doctor about this alternative, which will save you $1,000 a year."

Matthew: Let's get down to a more granular example. Let's say I'm one of your customers who is an employer, and I'm working with a TPA to administer a regional health plan or a TPA to administer my employee benefits. Maybe you want to pick a real example, of one of your employer customers. How does it actually work? What are the pieces that you're supplying to them? What are the pieces that they're really looking for?

I understand that a smaller TPA may not have done what some of the larger health plans have done and created their own online consumer health experience, as it were. Perhaps they're looking to you to provide that. What is the value proposition? What are the reasons for which they will engage WorldDoc?

Rahul: On the health risk assessment side, where organizations profile a population's risk, there's a lot of examples in the industry in which an employer or a health plan will incentivize a population to fill out a health risk assessment. We do that as well, it works great.

However, we go a few steps further, so that, if, on the basis of pharmacy claims, we know that 500 people may have diabetes, and we've done this with Coast Resorts, a casino here in Las Vegas. These 500 people that were on a diabetes claim file, out of a total population of about 7,000, were sent one letter, which invited them to come to the WorldDoc website and fill out a diabetes report card. About 150 people did that.

What's fascinating is that these 150 people, whom we taught to know their numbers, put in their cholesterol levels, their hemoglobin A1c, and blood pressures, and we created a profile of "Hey, am I at goal?" Simultaneously, we sent this to the employees' doctors, and we had that in our database. What we showed, within six months, was that these people that participated, that their blood sugars improved to the same degree as they would have if a nurse had phoned them at home. So, we believe, for working age people, commercial people, "Get on the same page with your doctor, reach your goal." This study was published in the Journal of Managed Care about a year ago, and really empowered end users to take better care of themselves.

Matthew: Let me ask you a bit about that, because, obviously, there have been these programs that have been introduced, and there's been a fair amount of evidence that, if you can move diabetics in one way or the other and make them behave better or work better with their physicians, you can actually improve outcomes and reduce costs. There have been a lot of different ways to that waterhole. We haven't really figured out how to do it systematically. Of those 500 folks you write to, how many are you getting to come to the website? How many does it take getting a nurse to call them and convince them to do that? How are you engaging that population?

Rahul: Adoption and engagement are one of the secrets that we often know how to do very well. Our customer experience team works closely with the human resources team of an employer, and with the executive team, to say "Hey, this needs to be a core strategy for the whole organization." We do an evaluation their food habits, their cafeteria habits, their vending machines, the hidden messages, and try to change the health culture of an employer. Then, to get more tangible, with the WorldDoc product itself, we'll have posters in the breakroom, we have paycheck stuffers, we have monthly newsletters that go out. It's a whole organized campaign. Then, with a small incentive, as little as $50 for getting on and doing your health risk assessment, we consistently have more than 70 percent adoption of WorldDoc. About half of our organizations choose not to have an incentive. So, on a strictly volunteer basis, we're at 35 percent, which is phenomenal in the industry.

Matthew: So, if you go back to your 500 diabetics out of a population of 6,000 or 7,000, is it 35 or 70 percent of that population that's adopting, or...

Rahul: No, because this was a mature client for us, in the first 18 months, we had already engaged almost 3,000 of the individuals to participate on WorldDoc. In the second year, we did the focused diabetes program for those 500 diabetics.

Matthew: You actually had 500 diabetics coming online and interacting with the system?

Rahul: 500 diabetics are the amount in the population. 150 of those worked with the system. .

Matthew: OK, so you've got a pretty good proportion. What's your sense of how you're going to reach the other 350?

Rahul: It's interesting, that's a great question. We did this as a pilot program, as a kind of one test pilot. You know, repeated mailings to the group. Nurse callouts by some of the local nurses might help, but I think repeated mailings, communication with their doctor, those kind of things. When we look at the populations, the non participants, the ones that did not participate in WorldDoc, they still went to their doctor in the following six months. They still continued to take medications. They did not achieve their diabetes goal at near the amount, and so more promotions needed.

Matthew: Right, I'm with you. I think anyone who's looking at disease management information in any of these categories knows that it's very hard to move the needle, especially on the folks you can't engage very easily. There are some things you can start to think about doing. Now, on the flip side of that, what is your relationship with the physicians in the communities, what actually nuts and bolts happens for a doctor who's got a patient in one of these programs?

Rahul: These programs work best when the physicians are notified in advance that a program for large employers is occurring. That way they have a chance to at least have heard about it prior to being blindsided by a report card that shows up in their file, in the patient's chart. We went ahead and did that, and we got buy in as well as from the office manager.

That's important, because, we're trying to get their buy in, get them to help the physician and patient get the goal, get the member to goal. When you're doing specific peer intervention, the physician relationship is important. We've done this in places where it's purely member driven, and it works, not to the same success rate, but it's been effective. We've done it with some cholesterol programs on a smaller scale.

Matthew: Right, it's one of the things where it obviously helps if you can get a decent concentration, I assume, with the local employer, and some local physicians have noticed it, it's more than just one or two of their patients. Is that how you marketed this, are you basically metro based programs? How are you actually going out and selling this program to employers so you can get more attention from doctors?

Rahul: I think, primarily, when we're able to concentrate lines in a region, for example in Montana we have over thirty five thousand members that have access to the WorldDoc system, so they're an organized effort to go out and educate the medical community. We're undertaking, with our third party administrative partner there, and that's more successful. We have a similar concentration in Columbus, Ohio and Cleveland, Ohio. When you're able to achieve pockets of concentration, you're able to get better usage of the system. Then when people use it, the physicians get a little more comfortable with it.

Matthew: Is your strategy then to basically get a big employer client or a self funded employer to be a client in one market, and then either market back via the TPA to their other clients, or market for the next door neighbors and try to cluster around customers you already have? Is that how you've done it, or has it been more simple?

Rahul: I guess that we've done it. I mean clustering is, I think, important. One of the things early on that helped us grow. It's that old gas station thing, right? If you want to build a gas station, build it next to the most successful one in town, and people will come to yours. When you're in a new market, even if you have some large national type customers, a lot of people don't like being the first to try something in a newer market. We've got quite a few employers in the Northwest, in the Southwest, Midwest, and just starting now to go out more in the East.

Matthew: In terms of the products of the sort you have there, which is the personal health management record thing which they might have 24/7, and then the PBM—WorldDoc RX—and then also, maybe you've already described it, but tell me a bit about the WorldDoc TX, please, the care management tool.

Rahul: The TX is amazing, and that's where because our care engine can import data, especially pharmacy data within twenty four hours, medical claims data, in a batch format, and laboratory values. We take direct feeds from Lab Corp. Because we're able to import data into this engine, we have a very robust electronic health record. We've only talked about the member using this data, and the system communicating with the member, however we do have a separate interface whereby a nurse could use this.

We have a health plan in Texas, where there's about sixteen of their medical management nurses who use this as their care management software charting system. This is their Microsoft Office for the day. What will happen is, each nurse has about two thousand members that they're responsible for. Each nurse is responsible for their own population. What our system does is segment those individual two thousand members into risk groups. The system automatically displays the different care gaps that are needed, so it'll display a hundred diabetics on one spreadsheet electronically and say, "Hey, these twenty five diabetics don't even have a hemoglobin A1C. The the next twenty five may, hey, the A1C's overnight."

It gives that nurse something to focus on for the day, and gives a measurement of accountability back to the manager of all these nurses. It's a phenomenal system for efficiency, and what we've been able to show over a couple of years is that when you measure and track the productivity of a nurse, and Heritage Health is the health plan. They've realized tremendous efficiencies in their care management department, and they believe it's a big reason for their low medical loss ratio.

Matthew: If you've got the engine system, your core database, you're showing the views of the member, you're showing another view potentially to a nurse care management system, it's the same sort of data, and then you've got also information there on the drug database you're analyzing separately. Tell me a bit more about how the PBM works? Do these products or services tend to get purchased separately, or did they just all get purchased together, and how does the PBM piece work in that compared to some of the big national PBMs or regional PBMs that they can be using?

Rahul: A big part of our PBM is transparency. Transparency of price to the consumer, to our employer clients, and to physicians if need be. What we try to do is to teach people to take appropriate medications, so that if you're on a $130 per month Nexium for heartburn, think about that $20 over the counter Prilosec and our PBM benefit will cover that, with or without a prescription dependent upon how the employer client wants that. That's a savings of fifteen hundred dollars per year on one prescription.

Now, our PBM, again, we're all about transparency, communication, education, and so the members realize this difference when they go up on our website. Our entire care engine is built on a PBM architecture, and it has that national center for prescription drug plan standards, the NCPDP standards. What actually occurs with most of our customers is that WorldDoc, we can work with other PBMs and display the information. So we work with multiple large PBM's including MedImpact, the country's fifth largest PBM, Pharmacare, and several others. What we're able to do is to show the real accurate pricing and transparency of each of the medications to the members.

Matthew Holt: OK, so, if I'm a TPA, or more likely I am an end payer, I may actually use that service in conjunction with a PBM contract I already have....

Rahul: That's right. We don't have to be the PBM, you know, it's there...We have a few clients that use it, and with our personal WorldDoc, our clients were able to roll out new, innovative programs and to demonstrate the success and then go ahead and take those to some of our larger customers who are comfortable and happy with their current PBM. The pharmacy data is just critical. It's critical to be able to get the data within 24 hours, and to be able to show the actual price. If you stripped away the conflicts of interest and all the behind the scenes things that occur in pharmacy.

Matt: Right, and there's—I've written a fair amount about that—the typical stranglehold the large PBM's have on both employers and then state governments in many places, and then some of the games that have been going on that more organizations are starting to chip away at.

Rahul: Governor Spitzer, we'll see what he does as governor now, right? The New York governor.

Matt: That's going to be very interesting. Have you been following the University of Michigan situation? Where university keeps out all of the PBM's in the heart of the organization just to run the claims and they've been doing the renegotiations and they found out they should have been saving a load of money by getting rid of Caremark or Medco. Pretty interesting story.

Anyway, let's talk just a little bit more about the progress of WorldDoc as a company. Give me some rough details. You've been there seven years, you have seen a decent client base, you said so, regionally. How many people have you got, what can you tell me about the revenues you have and what your plans are. Just give me a sense of the scale of what you're likely to be doing next.

Rahul: Sure. Well, it's an exciting time for us, Matt. January 2007, we earned our first dollar and we actually turned a profit.

Matt: Woo hoo! [laughter]

Rahul: Yeah! There seems to be a lot more pressure in the office nowadays compared to a year ago, and it's a lot easier losing money sometimes, but when you are growing. It's exciting now, we're just south of half a million dollars of software revenue a month, so we're on a run rate of six million, and we'll likely do eight to ten million this year. Where we're headed, we have perfect relationships with our clients, we enjoy what we're doing, we're constantly learning.

I think our product road map, the direction we're going is to try and automate care management and to empower members, empower people to make decisions, and the right decisions in collaboration with their doctor. That'll take us the next year and a half, and then afterwards, I think what we're moving towards is almost facilitating or bridging care. True care, where if I go see my primary care physician, and I have something wrong with my shoulder, and my exercises at home that I tried on WorldDoc aren't helping me, well that primary care physician, they're not, "Hey, OK, I've got a shoulder issue, what's needed?", they're like "Well, I need to see an orthopedic surgeon."

Well, why can't that primary care physician have a plasma screen with a video and get the orthopedic surgeon visually on the TV and he can see me as a patient and he could diagnose me over the internet? That's telemedicine, and bridging all of that, and bridging the data and information.

Medicare the last fifteen years will take care of that. It's a very efficient, effective service because then the orthopedic surgeon in two minutes can tell me what's wrong with me and suggest, "Hey do I want surgery? No. OK, well, try physical therapy. This is what you can do." Well, great, I'm happy. Those are skills and sculpt that are outside a lot of a primary care physicians' purview.

Matt: Actually, interestingly enough, I was yesterday down at Cisco, and they were showing me they have a new room called Telepresence, which essentially is like... I'll put a picture or two of this up on the blog... It's essentially a big conference room sliced in half and the other half of the table is a sort of bank of these big 5" plasma screens arranged in a sort of a circular shape where the other half of the conference table would be, and literally you're seeing this incredible video. Full-sized, life-sized video, where they're seeing you and you're seeing them. We're very close to getting that, but all over IP. We're very close to getting that kind of thing to be pretty much available, and so it's in the Cisco display room. Now it'll be everywhere in a year or two. I think you're dead right, there's a lot of options to actually get telemedicine and that kind of care integration much more on the forefront of general care. So I think that's pretty interesting.

Rahul: Yeah, just one quick comment. I think it's especially critical for the rural population and then, in many ways, the inner city Medicaid or underinsured. Those rural and inner city function very similarly, in that access to specialty care is very difficult. Telemedicine can greatly improve the efficiency, because the specialist is trained for procedures, but many times they're just needed for a two-minute consultation.

Matt: Right, and then of course the other thing is that they don't necessarily have to be in an expensive city in America, right?

[laughter]

Rahul: That's right!

[laughter]

Matt: There's some little ways to go before we have that done.

Rahul: I'm confident there's probably a few thousand doctors in India that are Board certified in American medicine and already have licenses in the United States and they're sitting in India because they're like, there's less paperwork there, and they're happier their families are there. This is a few years out, but hey, if I could see that person right away for five dollars or ten dollars, I'd love to do that, right?

Matt: Right. That's sort of foreign trade in specialist consults and online second opinions, you know, it's not so far away. People already started talking about that, and you can already get the Cleveland clinic to do an online second opinion and theirs is only five hundred bucks or something, If I could open a place in Thailand to do it for fifty bucks or twenty bucks or ten bucks, yeah, you might be able to do it. Naturally a possibility.

Anyway, let's come back to the real life, to the short term. Just to wrap up, who do you regard as your major competitors in what you're doing? Using some of the same terminology as the folks at Active Care Management and some of the other people, looking at the sort of care management angle Click4Care has been using. Do you think of them as your competitors, too?

Rahul: Yeah, I think Active Health Management, they have a very, very robust care engine built over years. I think their main model is to communicate with physicians or nurses to influence and manage a person's care. We're much more member-centric. I think the large insurance companies United, Aetna, Cigna, Anthem they've developed very robust, personal health records and some nice tools on their web tools. Certainly, we're not going to sell insurance, but we do compete against them for the presence of the portal, to the same client base. Then certainly, WebMD. Still, the majority of their revenue comes from advertising, but an increasing percentage is coming from employers, that purchase employer type portals that have a lot of the same functionality as WorldDoc. I think we're still quite a bit stronger on the pharmacy and the chronic conditions. Certainly, I think, in many ways, that's good for the industry. I'm excited to see that.

Matthew Holt: One of the things I say in my general stump PHR speech is that, when you start getting some serious businesses involved and companies you've heard of, it means that the people have been there for a while and will probably get more validation. When it's only people that no one's ever heard of, then it's much harder to sell something.

Rahul: That's right. People understand, I think, more and more, that you must focus on goals, on getting consumers to have healthy behavior, body-mass index, weight loss, fitness, exercise, diet, all these different manifestations. It's all a good thing.

Matthew: Let's push this out a few years, not so much on the telemedicine, though I think that's one clear area, what kind of changes do you think that this kind of chronic-care management and member communication, whether it's TPA members, health-plan members, however you want to define it, what kind of change will that make to local health-care markets? And you were at Sierra Medical Services before you were at WorldDoc, right?

Rahul: Sure.

Matthew: I think Jerry Reeves was there, involved with WorldDoc at the start, is that right?

Rahul: Sure, Jerry Reeves was our first C.E.O. We recruited him from Humana. Absolutely.

Matthew: There have been some very significant changes in how care is delivered in the Las Vegas market, inspired partly by him and some of the work you're doing at Sierra. My sense is that there's a link between the kind of work you're doing and the kind of peak things that they were doing. Can you talk about that?

Rahul: I was a medical director at Sierra Health Services. Seventy percent of their members choose to go to Southwest Medical Associates, which is their staff owned clinic. They have excellent processes, they were among the first to adopt electronic medical records, years ago, before hospital lists were a common term, Dr. Reeves, who was chief medical officer in the early '90s, put together a hospital-list program. They've all been very innovative, from a hospital management approach. When I was there, in the late '90s, we had a full department dedicated to population-health management. I'm not sure where that stuff is going now.

Many of the ideas that were there early, "How can we improve medical care delivery?", came from my years at Sierra.

I guess in the local Las Vegas market... Las Vegas continues to grow. There is a lot of consolidation of the casinos, which are still the major employers, but there is quite a lot of other employers. With the consolidation, and many of the casinos now having properties nationwide, we're starting to see the United Healthcares here, the Sierra Signets here, with much larger size than before.

Matthew: Would you say that you think that the impact of a WorldDoc type system, whether you or anybody else, but this care management system, with the employers or the TPAs or some third party, essentially a payer, using the data to oversee the chronic care and look at transparency of drug costs and many other system costs, do you think that that's going to be a driver behind some of the increased efficiency in the way care is delivered? We don't have to blame the point here, but everyone knows that care is delivered in a wildly varying manner in most American states and [indecipherable], that there's much potential for increased efficiency. Are you part of that movement, or are you thinking more about just the chronic care services and quality improvement?

Rahul: I think that, big jobs on every level of care, if you think of preventative health, if you're female, "Hey, you need a mammogram, you need your blood tests", get that stuff before your doctor's visit. Get it done before the physical exam. Well, that can be enabled with automated ordering, a tool that WorldDoc can communicate. WorldDoc Recorder sends you your personal health summary, and, when it's time for your annual checkup, it gives you the map, the locations, tells you to call the mammography place, get that done, and then see your doctor. That's much more efficient, much more effective.

I think for acute-care problems, if it's a Sunday afternoon and you have a four-year-old kid at home who has a fever, you have a presentation to give the next day, and the child may need an antibiotic, then you phone a nurse, who goes through a WorldDoc algorithm that says "It looks as if the patient has a sinus problem. An antibiotic would be helpful", and that nurse gets your doctor's name and number and calls the doctor and says "We will authorize $25 to you if you think these symptoms are consistent with sinus disease, and here's the symptoms", and, boom, you have an antiobiotic. That's much more efficient.

For chronic conditions, it's the relentless effort to get people to a goal. A physician is needed for the initial diagnosis and the initial visit management. After that, you should have to see the doctor just two or three times a year, for hypertension, for high cholesterol, for well controlled diabetes. But, every four to six weeks, there should be communication with a nurse or an electronic system to relentlessly get you the goal. Many times, you just need to increase your medication dosage, which could be done by an electronic algorithm.

So, then, doctors are taking care of sick people, they're in the hospital as needed, they're preventing and doing more education, rather than, say, the routine hypertensive follow up, which is a waste of everyone's time.

Matthew: I think it was one of the heads of quality care at Geisinger at the Information Therapy Center conference in September who said that we had too many $200 an hour physicians doing $20 an hour work. I think what you're talking about, and everyone is on this same idea, is how we can drive some efficiency into the system by taking that work out of the hands of highly expensive people and putting it into cheaper people or no people. The flipside of that, of course, is that much of the stuff that goes on that's unnecessary is being charged $200 an hour for... If you start taking it away, you might be looking at people's livelihoods. In some ways, that's the flipside of all of this. But, on the other hand, there's always more stuff to be done. So I don't know whether that would be the end of the story. It's been great chatting with you, very interesting to find out a lot more about WorldDoc. So, unless you have any overriding final comments, let's end it there. Do you have any last messages about WorldDoc?

Rahul: No. Thank you for the time. It's an exciting time, I think, to be involved in health care. There's a lot of change happening, many very progressive organizations are trying to improve health and reduce costs.

Matthew: Yep, and it will be interesting to see how you and all those other competitors and other players we've mentioned will work out in the future. I think it's a very interesting piece, and I've interviewed several of the others. Active Health Management, Click4Care, and some of the other players. I hope I'll keep being able to do that. So, with that, I want to say "Thank you very much" to Rahul Singal. He's the C.E.O. of WorldDoc, a Las Vegas based care management player. Thank you, everyone, for listening, see you on the blog soon.