98 – Investing in Health: Transforming Care w/ Anna Haghgooie

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[00:00:17] Vic: Okay. Welcome everyone to Health Further. Today, we have Inna Hugui from Valtryus. Inna, thanks for doing this. Really appreciate it. 

[00:00:23] Anna Haghgooie: Thanks for having me, Vic. 

[00:00:25] Vic: And we've known each other for a while and invested together on a couple of different things, but not everyone may know you in the audience. So maybe let's start off and go through a little of your professional background.

[00:00:37] Vic: Can you started at Sandbox and Blue Ventures and then came to Veltris, but, uh, give your background where you come from, where you get to. 

[00:00:46] Anna Haghgooie: Yeah. So I started my investing career, as you said, at sandbox industries, where I helped build the blue venture fund, which was an investing platform, um, in partnership with the blue cross blue shield plans across the country.

[00:00:57] Anna Haghgooie: Um, in my time there, we raised about a billion [00:01:00] dollars invested in probably over 50 companies. Um, but with a focus on, um, access quality cost infrastructure, um, to just try to help the healthcare system. Um, work better. Um, one of our deals back then was a company called Change Healthcare, uh, which was in the cost transparency space where we first got, got a chance to meet, probably well over 10 years ago now.

[00:01:22] Vic: Yeah, that's right. And Blue Venture, let's just touch on that for a minute. You brought together, maybe not all of them, but a significant portion of all the Blue Cross Blue Shield, uh, plans across the country. Into one group to find and then invest in innovation. That must have been quite an endeavor pulling together all the different blue plans.

[00:01:43] Anna Haghgooie: Well, it was, um, a lot of people helped get it done. So we had a strong partnership with the Blue Cross Blue Shield Association from the beginning. And then I would say the early blue plans that leaned in that really felt like they had to have a finger on the pulse of what was happening in the private markets, [00:02:00] um, really helped drive, um, I'd say a little bit of fear of missing out, um, from, from the plans that hadn't participated in the early days.

[00:02:08] Anna Haghgooie: So, yeah, we, we started with 11 plans. Um, and, uh, when I left, we had a 33 plans participating in the funds. And there was definitely a lot of, um, coordination and conversations that it took to sort of keep, keep that group of folks aligned, but it, it's, it, it became a special place to be. Place where I think, um, you know, blue plan executives could come together to, to really, um, talk about innovation and, and that often is not, um, unfortunately, where people get to focus their time when they're running large, multi billion dollar organizations.

[00:02:44] Vic: And I mean, I was from the outside of what I saw is. Kind of a learning and best practices sharing amongst the plans through the lens of looking at high growth, innovative companies and how it might change their business. A little bit of fear of missing out is probably [00:03:00] healthy too much. It might be too much, but the blues could could stand with a little bit of leaning into innovation.

[00:03:05] Vic: I think so. Yeah, and then, um, let's talk about Valtryek. So maybe describe your role there. You're managing director. I think is your title. Yeah. But Veltris is a pretty interesting investment platform itself. Maybe let's talk about the investment thesis there, how you think about what you're investing in.

[00:03:23] Anna Haghgooie: Yeah. Yeah. So, um, in 2021, um, Welsh Carson Anderson and Stowe, which is, um, you know, a long, longstanding 40 plus year old private equity fund, um, uh, that's focused on healthcare and technology throughout its One of the 

[00:03:39] Vic: longest and most established, I'd say. Yeah, 

[00:03:42] Anna Haghgooie: yeah, yeah. And they, they wanted to deploy more capital against the trend of value based care.

[00:03:47] Anna Haghgooie: So it was, you know, 2021, the heyday, I'd say, of a lot of those value models. Um, you know, getting public, trading well. Um, and Welsh really had written in, in many ways, at least from my perspective, some of the [00:04:00] playbooks on how to, how to think about value based care in this era of Medicare Advantage. Um, in a really meaningful way.

[00:04:06] Anna Haghgooie: Manage Medicaid, um, and, and yet had not been able to participate because these companies tended to be more venture stage, more growth stage, didn't need the size check that Welsh typically was writing. And so, um, formed this thesis around how to deploy more capital into value based care by, by creating a platform inside Welsh, um, to, to do those deals.

[00:04:31] Anna Haghgooie: And so Yeah. So 

[00:04:32] Vic: just before you jump into that. What is the standard kind of right down the middle size of a deal for, for Big Welch? 

[00:04:40] Anna Haghgooie: Three to 500 million is the type of equity check that they're looking 

[00:04:43] Vic: to. So for the value based care, especially, um, there aren't that many platforms of that scale, or at least then there weren't, maybe there's becoming more.

[00:04:53] Vic: I think they had pretty big success with NaviHealth, Where they [00:05:00] leaned in and kind of started at a much smaller level, I think it was 50 million, it might have been, might have been something slightly different, uh, and had a lot of success with that, but they can't do that, uh, too often just because of the amount of capital they're trying to deploy sort of.

[00:05:16] Anna Haghgooie: Yep. No, you hit the nail on the head. I think, you know, they had had, um, uh, several successes over, over their history and smaller, more, um, uh, startup year DeNovo type, type efforts with member health in the part D space with Nava health, where I got to be a co investor from the blue venture fund. Um, and, and even innovate in the, in the pace space, um, where they were real.

[00:05:42] Anna Haghgooie: Pioneers and, um, uh, had a very, um, innovative perspective on where, where an opportunity existed in the market, but they were all, I would say, subscale checks for the typical, the typical deal. And so that's the, that, that really was the opportunity is to, instead of sort [00:06:00] of doing one of those, every other fund, like how, how do we, how do we build a platform that can, can execute on, on the, those market opportunities.

[00:06:09] Vic: Yeah. Yeah, and then on the website, uh, the Valtryek website, you have, uh, the Valtryek Three Beliefs, which I thought was a really interesting way to frame things. So maybe talk about those beliefs and, uh, uh, how they came about and how they shape where you look to invest. 

[00:06:28] Anna Haghgooie: Yeah, I'd say that the sort of tenor of the beliefs is that the, the, the fee for service system isn't really serving many people well.

[00:06:38] Anna Haghgooie: And, um, that's kind of the core foundational belief that drives the opportunity set that we're interested in. And so, Um, broadly, we think about next gen healthcare as models that are accessible, um, get you to a clinical endpoint in a transparent and easy way and or hold hands on the stuff that actually [00:07:00] matters to people as they're navigating more complex, um, healthcare needs.

[00:07:04] Anna Haghgooie: And so we, we see value based care as a contracting structure, um, that can be really helpful in unlocking the ability to do things differently than. Um, just what's done today, which is this encounter based transactional system. Um, but we also see opportunities for technology, um, and, and other like access models to drive transformation.

[00:07:27] Anna Haghgooie: So while, while we're big believers in sort of the true value based care contract as a way to unlock the dollars to do things differently than, than status quo, it's not the only way, um, to, to drive next gen healthcare. 

[00:07:41] Vic: So, is it right, just to rephrase which I'm following, that the value based care contracting or reimbursement method is a piece, it's an important piece to align incentives, but it may not be sufficient.

[00:07:54] Vic: You might have to add other things, add other services, or bring technology to bear. [00:08:00] And what I liked about the beliefs is they really kind of frame, so, today's health system profoundly underforms for patients, providers, and payers. So, really, it's underperforming, sort of, for everyone. Um, reengineering the way healthcare is assessed, delivered, and experienced and paid for is a belief that Valtryek has, you know, kind of, we have to rethink or re engineer the whole system, and you have a responsibility, Valtryek has a responsibility to invest in or create vision organizations driving change.

[00:08:33] Vic: Pretty, um, ambitious beliefs or, um, large, uh, goals to attack. 

[00:08:40] Anna Haghgooie: Yeah, yeah, I think that's right. I think we We, um, you know, the, the, the reality is, um, you know, having now invested for over 15 years, um, in the market, well, well, there have been amazing companies that [00:09:00] have, have come and scaled and, um, the, the, the ability to really transform what it feels like to get care in America has been, um, slower than quite frankly, it should have been.

[00:09:13] Anna Haghgooie: And so to us, I think it's this idea that if we're going to do the brain damage of structuring a different type of contract, let's also make the investment in how we're going to show up for patients differently. Let's actually deliver on social needs and like the human side of healthcare. Um, and so we love to partner with entrepreneurs and companies that are sort of in it.

[00:09:39] Anna Haghgooie: For creating long term sustainable value, um, as they tackle these different, um, these different sort of opportunities or areas of dysfunction in healthcare. So I would say this is a little bit, um, our beliefs, but more importantly, we want to work with entrepreneurs that are very serious and understand, [00:10:00] um, how hard it is, but are committed to, uh, making, making a true change.

[00:10:06] Vic: Is it right it's almost like a signaling tactic like you're putting out these beliefs and management teams that are excited about that maybe are attracted and then and then hopefully you see the the really big vision um well built out teams that are trying to do something large and impactful. 

[00:10:24] Anna Haghgooie: You got it.

[00:10:24] Anna Haghgooie: Yep. And I think there's a level of seriousness, um, when you want to build your business that way to investing in the data infrastructure, the, um, MedEcon teams, the actuarial models, like there's a foundation of investment that has to happen to, to do this work well. Um, and so I think that's also a big part of, um, what we're looking for.

[00:10:45] Anna Haghgooie: Um, is, is sort of companies that understand that and, and are, are, are, are making or have made those investments. The flip side of that then is that these companies are payer ready. So having, having grown up, um, you know, with, [00:11:00] with blues plans and, and payer partners, um, you know, they, they need a payer ready entity to be able to do some of these big swings with.

[00:11:09] Anna Haghgooie: And so, um, Um, in some ways, you know, you, you've got to, you've got to have that, um, that level of sophistication to, to be able to credibly contract, um, uh, and, and do bigger things with, with payer partners. 

[00:11:23] Vic: Yeah. So let me dive into that for a bit. Like I was talking to a guy yesterday, he was a. Kind of a technologist and he's frustrated with the pace of change.

[00:11:32] Vic: You sort of said that, you know, the pace of change in the last 15 years has been, there's been some great companies, but it also has been slow for the patients, for the providers and for payers or for us as taxpayers, it's been slower than any of us want. And I kind of think that in healthcare, if you're going to drive change, you have to be aware that.

[00:11:53] Vic: It is a big system. People's life is at stake, and it needs to be serious. You have to have [00:12:00] enough, uh, capabilities, enough capacity, enough strength to abide by the regulations and really ensure patient care as you're approaching these new models. Is that part of sort of how Valtryek approaches things?

[00:12:15] Anna Haghgooie: Yeah, I think so. I mean, I think, um, I think we all want it to be faster. I think, um, it can be fast. Like, I think during COVID we saw the market, this industry move, move faster. Um, so I, I think when there's a, when there's a need to do so, the market can move. Um, but otherwise, like inertia, you know, regulation locks in the status quo.

[00:12:41] Anna Haghgooie: Um, those that have market power, you Uh, have no incentive to change and market power means distribution capital. So like, I think there's just, it's a, it's an industry that, that's quite sticky. And so you do need, um, external forces in some ways to, to, [00:13:00] to drive, um, the investment dollars coming in and, um, and, and, you know, people taking big swings.

[00:13:07] Anna Haghgooie: And I think over my investing career and. You've seen it to, um, you know, the passage of the high tech act and actually getting physicians onto digital systems. Um, the passage of the A. C. A. And this idea that there might be this consumer segment, um, at least when it comes to plan selection, um, expansion of medicare.

[00:13:28] Anna Haghgooie: Medicaid, the growth of Medicare Advantage, um, the sort of influx of the CMMI models. Like, I think all of these, um, moves sort of drive opportunity for entrepreneurs to, to sort of execute and show that there's a better way. And, um, once you do that and show there's either a cost advantage or a, and patients are, are moving, um, you know, with their feet and choosing to consume care in different ways, then I think the rest of the market starts to react.

[00:13:58] Vic: And let's double [00:14:00] click on your concept of, uh, payer readiness. Is that part of, uh, what's needed to drive change where you might bring a new way to deliver care, a new provider, um, design, but, uh, your experience at, at Sandbox and Blue Ventures and then now at Valtryek, you know, sort of what the payers need, how to plug into their systems so that it can scale, so that you can actually have a, a meaningful impact on Thanks.

[00:14:28] Vic: A large percentage of the population. 

[00:14:30] Anna Haghgooie: Yeah. 

[00:14:31] Vic: Yeah. I mean, what's the, what's the most common thing that a management team wouldn't realize that they need to do in order to be payer ready? 

[00:14:41] Anna Haghgooie: Um, I don't know that it's fair to say management team wouldn't realize, but certainly just like data exchange and getting through a security questionnaire is like, uh, uh, for the first long pole, um, in the tent and, um, like under understanding that and being ready to actually, you Have a place to land data [00:15:00] and, and, um, and get through those, those security, those security audits, then you get into like pricing and contracting, and there's a level of, um, nuance and complexity to be able to structure a contract that's good for you as the, as the startup, but also is, um, uh, you know, solving the payer's needs.

[00:15:20] Anna Haghgooie: And so I would say. In my experience, um, you know, I've been part of companies where, you know, we, we pushed and signed contracts ahead of, um, to, we just signed what the payer was asking to get a contract signed. And there are others that have slowed it down for what ends up being probably another six months to try to get the contract where, where it's going to be a good long term contract.

[00:15:46] Anna Haghgooie: Um, The latter is so painful, but almost always the right decision to a point. Um, at some point you've got to have a customer to, to get going. Um, and then I would say like just the credibility [00:16:00] to step into some of these risk models or, or some of these transformative models. So like, do you have the balance sheet?

[00:16:05] Anna Haghgooie: Do you have the team in place? Again, I think, um, uh, MedEcon and data are like, Just foundational, um, to be able to understand everything from, from what's happening in the existing population to, um, uh, to, to being able to price a contract, to being able to understand how you're performing against it. 

[00:16:25] Vic: Yeah.

[00:16:25] Vic: And do you think, well, I think that it's, it's one of the things that Veltros brings is. For management team, you can introduce your yourself or other folks at Veltris or your operating partners or network have gone through this many times before. And so you can sort of help them think about what questions are going to be asked and really build the credibility before you give that 1st impression to the payer.

[00:16:49] Vic: Because it's a moment, it's a credibility momentum thing. If you show up with all the answers that the questions they want right away. You start to build credibility, uh, and if you [00:17:00] are not ready, then you're on this 24 month, uh, you know, March of, uh, lots of due diligence, uh, because they're worried about messing up their systems.

[00:17:10] Anna Haghgooie: Yeah. Yep. Valtrous was started, um, in partnership, my two other, other partners, Kerry Witte and Tracy Ball. You know, they're, they've spent their careers building and running large scale operations, including many payers, um, and payer functions. So, um, it absolutely helps, uh, you know, that we've got folks that have been in both the buyer seat, um, and the operator seat, uh, to be, to be able to help our companies, um, be.

[00:17:36] Vic: Okay, then what's the relationship with, um, Wells right now? So you trade deals back and forth based on the size, so you might see a really big opportunity and pass it to them. How is the back and forth with, with Wells Carson? 

[00:17:50] Anna Haghgooie: Yeah, I mean, I think we're the way that we, um, approach the market is, you know, we're, we're sort of in, in some ways a one team where like we can talk [00:18:00] to an entrepreneur about a minority earlier stage transaction all the way through, um, you know, if they're trying to do a majority, a majority deal.

[00:18:09] Anna Haghgooie: Um, and in the healthcare markets with the way that in particular on the payer side and these value based care side, like the, the, the, the companies run the gamut, um, between sort of, um, stage and capital need all the way through. And so, um, that's, that's really the, you know, it's a very collaborative approach, um, between the, between the two teams and, um, Uh, and and and really play play to each other strength.

[00:18:37] Anna Haghgooie: So, you know, we we see a lot because given the side of the market that we're in, and we're all talking to the same payers. And so, um, there's a lot of coordination between between us all. 

[00:18:48] Vic: Great. Okay. So, um, we have a decent number of management team folks in the audience, health, uh, health system executives, physician payer executives.

[00:18:58] Vic: What what are you [00:19:00] thinking about as for for 2025? What are some themes? And what are you looking at as an emerging space? That could be pretty exciting. 

[00:19:07] Anna Haghgooie: Yeah. Yeah. So I think, um, one of the spots just given the headwinds and Medicare Advantage, I'd say a lot of a lot of, um, investors are shifting to look at, um, what I'll say, like more specialized populations.

[00:19:22] Anna Haghgooie: So whether that's, um, you know, the dual eligible populations, the, um, populations where there's integrated, um, manage long term services and supports with, with clinical models. Um, so those are, those are both kind of end markets that I think are getting a lot more attention, um, from, from investors, um, than they have the last, the last several years.

[00:19:45] Anna Haghgooie: Um, and we think there's again, a lot of opportunity to, to sort of reallocate how those dollars get spent, um, to, to drive value, um, across, across. 

[00:19:56] Vic: You might segment off a particular population based dual [00:20:00] eligible or special needs or something like that. I've seen a lot of disease state focus as well. Like, maybe you pick cardiac or you pick some other disease state where you kind of focus on that.

[00:20:15] Vic: And try to get some critical mass. Is that something you're looking at? 

[00:20:19] Anna Haghgooie: Yeah. So we've, we've definitely done a bunch of the specialty models, um, within our portfolio, whether it's the substance use disorder population with way spring or 

[00:20:29] Vic: similar to that. 

[00:20:30] Anna Haghgooie: Yeah. Um, Taylor care in the musculoskeletal space.

[00:20:33] Anna Haghgooie: And I, I think, um, the truth is like there are there are probably still more to do where there's a big enough spend and a need for a specialized contract between the payer and that specialty area. When you start to get into stuff like cardiac and pulmonary, Um, the, the need is, um, I would say a little bit more like how do you, how do you think about the, the care and the actual like provider services associated more than [00:21:00] maybe a risk deal?

[00:21:01] Anna Haghgooie: And so thinking about like, um, pulmonary rehab as an interesting, um, underutilized service, like is, is there a different way to provide that, um, either through some virtual or hybrid model? Um, that can actually increase the utilization of a clinical service. Um, so I think those are all really interesting, um, and spots where, where we're spending time.

[00:21:23] Vic: With some of those, you might have to, uh, be integrated or have partners in acute care settings. Whether they're part of the core business or more likely they're sort of partners or, or you, you refer back and forth. Is that right? 

[00:21:38] Anna Haghgooie: Yeah, the, the, like health system service line extension model, I think, is another interesting thread, which is, you know, there are things that, um, aren't going to necessarily be core to a health systems business, but they do have, um, the eyeballs, the brand, the reputation in a market and can open up, um, some of these more virtually, um, oriented service [00:22:00] lines to, to their, to their community and their patient populations.

[00:22:03] Anna Haghgooie: And while they're not necessarily big money makers for the health system, um, it helps keep, um, people in their community sort of connected to them and, um, and getting the care they need. 

[00:22:14] Vic: Yeah. So like your teams maybe could get more scale and run. The, um, operations efficiently where you could make decent, uh, gross margins, net margins, but it wouldn't be that attractive to a single health systems.

[00:22:28] Vic: And so there's a natural partnership. There 

[00:22:31] Anna Haghgooie: you go. Yep. Yeah. 

[00:22:32] Vic: Okay. Um, I know you've been at, we're recording this on the 23rd. HLTH Health in Vegas is just now finishing today. I think it's the last day. This will air in a week or so. So you're in the middle of it. I don't know if you had a chance to have any takeaways, but how was the event?

[00:22:50] Vic: I skipped it this year because I can only take so much of HLTH and this year I decided to skip it. But how was it? 

[00:22:58] Anna Haghgooie: Yeah, no, it was, it was a good couple of [00:23:00] days. I, I, I had a, um, a good set of meetings met with a lot of entrepreneurs, um, a lot of co investors. So it was, it was well attended. Um, and I would say generally a fairly optimistic, um, uh, optimistic air, um, as much as there's a lot of headwinds in healthcare, um, um, You know, there, there have been some, some big wins this year.

[00:23:23] Anna Haghgooie: I think people are expecting the IPO markets to open back up next year. Um, and so I'd say generally speaking, like a lot of energy, um, uh, around, around where we're headed. 

[00:23:36] Vic: Yeah. And the election, uh, we're going to have the election in, in a couple of weeks. Uh, at least my view is I want the election to be over and then, you know, I think I can work with any kind of administration, but it'll be good to have the clarity of, okay, this administration is now in charge, at least for a couple of years, and then we can work with that.

[00:23:59] Vic: Um, [00:24:00] what was the sense out there? Are people hoping that one side or the other will be better for healthcare or? Is there, um, 50, 50 split? What was the sense? 

[00:24:09] Anna Haghgooie: Yeah. Well, I'd say the only people that are hoping it to be over more than you or anyone who lives in a swing state, given 

[00:24:15] Vic: yes, that's right. That's right.

[00:24:19] Vic: Republican, but yeah, I think there are swing states. I'm going to be peppered with ads all the time. 

[00:24:24] Anna Haghgooie: Yeah. Um, you know what, honestly, it, it, it's, it's relevant in a couple of Pretty small pockets, um, in, in sort of my world and deal flow, like what's going to happen with ACA subsidies, um, Medicare advantage headwinds.

[00:24:39] Anna Haghgooie: Like there's, there's a few of these buckets that like may fall one way or the other depending on, on who's elected. But I think when we, when we talk about, um, you know, getting more value for the dollars we spend in healthcare, like that's a bipartisan goal. Um, and, and quite frankly, well, well, Things might be called differently, or there's [00:25:00] different emphasis on different parts of the program, depending on who's, who's running the show.

[00:25:05] Anna Haghgooie: Um, the, the general fundamental ways to get there, I think are pretty well, um, uh, there's good alignment I'd say between, between both. 

[00:25:15] Vic: That's how I view it too. Like sort of, Delivering more effective care where the physicians and nurses and caregivers, you know, are fulfilled in their job and earn a living wage and getting better outcomes for lower cost that that sort of works in either administration.

[00:25:33] Vic: You might have different framing. It might be slightly different reimbursement. But I think we can. VCs can work either way really. 

[00:25:43] Anna Haghgooie: Yeah. 

[00:25:44] Vic: Okay. Um, I want to highlight a couple of your portfolio companies just to sort of showcase the type of deals that you do. Um, I had, uh, focused on, uh, Wayspring just cause I know Carter here.

[00:25:58] Vic: And, uh, so maybe [00:26:00] describe Wayspring, uh, what they're doing and, uh, talk about how that sort of represents Veltris, or maybe there are some exceptions there that are not, uh, Exactly sort of a Veltris core deal. 

[00:26:12] Anna Haghgooie: Yeah. Yeah. So way spring, um, is a Nashville based company led by Carter pain and a, and a really wonderful management team.

[00:26:20] Anna Haghgooie: Um, and, and they partner with manage Medicaid plans to essentially carve out the risk associated with the substance use disorder. Diagnosed patient population. So this is one of these value based, um, models that's, you know, 365 day risk on, on a belly button level. So like what, who are the people that fit this cohort, um, based on a diagnosis.

[00:26:45] Anna Haghgooie: And then what Wayspring does is essentially takes that attributed risk and figures out. Yeah. Um, you know, who they need to engage and how they need to work with them in order to get a different, um, utilization pattern, quite frankly. And so, [00:27:00] um, the company works, um, really, uh, successfully to drive engagement of the patient cohort that appears to be struggling the most based on the data, um, that they're, that they're getting from their health plan partners.

[00:27:15] Anna Haghgooie: They show up in the community and work with community based organizations to essentially put in a system. of care for these members. And care is not actually what we think of as traditional health care. It starts with social needs. It starts with how do we create stability in someone's life? Do they need a hot meal?

[00:27:33] Anna Haghgooie: Do they need a warm bed? What are the things that they need in order to, again, start to then have a conversation about what recovery might look like? And I'd say in our current system, you know, that patient is showing up To the emergency department to get a hot meal or a warm bed or they're cycling through inpatient rehab and then sent back out into into the, you know, the community without a hot meal or a warm bed.

[00:27:58] Anna Haghgooie: And so really what way [00:28:00] spring is is doing is starting with those foundational layers and then working to again, get this person tied into a system of care that addresses. Um, substance use dependence, mental health, and then ultimately physical health. Um, and so the stories are incredible, um, as far as, you know, the lives that have been changed through the work that the way spring team is doing.

[00:28:22] Anna Haghgooie: Um, but they also have proven that the model, while it costs a lot to, to do that, um, ultimately saves money. And so what I love about it is you're repurposing dollars that are being spent right now, um, You know, in a, in a health system or in a inpatient rehab, and they're not, they're not dollars that are not 

[00:28:43] Vic: utilized very well.

[00:28:44] Vic: You were not designed for this population with this goal. That's sort of a, you know, 80 is really good at dealing with trauma, maybe not good at complex, social, behavioral health, substance abuse [00:29:00] issues. 

[00:29:00] Anna Haghgooie: Got it. 

[00:29:01] Vic: You got it. I think it's a really interesting, uh, example of. Where this value based care, uh, contracting structure allows Carter and his whole team to really think about the patient and caring for the patient in a very different way.

[00:29:17] Vic: Because they have that capitated risk, and then they can choose how to spend the money. It might be that they partner with a local nonprofit community, uh, partner. To deliver meals or deliver, I don't know, one place to sleep or other social services, teach someone how to find a job all those kind of social services that really are building blocks to allowing the person to have a productive, rewarding life.

[00:29:46] Vic: And that from that foundation, you can then start working on the recovery and substance substance disorder. 

[00:29:53] Anna Haghgooie: You got it. 

[00:29:54] Vic: Yeah. And then, you know, if. If the team is successful. By [00:30:00] definition, they earned money relative to the lower spend, but they can only do that by helping the people recover, helping the people live more productive, less, uh, less expensive lives.

[00:30:13] Anna Haghgooie: Got it. 

[00:30:14] Vic: Yep. 

[00:30:15] Anna Haghgooie: Yeah. And so I think that, I mean, it's a good showcase, I'd say of like what Valtruis, you know, was, was set up to, to do, which is like, there's a, there's a lot of complexity in, in, um, uh, you know, getting to that end, end state. Um, and so, and so partnering again with management teams like Carter that are very serious about, um, about.

[00:30:40] Anna Haghgooie: Changing the status quo very substantively for the patients that they're serving is, is, 

[00:30:46] Vic: is. Talk to me about that. What's the scale of Wayspring? How many states or what's the, uh, give us a perspective of how big it is. 

[00:30:54] Anna Haghgooie: Yeah, I think they're in seven states now and in many of those states have multiple of [00:31:00] the managed care plans as partners.

[00:31:02] Anna Haghgooie: So they're able to essentially bring this level of service into the communities and serve, um, serve Medicaid patients. Patients across multiple plans. Um, you know, they've, they've grown exceptionally well over the last three years. Um, and, and really starting to prove a track record on savings, which is, which is what we're all really excited about.

[00:31:24] Vic: Yeah, that was my next question is what's the time horizon that you think is fair to judge a company like WaySpring? 

[00:31:31] Anna Haghgooie: Yeah, each of our value based care companies are different and it just depends on like what the risk is that they're contracting around and how sort of long it takes to generate an ROI in the substance use disorder population, you can see the savings within within the 12 months.

[00:31:50] Anna Haghgooie: Sort of window. So they're in your savings. Um, and we're, we've gotten through, um, two years of reconciliation with our most mature, most mature clients. And, [00:32:00] and, um, what we look for is sort of escalating savings year over year. So, as you begin to build relationships and drive higher engagement, um, get your system of care humming in a given community, um, are those savings, um, you know, accumulating year over year over year at a cohort level.

[00:32:19] Anna Haghgooie: And so hopefully 

[00:32:20] Vic: you did. The team and the algorithms and the community partners and how it all fits together, you're getting better, smarter, more efficient each quarter. And so you start to see escalating savings in that through that lens. Okay. And then talk to me about Tuesday health. I don't know Tuesday health as well, but I'm really interested in that space.

[00:32:41] Vic: So maybe describe what it is and how it is different. And in some ways the same as the same kind of model. 

[00:32:48] Anna Haghgooie: Yeah. So Tuesday Health, um, is our company that's focused on end of life care. Um, and, and essentially the, the thesis, um, that led us to [00:33:00] Tuesday is that, um, despite all of the complex care management companies and risk based primary care, um, nobody was really, um, excelling at identifying the right time.

[00:33:13] Anna Haghgooie: to drive end of life conversations and services. And what we realized is that one of the reasons why that was so hard is because you really have a hard time teasing out from claims data and utilization data when that right time is. And because the, the drivers typically tend to be certainly utilization and diagnosis data and those things, but also coupled with someone's functional status.

[00:33:38] Anna Haghgooie: Their symptom burden, how, how are they experiencing the systems associated with their diseases and then what is the caregiver dynamics available to them in their home in their community? And it's those things that actually are the drivers of, um, you know, how somebody is going to. experience those last 12 to 18 months of [00:34:00] life.

[00:34:00] Anna Haghgooie: That coupled with the fact that hospice as a benefit is a really wonderful benefit, but it is expensive. And there's this Goldilocks paradigm within hospice, which is patients are either getting on hospice too soon. You know, a nursing home patient with dementia that Probably does need a little bit extra than what they're getting today, but probably doesn't need the full hospice benefit to folks that are getting on, you know, three days before they're passing.

[00:34:27] Anna Haghgooie: And that's just not enough time for hospice to deliver any, um, any value or services, um, to that family. And so this, this like Goldilocks problem of how do you get it just right, um, where you're bringing somebody into that, um, set of services at the right time in their, in their journey. And, and again, one of the reasons why that's so hard is because nobody's really focused on, on that, um, in the, in the existing system.

[00:34:53] Anna Haghgooie: Yeah, 

[00:34:54] Vic: and it strikes me, it takes a lot of, um, talking to the patient and their [00:35:00] caregivers and listening, which is hard to do at scale. You can't just sort of run a risk stratification and say, okay, these people are the ones that need it. It's more nuanced than that. Right. 

[00:35:13] Anna Haghgooie: That's right. That's right. So we partnered with, um, Mass General Brigham who had, um, uh, a really talented palliative care, um, research, uh, program in the beginnings of a, of a tool.

[00:35:26] Anna Haghgooie: And so, um, their investors in the business as well as, um, contributed some assets. And then CareSource, uh, which is, uh, uh, uh, managed Medicaid and dual and dual eligible plan based in Ohio, um, who, who also was really interested in, in this space. And, um, we brought in a number of, um, executives who, um, are also very passionate about this space.

[00:35:51] Anna Haghgooie: I think the, the one thing is we went out and sort of put this together is, um, you know, folks that have, Have are now sort of in [00:36:00] leadership positions across the industry, given their age, many of them have have dealt with end of life with their parents. And and so it really hits close to home, no matter how well resourced you are.

[00:36:13] Anna Haghgooie: It's not great. Um, there's not a great model of, of care and support in this country. Um, and similar to birth, you know, you're only going to do it a handful of times in your life. How are you supposed to have the experience for, for sort of how to work through prenatal process? Well, um, similarly with death, you're, you know, hopefully we'll only have to navigate a death and dying experience a handful of times in life.

[00:36:37] Anna Haghgooie: And so. Yeah. There really is, um, I think a need for, um, a partner that, that can help sort of navigate and, and prepare, um, families for, for what that, what that's going to be like. 

[00:36:49] Vic: Yeah. And it's so, um, it's so intertwined between like the emotional pain with the, the patient who is, is scared and their, their [00:37:00] loved ones combined with the confusion of, well, these options.

[00:37:05] Vic: Are possible treatments, but they're going to be inpatient and there'll be lots forget the money. There'll be lots of side effects and tubes and it'd be difficult for my parent, but maybe it could really help and could buy another several years. And so getting an honest. and kind of unbiased partner to help with that, I think could be really valuable.

[00:37:29] Vic: But there's, there's a lot of trust that has to be established in order to sort of get that buy in. 

[00:37:34] Anna Haghgooie: Yep. Trust. And then I think some of it, you know, there's, there's even just like, you don't, you don't know what to expect. And so, you know, the, the process Um, watching someone struggle through end of life is it's it is painful and so the default position is to call the health care system to come in and try to help and the health care system is not set up to sort of, um, understand a more palliative [00:38:00] approach, um, which is, you know, all around whole person care goals of care.

[00:38:04] Anna Haghgooie: It doesn't just mean hospice. It's, it's actually much more about, you know, sort of managing symptoms so that people can achieve goals in life. And so, um, it's just a different orientation and, um, we're, we're pretty excited. Um, you know, the company is, is young, it's just a year old, but, um, is working with patients and, um, and, and, you know, for, for better or worse in this industry, there's just so much low hanging fruit.

[00:38:32] Anna Haghgooie: And, um, there's, this is a category of, of care where, um, You know, people are, are very interested in having somebody come in and help them with this process. And, and in return, um, you know, I think, I think we're starting to see the beginning of, of a model that's, that's working really well. 

[00:38:51] Vic: Yeah, I mean, I, I would say the traditional fee for service system, which is still, gosh, is probably 90 percent of the revenue running through the system.

[00:38:58] Vic: Or maybe, maybe you have [00:39:00] exact stats, but significant part of that. That system is very, it's optimized for, like, acute interventions. Let's, let's fix this. thing and then send you home. And as you get towards the end of life, that's not necessarily what's needed. You have lots of, um, health conditions and they're beginning to add up on each other.

[00:39:23] Vic: And it's about sort of managing this for the best quality of life, which is a different, just a different mindset or different approach. 

[00:39:30] Anna Haghgooie: Yep. Yeah. And the research suggests that palliative care actually helps people live longer. Um, and, and have less trauma, um, through the dying process for those that are, have survived.

[00:39:42] Anna Haghgooie: So I think there's, there's really, um, no downside. And so the real question is like, how do you Take what has been an under reimbursed, um, uh, service line and healthcare and figure out a sustainable model for, um, for [00:40:00] figuring out when to spend those extra dollars on the service line in a comprehensive way.

[00:40:05] Anna Haghgooie: And so that's really what we 

[00:40:07] Vic: all know that the last 12 months of life are really expensive, but it's difficult to know when that 12 months starts. Because obviously you don't know when the person's going to die. And so that, uh, how is Tuesday Health? What is the contracting set up for you? Is it again a capitated rate or is it a different format?

[00:40:28] Anna Haghgooie: Yeah, so Tuesday's been going to market pretty flexibly just because there's a lot of different pools of populations that can benefit from the services. But ultimately, one of the tenants that we believe in is we want to be accountable for engagement. So we want to take what What is an attributed population based on the data that we do have, um, and we want to engage that population to then understand sort of where they are in that process.

[00:40:52] Anna Haghgooie: And so I think that's the, the other piece is, you know, seeing prior models of like one size fits [00:41:00] all you're either in or out similar to hospice. It's one size fits all you're either in or out. This is much more of a gradation of what is that patient need at this point in their journey? And how do we start to support the family and the patient?

[00:41:13] Anna Haghgooie: In a way that gives us the trust to help them all the way through. Um, so we want to be at risk for engagement. Um, we want to work with, um, uh, folks that currently hold the risk on that patient population, whether it's risk based primary care or a payer. Um, and, and we're going to work with those longitudinal care providers to essentially integrate into that, that patient and that family's care.

[00:41:37] Anna Haghgooie: Um, and so. Uh, you know, there's, there, we want to be at risk, um, for, for outcomes, because we think there's really meaningful outcomes to deliver, but we're, we're fairly flexible. 

[00:41:48] Vic: And I know you said that 1 of the things Tuesday is exploring or, or sort of challenging is the time when this topic should be brought up.

[00:41:57] Vic: It strikes me we need to start having [00:42:00] much earlier. Is that what they're found? Or when, how, when are they starting to engage? 

[00:42:04] Anna Haghgooie: Yeah, so the, the, the attribution model is trying to catch folks within their last 24 months. Um, uh, of life so that there, that you have some time to actually engage and build a relationship and start the conversation.

[00:42:17] Anna Haghgooie: Um, the, the, the, in that patient cohort, um, there is a concept called prognostic awareness, which is essentially, does the person even know that they're, They're likely, um, you know, headed towards a somewhat shorter window. Um. 

[00:42:32] Vic: So, for instance, uh, 78 year old man falls and breaks his hip. I think he now is in the two years left to live, depending on, because there are lots of other factors, but, but he may not be aware of that.

[00:42:48] Vic: Um, and so how do you, how do you bring up that topic and talk through what's going to happen over the next few months or years? It can be, it's emotionally [00:43:00] charged at least. Yep. 

[00:43:01] Anna Haghgooie: Yep. Emotionally charged. And there, and I would say this is where, like. I don't know if you've spent any time with palliative care clinicians, the nurses, physicians that do this work.

[00:43:11] Anna Haghgooie: They are very skilled. Um, sort of having, having these conversations. 

[00:43:18] Vic: Yeah. I mean, I think they're typically, they're, they feel like saints to me. Like, I don't know how they do the work they do, but it's incredible. 

[00:43:24] Anna Haghgooie: Yeah, and I think it's been an underappreciated, um, you know, clinical cohort in, in the current reimbursement system.

[00:43:33] Anna Haghgooie: Um, and so, but I, but it's also part of why this doesn't happen, right? Because I think most other clinicians and, and stakeholders in the healthcare community are not comfortable, um, you know, having those conversations. Yeah, they 

[00:43:46] Vic: weren't really taught it very extensively in medical school, if at all. And so they just, they don't want to say the wrong thing and they just end up not talking about it that much.

[00:43:57] Vic: Yeah. Yeah. But it's great to have a [00:44:00] partner in Tuesday Health or an organization that they can, they can pull in. Either you can help them better learn about it or they can hand, hand the patient off. 

[00:44:09] Anna Haghgooie: And it's not just the conversations. Like it's also like, what's the system of care to help somebody as they're managing functional.

[00:44:16] Anna Haghgooie: Decline and, uh, increasing symptom burden and, and so it's, um, it's all of the psychosocial and emotional parts, but also, um, you know, a true system of care as well. Um, 

[00:44:31] Vic: excellent. Um, well, it strikes me that belchers is really kind of leaning directly into kind of the core of. Figuring out how to fix this profoundly underperforming, underperforming system that we all live with now.

[00:44:45] Vic: So I really appreciate the work you're doing. Are there other topics that we should touch on or themes that we didn't cover? 

[00:44:52] Anna Haghgooie: No, and I just say, um, it's actually the entrepreneurs that are doing the hard work, the leaning in. Um, but we, we do [00:45:00] love to, uh, To partner with with those folks and help out the way that we can as capital partners and board members.

[00:45:06] Vic: Yes. 

[00:45:07] Anna Haghgooie: Yeah. 

[00:45:07] Vic: Okay. And thanks for your time. Give a how should people learn more about you or Valtryek or maybe I'll put links in the show notes for your website, but there are other things that you want to point to. 

[00:45:21] Anna Haghgooie: Yeah, no, I think that's a good spot. Um, uh, you know, reach out if you've got ideas and, um, appreciate the opportunity to, to share a bit about what we're up to.

[00:45:31] Vic: Great. Thanks, Anna. Appreciate it. 

[00:45:33] Anna Haghgooie: Thanks.