This article is sponsored by VyncaCare. This article is based on a discussion with Darren Shulte, MD, CEO at VyncaCare. This discussion took place on December 7, 2023 during the Continuum Conference. The article below has been edited for length and clarity.

We’re really going to get into how VyncaCare helps partners elevate care when it comes to serious illness. We’ll also talk a little bit about VyncaCare’s plans for the year ahead. Darren, I think most of our audience members here come from traditional home health, hospice, maybe senior living, maybe the SNF space. VyncaCare is obviously a little bit different from those types of providers. To start, could you go over the business model?

Darren Schulte: VyncaCare serves patients in five states in the West. We do so for supportive care and serious illness management. We are an integrated practice led by physicians and we do so in order to provide five basic pillars of care. We do this, by the way, in a hybrid model. Both at home, in person, as well as virtual. We’ll describe sort of the ways in which we do that, we think, in a more intelligent manner.

The areas that we serve are clinical care, behavioral health needs, social support, care coordination, and advanced care planning. We think that in totality, it relates to the care of individuals with serious illness. We do so for both children and adults. Serious illness management for us is not simply palliative care, but those individuals living with particular conditions and may have certainly more than a year to live, but end up bouncing around in particular institutions or settings or having very fragmented care. That we’re filling the need with respect to what we do and how we do it, which I’ll explain to you.

We are paid by our health plan partners in either a traditional fee-for-service manner or in a case-rate approach. We work with our referral partners, as well as our health plans, and partners can be primary specialty physicians, home health hospice, assisted living. These are where our patients typically reside and where we think we can fill a need that we see and we continue to see in the community.

You mentioned palliative care and I think that’s a good transition into this next question. It’s my understanding that the VyncaCare business model has evolved over time and evolved since you became the CEO. Could you share a little bit about that?

Yes, we started in 2013 as a software company providing advanced care planning tools, software as a service. This is actually still used by over two dozen health systems today. The tool enables an EHR integrated ability for individuals and their providers to electronically create, store, and share advanced directives, pulse forms, other documents to direct sort of end-of-life care.

The founders at the time thought it’s fantastic to look at this as opposed to the pieces of paper that typically people have in their pocket or on their refrigerator and typically not when it’s needed when they’re at the ER or in the hospital or elsewhere, right, and their goals of care are not being met because no one knows what exactly they are.

Two years ago, we acquired a palliative care practice, Resolution Care, that provided palliative care to those in the Northern California area. With that, we’ve since expanded beyond palliative to supportive care, serious illness management. We did so, again, in a way that’s hybrid, not simply virtual. A lot of what Resolution Care did was in a virtual setting. Certainly set them up well during COVID and during those periods of time. We’ve expanded that practice and did so in a way that’s technology-enabled which we can get into because that’s an important piece of how we deliver the care that we deliver.

One of the reasons why I was really excited to have you here at Continuum and then do this fireside chat with you is because of your background for a couple of different reasons. One is you were previously Chief Innovation Officer and President of Advanced Technology at Centene, which everybody here is sure familiar with. What did that role entail exactly and then what drew you to Vynca?

I arrived at Centene through the acquisition of my last company, Apixio, which used natural language processing and artificial intelligence to read physicians’ typewritten notes and read with machines to understand the underlying quality of care being provided and risk adjustment work. I like to call it healthcare ChatGPT before ChatGPT was a thing.

When we talk about AI, we’ll get into the different AI models. When the company was acquired, Michael Neidorf, then CEO, said can you come and help lead our innovation because we want to try to bring some technology to our administrative and operational needs of the business and help our provider partners to do the work to care for our members that we serve.

It was interesting being inside a payer. Certainly, I’ve always sold to payers in my entire career at health technology companies. Certainly inside was quite fascinating.

Along the way we saw the following, which thought there’s a need, a need that’s not being met. Centene, as you know, is a big Medicaid provider, right? The largest Medicaid managed care organization in the country. I continually saw a lot of its members that are living in rural situations and underserved, not well served again by the health care, navigating a fragmented health care system and generating a lot of cost. There was this sort of hand-wringing over how we do this and how we manage the cost of our members. Continually we were seeing a number of different point solutions.

Vendors that would come in doing just the tech. Labor-intensive, administratively burdensome, post-acute organizations doing this and that, providers that wanted to do at-risk models. You saw pieces of the puzzle and you never didn’t see one continuum.

When I looked at this, I thought there’s an opportunity to bring assets both in the technology realm, but also in new and novel ways of care delivery, especially to address the rural underserved. Those that increasingly make up a greater proportion, not only our cost but the individuals we serve. Some of whom are elderly and some of whom are not.

In looking at that, it gave me a great opportunity while working at Centene to say what is it that we can do for these populations? Number one, technology is helpful, but only in so far as you control the care delivery as well. If you don’t, what your partners are going to see is the inability to, I would say software is never done. When you create something, whether it’s predictive models for care acuity and you don’t own the care continuum, you don’t understand whether those care acuity models work. It says high-risk, but you go in the home and you see an individual that is 65 and playing pickleball.

On the other hand, you see a low-risk patient in a piece of software and you go in the home and they’re on six liters of oxygen and they’re smoking and they’re actually about three steps away from being taken to the ER. If you’re a software company, you’re not getting the training data to refine the model. Interoperability is actually not that big a deal now, given standards, if what to do with the data. If you create a data fabric, you can create a better determination of the patient’s profile and what their needs are, and then you can use that to direct care, right?

Third is care delivery, which is still based on an old style, some anecdotal model, but technology could tell you in this intervention, at this point in time, for this patient, we map the outcomes that happened or didn’t, and we can change the intervention model. We can actually influence care, not simply rising risk, but how can we provide a closed loop?

I said to myself, let’s figure out a way in which to have a care delivery company and infuse it with technology and data assets to address seriously ill individuals that are underserved in the communities that Centene serves but weren’t well represented by the vendors there, that weren’t going to get the job done.

I worked with my former board chair of my last company who told me there’s a company called VyncaCare, whose founder has done a good job and is ready to move on, and with the assets that Vynca has, both from technology, right, starting in advanced care planning, with integration and EMRs like Epic, understanding what that looks like from a data interoperability standpoint, and then the fact that they have a good care model.

More than half of our patients are Medicaid. By the way, you can make money caring for Medicaid individuals in a fee-for-service model if you have the right technology, the right ability to have the right workforce, doing the right things at the right point, which we’ll get to. I said there’s something here, good care model, good technology, getting better, right? This can be the jumping-off point.

I think earlier today, one of the first discussions was, do you create it or buy it, right? In terms of the sort of approach to serious illness. I said to myself, let’s have this as the starting point for a healthcare platform, and will enable us to scale the right care for individuals across different settings. That’s what attracted me to Vynca, and six months later we’re now sort of getting going on bringing technology leaders ahead of my previous companies.

After medical school and residency, I went into health care technology startup. For me, that technology bit is, I wouldn’t say the easy part. The hard part is actually marrying that with care delivery, such that you’re efficient, effective, and the providers want to work for you, right? That’s another differentiation we’ll get to. How do we make it such that it’s a pleasing experience for our care providers to do their work, and not the administration that they do today, that causes more burnt-out providers that need their own mental health?

I’m glad that Centene’s in the past, Vynca is in the present, and I think Centene will be well served by others who can worry about technology innovation.

Darren, Vynca partners with a bunch of different types of organizations. We’re talking health plans, we’re talking ACOs, we’re talking hospitals, among many other groups, some of the providers in this room perhaps, definitely at Continuum. Can you walk me through the value proposition for them, providers to work with Vynca? Why should partnering with Vynca on serious illness and supportive care be a priority?

We are trying to provide, I call it the ‘connected tissue’ that we don’t see in the industry to help these patients, especially those complex patients that we see that have needs across both the clinical, behavioral, and social domains. They also often don’t get access to the right care, and there’s a lot of health inequity.

Our primary care partners, they’re going to come to us and they say the following, Darren, I don’t know whether or not my patients are even well served, they’re at home, they may come into the office to see me, I only have 15 minutes to see them, and that’s not even scratching the surface of the issues they have at hand, right?

I’m dealing with the inbox that’s overflowing with messages and calls and whomever from these individuals. Can you help? Yes, we can. Yes, we’re paid separately. You still get your reimbursement. We will help alongside you, and we will make sure that there’s a continuity of care that we’re extending your reach with your care plan, and that you’ll have the data and the information about what we’ve done because we have eyes and ears in the home.

Talking about remote patient monitoring, right? I agree with you, it’s not simply like biometrics, but how do you feel today? One to five. How are you doing? Actually, in the future, we want to create a bot, someone said Amazon, right? Imagine like Alexa that’s hearing what’s going on in your environment. You can talk at it and get some response, but you can also listen to the home environment and understand what’s happening. If you hear a certain sound, they may have fallen. If you hear the toilet not being flushed day after day, they might have a UTI.

The things we can do with aging in place and eyes and ears on the patient in the home that primary care will never see. Simple things. ADT feeds from the hospital. Maybe they’re in the hospital and they just got discharged.

Our home health partners will say, listen, the primary care signed orders, but they’re not round. We can help to provide the medications, prescriptions if needed, DME orders if needed, right? We can do the things to help the home health agency do right by their patient and be a place they can discharge patients to. When they feel nervous, what’s going to happen to my patient?

In home health they’ll keep them on longer because they don’t know where they’re going to go. We can be that, because often these patients may not have a continuity of care with their primary care physician. We can have to help their goals of care, advanced care planning, such that they can be because they’re probably hospice, some of their hospice eligible, they just don’t know whether or not they want to go to that situation, to that facility or that care environment.

We often say we are a complement. We’re not trying to do what you do. We support the areas in the continuum that have gaps. Today, a lot of the hospice and home health, they do palliative, but they do it in order to provide that continuum. They’ll call it a loss leader. For us, we make money at it. I think because we’re a little smarter about what we do and how we do it.

Again, the hybrid approach. Some patients don’t want you to be in the home all the time anyway. We tell our, we tell our partners, listen, we can do telehealth as it makes sense based on the acuity of care needs, the preferences of those patients, where we see that the interventions work. Remember, with data you can know if the intervention works. An intervention with a television might be just as effective as driving out to the home. We tell our partners that we think we have a way in which to provide the right level of care in a complementary fashion.

There’s no threatening, and it’s also I’m not taking your dollar away. Now if we’re in an at-risk agreement with an ACO, certainly we’re all on the same page. We’re also not trying to do things in a way that will sort of put at risk the revenue source of our partners. The only other thing I’ll say is we’re going to make it the easy button for referrals. We’ve created in terms of our platform, I call a frictionless approach to referral and patient acquisition. With a name, a number, and some other information, I can determine pretty quickly if you’re clinically eligible and plan eligible.

Because we actually have, which all of you could do, there’s HIEs or health information exchanges out there in which you can get the medical record. Instead of having someone read it, you can have a machine read it and say I’m going to compile the profile of this patient clinically and determine whether or not they’re eligible for you, your program. Right? With your referral partner, you have the easy button. We have the ability to then serve up to our clinicians, what we need to do and for whom we need to do it. Because that easy button is critical. Otherwise, our partners are going to look at us like another piece of work to be done and inertia to be overcome. That’s difficult.

You mentioned how so many people describe palliative care as a lost leader. I think looking back at the past year, the LinkedIn post for me that got by far the most comments and attention was a post highlighting some home health and hospice executives referring to palliative care as a lost leader. Many people chimed in. It’s like, no. There’s definitely that thought out there as well.

Here’s the deal. Palliative care, as I’ve learned, right, I didn’t grow up in this industry. I grew up in health care. I was on the data. I was in the back office of health care. I did all your data analytics, all the other things that sort of made it work. You’re all on the front lines. I’m not this 25-year home health and hospice operator. I greatly respect those that are and have made their way in the community.

I think with a couple things. One, palliative gets a bad rap because it’s associated with the big H word, hospice. No patient wants to be in a hospice. Very few want to be in hospice. Very few physicians want to refer anyone to palliative care, which is a slippery slope in their mind to hospice. We think of it as supportive care, but also not simply for those that have a year left to live traditional palliative practice.

I think that if you make your way at understanding the needs of the population, what interventions work, the sort of right blend of the right type of visit, it can work. You can make money, I can assure you. Right? You’ve got to put a focus into it and not simply think of it as a marketing tool.

Again, you got to sort of describe what it is, the value it brings, and how it’s going to make a difference. Part of it really is not calling it palliative care. Supportive care came out of the oncology field, where supportive care was synonymous with palliative care.

When you call it supportive care, you have a lot of folks saying yes. Because the oncologists will tell you your chemo, your immunotherapy, your radiation, and surgery, and from symptoms, call the front office. Oh, they’re not open to you. Oh, you’re stressed and anxious because you have a cancer diagnosis? Go to your behavioral health provider. Right? Oh, your social needs, you don’t have enough like rental support? You don’t have a refrigerator for your meds, whatever, that’s too bad.

Anyway, it’s well-known. This is not something we’re making up. Then it’s unfortunate because every cancer patient should be on supportive care. Every heart failure patient, every person with COPD, dementia, you name it, liver disease, kidney disease. Specialists don’t do right by their patients. They are the same 20-minute treadmill. If you care, I’m passionate about it.

I think it’s a huge hole in the continuum that these seriously ill patients who aren’t traditional palliative patients are falling through the cracks, especially in medical deserts that I call a lot of rural situations. They’re the deserts because they don’t have the practitioners that know and understand them and also that they don’t even have access to them. No, I think of it as much more than a lost leader.

We’re trying to help with the education and awareness of palliative care here at Aging Media too. We launched a new palliative care news publication a few months ago. I think that comes out every week on Thursdays. If you’re interested in learning more about that space, definitely check out that newsletter.

Among the partners VyncaCare works with, yes, there are the providers, but there are also the payers. What’s the value proposition to payers? Is it how VyncaCare has lowered the total cost of care? Then also thinking back to those days at Centene, what lessons learned or pieces of advice would you give to the folks in this room, the providers here at Continuum?

Payers are hard to deal with, but they’re necessary. They pay for the care. That’s why they’re called payers. Payers are inundated with a number of lots and lots of vendors, lots and lots of ROI, and lots of costs. Everyone’s saving costs. Everyone saves for hospital reduction. Everyone reduces hospitalizations by 30%. Everyone’s got five to one ROI. You’re inundated with them. Get in line, right?

I would say a couple of things. Payers do care about more than cost of care, but it’s important. They care about member satisfaction, member engagement, member loyalty, right? They need folks in MA, right? You have a choice. They want to ensure that they have their membership year over year that sticks with them. They want it easy. They deal with a lot of vendors. Be easy to deal with. Be differentiated. They see too much. They’re people trying to get their job. Vendors are a little bit of a necessary evil. Sorry to say if there’s any payers out there. It’s just the way it is.

Now, cost savings. Be rigorous, show the data, and have your models that work. Too often we saw at Centene the pre-post model of savings. Before us, it was X, number of hospitalizations per thousand. After the intervention, it was Y, something lower saves money. You said, well, what’s that compared to? It’s just pretty, that’s not going to work.

Now, I realize we can’t randomize people to your intervention, so let’s assume that that’s the most, that’s the rigorous, I can trust that. Independent of that, what we did is we were starting with studies and we did one with patients last year. 900 total patients, 300 of whom were– 900 were referred to us by one of our payer partners, the Medicaid plan. We called each and every one of them or tried to enroll them. 300 eventually enrolled. The others, we, in this particular study, we tried to reach but couldn’t reach.

They looked dissimilar in terms of these referrals that were clinically eligible, they just weren’t enrolled in our program. Not quite randomized but close. We tracked both of them in terms of pre-post. How did each one, how did our group do in our program at VyncaCare and Supportive Care? Medicaid recipients, pretty sick. How did these folks that were referred to us do, which we can track based on their hospitalizations and ER visits?

We can track the people not in our program. We found that those in our program, based on looking at three months post-enrollment in our program, were able to save about $1,500 a month, primarily due to reduced ER and inpatient visits. Again, that was compared with a group that was otherwise looking clinically similar but not enrolled in our program. We think those are the types of things that you need to provide, as all the details supporting your ROI.

When you go to your payers, they do care about cost savings. They also care that we have a 94% patient satisfaction. Patients stick with us. They like us, right, in terms of the care we offer. When they know that their health plan sponsored this work, we tell them, tell your plan that this was something that you benefited from because of your health plan. Let them know because they care about patient satisfaction and reducing turnover and the like.

Anyway, have that in mind. Because again, these folks are inundated with all things and everybody looks stellar. You just have to be able to differentiate yourself.

Looking ahead at 2024, even beyond 2024, I know I’m excited about seeing some of the lessons learned from, for example, the emerging payment models we’re seeing, like ACO REACH, like GUIDE. I think there have been some other examples from CMMI this year. What are you most excited about looking ahead at 2024, whether it is something like the GUIDE model or something else entirely?

I would say that CMS is one of the most, this might come as a surprise to you or you might disagree, but CMS is one of the most innovative health organizations in the country. They’re trying. Now, CMMI has done a lot of things, most of which hasn’t saved any money.

I think out of the 54 alternative payment models. Maybe three. I think it’s four. Four. One of them has been the home health value-based purchasing model.

Listen, they’re trying to innovate. That’s fine. If I step back, I’ll say to myself, payment reform is one thing, right? We got to go get the care delivery right in the things we just described. No amount of payment reform is going to make that work. The other thing I’d say is you can make a sustainable, profitable go at it with the current payment models.

You can. Which may be like the one thing that people don’t leverage enough, like to be able to do that.

They don’t sweat the details. What I will say is you have to be able to know the effect, when you’re sending a clinician to a house or you’re doing any interaction, you have to say, is this one thing going to move the needle? What’s the best and highest use of that person’s job today? Is that caseload optimal? How much of my clinical allocated labor is being used today?

You need data to tell you whether or not that’s working. You don’t just say, well, four visits for that patient for that month, check. What were their outcomes? What was their acuity? Did you need to do that? You have to go separate your patients according to acuity and needs and map that to the interventions you’re doing. That takes work.

Vendors are not going to tell you that. They’re going to give you all kinds of training models that were trained on not your population. They don’t know your care delivery model. Their acuity scores might be trained, what they call trained in AI, you have to go train it on data. It’s trained with someone else’s delivery network and model, not yours. If you don’t match that, you’re just sending a bunch of expensive talent over to the home and you don’t have to do that.

I would also say that in the fee-for-service world, you have a lot of fun. You have E&M, you have CCM, you have TCM, you have RPM, you have behavioral health. I can tell you with all of that, you can do a lot. That’s independent of case mix and case-based rates. Now here’s the thing about CMM models and guides for dementia. That’s great, but in 2030, they may pull the plug. In 2029, they may pull the plug and all you’ve done is created some.

The other thing is they ask for too much. They do things in a way, like the oncology care model, $80 PMPM. That’s not going to be, no, that’s not going to work. What are you talking about? They did it so CMI will show cost savings. That’s why they took EOM and made it an oncology care model, right?

When you look at the guide for dementia, we’re looking at it from a margin perspective, like actually making money. No, that’s not going to, it may work, but that’s going to take some effort. Not that we standardize, not that we standardize, care is not standardized. It’s not McDonald’s, right? You can’t just sort of say, I have the guide care delivery model. I got this delivery model. I got that delivery model. Then, by the way, the plug is pulled or they change it. It’s like, maybe we’re just thinking about an old-school approach. It’s like, you can make it work in the payment models today.

I know MA is sticking it to a lot of folks. It’s true, but if you start with the right sort of provisioning of care resources, communicate delightful providers, better patient experience with a data fabric, data that tells you whether you’re working, I call it an experimentation platform, intervention platform, then I think you’ll be able to be successful in this.

Living with a serious illness can be difficult for patients and their families. VyncaCare is committed to empowering individuals, their loved ones, and their care teams with supportive care solutions that deliver care when and where they need it. To learn more, visit: https://www.vyncacare.com/.