From 2009 to 2013, Dr. Farzad Mostashari helmed the Office of the National Coordinator for Health IT. In his ONC days, he oversaw implementation of policies such as the meaningful use and Regional Health IT Extension programs. He brought a bit of flair to the office with his positive attitude and iconic bow tie -- which has been placed on cultural level high enough to have its own Twitter account. That's BronxZooCobra level.
Today, he spends his time as CEO of Aledade, a company that partners with independent primary care practices to help those physicians enter into value/outcome-based care contracts. Founded in 2014, Aledade, which has raised $34.5 million in venture capital, is now operating in 10 states working with 120 physician practices, and caring for approximately 100,000 Medicare beneficiaries. Following an initial focus on ACOs, the company is in the process of expanding to value-based contracts with commercial payers.
Put succinctly, Aledade provides upfront capital, customized technology platforms to optimize EHRs, tracks patient spending, assists with outreach, provides on-the-ground practice support and assists with compliance. As part of our Healthcare Influencers series (check out our first installment with Rhode Island Sen. Sheldon Whitehouse here), Farzad spoke with Healthcare Dive on his past and present.
Healthcare Dive: Where did your interest in health IT and health policy begin? How has it grown?
Mostashari: It really started from the public health perspective asking, “How do we save the most lives?” This was the question when I joined the New York City Health Department out of my fellowship in the [CDC] Epidemic Intelligence Service.
For me, the question started with saying, “We need to get better at analyzing patterns of disease in society so we have our finger on the pulse of the city as a patient.” The first major project was setting up what would today be called Big Data infrastructure to track disease, health, morbidities, behaviors, and mortality in as close to real time as possible and to see if our policies were working. For example, if we raised the cigarette tax, what happens to people buying nicotine replacements?
When I first got introduced to the EHR, some questions were, "How can we get into healthcare data?" and "Where is there digital data in healthcare?" There barely was any. All healthcare data was on paper except for billing systems so we used billing and registration system information.
The first eye-opening glimpse for EHR’s potential was when we were working with the Institute for Family Health and they had implemented Epic and for months they had been using it to show them how badly they were doing. Then they put in a decision support that said, “Patient elderly did not have a pneumonia vaccine that could prevent potential fatal pneumonia infections. Click here to order the pneumonia vaccine.” And that simple actionable information at the point of care dramatically increased the number of pneumonia vaccines that were given. That, to me, was the "aha moment" where EHRs could not only monitor healthcare but could be a major force to improve the safety and quality in healthcare.
You’ve seen the growth of health IT from the ground floor. Where are we now and what has been the biggest change as far as health IT goes?
Mostashari: We are somewhere between 60-80% done digitizing [healthcare data], which is an incredible first step. It creates data that can be used to transform everything we do in healthcare. But we’re only 5-10% the way through optimizing that technology and to really change the workflows to accommodate this new way of delivering care. Right now, we’re in this awkward phase of using 21st century tools with 19th century workflows and it’s no wonder there’s this awkward and oftentimes frustrating mismatch between the digital possibilities and the workflows we’re asking them to fit into.
How was your experience at ONC?
Mostashari: It is one of the signal honors of my life that I had that opportunity over those four years to work on something that impacted the lives of patients, doctors, and hospitals from Alabama to Alaska. It is mind-blowing the breadth of change that had to happened and I happened to be in that place in that time to help implement the HITECH Act in those years.
One of the things with health IT you realize is there are many simple and persuasive and wrong prescriptions for when people ask, “Why couldn’t you just 'blank'...” because of the mix of technical, privacy, business, policy, and interoperability [interactions]. Every moment in my day held some incredibly worthy and complicated policy technical regulatory implementations issue and it defies simple solution. Our healthcare system is incredibly complicated and diverse and finding the best way forward was a real privilege. I may be one of the only startup CEOs who doesn’t think this is the hardest job they’ve ever done.
When you’re a public figure, how are you able to continue to do your job in the face of public criticism?
Mostashari: One lesson I learned from my predecessor David Blumenthal was transparency and openness is the key. We knew there would be thousands of hours of discussions with many stakeholders and it was all going to be in the open. One of the early decisions we made is to let [everyone] know why and how these decisions that were ultimately made were made and based on what evidence and what thinking.
The other thing we said was, “Eye on the prize, feet on the ground,” to always articulate our goal and bring things back to the intent of saving lives. Those were my policymaker prescriptions for how to move ahead in incredibly complicated and contentious waters: transparency and openness and always being clear and steadfast in the goals guided by data in the execution.
How is Aledade helping public health initiatives?
Mostashari: Everyone knows prevention is better than spending vast amounts of money and treating people after they’ve gotten sick. For a long time, prevention and better management of chronic conditions didn’t pay. So I felt like for two decades I was pounding against a wall trying to get to better health for the population against the incentives that were shaping the delivery and the payment systems. Now, there is a window that is open in that wall and we are trying to crank that window as wide as possible for as many people as possible to take better care of people, manage chronic illness, and improve safety, because if we reduce those bad things no one wants to happen but no one was willing to pay for, we get to share in the value that we create. So for me, I was so excited to find a place where the business model is aligned with population health -- not at odds with it.
How can accountability be made more attractive to physicians and hospitals?
Mostashari: I think the key is primary care physicians want to be accountable and want to do prevention, but they have the long odds against them to do it effectively because they lack scale. In many cases, they’re in small practices or lack IT capabilities or the ability to have the scale to impact what happens outside of their four walls when the patient goes to a specialist or referral. Sometimes they lack the capital to be able to organize themselves and hire staff to help them, so what we do is give them all of that.
What they are lacking is an “easy button,” and we give them an “easy button” to embrace accountable care. Demand is incredibly strong for what we’re offering. I think the resistance people attribute to primary care is them being overwhelmed. They’re not resisting the concept, they just don’t know what the first step is.
Your growth has been very good. To what do you attribute this growth?
Definitely the macrotrends are in our favor. I’m surprised there aren’t more groups. People say, “Do you worry about the competition?” I wish there was more competition because the true competition is fee-for-services.
I think part of why we’ve been able to do what we’ve been able to do is you really need to have superpowers in different things and there are not many groups that have the understanding of informatics and EHRs and workflows and small practices and care transformations in the field -- who have the analytics understanding and the ability to do big data analysis and find actionable insights out of the mass of data, in addition to the ability to understand regulations and to be able to do all that goes around clinical practices and work effectively with them. More than any one thing, it’s our ability to bring all those components together that I think makes our value proposition.
What is your advice for anyone interested in entering health policy or the health IT space -- or to potential competition?
Mostashari: Focus on the outcomes. Let’s get away from compliance thinking. Let’s raise the ceiling. Let’s be pulled up to the outcomes instead of pushed away from being bad. Keep asking, “What are we doing this for?” to not get so caught up in the compliance of checking the boxes and documenting that we lose sight at the end of the day of what we are doing this for.
That’s what I love about this startup and effort. It doesn’t matter if you do all the right processes if at the end of the day you’re not helping people not get sick and not end up in the hospital. Then you haven’t succeeded. Talk about the intent. Paint the vision of the future. Know what you’re trying to get to and be brutally honest with yourself where you are.
I do want to emphasize in healthcare, there’s a lot of talk about payment systems and IT and delivery systems but at the end of the day, it’s about the relationship between the caregiver and patients. Everything we’re doing should be strengthening those bonds and bringing into alignment what’s best for each of the actors. The job of policy is to bring those into alignment and the job of the people in the field defined by those rules is to make those succeed in a way that’s most meaningful to all.