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.