Asynchronous Care

- Hi all. Thanks all for joining. This is really fun and I'm really excited to do this panel today. Today we're gonna be talking a little bit about asynchronous care, which is a care modality that's exploding around the country, but still a relatively small and under-discussed way of delivering care. Obviously relevant to a lot of folks here. We have two awesome panelists who I'm gonna pepper with questions and let introduce themselves. First is Dr. Jason Chirichigno, who works at a really cool organization called Galileo. Jason, I'd love to hear a little bit about who you are, where you're from, and how you got to the point you're at today.

- Great, thank you so much Rishi. Thank you so much for everyone being here. Really appreciate the time taken out of your days. It's really a privilege and honor to be here. Like what Rishi said. My name is Jason Chirichigno and I am an internal medicine physician by trade. I was born and raised on the east coast in New York City and I was lucky enough to train in New York City, trained at Lenox Hill Hospital, was at a great three years, decided that I didn't want to be a specialist, I didn't stay back to be chief, but came out and started my career at the time at a very small place called One Medical, which was kind of big in San Francisco and big in New York. Really thinking about how we reimagined primary care. Was lucky enough to help support the Los Angeles district for about eight years, growing from just two of us and a couple patients to a lot of us and a couple hundred thousand patients. But there was really always something gnawing at me in the back of my heart and in my brain. We always talked about delivering high quality care really to everyone, but honestly it was really limited by our brick and mortars. When you have an office in Beverly Hills and Santa Monica, you're really excluding the rest of Los Angeles. So I really said, I need to do something different. The pandemic comes through Los Angeles and I reached out to One Medical's founder, who's now the founder of Galileo, and I said, "Tom, I think you're doing something different." And I sneakily snuck in and caught a shift in July of 2020 and in four hours, and this is not hyperbole, I saw more patients of color, more patients asking to speak another language, more patients who couldn't afford Cobra on our little mobile app. And just the beginning that I did in eight years prior to that. So I knew that really lit up my mission and we'll talk about this moving forward, Rishi, but for too long I think telehealth, digital health, whether it's synchronous or asynchronous, has really just pat itself on the back for just improving access. But we have to really start pairing access with quality and making indent and helping systems and save money. And also when I'm thinking about talking to you guys in the ER, I think it's an incredible way which we'll talk about to really kind of collaborate together to help to prevent these ER visits don't need to happen. And then on the back end follow up as well. So I see patients at Galileo seven days a week, just a couple hours, and then I help build bigger picture systems, things our Spanish language access program. And then I really get to help explain how we're different than traditional telehealth and how we really think of ourselves as a digital medical practice. So happy to be here. Thanks for having me.

- Amazing. There's a lot that was said there that we're gonna dig into and especially interested to dig into Galileo's care model, where async plays a role in it. But I'm gonna save that for a second. Dr. Deepa Ravikumar just came on. Thanks Deepa for joining. So just for my conflict of interest, Deepa was my former assistant medical director at Mount Sinai, helped train me. So just so everyone here is aware. She now has a really cool role at Ro and Deepa I would love to hear just a little bit about you, your background and how you got to where you are today and what your current role is like. We may have lost Dee, I just saw her face disappear, so I think she might have had just some connection issues, which is okay. Jason, back to you, you mentioned a bunch of really awesome stuff. Can you tell us a little bit more about Galileo and specifically, I know there's two sides to Galileo, where the side you play on, how that goes and the care that you deliver there.

- Yeah, absolutely. There is two sides. Just real quick. There's one side of the business that really focuses on the sickest of the sick patients, whether that be in urban areas or very very rural areas where we have a model where people can go into the home and it's a collaborative model with social workers and all of the above, which will ultimately be integrated with the digital model. So I work on the digital side of the business. I'm licensed in all 50 states in DC, 51. We started five years ago, very simply direct to consumer. And then we've been thinking and really moving into working with one of our largest people we work with, United Healthcare in the ACA market and making sure patients who really can't afford very expensive health plans, have access to care all across the country in about 12, 15 markets right there. So what we do is we are a mobile app, where people can, if they're just direct to consumer, can pay a very minimal price of about $250 a year for unlimited access to us. And there's no claims associated with this. This is just a running conversation on all our cases. But then we built this into really the first virtual health, virtual first health plans. So if you're thinking about this, if you're a United Healthcare, ACA patient, say in Florida, and you have one of these virtual first plans, we are essentially your PCP of record, so we really want to handle everything for you. We're gonna connect you, we're gonna start working on your diabetes, your hypertension, and really dig into the longitudinal issues. And then we can work within their network to get you to a specialist when needed. But also, just so you know, at Galileo we've essentially melded primary care with specialty care. So we're really trying to decrease the amount of time that a patient has to spend at a specialist's office, decrease the spend, decrease the miss from work. So when I'm on the platform, I can say, "Hey, I have a patient with infectious disease issue." I can ping in real time our own internal specialist, say Dr. Kerr, I have Rishi, I think he has this condition, I'd like to use this medication, I'd like to use it for seven days. And the collaborative model we've really built allows us to say, hey, the patient then doesn't have to relay the conversation again to have anything lost in translation. There's no labs being sent out, there's no faxes being sent with referrals. And then she can come back to me and say, "Jason, you know what, you have the condition, you have the medication. You might have missed that paper that came out in the journal last, two months ago that says you can actually take that course from seven days down to three days." So that's the internal model that we've built. And then the patients moving forward, which I'm sure we'll talk about, the piece for me that is really most meaningful is asynchronous care in so many ways really flips the paradigm for me. When I think about my 10 years in the office, I was delivering care on my time on One Medical's time. When you move to an asynchronous model, care is delivered on the patient's time. When we step back for a second and look at statistics on when patients are utilizing us, it really varies, 50%, 5% of the care might be delivered outside the traditional doctor's office hours. And this is something that we really pride ourselves on. Also really partnering with local PCPs, it's very important to me. I'm not the business person. I'm the doctor. I wanna make sure that we support community relationships, whether that be in a hospital, whether that be with hospital specialists, whether that be with local PCPs. So we're collaborating all the time. A PCP is now built up an office where they're backed out for six weeks. Let me handle that one blood pressure medication refill, and then close that loop for you and the patient.

- Yeah, amazing. So essentially Starters, the primary care clinic has a couple different arms. Now building more of a multi-specialty practice group, but you're really firmly passionate about the primary care and really delivering quality care via telemedicine and async.

- Yeah, sorry, go ahead Rishi, yeah.

- Yeah, no, I think there's a ton more to dig into there. I see we got Deepa back. The internet gods have let her back. Deepa, I gave you a little intro and told everyone here that you trained me. Do you mind telling us a little bit about yourself and your current role?

- Sure. It's nice to see you again, Rishi, and also to see all of you. Thanks for joining. So I'm Deepa Ravikumar. I'm an emergency physician who previously served as the associate medical director at the Mount Sinai Hospital where I can't take full credit for Rishi, but maybe some partial credit. During my time at Sinai, particularly around the COVID pandemic, I did develop and implement synchronous and asynchronous telemedicine workflows across our systems, emergency departments, urgent cares and outpatient clinics. This was really my first exposure to asynchronous telemedicine. Definitely saw the direct value for asynchronous telemedicine in decreasing emergency department and urgent care utilization. In terms of my background, I went to medical school and residency at the University of California San Francisco, received an MBA from Columbia's executive program. Currently I am the VP of clinical practice at Ro, which is a direct to patient digital healthcare company designed to help patients achieve their health goals across sexual health, metabolic health, fertility and dermatology. So definitely a shift away from urgent care and emergency medicine. I oversee more than 80 physicians and nurse practitioners who are licensed across 50 states in DC and they deliver care through Ro's proprietary platform that seamlessly combines the telemedicine experience, diagnostics and pharmacy.

- [Rishi] Amazing. So you have the health system angle and now private entity angle. Deepa, I'm gonna stick with you for the moment and Jason, I'm gonna ask you the same question. So this is a room full of mostly ER docs, mostly those who have some experience delivering traditional telemedicine, synchronous bi-directional audio, video. And then there's a ton more experiences in the room too. But just for folks who maybe that's their core experience, what is asynchronous care?

- Yeah, I think definitely all of us are at least familiar with synchronous care. So asynchronous care, on the other hand, is a store and forward method in telemedicine where patients electronically transmit their medical information to a provider. That provider uses that information to evaluate the case, render some service outside of a real time or live interaction. So for example, patients can submit health information by answering dynamic sets of intake questions or sharing photos or videos through a patient portal, and then their provider then reviews the information at a later time. I think that in terms of how we're using asynchronous care at Ro, we are continually actually refining the asynchronous care delivery model for both patients and providers. We take state regulations into consideration of course, but the vast majority of our care delivery on our platform is asynchronous. Our providers review these dynamic online visits, they collect structured health information, they make treatment decisions, they manage side effects, they counsel patients all asynchronously. I think something wonderful that Jason called out to is this idea of doing it on the patient's time or the patient's watch as opposed to being limited to when our clinic hours are open or when our providers are available.

- [Rishi] Yeah, no, that makes a ton of sense. And I think something that I want to grab onto there is this notion of structured health and giving the patient the scaffolding to tell you what their issue is. And I know the way you guys do it and the way a lot of other folks do async maybe as opposed and to Jason's company and how they do things is this notion of smart forms and people entering intake information to then give a legible history to someone a provider. Can you talk a bit about that? Maybe on the patient side and then as the doctor on the back end, what do they do and then what do I do as the doctor who sees something like this?

- So when patients answer questions through a structured format, you can imagine a very extensive intake visit is possible, when they answer questions in a certain manner, you can have the system ask appropriate follow-up questions. You can actually tailor that patient's journey through the online visit, which is what makes it dynamic to really elicit the most pertinent aspects of the health history that would be relevant for treating that patient. So the way that our providers use this, and this is where I say that actually asynchronous care, there's a thought that there is something lost in asynchronous care. I actually think that the vast majority of our providers feel that this is a safer, more consistent way to obtain a patient history from a patient, even more so than a live synchronous conversation.

- [Rishi] Hmm. And I just wanna dig into that a bit, why do they think that?

- I think as opposed to a live synchronous interaction where the conversation may wander, you may not get to all of the contraindications, both absolute relative considerations to prescribing and treatment in such a systematized fashion as you would in an asynchronous visit. Oftentimes things can be missing in a synchronous visit where an asynchronous visit would've actually captured that very consistently across providers. I've definitely seen this utility when we're scaling our services at Ro and trying to standardize the way patients receive care through 100 providers across 50 states.

- [Rishi] Yeah, you can imagine something like standardization is a lot easier. And I've had this, did the resident ask every PE risk factor question? Do they ask every red flag back pain question? Maybe, maybe not. I'm gonna go ask the same questions anyway. Judd has its hand up. Judd, I'm gonna get to you in just a second. I want to give Jason a chance just because I think your model over at Galileo is a little bit different than direct to consumer like Ro is. For you if I was gonna ask you what is asynchronous care? How would you answer that question?

- Yeah. And first these are incredible answers and I stand behind all of them. I think it's very interesting. I love to give the highest level asynchronous care is care delivered on the patient's time. That's number one. But then we can dig in everything she just said is critical, so I tell this story a lot. I think about myself in the office for 10 years and the very first question I ask when you walk in Rishi, what brings you in today? And it's a fantastic question to start the conversation, but because of all the things she talked about, I'm four or five steps ahead when I'm at Galileo. So first we're thinking about taking technology. Now again, I'm not the engineer, so I can't tell you to do this. The system understands that there's a very big difference between Rishi, I'm gonna give this up now Rishi, who's a 20-year-old male with one medical condition. The system already knows versus a 75-year-old male with 10 medical conditions and they're typing in the same complaint. The system can then tailor those questions. When I think about myself on a good day in the office, maybe I asked 30% of those questions, on a good day, due to my limited time, we're talking seven to 15 minutes in the office and due to my limited memory, just we've all trained and worked very, very hard for a very long time. But that's what that is. Those questions are the critical piece of the intake, and then again, there's a very fine line. So Dr. Ravikumar will also talk about this, building true intakes that don't overwhelm the patient. Of course you can be extensive. You have to make it so that it's engaging and that they continue to the answer appropriately. Then the ability from there to digest that. And then honestly, I'm probably about 80% of the way to a diagnosis just from that intake because they were the critical questions. Because the tech side built in understanding that when an 80-year-old male answers like this, it means this. When an 18-year-old female answers like this, it means something very, very different. So you combine those two things and then I know this is not the full scope of this. I do think though it's very important within an asynchronous world to have that ability to transition at any given moment. We do this a lot and what Dr. Ravikumar was talking about before, this is not to micromanage providers, but when we're thinking about standardizing care, yes we spend, we really pride ourselves on really delivering complex longitudinal care, the diabetes of the world, the hypertensions of the world, the anxiety and depression. But when you focus on things like UTI, cold coughs and flus, we spent a year looking at how that's delivered. I can see now that if within four exchanges of text messages that that was not solved with IE prescription or a trip to the, somewhere else pivoting to video solves it 95% of the time with that next move. So that's the level of detail you can build in. And then on the backend you can build a culture like Dr. Ravikumar was talking about, with this group of providers that's built on collaboration and feedback. This is what we do every night. I've been to the doctor for 15 years. I'm on the platform seven nights a week. When I hop on the next day, Rishi, you say, "Hey Jason, I see that you saw Carla yesterday, you did A, B, and C. Why did you do C, have you thought about D?" And let's be honest, that does not happen day to day in and out in a primary care practice anywhere. Just 'cause you can't do it 'cause the system's not built for that. So you take a system now or you getting patients who haven't had access to care, high quality care and now you're giving them access to high quality care where providers are continuously learning and I'll be the first to admit, I've learned more working collaboratively as an asynchronous physician in the past four years than I did on my own in the previous 10. So that's, I think some of the beauty of asynchronous care, all the things Dr. Ravikumar is talking about with the added bonus of the way we can collaborate on the backend.

- Yeah, that's something I've never thought of. And something that's amazing is that because you have this written record of everything that was done, everything the patient told you, everything that you spoke back or typed back or then transitioned, the quality infrastructure that you could build into that becomes super duper rich 'cause otherwise what do we do? We take 72 hour turns. Did you click the sepsis button on time? You're, the sort of now you're really in the patient interaction. You can say what did you actually say and how did you say it? And then what was the outcome from there?

- I think it's a lovely thing for the patient as well. When we're sending prescriptions, we built our editorial team, the medical team has built these, I'm sure Dr. Ravikumar is the same, these incredible care plans. Rishi, I've diagnosed you with this, this is what you're looking out for. We can then build in check-ins day two. Were you able to pick up your prescription? We're picking up social determinant health issues on that day two check-in. Day 14, whereas in the office, the diabetic on metformin would just stop taking the metformin. I would never know. They show up at month three and their A1C continues to rise. Now I know on day 14 that they're having side effects. We can switch to ER, in real time we can move to nighttime for different things. So we're really able to head off a lot of issues in this asynchronous world. Especially as the patient really understands that the doctor's visit is no longer confined by the walls or the time, it is a running conversation when you're asynchronous as long as the patient needs.

- Yeah, I think that's really powerful. You wanna get to Judd, but I think this notion of extending the, especially for ER docs, so we think about acute care and acute care episodes, extending the acute care episode from the four, six or 12 hours. You're in my ER and then you're not my problem to work. Let's check in over days and see how this goes and use time a little bit. And I suspect it gives folks a little more freedom and a little more room to breathe clinically to not say I have to admit or discharge this patient, but I actually can check in on them tomorrow and see how they're doing. Check in on the next day, see how they're doing. So I think that's really powerful too.

- I do wanna echo that Rishi just for one second, which is something that Jason spoke about which was so spot on I thought is this idea that it really extends the visit and extends the impact that we can have on the patient. We think of telemedicine as almost removed, but asynchronous care really bridges the gaps so that we can actually follow up with patients on their own time as they're experiencing their treatment, potential side effects, questions that occur along the way. It really extends the reach that we have with the patient and almost allows for I think, superior monitoring to an in-person interaction with a provider.

- Totally. We have some amazing questions coming through the chat. I wanna start with Judd 'cause he had his hand up for a while,

- So, my initial comments earlier on is I have no trouble believing that asynchronous interaction could get a lot more detail than a synchronous interaction or an in-person interaction. But my thoughts have evolved to, in listening to the two of you speak, do you really have anything special besides caring and follow up? My experience, and I'm gonna be very bold and say all these provider networks that exist, that do broad-based care on their own, the kiosks, they all sooner or later fail. Some of the big networks that were brought for billions of dollars, half of those clinics are now closed. And I believe the reason that is, and this is just my belief is because they're not linked to a health system. I know because we've surveyed our patients, they couldn't give a damn about seeing an academic doctor. They just want to see a care provider. So they're not wed to us, but they are wed to having continuity of care. And so you guys have a fantastic front door and Ro probably has a more narrow front door where there's less referrals. Galileo probably has a need for more referrals at the end. But I listened to you and what you describe and geez, if we were a health system that wanted to do that in our region, we should be able to do that. So my question is, is your secret sauce, technology or is it actually just caring and follow up and devoting yourself to that? And that is then tied very carefully to the payment model because if you are taking all cash and I at Jefferson can't take all cash because I have a deal with that person's payer and I have to take their insurance, does that make it impossible for me to do what you are doing even if I wanted to and had the resources? So kind of complicated rambling, but I'm curious to hear your thoughts.

- Dr. Ravikumar, do you wanna go first? I wanna make sure you wanna pick. No, I--

- You can go.

- Either one. I think it's a, Judd, I think it's a critical question and one I think about a lot, I've been lucky enough to have the privilege. One of the other things I do, which I didn't mention is I get to go out as the clinical person on all of our sales calls, and those sales calls are with health insurance, health insurances, those are with health systems and those are with employers. So I really understand these concerns. So first the, answer your first piece, all the things you mentioned are important. The caring, the dedication, all that. Yes, there's a mission associated with this in general. That's number one, the technology piece. And I think the ability to really drill down on the level of quality of care is very different than an in-person setting. But I do ultimately think you're right and we are moving this direction. We do want to be paired with the health system. Absolutely. And I'm actively doing this right now across the United States. We did this at One Medical, we thought it was critical. We're gonna do this at Galileo as well because we need those super academic resources. We can continue to partner together to take care of the day to day. But I'm gonna need the subspecialist, the super subspecialist at times who's not on my platform. But again, so for our piece, I think it is the caring, it is the technology and the way we can really I've never seen, I don't, I'm sure it's out there somewhere, but I've never seen the degree to which we actually manage clinicians who are willing to be managed like this, the level of detail on the weekly day to day on the feedback that they get. So I think that's a different piece compared to the general PCPs in the world. But I do think ultimately we will need health systems as well. Hopefully that answers a little bit.

- Yeah, to follow up on that, I do think that it's more than the care and follow up. I think that the technology does play a lot into this. I think that the way the dynamic intake process flags comorbidities, contraindications, considerations really does lend itself to providers being able to evaluate patients with ease, document in a way that is sound and follow up with patients that's more tailored to that patient's experience. I think that the technology is something that can be borrowed by outside health systems. To your initial point, Ro does focus more on condition-based care. We are an adjunct or complimentary to your primary care physician, not intended to replace your primary care physician. That being said, I do think that the positive interactions and the positive outcomes that patients have on our platform do flag them to conditions that they otherwise may not have understood that they had or realize that they had. And we do encourage and help plug folks into primary care and to larger systems. So I think that's how we relate to larger systems at Ro specifically.

- Amazing. Jason, I think you got one more thing I want to go back to.

- I forgot one last thing, Judd, sorry. I've sat with a lot of these health systems and really it is a decision that they can ultimately make, is this worth the investment? It's a big investment in time and a big investment in money of building their own. We're in talks to, we can white label things for health systems and then reconnect through their systems where their specialists could be part of our team and vice versa. And then I think about this as health systems wanna expand their reach in counties, we're thinking about Georgia per se, I wouldn't name the actual place there, but as they want to move out, they don't necessarily need to open primary care clinics. We can then be essentially the PCPs in these extended communities and then feed back into the system as they build more and more systems. But I think it's really kind of 50/50 out there in the world right now on the health system side, about half wanna build their own and see what that's like with their own internal team. Other half are like, hey, these people know what they're doing, they've been doing it for a long time through multiple organizations, let's go ahead and partner with them. So we'll see how it pans out. But I think we're, it could go either way.

- I think one interesting piece in health systems is asynchronous care, I think we can say is a bit ill-defined and a little vague. It can be smart forms, it can be texting, it could be a whole bunch of stuff. But there has been one form of asynchronous care that's grown tremendously over the past 10 years, let's say. And that's in basket messages to PCPs. And what we hear about this is that our PCPs can't handle it. They're overburdened, they're blowing up, they don't know what to do with it. Why hasn't our current, why haven't the health systems already leaned into this type of care? Why can't they handle it? What's different about it? Jason, maybe I'll start with you.

- Yeah, no, it brings back such memories for me. I think One Medical was one of the very first digital PCP organizations that allowed email and I think back to myself day one post-residency starting as a brand new attending. And I loved it. I used it as my method to really to write these summaries before the technology was there to say, "Hey Rishi, we talked about this. Dr. Ravikumar, we talked about this, let's follow up on this at this time before the tech was there." But then as we know, year one becomes year two, year becomes year nine, when I have this enormous panel, I could not handle it anymore. And now again, in the back of my mind, one of the biggest concerns when I moved to Galileo was I'm moving outta this individual model where I base all of our connection on this individual, but I realize now the ability to handle those messages 24 hours a day distributed across a team is the way to do it. There's no other way to do it, especially when you're scaling. So I think if you build strong teams as a baseline, the ability to communicate amongst the team, build your own EMR so that way you're not just taking things off the shelf that can actually teach the providers how to communicate with each other and delay this information. And then as you're scaling across the country, I know there's some questions about different regions of the country, build smaller teams within the larger team across the organization who really know that subset of patients. And then you can really handle those pretty well. So I think it's coming for all these health systems and I think we'll partner, but the email burden has been way too much for the individual provider across the right, of course.

- Yeah. Yeah and I think it gets at Judd's question, which is really deep, which is when you have this group that's been trained and learned and practices in this pretty confined way, can you break out of that? Or do you have to bring in a partner? Our health systems are gonna try to build this until they're blue in the face, but do they have the capability? I don't know. I think that's an open question. Deepa, you have both--

- [Deepa] I have--

- [Rishi] Rishi--

- I was also gonna, oh, sorry, go ahead.

- I was gonna say you have both points of view. You came from the health system, you're outta the health system now. How would you react to that?

- Yeah, I think that something that I am just noticing with the differences is that again, the burden is definitely being placed on providers in the outpatient setting with the use of email, chat in a typical outpatient setting. That's what I'll say. I think what our providers find very valuable about it is when we're able to effectively integrate technology and as Jason mentioned, the appropriate people to help manage this load or this inbox of the patient having constant access to their providers. So I think that this is a place where AI and LLMs will be integrated into platforms in the future to augment a practitioner's impact, hopefully reduce burden on a practitioner by helping practitioners identify key concepts within messages, personalize their responses, even manage more common questions that come a provider's way. I do think that this is a big space for AI and LMs.

- Yeah, absolutely. Deepa I'll stick with you 'cause Satta had a really interesting question in the chat. And then Jason, I want your answer too. We think about advocacy in this group a lot, sort of pushing for telehealth to be more permanent, the flexibilities that were made during COVID so we can build the right CPT codes and get paid for the work we do. What is the business model at Ro and how is it similar or different to the one that you saw at the health system?

- Sure. So Ro's business model is different, as I mentioned, we're direct to patient or direct to consumer. So what that means is that patients who are, who come onto the platform are evaluated for appropriateness for some sort of treatment or intervention. And then we're paid in cash pay. So for the Ro body program, which is our metabolic weight management program, we do work with patient's insurances in terms of gaining coverage, but ultimately the business model is direct to patient or cash pay. So it's very different than what I saw on the inside of a traditional health system. So yeah, I think that Ro's business model is, although we work with insurance, is primarily cash pay.

- Yeah, totally. And that just to state the obvious allows you to not need a CPT code to do the thing that you do. When you're cash pay, you can deliver the care that you wanna deliver, you can record an EMR, whatever you want, but it opens up the ability to do what you think is the right thing rather than wait for congress or someone to include some way of billing.

- Yeah, that's right. I mean, when we work with insurances to get coverage for our patients for certain treatments, we definitely get involved on the insurance side through CPT codes, diagnostic codes, all of that. But again, given that we are not limited by that alone does help us with the flexibility.

- Right, right. Raises obviously some equity issues, but that's why we're here to have those tough discussions. Jason, how about you? How does Galileo make money?

- Yeah, just like Dr. Ravikumar, we started as direct to consumer as well, at a relatively very low price point, about $250 for the entire year, unlimited access with no claims being made. But then after that we're really agnostic to insurance. We really play in all the fields, so I can walk you through just a few of them, working with United Healthcare and the ACA market, where we actually built a virtual first health plan. So we are built in and literally if you purchase this plan, we are your PCP of record. Also, we go in for things like risk with these big health insurance companies, we're gonna make sure we're meeting goals. There's always money on the table for meeting goals on colonoscopy screening, diabetes management. We also work across in Medicaid and Medicare, we are building very specific programs across the country in places like New Mexico with maternity deserts, with certain health insurers to make sure we can help pick up on these patients and deliver some virtual care and to make sure they're being covered. So across the gamut, we also are doing things like working with small employers who are self-insured to build things called MECs, minimally essential coverage where they get emergency room coverage, but they're also getting Galileo as a benefit to be their PCP. So again, I think we really see the gamut of this across the way. We also work with employers on a per member per month, per employee per month, where they're covered, but then also their family's covered. So we're really agnostic. We wanna really cover as many people as we can through all different models.

- Hmm, got it. Yeah, so you're very much in the business of figuring out insurance and you fully moved into that world. Yeah. I wanna get to Carly's question, which is really good and maybe Jason, I'll stick with you here. All 50 states, both of you organizations, these states have totally different practicing environments, antibiograms, medical legal issues. How do you deal with that?

- Yeah, this is a critical one and the legal issues were worked out a long time ago, this stuff is actually out there. It takes a while. It's not all in one place, but I understand and know that the state of New Jersey requires a video visit to establish care prior to doing any text, interacting, with certain other states as well, whereas a state like California, you can just engage right away so that's been worked out and there's always a team continuously thinking about that. There are nuances, certain medications are classified differently in different states. I cannot prescribe Neurontin, Gabapentin in the state of Kentucky the way it's classified in Kentucky as opposed to California. So there's medical teams and legal teams always on that. Then this is the piece I think is really beautiful and critical. Our patient support care navigation team spends an incredible amount of time understanding communities. When I was building our Spanish language access program, we knew that we were gonna be with United Healthcare in these five major cities and the surrounding suburbs. I know that right outside of Miami, these zip codes, this is a Cuban Spanish community. Okay, so we're gonna dig in, we're gonna look for providers who understand communities, we're gonna understand the nuances. So there's a lot of work being done continuously based upon where our patients are. Now, of course, do I have every zip code the US dialed down to who the best specialists are everywhere? No, we're working with that, we're growing at that. So if we're preparing to sign a deal and say Montana, we're gonna spend a ton of time understanding the local community, understanding the resources, understanding things like the antibiogram, and then really dig into that. So it's a work in progress. And then we've also, just we've broken up our teams into different regions as well and they do very specific subspecialized work focusing on those regions per se.

- Yeah, awesome. Thanks for that. Deepa, I feel like the answer might be similar for you, but I wanna pose the same question to you. How do you manage that expansion?

- Yeah, I think that a key here is the technology and of course the ongoing legal efforts to understand state regulations. So the way we apply asynchronous care varies from state to state. As state regulations change and get updated, we're able to integrate that pretty seamlessly into our platform so that our providers don't have to think about it or worry about it. So you can imagine what this means is that depending on the state, additional counseling or different treatments that may require different types of questions or considerations, that is almost baked into the provider and patient experience on a state to state level using the technology.

- Yeah, right. That makes a lot of sense because one person can't keep this all in their head, so you have to build systems around them to support this care. Deepa I wanna stick with you just for, I'm sorry it's me. I wanna stick with you just for the moment just 'cause I know you're an ER doc, I know your heart and soul's in the emergency department, as is a lot of folks on this call after you've worked with this technology more, seen smart intake on the pure async side. What gets you excited about how this can impact emergency medicine? Where do you think in five or 10 years we're gonna be, are you think we're gonna be using this in the ER? How do you see that going?

- I think that there are multiple ways in which asynchronous care could and should impact the way that our communities think about usage of emergency departments. I think first of all, asynchronous care could be a gating mechanism in the sense that maybe avoiding unnecessary emergency visits, that's a key one that we're all affected by. I think when patients have more seamless access to care that is outside of the emergency department, I think that that's a good and a positive thing and can definitely mitigate some usage of the emergency department that may be less effective or less useful. In terms of within the ER I think, or within the emergency department as a whole, I do think that there could be some ways to integrate the asynchronous concept as we bring patients in, as we triage patients. And of course most importantly through follow-up coordination of care, adherence to recommended treatments, all of these are ways that we could, as you said, extend the reach of that finite, hopefully finite ER visit. We can bake in asynchronous care there. So I do think that the overall impact on the patient experience could be significantly improved through the use of asynchronous care when we specifically think about its emergency department usage. I also think that there's a whole idea of helping to avoid those unnecessary visits or visits that might be better served elsewhere.

- Yeah, yeah, I do think there's a bit of tension here and Judd and others probably have spent decades thinking about this and I've spent just a couple months thinking about it and that it's these low acuity visits tend to keep the lights on at a lot of ERs. I see a UTI in the fast track section and I think, man, this is a bit of a failure of our healthcare system, but talk to the person responsible for the finances and they'll say that sore throat, that UTI, that keeps the lights on here, we get to charge a facility fee for that. So I do think we in the telehealth world broadly think about this a lot, but there is some tension to doing something outside of your site of care and quote unquote losing the revenue or losing the business there.

- Well there's also, I'll add to that Rishi one of the biggest problems, and we know this to be true from surveys for our direct to consumer on demand Jeff Connect platform is it's like a direct to consumer marketing campaign. They don't remember it exists unless they have, unless they see it when they're sick. So sending out mail is saying, remember this when you're sick, the natural reflex these days is go to the ER. So, and which is why, I mean I love this story. I run a chain of urgent care centers too, but when I was first opening them a decade ago, had a conversation with Don Healy at Pitt and Don described to me at their Shadyside hospital, they opened an urgent care center literally across the street from the ER, saw 120 patients a day in six months. And their ER volumes continued to rise because people still, where can you get one stop shopping as miserable as it is and used to be four hours now maybe it's 12 hours, you go home and you kind of know as much of an answer as you're going to get. So the challenge for us, although I agree with you on the finance side, if we're in a chaching model, we still want that revenue, but it's how do you get the patients to be satisfied doing something else? And maybe more importantly, how do you get them to remember it at the time when they're sick? And it's super, super hard to do those things.

- I think that's a perfect question for Jason, and I want Jason to jump on that because this is something that you guys do every day. You don't want that Galileo patient going to the ER across the street. You want them to topping on the app and giving you that problem. But I also Judd, I like the phrase one stop shop and the ER is that, it just solves every problem for most people if you're willing to wait for it. But maybe, what I'm hearing more and more in this conversation is that we need a one start shop, maybe just the place to, the right place to start for everything is right and then we can get the patient to where they need to go after that. But if that start place is really trusted and really valuable and gives you good advice every time, maybe that's enough. Jason, I'd love to hear your reaction to what Judd said.

- Yeah, these are such great thoughts. I love the concept, we've all talked about the digital for front door, but the one start shop. But I really do think this is an incredible place for primary care docs in the ER to finally start collaborating. I don't, granted I've only been a doctor for 15 years, but I don't think it exists. I really don't. And I think there's a few ways we can do this. And to answer Judd's question, it's not a direct relationship, but I spend a lot of time thinking about engagement on say something much simpler than someone being sick going to the ER. But on the employer side, I sell to an employer, now all of a sudden 100 employees have access to this new service. How do we get them to actually download the app and actually get engaged? And there's a bunch of different ways we do this through, I'll get on a call, a couple webinars and walk through the app, explain what we do. But you're right, it's not until they actually have that first experience, which is a positive experience, we try to make it as positive possible, welcome video visit and take care of an issue. I think there are ways to do this ultimately on the sick side. They just have to have actually experienced it first. So it's something that has to be there, it has to be advertised. But I think on the backend, which could be the downstream solution to this is what I really envision is when I see a patient leave an ER, there's always, hey, please follow up with your PCP within three to four days. Now 40% of the United States does not have a PCP. This is a great place for ER docs and PCPs to collaborate. Again, I'm not trying to sell Galileo here, I'm just talking about the concept. But something like Galileo, if Judd has that and says, "Hey, you don't have a PCP, you can try this tonight." And we can work out a way that would be free to the patient. Someone would get paid somewhere and they can just start engaging and we can have that. We have visits for post ER visits and it's a much longer visit, 30 minute visit where we sit down, why'd you go to the ER? What went on in the ER? Did they add any medications? Are you taking all your medications? That's the kind of stuff I think can really game change 'cause then they now have an established trust relationship where they've actually had a video with someone, they know they can get us. We're having this talk at two in the morning east coast time when I'm in California at 11. And then it prevents the next ER visit. It takes trust, but I think we could definitely build it over time. It's gonna take a little while to see those results, but I think we could definitely decrease the number of inappropriate ER visits with things like post ER follow-up being done through a virtual telehealth solution. Just some ideas.

- Yeah, and I think it's really where this sort of artificial wall between our specialties breaks down a bit and we see this in the language around telehealth itself. I've run a, or just ran a virtual urgent care, which is an urgent care that we're just gonna put in the sky and, but it's an urgent care. It's not a primary care office. But what if we wanna do some primary care? And I think what we've learned about telehealth and async, whether it's async, whether it's video, is that you start breaking some of these barriers down and it's really not as simple as what specialty are we putting in the sky? It's really what kind of care are you doing? How often, what touchpoint is this? How much responsibility are you taking? You start asking bigger, more general questions that are hard to answer and they don't fit cleanly in something like a hospital department, and I think that's why stuff breaks down a bit. I wanna welcome more questions in the chat, so keep throwing 'em in. I wanna ask Anthony's now, just so we get to it, has there been any thought on the connection between care like this and remote patient monitoring? Maybe I'll start with you Jason. Do you guys do some remote patient monitoring at Galileo? Does it tie into your care model?

- Yeah this to me, I always thought when I first decided to come over, I thought this would be like the panacea of all things. But as we know, this is complex, a continuous stream of data where we go. I think at the moment, we're still very targeted, working with our diabetics in our sub diabetes program on CGMs, ingesting all this data constantly can, as you guys all know, can provide a whole slew of other issues. It's interesting, I was thinking about, I wonder what you guys think as ER docs. This is not scientific, but when we're thinking about simple things like pulse oximetry, blood pressure and scales, I would guesstimate, based upon seeing patients across the US that, well over 60 to 70% of patients now have all these devices at home so I'm at least getting vital signs with each visit if I need them. The next level of Apple watches and CGMs and Ora rings. I don't think we're there yet, to be honest. And I think that companies say that they are might be fibbing just a little bit, but this has to be an integration in the future. And I think that Dr. Ravikumar said, maybe this is where AI really helps me as a clinician. It ingests all that data, it presents it to me in a nice package. It alerts me that Rishi is having this run right now and I can engage you, but I don't think we're quite there yet.

- Yeah, yeah. And I think this is, it's what I've been getting across the board is that we have a real signal to noise problem with RPM right now and everything depends on the population that you deploy it to, but we've all sat in emergency departments with monitors beeping the entire shift and can you imagine that across 5,000 or 5 million patients, I agree. I just don't think we're there yet. Deepa, I'd love to hear your reaction to that, especially in the context of Ro moving into more of the metabolic health GLP1 space. So as you're taking that more longitudinal angle to things is RPM something you're thinking about?

- So definitely always exploring different applications of RPM. I think like you said, the signal to noise ratio can be challenging and especially filtering that information to providers. How do they apply it? How is it relevant in their management of different conditions, verifying the data. I think that these are all considerations that we think about when integrating RPM into the Ro experience. So for example, when we're thinking about integrating Apple Health or CGMs or remote weight management, all of these considerations come into play about accuracy of data, the utility of that data for actual medical decision making or clinical decision making and how to counsel patients based on that.

- Yeah, that makes a lot of sense. We're coming up, we have 10 minutes left and I wanna leave time for questions, but I wanna ask one question first. Both of you have mentioned AI and large language models separately. Where do you, these systems, both your companies I think were founded before ChatGPT came out onto the forefront and we started thinking about conversational AI in the same way we do today. What AI or anything else in the next few years, what do you think these types of technologies open up for async and your companies and your care models in general?

- The way we think about utilizing AI and large language models is not necessarily to replace providers, but rather to serve as an adjacent to enhance a provider's impact. I think that, for example, we explore using AI to help better tailor answers to patient questions, understand more about what our patient concerns are. So these are all applications that we think about when integrating AI into the asynchronous experience in particular.

- Hmm. You're not currently having a chat bot talk to a patient right now?

- Correct. At this time we're not having that. We have people who are again, assisted through AI actually answering the patient questions.

- Yeah, yeah. And I wanna get to Jason here, but I think as we talk about this world, something that I keep thinking about is medical education and those folks, the residency folks, because right now, in a really basic way, a smart form is presenting a patient to you and you're an attending and you're reading the answers and you're judging their, if it's good, if it's bad, what else you want to ask. And you're, and this is almost the relationship I've thought through with this technology. And I think with these chat bots, I think we're gonna sort of get more how we're gonna evaluate them. I think maybe a little bit how we evaluate medical students and residents. Are you an interpreter? Are you a history gatherer? What are you doing in this space? So I think that's really powerful. Jason, how about you? Where do you think this is going?

- Yeah, it's such a great point. I think also, it's interesting. I'm lucky enough to get to speak to so many people interested in what we're doing and asking these questions a lot. And there's really such a push out there, even though people understand where AI can take us and all the positives, they still we're in medicine and they still really want that human connection. they're so often they're like, what is the initial intake? Is it always doctors? And I think that's the piece. It really has to still be, but just what Dr. Ravikumar was talking about is really enhancing the clinician through so many different ways. And I can think about this right now. When we're thinking about finding misses in cases, so you said before, everything's laid out for the clinician, but so clinician still has to follow through on that. So setting the AI back into the system to pick out where these errors were, I think is a fantastic way to help educate and teach so we can identify these things and then again, standardize how our providers do this. Also, it's the same concept, right now we've built a lot of this, our care plans in terms of what is the highest level of quality care for these particular conditions that can be automated in the future as opposed to people doing research. So I think there's a lot of space we could use this for education, you mentioned, to help continue to update us and what we need to know, and then also really to help give the providers feedback as to what they're doing in real time.

- Yeah, you gimme three amazing quality ideas during this talk. And I think that's incredible because when I was a resident we did this and it was just me doing chart review along with our 100 residents. It's, look at every intubation that we did in the department. Let's look at every, and it's, wouldn't it be great? Wouldn't it be great if AI could just do that, crystallize the learnings and then feed it back to us so then we can act on it. And that's I think really the promise of this technology moving forward. Anthony's got another question that seems pretty inside baseball, but we're gonna go through it. Reimbursement reduction for these types of services, specifically 9928 X codes going away. Anthony, if you're here live and you wanna jump in, and I'm not super familiar with these, but if you wanna speak to that, speak to these codes in particular a little bit more.

- [Anthony] Sure. So, sorry, I'm not on video. I'm out and about today.

- It's okay.

- [Anthony] But so 9928 X codes are the codes that we use in the emergency department for emergency department telehealth and for in-person encounters as well. My question is more, I heard in the future those may be going away on the next physician fee schedule that CMS releases, but it's more of adjacent question to that is, do you have any worry that the codes that you all are using for follow ups are potentially gonna go away? Is there gonna be a general overall reduction in telehealth reimbursement started by CMS and then maybe followed by the private insurance companies. Is that something that's on your radar? Is there anything that you're doing to lobby against that?

- Yeah, no, I think this is definitely a concern. I always get the acronyms mixed up, as to which law was enacting what, so apologies it was extended for a little while. Then there's the concern, if that goes away, do you then go have to go back to a fee for service model, which I just don't like. I think over time, my hope is this that we can prove these things out. Again, I don't want not gonna give away the whole sauce here. And when we're working with large insurance companies, we can decrease costs. If you're doing digital medicine correctly, in the past, what's happened is it's really served as a waste station just to continue to refer, I'm not gonna talk bad about any competitors, but there's a lot the history of it. The primary care is not as in depth as it needs to be, but if you can really reduce costs over time and continue to prove that out, I think these codes will stay around. Right now they are, you're absolutely correct, there is talk about them going away, but I think this will bear out that truly complex digital, primary and specialty care that can be done outside of the facility, which ultimately save the collective system money, which will allow these codes to stay. But then again, we have to continue to think about alternate payment methods, sharing risk or different ways while they're debating this. So it's definitely out there. Similar concept to controlled medicine prescribing via telehealth, there's been back and forth and there's been a lot of positive outcry, but let's continue this and held onto it for a little longer. So I think we'll ultimately win the battle, but we might lose one or two more. We might have one or two more losses along the way, is what I'm thinking.

- Yeah, makes a lot of sense. Deepa, I know you guys do a lot of cash pay, but is this on your radar?

- We definitely have a legal team that advocates for billing reimbursement considerations of different modalities for telemedicine across states. So I don't know if this specific issue is on their radar, but it is something that we consider, which is just looking at the landscape as a whole. Where is telemedicine evolving? How can we attempt to influence it in what we believe is the right direction with more not only acknowledgement but embrace of different modalities and reimbursing for them fairly.

- Yeah, absolutely. And to Jason's point too, when you start solving people's problem in a lower cost care environment like digital and actually saving someone money, maybe it's time for us as a specialty to think a bit outside of CPT codes, how can we move past fee for service medicine and get in the risk game as emergency physicians? This is a personal bugbear of mine. So Anthony, I'm gonna hijack your question there. I wanna leave the last couple minutes for pure open floor. Just see anybody jump in, ask whatever you want and I wanna say thank you to our panelists. This has been just an incredible and awesome hour. So thanks for giving us your time today. Thank you.

- [Shivam] Hey, this is Shivam. I'm one of the, thank you so much to both of you. I'm one of the ER residents at Mount Sinai. I've been fortunate enough to work with Rishi and learn a lot from this panel and him as well. I guess one question I had is, where, I think we touched a little bit upon medical education, but where do you folks see the integration of telehealth, virtual care, asynchronous care for trainees, for fellows, et cetera?

- It's a fantastic question and I hadn't really given much thought, but just randomly yesterday some recruiter reached out saying, "Hey, can you let nurse practitioner students shadow you?" And I was like, "Would this count?" And I wrote back, just to let you know I'm primarily a digital health provider and they're like, "No, we'd like to see them in the office." So this has to happen. And I don't have the answer yet. I think it's gonna have to be a piece. I didn't mention this, but right now the way we're hiring at Galileo, we're not hiring anyone without seven to 10 years of just general clinical experience 'cause we know how difficult digital medicine can be without having that in-person experience. So I think we're gonna have to have some hybrid residency programs. But again, I'll turn the bat over to Dr. Ravikumar 'cause she has a lot more experience in this education world than I do. But again, great question. I hadn't thought about much literally till yesterday and now, but it's gonna have to happen 'cause this is the way, and also we haven't talked about this, one piece that is really great for the clinician is on the backend work-life balance. Even though I'm working, it's very different than when I was in the office five to six days a week for 12 to 14 hours a day. I can still do a lot of work at home, but then I can go see my kids, there's little things I can do and it really kinda works on burnout as well. So I think it's gonna be an important piece moving forward. But thanks guys.

- Yeah, I think that that is an excellent question and I think what we've seen with medical education and training is that it always takes a little while to catch up. I think all of us can acknowledge that the way that we train physicians, nurse practitioners today is not always relevant to how they ultimately end up practicing. I think similarly, the integration of telemedicine, both synchronous and asynchronous, but really asynchronous as well. I think we're just gonna see more and more of a push of our practice, our personal practices to the telemedicine realm, particularly the asynchronous realm. I think giving our trainees this experience upfront, teaching them about how to effectively integrate it into their practice, their limitations as well, of course to thinking about burnout and how they spend their time. I think that this absolutely has to be pushed to the education process and the training that they go through. For example, when we counsel our nurse practitioners who are not necessarily new to telemedicine, but maybe new to the type of telemedicine that we're practicing in Ro, we do have additional training in education for all practitioners on the platform about how to understand and integrate both the limitations and benefits of asynchronous telemedicine. So we're doing this a little bit late, after they've gone through their more formal training, but I think that there's absolutely an argument to push it even further down the funnel or earlier on the funnel I should say.

- Incredible. Yeah, and I think Danny just included something in the chat around what's happening and there, we just talked about this on our exec meeting. We're gonna do a whole session on residency and training and telehealth, but I think what we keep hearing from our trainees over and over again is that they want this exposure and they wanna be prepared for the type of care they're gonna delivered later in their career. Guys, this was so amazing. Thank you for taking an hour outta your busy days. I got a ton out of it and I think the section did too. So Jason and Deepa, thank you so much.

- Thank you too, thanks everyone.

- I know we're a meeting so I wanna let folks go.

- [Jason] Take care everybody.

- Thank you everyone.