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Where we share our weekly news debriefs and discussions with industry experts. These are lo-fi recordings aimed at giving our readers more opportunities to engage with our analysis and a view into some of the conversations that shape it.
Martin: We're super lucky today
to be joined by Tim and Dr.
Malick, um, CEO and CMO respectively
of Hopscotch Primary Care.
Rural Health has been a.
Uh, in the news a lot lately, but the
hopscotch primary care folks have been
working on it for a lot longer than,
um, the recent conversations on the
Rural Health Transformation Program.
So we're excited to get their view,
hear more about the business and
also, um, what's going on in the, the
rural health care world at the moment.
Um, first question for, for you
two, I think is on the headwinds
or unique challenges that rural.
Um, healthcare and primary
health or primary care have.
So when I think about it, I think,
you know, it's generally thought
of as a, a hard business to be in.
There's a worse payer mix.
The labor markets a little bit worse.
And so I'm curious to hear from
you, like, what are those, those
things that make rural primary
care so challenging or difficult?
Tim: Yeah, sure thing.
Uh, first, really happy to be here today.
Uh, been been a long time member of
the community and, uh, serendipitous
timing Last night, uh, a friend
and colleague reached out who I
talked to last year, and, uh, just
she wanted advice on a job search.
One of the things I told her was, you
gotta subscribe to HTN, uh, see what's
going on, see what's really happening.
And she emailed me last night
and said she actually got a job
through someone she met through the
community, and she was thrilled.
It was a really high impact
startup that she, it was like a
fits really well for her passion.
So, uh, shout out to Maeve.
Really congratulations as well.
Um, and, and you're right.
We, we have been working on, uh, on
building out a model that is well
suited for rural for a number of years.
And now the policy world is turning
its attention to the, the problem and
problems in, in rural are, are pretty
well documented, but, but really
underdressed, uh, from, from a sort of,
and then that rolls up to a policy level.
Uh, we think of it in a few categories.
Access problems are at large, and you hear
about hospitals shutting down hospitals,
uh, access to hospital services,
inpatient emergency, and the like.
Primary care is a really important
adjunct to that primary care.
Short, if you look at the relevant
HIPSA measures, sort of by any
measure, almost every rural
area has a, a serious shortage,
structural shortage of primary care.
There's a number of structural,
structural problems, whether it's
technology, drive time, and aging
workforce, that is also driving the,
the access challenges in primary care.
Um, and then, uh, a very
high disease burden.
So all of the, the chronic diseases
are significantly higher burden in
rural, in the southeast, we have, uh,
a number of other health burdens that
we, that our patients are dealing with.
Um, it, you know, from our perspective
though, this, this is why we have
built hopscotch the way we built it.
It's a, it's a high touch, high tech
enablement model and model that is
directly solving the primary care.
Access challenge.
We are bringing, we are bringing providers
to rural and small town communities in our
launch market in western North Carolina.
We're doing it in a way that excites
our teams and helps us recruit
and manage our clinical hubs.
Uh, and this makes a, this makes a huge
difference on the lives of our patients.
Uh, and it's a, it's a, it's a
great time to be building right now.
Technology has changed dramatically where
the cost structure of bringing services,
whether it's virtual specialty care.
Or extending the capabilities of
our teams is dramatically easier
than it was five years ago.
And now there's this massive policy
investment in, uh, the form of the Rural
Health Transformation Fund, $50 billion.
That's about 50 x per 50 x
what the Innovation Center
was on a per capita basis.
So a truly massive investment in
transformational care models, technology
projects, uh, workforce development,
and directly supporting access
in the communities that we serve.
Martin: And before we kind of zoom into
your business and, and learn more about
Hopscotch Primary Care, I was wondering
if you could kind of talk to us a little
bit about the Rural Health Transformation
Program and just sort of philosophically
given your vantage point as you know,
working really deeply in this space, like.
How, if you were, uh, uh, talking to
a state, which I'm, I'm sure you are,
um, about how they should, they should
use this money for transformative
purposes, not just backfilling what
they're gonna lose from, from Medicaid.
How would you think about, um, how
should they think about that investment?
Tim: Yeah, I think it's really
important to take big swings here
and to try to directly improve
access, not attempt to paper over,
uh, a system that isn't perfect.
Working to not pour money into
business as usual, essentially.
And so to me that is, it starts
with setting aggressive goals around
improving access and improving actual
health outcomes and mortality outcomes.
Uh, it also starts with, uh, real
thought about how you actually do that.
And, uh, for what we do, uh, that's
directly providing access to primary
care makes a big impact on hospital
utilization, on patient experience,
on patient, really patient lives.
Uh, and extends lives.
And so we've seen, you know, on a
practical level, a number of the states
we've been talking to are setting goals
and, uh, applying for funding around
directly increasing the number of PCPs
per 10,000 population in rural counties.
We've seen significant investments
in topping up and extending
existing workforce programs.
And so these are, you know, national
Health service core like, or, uh,
there's a program in North Carolina
called the High Need Service Area Bonus
Program for Mid-Career Physicians.
These are really significant and they
allow us to directly, uh, to directly
pass through funding and support our
teams in, in tapping into funding that
can help increase their compensation
by very significantly versus what
they could get in, uh, in urban areas.
Uh, and then, you know, the, the
challenges and that, that people
don't wanna live in rural areas.
A lot of physicians do.
They just don't have
access to, uh, the type of.
Practice that they want to, that they
want to work in, uh, that's something
that we're able to do as well.
And then for, you know, the non hopscotch,
you didn't ask about hopscotch in that
question, but like there's, there's a
whole bunch of ideas and initiatives
floating around in, uh, extending hospital
care and bringing virtual specialty
services to rural, uh, and building
out better support for maternity care
and, uh, and other shortage services.
Uh, that, that I think you can.
The, the key to me is just to try
to, try to really move the needle on
a couple of really important things
rather than try to boil the ocean.
Aditi: I'll just add to like what's
so fascinating about this $50
billion transformation fund is the
money has to be spent very quickly.
It's an, it is an a massive chunk of money
that has to be spent very quickly, which
means from a state perspective, you're
looking at warp speed implementation.
And one of the things that states really
have to be able to measure up on is
measurable impact that is sustainable
beyond the five-year funding cliff.
And that's where, to Tim's point.
Investing in business as usual looks
great for five years, but when you get
to five years in a day, what happens?
And so I think there's truly in
the spirit of transformation, this
opportunity to invest in ways that are
super charging investments that can
actually self sustain beyond those five
years, like investments in primary care.
Kevin: Tim, I, I wanted to pick up on, um.
A comment you made about recruiting
docs into, uh, rural areas.
And I'd be curious, kinda as you think
about Hopscotch model and entering
a market like Asheville, like, could
you walk me through, are you guys
like creating a hopscotch tin in the
market and are you bringing docs into
that tin, employing those docs in
the primary care clinics and then.
How, like, how do you think about
that recruiting conversation?
Like, it strikes me that you could go
the route of recruiting docs who have
been in Asheville for a long time with
new care model, new support, resources.
You could go out of Asheville, bring in
docs who are, you know, out of school,
coming in, building out their panel.
You could go to the like
advanced care model startups.
Like how do you think about what
that doc looks like and what that
pitch is like to them when it's like.
To your point on, it's not that
hard to recruit to rural areas.
Like I, it wouldn't take me much
convincing to move to Asheville
and like go live in Asheville.
But like, is Asheville representative
of, like, how, how does that
conversation work across rural markets?
Tim: Yeah, great question.
Um, and I'll, I'll take the
first part of that and, uh, and
working backwards a little bit.
So I had a similar response to you
when, uh, when I was contemplating,
well, is, is Asheville really rural?
Um, the, the c the communities we serve
are not just Asheville, but are an an
hour and an hour and a half drive in,
in every direction from Asheville.
So we are really in mountainous
Appalachia and a, a number of small and
midsize towns surrounding the region.
Um, and, and so we, we have have a lot of.
Reps, even in our first launch, uh,
community, uh, where we have really gotten
to understand what we need to serve these
clinics and these, uh, these areas that,
so that they can be successful both from a
talent and from a care model perspective.
Um, the, you know, there are a lot
of communities like that look like
Asheville that are, you know, sort of
medium, medium-sized, medium-sized town
surrounded by a lot of small towns.
Uh, all over the Southeast and the
Northeast and the, the southwest.
So this is a, a pretty common
dynamic as we've looked at where we
go next and the, the, the question
on like, how do we enter, how do we
begin working with a a, a care team?
Uh, we have found, uh, this was
a, this was a light bulb for me
that, that makes a lot of sense.
You, you think about the
decline of independent.
Across the country, a very well
understood story at this point.
That's a combination of it and
contracting and the difficulties
of running relatively complicated.
Small, small businesses at this point,
um, that has hit rural especially hard,
where physicians who have been, uh,
leaders in their community and running
solo or two member practices for 30 years.
Don't have anyone to hand
their practice off to.
They, they can't find a succession plan.
And so there's a lot of patients that
are sort of on the verge of losing their,
their family medicine doc who they,
they haven't, they've known forever.
Uh, and that that family
medicine doc is already drowning.
Uh, and so our opportunity and what we
can provide to the, those physicians is
a natural transition plant into a care
model that is very appropriate for their
patients, and that is very high touch, and
that that makes a huge difference in their
lives, as well as just the, the basics
of continuing to provide access, right?
Flip side is we can provide a
place where physicians will want to
work and not have to have the full
responsibility for everything running.
And it's a family medicine
practice on their own.
Um, and Dr.
Malick has done a lot of thinking about
how that, how that evolves as we begin
to, uh, as we grow and as we, uh, wanna
recruit more and more from both from
the region and then from the, from
other parts of the country writ large.
Aditi: Yeah, agree with all of that.
A couple things I'd add, just
Kevin, to your question of
like, where do folks come from?
Are they native to Asheville?
Are they relocating?
We do a mix.
We've done a mix.
I'd say that the core components that we
look for are clinical excellence, care
model excellence, like somebody that
can understand how to, how to operate in
a, in a full risk provider environment,
and then people leadership excellence.
The what?
What draws folks to us?
I think where our value proposition
to physicians and clinicians is
the strongest is a couple things.
One, we are, it's, it's way more fun,
just literally like the day to day
of working in a clinic where you are
fully capitated because you're not on
the fee for service treadmill, right?
Like our, our docs are not seeing 30
patients a day with 2000 patient panels.
So people have the time to actually
get to know their patients.
Like my favorite thing that our docs
will say to me is, oh, this is how I've
always wanted to practice medicine.
Um, and the, the.
The business model, right?
The capitation, economics that
underlie that makes that possible.
Um, the other thing is the tooling.
It's, you know, and, and Tim
alluded to this, like this is not
the independent and primary care
practice that I grew up watching in
the eighties and nineties, right?
Where like, you work 80 hours a
week, you are your own, you're your
own contractor, you run your own
payroll, you pay all the bills, right?
Like we handle all of
the back office stuff.
But alongside that, again,
because of the underlying
capitation model, we're able to.
Staff these clinics in a
way that's really effective.
And so it's both the staffing
model and then the, the
technology that underlies that.
So I'm a huge believer having been a
primary care doctor, like I saw patients
in our Spruce Pine clinic two days ago,
like the ability to have technology and
tools that WIC away the administrative
garbage, frankly, that is burning
out doctors at unprecedented rates is
something that we take really seriously.
So that like that's how
you actually make it both.
There's an appeal to living in small
towns and you know, like better cost
of living, better work life balance,
but coupled with a practice environment
that actually is fun and sustainable.
Martin: Yeah.
Before we get into, oh, sorry.
Before we get into.
Care model.
Um, I have another question on the
human, human capital side of things.
So, Dr.
Malach, when we first spoke, you
talked about these entry points to, um,
like the, the different entry points.
I was wondering if you could
kind of share with the audience.
The different routes that a doctor
might take to, to considering a move,
um, a move to something like hopscotch.
Aditi: Yeah.
I have often described, um, medical
training or the medical profession of
like, it's like being on the freeway.
Freeway if you're on the
West Coast highway, if you're
on the east coast, right?
But like, there are defined exit ramps.
One of the most clearly defined exit
ramps is when you come out of your
postgraduate training or residency.
So there's a, there's an off ramp there.
'cause like.
You gotta get a job, right?
You're either getting a job or
you're going onto additional
training, like you're staying on
the highway to go into fellowship.
That's another exit ramp.
And then beyond those two exit
ramps, it's pretty stochastic.
So it'll, you know, people will move for.
A spouse is changing jobs,
a family illness, right?
Like the people move and obviously people,
people change jobs, but the, the window of
opportunity from a recruiting perspective
is the widest open at those exit ramps.
And so one of the things that we're really
working hard to build is the pipeline and
the partnerships, um, to be able to, you
know, alongside our university partners
or alongside folks that are actually.
Training the next generation of
clinicians to be a place where
those people can actually then come
and, and work for years to come.
Kevin: One of the things I'd be, I'd be
curious to pick up on and this, so we
had town hall folks on a couple weeks
ago fund and it's very AI centric forward
and they, they talked hopscotch one.
Kinda leading examples of, um, of what
they think is going on in the ai AI space.
And I'd be curious if you guys
could share a little bit about how
you think about that technology
tooling, how AI is changing that.
Obviously we, we read the news and
hear about, you know, there's a,
a group in South Carolina that's
expanding, uh, their urgent care slash
primary care model because there's
more coding opportunities for them.
Um.
We hear a lot about ambient scribing
and whatnot, but I'd be curious if
there are, like how you may framework
perspective, think about implementing
AI as an organization and then if
there are any tactical use cases that
you could talk to where you've seen
particularly strong impact of it.
Tim: Yeah, for sure.
I'll, I'll, I'll start and then, uh, Dr.
Malick can, uh, can speak to some
of our favorite clinical use cases.
A, as I mentioned, we, we find it
tremendously rewarding to be building
these types of services and the supports
for our, our, our clinical hubs right
now, as opposed to several years
ago because the technology is, yeah.
Having fought the EMR battles for like
two, two decades at this point where
everyone was fighting every step of the
way, it's creating friction and to like.
It, it's, it's flipped on its head.
We, we still have to go through really
careful governance and implementation
processes, but like we're, we're tr
we're aiming for interventions that
delight our care teams and our patients.
And we're, we're having a pretty good
track record on that at this point.
And ambiance grads really
are a game changer.
Just the sheer amount of
like, it, it's another.
It shows up in our patient feedback
and patients notice that their
doctor's ta talking to them,
not talking to the keyboard.
Um, we, you know, by virtue of being
in a, in a capitated business, we
have the opportunity to leverage
automation technology, including
AI sort of across the full stack.
So wherever we have significant
administrative work going on, rote
routine work, yes, with the care teams,
but also with back office staff, all
sharp prep, all sort of the entire.
Uh, the entire flow before and after a
patient visit, or even before and after
we get a patient engaged with us, we
have the ability to, uh, and have built
a team that's capable and ready to deploy
technology to dramatically simplify and,
uh, leverage the every member of the team.
Um, we, you know, I,
I will tee up, uh, Dr.
Malick to, to talk about one of my,
this is not ai, but like one of my
favorite solutions is this, like, it's
always been a desire to have, uh, rapid
virtual specialty consults available.
We finally have solved it where like
we can actually get consults from 20
specialists to, to expand the, the scope
of what a primary care doc can do in a
visit within just a couple of minutes.
And, and it's awesome.
Uh, and, you know, really, uh, high
support from the care teams and, and you
can see like how it can save patients
months of wait times in many cases.
Aditi: Yeah.
I'm happy to jump in maybe, um, Kevin,
to the first part of your question of.
Like framework for how to think about it.
I think about it as AI is
supercharges the care model.
So there's, there is no
substitute for human connection.
Like, call, call me crazy
and old fashioned about this.
But like even in the era.
Of ai, like we're not replacing
the humans anytime soon.
We are giving them additional
teammates that can supercharge the
best of clinical care alongside
the best of human connection.
And I think of like three
specific domains where AI in the
care model is really valuable.
The first I I sort of talked about is
just like cut out the administrative
garbage that like takes up time
that nobody wants to do, right?
Like ai, ambient scribes are, I
think the perfect example of that.
Um, we've seen in our own data.
Um.
Over over 80%.
I think it's about 85% of our PCPs use
an ambient scribe over 80% of the time.
It decreases pajama time.
It decreases the amount of time they
have to spend in the charts, right?
It's like a rare case of a win-win win.
Um, the second big bucket is around
making care more effective, right?
So we can now use ai.
To level up and exceed the standard
of care around chronic disease
management and other things.
And then the third is where, um,
where, um, Tim left off around AI
being able to supercharge access.
Um, so, you know, like we, 20% of America
lives in rural parts of the country.
There are some people that'll tell you,
oh, well the future of rural healthcare
is like, everybody gets a chat bot.
The, the hospitals will take care
of all the procedures and like, you
know, like you take, you stitch those
two things together and like, great,
you've now solved the access problem.
Um, but like two days ago I had
to, I had to drain an abscess.
Like who does that in the world of AI
chat bots and, and hospitals, right?
Like there's, there has to be the
primary care layer, like the primary
care layer that's so important there.
But what AI allows us to do is.
For example, care managers become
that much more effective, right?
They can touch that many more people.
Mm-hmm.
Remote patient monitoring
becomes that much more effective.
And in the example Tim gave, we, we
partner with a platform, not AI specific,
but in the broader theme of technology
and tooling where, um, our PCPs, our
docs, nps, PAs, can pull out their phone.
Type in what's colloquially known
in medicine as a curbside consult
and get a response from a board
certified specialist in under a minute.
And that saves the patient from
having to drive, you know, an hour
in any given direction, very often
saves them a trip to the hospital.
So takes cost out of the system,
delights patients, improves access.
Martin: That's a perfect lead in
to my question, I guess, about
your care model specifically.
So if I'm thinking about a
hopscotch primary care clinic.
Um, what does that staffing look like?
How is it, you know, how are you sort of
geographically spread out in the area?
How close is like one clinic to another?
Um, and yeah, how do you staff it?
Tim: Yeah, the, our existing footprint
is generally in the region, Western
North Carolina region, uh, 30 to 60
minutes, one removed from another.
So we have pretty, we have solid density
in the, the markets in which we operate.
And, um, you know, I've been
spending a lot of time around
the rest of North Carolina.
Um, uh, we, we have connectivity with,
uh, with and really good visibility
in the region, and so people I talk
to in rally, almost inev inevitably.
Have a parent or a relative
who's one of our patients.
And so we, it's been really important
to us to go deep and to be, you know,
a, a, you know, a good partner to the
existing healthcare infrastructure and to
be additive to, uh, to the access there.
Um, we, uh, as Dr.
Mallek mentioned, we spend a lot
of time making sure that we are,
uh, staffing our teams effectively
and that we are bringing talented
leaders into those teams and then, uh,
supporting them well, uh, we, we do.
We have, uh, generally call them
three to four, uh, provider,
uh, clinic hub locations.
And so, uh, these can support, uh,
Medicare panels of 2000 plus, uh, once
they're fully at, uh, study state.
Um, but they, you know, it
takes, it takes time to grow.
One of the unique features of these
markets that's sort of obvious
when you think about it is like.
There is such care desert, uh,
nature to these areas that, uh,
they, there's a lot of demand.
You open up, people will come to grand
openings, people will come, take tours,
have partnerships with the YMCA, we
do a variety of community events.
So it's an, it's a model where it's
unusually easy to get people in
the door, and then you demonstrate
that you can provide a good.
Quality service, and they're,
they're very engaged and loyal.
Once they get to know our teams,
many of them have relationships
with our care teams that predated,
uh, predated our clinics.
Uh, but you know, that, that, that
shows up and we can really establish
long-term relationships and, uh, get
to know our patients very well, manage
them better and better over time.
Um, Dr.
Mal, is there anything you wanna call out
about, uh, staffing or anything that's
different from, uh, your prior experience?
Aditi: Um.
Um, yes.
So what, what I'll say is just like
within a, within a given clinic, just
maybe bring it to life, um, a medical
director alongside an operational leader.
It's important to us because we
do track metrics really closely.
So you've got somebody who wears that
clinical leadership hat alongside somebody
who wears the operational leadership.
Um, the two to four PCPs typically.
And then we have, um, not necessarily
co-located in the clinic, but
sort of quasi decentralized
or hybrid across the region.
Transitions of care nurses, case
management, nurses, um, community
health workers, um, and the like.
And so that, that's what allows
us to be able to do not just.
Um, good primary care on the medical
side, but to be able to get ahead
of very often the social issues that
can land people in the hospital or
lead to, um, utilization downstream.
So very much a team-based model.
Martin: And given the rural nature of
the business, how do you think about,
you know, like referring to hospital,
like the curbside consult seems like
a great application of technology.
I would imagine though there's
still times when someone needs
to like go to the hospital.
How do you think about, you
know, as a capitated provider,
building out that referral network?
Aditi: Yeah, I'm hap I'm happy to start.
It's very much a partnership driven
and so like you're absolutely right.
You can, you can, a cardiologist
can tell you how to.
Titrate a beta blocker, but like you
can't cast someone over the phone, right?
So there, there are things that
you're always gonna need to go,
um, to a hospital setting for.
Um, and we, um, we have around each
of our clinics and sort of in the
broader region, um, great relationships
with our health system partners.
And so, um, we're continuing to build
out or continuing to think about,
uh, preferred networks of sorts.
But we have some of that already in place.
Tim, what would you add?
Tim: No, I mean, I think that's
right, that you, obviously you
have limited options in, uh,
in rural parts of the country.
So you, you work with what you've got.
But, uh, I think establishing
relationships so that there's
continuous care management and follow
up after, after any, uh, inpatient
or acute utilization is, uh, it's
really important part of what we do.
Kevin: So now that we've got two minutes
left, I wanna tee up one last really big
meaty topic, which is value-based payments
and how all of this gets compensated.
I, you know, conceptually I've got
this mental model of this country
doesn't pay independent primary
care and off across the board.
Rural health, that problem is exacerbated.
So the, the model is generally underwater.
That's part of what causes
the financial problems.
That's where it makes sense that cap,
global cap contracts come into play
to help with that economic structure.
I'm sure you guys have seen public
markets, private companies, the issues
with V 28, global cap models, the kind
of retreat from that, and now this
like more thoughtful entry into risk.
I'd be curious if you guys could share
how you're thinking about supporting
primary care payment models, what
percent of the business is global cap,
how you think about kind of what ideal
unity economics look like from your
perspective supporting primary care.
Tim: Yeah, no, I, I think
that's exactly right.
And so we, the way we think about
it, it's a co a couple things I
point out, like one, we're, we're
an entirely post to V 28 business.
Uh, we, we really have, uh, scaled up
only over the last couple of years.
And, uh, neither Dr.
Malick nor I joined this business
because we are interested in being
like the best coding operation, right?
Like it's important to fully
understand our patients.
Our patients have very serious.
Problems.
And, uh, it's essential to have a
risk adjustment system that rewards,
uh, rewards capitated providers
for taking care of sick patients.
And I think that we're, uh, we
see that, that the V 28 world
works just fine for that, and the
economics work very well for rural.
Regions because you have lower costs
of inputs, you have lower cost of real
estate, uh, and a variety of other
contributors that, that are tougher
to deal with in urban, including what
we talked about earlier of the, the
demand side dynamics of patients,
uh, are loyal once you prove that
you can take good care of them.
Um, a broader, broadening the
lens a little bit, I think that.
Uh, the, we have, we're in sort of
a trough of a cycle right now where,
uh, the, there's been a number of
strategic challenges at the, the
highest levels of the industry.
Um, but as we look over a period of
decades, going back even to the nineties
and before, we think the best primary
care businesses have generally been
built on a capitated infrastructure.
Uh, it, it is what really aligns
incentives and provides resources to
overcome what you described accurately of
the historic underpayment to primary care.
Uh, but, but we've seen consistently
in, you know, whether California,
Pennsylvania, Wisconsin, Tennessee,
that the best primary care and group
practice models have been built
on this type of infrastructure.
And we are, we see ourselves as
bringing that type that, that best in
industry standard to rural communities
starting in Western North Carolina.
Martin: Kevin, I'll
just interject quickly.
I think we have them for 15 more
minutes so we can Oh, we do?
Yes.
Kevin: I thought we were done
at the bottom of the hour.
Perfect.
Martin: Um, which is great because
there's, I think a lot of, of things
we can talk about on this question.
I'm taking that broader lens.
Can you kind of talk a little bit about
your payer mix, um, and how you sort
of, is it, is it mostly on the MA side?
Do you do Medicaid and are you doing
taking risk on Medicaid patients?
Can you give us kind of a flavor for that?
Tim: Yeah, our, our clinical model is
senior focused, and so the, the core of
our work right now is in, uh, Medicare and
Medicare Advantage patients, and so we,
we do take risk across our entire MA book.
Um, we have, uh, above 50%
penetration and Medicare Advantage
in Western North Carolina.
Uh, and we are also in the REACH program.
So, uh, between those two, we, we
have very full, full saturation
of our Medicare panel for the,
the type of contracts we need.
Um, we do also, uh, care for, uh, some
Medicaid patients and some under 65
commercial patients, um, in, in areas
where we have either made a practice
acquisition transition, um, and where.
We have, uh, maintained continuity
of care for those patients.
Kevin: I'd be curious what that looks
like having, having worked on some
of these models before and thinking
about like, you know, the grand
opening events in the community,
whatnot, and how, how that shows up
in the community and feels for Doc.
Like, if somebody comes in and says,
Hey, like, I want care from you guys.
How do you, how do you navigate
that dynamic when it's, you
know, somebody under 65 whatnot?
Like, what, what are your docs doing?
Are they still seeing patients?
How does that work in local communities?
Sure.
Tim: Yeah.
I think this is a little bit of
a, a now versus what could be
in the future question as well.
Like we, we have a, you know, we were
really focused, uh, intently on proving
that our care model works for the
populations for which it was designed,
which is, which is the Medicare and
pri, you know, primarily the over
65 Medicare and duals population.
Uh, that, that's been a tremendous
amount of work and, uh, and we're
really seeing the results of that
right now in terms of performance.
Extremely high performance on
quality ratings, extremely high
patient satisfaction, extremely
strong improvement on MLR.
Um, we do see as I'm, as I mentioned, a
number of patients that are not in our,
our sort of risk comparing contracts.
And so, um, the, and we, you
know, do our, our darned best
for those patients as well.
Um, in general, like, you know,
community and, uh, other family medicine
practices are happy to have support
and happy to have additional capacity.
And so I see us as, uh, you know,
just like we're not trying to take on,
uh, all hospital services ourselves.
What, what we're working on right now.
Is a major need, uh, care for
seniors with chronic, with a
variety of chronic conditions.
Um, over time I do hope to roll in
additional, uh, service lines that
we can really focus on growing.
Um, and that's an ongoing
conversation with the state and
with our, uh, payer partners.
Martin: I'd be curious to hear
a little bit, I feel like.
You know, when we talk to folks who are
taking, taking risk, it's like for a, in
a normal risk con, or not a normal risk
contract, but in a, like the, the typical
risk contract, a lot of the game is
like, how do we avoid admissions and, uh,
unneeded or unnecessary ER utilization?
I'm curious if there's any kind of
discrepancies or, or oddities specific
to the rural population that make that,
that different or, or more challenging.
Dr.
Malik, do you wanna take this one first?
Aditi: Yeah, I'm, I'm happy to.
It's largely pretty similar.
I mean, if you think about to Tim's
point, so many of the, so many
of the communities that we serve.
Prior to our arrival, the primary point
of access into care was a hospital.
And so you, we see tremendous
impact of our care model just by
catching people sort of upstream
and in a different site of care.
And so spot on that, on the utilization
side, like the familiar drivers that you
pointed out of keeping folks out of the
emergency department and keeping 'em outta
the hospital is really important, I think.
The, so it's, it's a similar set of
patterns as what you might see, let's
say, in a more urban area, but it's, it's
amplified in a rural area because there
are limited access points into care.
I'd say beyond that, the other
thing we focus a lot about is.
Expanding the, the full scope of primary
care so we can be the place where our
patients get the most comprehensive care.
So I gave you that abscess example, right?
Could a like, you know, if you were
in a, like I, I trained in Boston.
In Boston, you would send that to a
general surgeon, but we don't need to,
we have, we have the ability to do that.
Within our four walls.
And so it's, it's both a shift on
inpatient utilization, but also really
maximizing the scope of comprehensive
services available in primary care.
And we see the same cost pressure
that, you know, I think everybody
like Mercer will tell you this.
Any big employer will
tell you this, right?
Like, um, uh, part B drugs, right?
Like specialty pharmacy is
an area we have to look into.
And that again, is not, it's not so
much that it's different in a rural
area, it's just, I think the way you.
Solve for, it looks different
for us than the way you might
solve it in a more urban area.
Martin: Yeah.
Um, Kevin, it looks like
you had a question, or maybe
he's frozen, looks frozen.
Uh, it looks like he's frozen.
So one of the other questions that I
had, um, is I, it feels like in the.
Rural Health Transformation
program application.
There was a lot of talk about
advanced scope of practice for, or
like a changing scope of practice.
I'm curious what this looks like
in North Carolina and just sort of
generally what's your philosophy on,
uh, you know, nurse practitioners,
physician assistants, pharmacists
and, and, and, and apps like that?
Tim: Dr.
Malick, you start.
I've got some thoughts as well.
Aditi: Yeah, I mean, like, I, I say
this as a physician, and this will
probably be a controversial thing to say.
Maybe it won't, like there
aren't enough doctors.
So like if, if we continue to
live in a world where we say,
well, doctors are the only people
that can provide this care, like.
First of all, too expensive
and not enough of us, right?
So we're just headed towards like,
there's a very obvious supply and
demand mismatch problem there.
Um, that when left unchecked
is only gonna cause.
Like continuing, um, continuing upward
cost pressure and access problems
that we already find ourselves in.
And so I, you know, when you,
when you zoom out, I don't think
there is any better option.
And I say this having been a policymaker,
like there, I don't think there is a
better option than to say we need to
think thoughtfully about how we expand.
Scope of practice and making sure
that people can operate at the top of,
top of scope and top, top of license.
And so when I, you know, our, our
model certainly we have wonderful nurse
practitioners, physician assistants
on our teams in North Carolina.
The, um, the certification bodies require
a supervising physician and there's this
very state by state as you no doubt know.
Um, but hey, welcome back Kevin.
We were just talking about, um, scope
of practice for advanced practice
practitioners, um, and the, in North
Carolina there's requirements at, at,
uh, the certification bodies that are
at the state level around supervising
physician and frequency of case reviews
and that sort of thing that we have
sort of baked into our model, but also
allows us kind of flexibility as we enter
different markets in different states.
But like globally, I don't
see a way outside of.
The access shortages that we find
ourselves in beyond being able to, uh,
broaden scope of practice with appropriate
oversight and supervision, um, to make
sure people get the access they need.
Tim: Yeah, I would, I
would agree to all of that.
I, I think CMS has been very
intentionally, really, this is
like a multi-decade project, right?
With CMS, uh, wanting states to figure
out a way to expand scope consistently
for, uh, for non-physician practitioners.
And, and we certainly do prefer the
expanded scope rules, uh, while respecting
that there, there's a whole bunch of state
equities and considerations that come up.
Uh, but the, the CMS
process has, it has really.
Ignited a lot of, uh, vociferous
conversations in the states
that we're, that we've seen.
Um, I think you've seen that in,
in, uh, the handful of policy areas
that that CMS identified as well.
Uh, they, they, they're
taking on certificate of need.
They're, they're looking at promoting
healthy behaviors and exercise programs.
Um, but I, I think that that
is having its intended effect.
There's a lot of, uh, a lot of, uh,
policy discussions happening in state
legislatures and, uh, administrations
right now on these exact topics.
Oh, the the other, the one other
thing I would say is we are huge
proponents, and this is a real
pain point bordering four states.
Of, uh, we, we need to make it
dramatically easier to get licensed
in a state that you are adjacent to.
And North Carolina has seen policy
progress on this last summer that
they're joining, uh, one of the,
the big interstate compacts for
physicians and nurse practitioners.
Uh, but like, it's just way too hard
to recruit someone from Tennessee to
get them to drive 30 minutes over the
border in North Carolina, get a license.
It, it takes like six months.
And this isn't like a
North Carolina only issue.
Aditi: It took me six months to
get a North Carolina license.
I've been licensed in five other
states, and it still took six months.
And so to Tim's point, right, like
if, again, like we're staring down
the barrel of, of an access problem,
but we, and for a good reason, I'm not
saying we need to blow up licensing,
but you know, the idea of somebody
has been licensed, credentialed and
has a relatively impeccable record,
it should be much faster than it is
in practicality for that person to be
able to ramp up in a different state.
Kevin: Can I ask what, what actually takes
the six months in a process like that?
Like is it just waiting on an approval?
Like where, where is,
where does that time go?
Aditi: Um, yeah, again, from
like painful personal experience.
So, um, uh, first of all, you submit
every document ever about you.
Mm-hmm.
Um, so like from, you know, age 18 to,
you don't need to guess how old I am,
but it's, you know, it's been some time.
Um, and then you wait.
Maybe you get a, maybe you get an email
or a phone call that says, uh, Dr.
Mulik, we see that you didn't submit this
thing from when you trained at blah, blah,
blah place, or, you know, so there's,
there's some amount of follow up around
just what I imagine is a documentation
checklist, frankly, on their side.
And then I think it's an incredibly
human labor intensive process.
So like, like talk about things that are
ripe for automation possibility, right?
Like it is literally a human that
I, I imagine sits there and reviews.
Scores and scores of pages now
for individual applications.
Um, and so I, my sense is the bottleneck
is just like entirely labor shortage or
just the sheer volume of time it takes.
Kevin: Yeah.
The things you learn.
Aditi: Yeah, that's right.
Kevin: One of the, um, topics I'm curious
about in the industry these days is
kind of the, like going back to the.
Flow of VBC dollars, um, and tying it to
compensation model of physicians, like
how the, the, the VBC performance actually
impacts comp for providers in these
practices and the types of conversations
you're having with those providers
around, here's what the model is, here's
how you drive performance in the model.
And, you know, I, I know some
practices share savings with their
providers and like, how do you guys
think about that philosophically?
What are the conversations you're having
with docs and the practices about.
What these VP C models mean,
what performance means and
how does that impact comp?
Tim: Yeah.
I, I will start on this one 'cause
I, I want to, you know, intentionally
keep this relatively high level, uh,
'cause some of this stuff is obviously
sensitive for our team members.
Sure.
I, I think it's really important
to me that we pay our teams.
That we pay our teams well and
fairly and that we, when we all
succeed, then everyone should
be compensated accordingly.
And that will mean different things
for different parts of the care
team and different parts of the
management team and what, what we
call our clinic support center.
Uh, so I think that getting alignment at
appropriate levels around, uh, whether
it's, uh, performing on a, a particular
clinical initiative for care team members,
and it could be a welcome coordinator,
someone who's really driving patient.
With our care teams, uh, might
have appropriate incentives
attached to something that's
discreet within a quarter.
Uh, versus I think it's also
important to roll up for, uh, for
clinicians who are really impactful
in affecting overall, uh, mar market
or community or hubs performance.
Uh, they should also be compensated
for success on those metrics as well.
That might be much more longer term.
They might be multi-year in nature.
Right.
So it is something we talk, we
spend a lot of time talking about.
Because I think it's really important,
one, just to, to be, to be fair, and two,
uh, to be very aligned, uh, economically.
Uh, but then two, to have a really
attractive, uh, value proposition so
that we're, uh, paying, paying well in
the market, and then ideally with the
help of those public subsidies, leveling
up significantly what our team members
could get if, uh, working with us
versus, uh, working with a, uh, someone
in, in Chattanooga or, or Charlotte.
Aditi: I wanna draw a contrast here.
'cause I worked in a large health system
that was part of an A CO model and one
of the biggest failures of the payment.
Funds flow in that model is
your, like, think about the
behavioral economics of it.
You're relying on the provider
at the point of care to be doing
all the right things, right?
Keeping people out of the hospital,
doing all the quality screenings, like
checking all of the boxes for what
we all believe to be high value care.
They reap none of the
rewards of that, right?
Because the a CO gets the money and
you know, and maybe you get a check.
Six months later, you're not sure
what metrics it was tied to, right.
But so the, the people doing the work are
not the people that benefit financially
from positive outcomes of that work.
And so, to Tim's point, one of the
things that we take very seriously is
an alignment of incentives around the
outcomes that we know are gonna be
best for the care model, best for the
business, and making sure that those
incentives translate at all levels.
Martin: Now we are actually at time.
Um, and so I want to first of all
thank you both, but for people who are
curious and want to follow the Hop Scots
story, how can people get in touch?
Where can people find you on the internet?
Tim: Yeah, look, look us up.
Hop Scot's Primary care.
Uh, Dr.
Mallek has an increasingly prominent
social media presence on LinkedIn.
Uh, I'm trying to keep up.
Uh, and, uh, you know, we'll, uh, we,
we've got a few other social channels, but
at LinkedIn and, uh, and our, our website
hopscotch, uh, primary care, uh, which I
think is actually, and this is, uh, it's
uh, I believe we are at Hello Hopscotch.
Am am I right on the public
facing version of that?
Aditi: We are indeed.
I'm also chuckling, Martin.
'cause like generally it's not hard
to find people on the internet.
But, but yes, um, LinkedIn
or hello hot scotch.com
would be lovely.
Um, yeah, please do reach out.
Would love, um, would love
follow ups as, as you can tell.
Um, we love talking about this,
like always happy to chat.
Um, Tim and I are former government
officials, like always happy to chat.
Government programs.
Happy to chat.
Um, happy to chat.
Rural Health, happy to chat Hopscotch.
Appreciate you guys for the time.
Martin: Yeah,
Kevin: thank you guys.
Thanks so much.
Thank you
Martin: so much to chat.
Bye.
See you,
Aditi: bye.