Episode 2: Virtual care is where you want to be with Dan Trencher

Justin Steinman:
Definitively Speaking is a definitive healthcare podcast series recorded and produced in Framingham, Massachusetts. To learn more about healthcare commercial intelligence, please visit us at definitivehc.com. Hello and welcome to the latest episode of Definitively Speaking. The podcast where we have data driven conversations on the current state of healthcare. I'm Justin Steinman, chief marketing officer of Definitive Healthcare and your host for this podcast. I'm joined today by Todd Bellemare from our Definitive Healthcare team and our special guest, Dan Trencher. Dan is senior vice president for corporate strategy at Teladoc and a member of the Teladoc executive leadership team. Teladoc is the global leader in whole person virtual care offering services that include primary care, mental health, chronic condition management and more. Before this role, Dan led product management for Teladoc and previous worked at WellPoint and WellChoice. Let's dive right into the conversation.

Justin Steinman:
Dan, welcome.

Dan Trencher:
Thanks Justin. Thanks for having me here.

Justin Steinman:
We are thrilled to have you here. So it'll be a really interesting conversation. So let's get going. I want to stay are with an easy one. I just described Teladoc as the global leader and whole person virtual care which frankly I pulled directly from the about us section of your website. I always thought of Teladoc though as a leader in telemedicine. So tell me. What's the difference between telemedicine and virtual care and why does Teladoc choose to position itself as leader in virtual care?

Dan Trencher:
It's a great question to start with because telemedicine or virtual care is an industry that hasn't had a lot of clear terms over the course of time. So where I'd start is that the key difference is that virtual care is much broader than telemedicine. In telemedicine is where Teladoc got its start. I think of telemedicine as a live clinical interaction between consumer and a provider or sometimes a provider and a provider, but it's very much a live sort of discreet visit or interaction. Virtual care is a whole lot broader than that, right? It includes ongoing chronic condition management, digital tools and digital self management, AI driven reminders and nudges, remote monitoring, ambient sensors and I could sort of go on and on. That's all part of what certainly today is virtual care. So it's funny, I often say people know Teladoc or the industry best for live visits and that's what a lot of people interacted with over the last couple years so that's actually a very small part of what we do today. It's important for many of our services, but it is a pretty small part of it.

Justin Steinman:
So I bet a lot of our listeners have probably used Teladoc, but may not even know that they're using Teladoc. So who do you sell to? I can't go off and buy you as a consumer?

Dan Trencher:
Well, actually you could.

Justin Steinman:
Good.

Dan Trencher:
That isn't the sort of the center of our go to market strategy so it's probably helpful to think in terms of the trajectory of the company. Certainly and I started with the company just about 10 years ago. We started by selling virtual care telemedicine as a service to large employers and then health plans picked up on it as more of their clients bought in to trying telemedicine. We sort of expanded from there to serving hospitals and health systems. They're often with a more of a technology platform, software, hardware and services on top of that. So go to market that way as well.

Dan Trencher:
We do actually do a fair amount of direct consumer mostly through a part of our company called Better Help which is the leading online digital therapy platform. So it is definitely a mix and we've actually gone international as well. So clearly the US is still the biggest part of our business, but we have real sort of business and operations in country and Europe and south America, in Asia, Australia, and sort of many areas around that, and it's interesting as a healthcare executive, you don't often get the dude that brought a pallet, right? And so to have an international and sort of multi-stakeholder sort of go to market which makes it pretty interesting. 10 years later, it's still pretty interesting.

Justin Steinman:
Yeah, that sounds interesting. Telemedicine experiences just crazy growth at the start of the pandemic. We talk a lot about using data in this podcast so I got some really cool data, probably not going to surprise you. Surprised me when Todd and his team pulled these numbers in. I'd love to get a reaction, but 2019, roughly 1.2 million patients had a telemedicine claim. That jumped to a whopping 68.7 million in 2020, and as of November 2021 which is the latest data that I have today, it's about 64, almost 65 million visits. You assume a steady run rate that's probably another 5.4 million visits in December for close to 70 million visits in 2021. So you're looking just to kind of recap there, 1.2 million in 2019 to 70 million in 2021. That's crazy, how did that feel for you being in this business?

Dan Trencher:
Well, it certainly was a pretty interesting time last March and April because as you know, things happen pretty quickly and we're used to seasonality in our business and always see it grow with cold and flu season in the fall and come down a little in the summer and this was a step change in a matter of a couple of weeks so definitely took a little adjustment sort of hour to hour at that moment, but what's really interesting is once things settled in a little bit, what we really saw was a massive change in as you said, consumers and providers honestly getting their first exposure for many of them, obviously we've been operating for a while and many of our clients had success with our programs, but at an aggregate level, you started at an industry level, a societal level, most people got their first experience, right?

Dan Trencher:
And what was great was that all of the feedback was that people's first experience was good. They really enjoyed it. I think it was 80% plus if people said their virtual care experience was at least as good if not better than what they're used to getting through the traditional sort of community delivery environment, and what we saw is that as consumers had these experiences, their expectations started the change about what their virtual care experience should be, right? And started people started comparing it more to my shopping experience through an Amazon or something, or when I book travel, or when I bank and these other sorts of deeply digital experiences and the seamlessness and the personalization of how those companies have created those experiences, that's what they started to bring to healthcare which is super healthy, right?

Dan Trencher:
Because I think I firmly believe that consumer's expectations about their healthcare experience have been way too low for way too long and it was super healthy to sort of start comparing healthcare to other industries and what we saw from that was then was the buyers in our industry which are predominantly still employers and health plans and hospitals and health systems. Their expectations started to change because they saw the consumers were really starting to adopt and they saw that virtual care could be really strategic to their businesses, right? Particularly on the health plan side and the hospital and health system side so it wasn't just a sidelight, it wasn't just kind of an additional benefit to offer. It became central in many cases to the strategy of a plan or of a hospital health system and how they stayed open, how they delivered care, and so those expectations started to change from a buyer perspective as well, around broader, more integrated solutions, consumer experience provider experience and we see that's all good, right? We see that's really the future.

Todd Bellemare:
Yeah no, I was just thinking that when you talk about that holistic view of what telemedicine is versus what virtual care is as we see people try to or start to change their opinion about, "Oh hey, I can do this too and it works." Which is probably a far cry from where it was maybe six or seven years ago as internet speeds have gotten better and it gets easier to start to get into that sort of thing and feel like you're getting the full bandwidth so to speak of your health visit. Do you see sort of that trickle down effect of everyone's got their Apple Watch or their Fitbit or whatever saying, "Oh hey, I now have this portal online that I can interact with my healthcare providers. How do I get this stuff in there?" All that other stuff that could be encapsulated by virtual care, it's now not just the visit with the doctor, it's, "Oh, hey, my heart rate is on this thing, my steps are on this thing." So that sort of thing, have you seen that sort of pick up after April of last year?

Dan Trencher:
Yeah, I would say more broadly that as you said, beyond the sort of the clinical visit has been critical and it is a bigger part of our company too, right? As you know, we merged with Livongo during the course of the pandemic and a key element of those offerings is around the gathering data through devices. Those are generally sort of special purpose devices that gather blood sugar readings and blood pressure, but similarly, heart rate and other sorts of data that can come from wearables or your watch are going to become I think, increasingly part of the picture on how virtual care in a longitudinal way is delivered. I'd say that's one of the big transitions in the environment. It's less sort of just that these devices are out there though there are more devices out there than ever.

Dan Trencher:
But as virtual care is transitioning from being sort of very supportive, very episodic and transactional to being longitudinal and really often central to how consumers are experiencing and accessing care. There's a lot of talk about virtual primary care as a broad term which I'm sure we'll talk about more and within that is the underlying principle of a longitudinal relationship, right? Between a patient and the technology, a patient and a provider and all those different types of additional data can be super powerful, right? Because as you know, a lot of in the community, all the care is squeezed into any year squeezed into maybe an hour when you're with a physician, but care is 365, 24/7, right? And that's the promise of how these devices and technology can really enable consumers to access care manage their health throughout the year.

Todd Bellemare:
You can almost think of something like the Framingham heart study, right? The longest running trial pretty much or longitudinal study of health and how it connects to other people in their lives and how maybe behavior spread and now taking this amount of data now that we are really intertwining it with our visits and then saying, "Oh, okay, let me get the rest of my data in there." It almost explodes that Framingham Heart Study into now almost anyone can do it and when you think about, anyone being any company that can consume this data and then look at it and start using ML or AI strategies to say what does the outcome look like for a patient profile with these indicators and so that to me is what blows my mind and what I'm super excited for. I have a very optimistic view of what this data can do for us and where we'll be in five, 10, 50, 15 years or so. So to hear that these are all the things that everyone is thinking about when they're looking at this data, that it warm my heart.

Dan Trencher:
And I think you hit the nail in the head. As more devices of various sorts come online, there's more and more data, right? And so it's not the gathering of the data, even the aggregation of the data is where value is created. It's about the analysis of the data, using AI, as you said, an ML to generate insights, to help clinicians do their jobs better and to help drive behavior change at the consumer level, right? So that they can manage their own health better in terms of their eating decisions and reminders, in order to improve adherence to medical directions or to medication adherence itself. That can be really powerful and that's obviously an area that we're really focused on is that use of the technology applied to the data to change that consumer and provider behavior.

Justin Steinman:
So it's an interesting topic that you get hit on there Dan. We recently had Michael Greeley from flair capital here and we talked a lot about the retailization of healthcare, CVS, Walgreens, Walmart offering primary care, right? And Michael and I debate whether it's possible to get true longitudinal ongoing care out of retail store versus a PCP. Now, we've got telemedicine and Teladoc jumping into this space. Now, we've got a macro problem in this country as we all know, it'd be the association of American medical college has said, "We're looking at a primary care physician shortage by 2033 of somewhere between 21,000 and 55,000 PCPs." So we got a problem here, but what worries me is almost the disaggregation of longitudinal care because we're going to have, I go CVS, I have my PCP, I go to Teladoc when I have something incidental at two o'clock in the morning and then I've also got all this device on my iPhone. How do you stitch all that together to really create that longitudinal medical record?

Dan Trencher:
Yeah, it's a great question and you're right. The basic premise that sort of the virtualization of primary care is a big opportunity. We talked about it, our vester day a lot. There are a lot of companies out there going after it with different types of models and the first thing I'd say is that I do believe that virtual care is well suited perhaps uniquely well suited to really drive longitudinal care for the reason we were just talking about, that longitudinal care isn't just having a visit every year, right? It is the ongoing, so support for the patient. For us, we include 24/7 access to a care team and nurses for messaging as an example. So that's sort of always on and available element I think really supports having a longitudinal relationship, a care plan that the patient and the coach have created together, right?

Dan Trencher:
And is automated and can be tracked and reviewed together. I think there are a lot of powerful elements of virtual care that I think you don't see as much in traditional community care. You think about a diabetic, are they really writing down in their little book and bringing those results? And that's sort of the standard of care for managing diabetes care often, and obviously we can do a lot better than that using technology, but the one thing I think is super important is that as we look at the question of virtual and brick and mortar, right? It's often positioned as an or, right? Sort of which is going to win and is virtual going to replace brick and mortar and I firmly believe that it's an and not an or.

Dan Trencher:
And one of the analogies I uses is I think about music, right? So we started with an environment. The CD replaced the record and music streaming replaced the CD. So yeah, technology can just create a better consumer experience and it might sort of eat for lunch the previous way to get a certain thing done, right? Listen to recorded music, but if you think about what actually happened to music, while streaming and recorded music was growing, live concerts grew exactly the same trajectory and I use that as analogy because going to a concert is different than listening to your favorite band on a streaming service just like going to the doctor can be very different than managing your chronic conditions through virtual, and it's really the combination of both for different people, different times, different use cases that I think is going to be the future.

Dan Trencher:
So really is that more hybrid model of care which requires in healthcare, a lot of coordination and sharing of data, so those aren't two separate islands so to speak, and that's something that we're really focused on as we sort of build out our primary care model is having those connections in a bunch of different ways. We talk about the last mile a lot, right? There's sort of that analogy from delivery where if you think about the end to end, I'm ordering something and having it show up at your door, the last mile is that last, leaves the warehouse in the truck, gets to your door and we're spending a lot of time on that as applied to a virtual experience, right? Because you can do virtual all the way up and through you need a lab test done, right?

Dan Trencher:
Or you need a foot exam or you need your prescription filled and then it's like we'll go out in your car and drive around and wait in line and do various things. So one element I think is bringing elements of a care experience that tend to be forced to be in person and inconvenient to bring them into the home. Ultimately, the home is I think the future side of care increasingly from where it is today, but where there are clinical services that you obviously can't bring the MRI home or there are certain things that are going to make a lot more sense to go to the specialist office for therapies or different types of exams, really having a tight connection in terms of the referral itself. So you know you're getting referred into a high quality, in network and perhaps inside the COE or inside the preferred network for your health plan provider.

Dan Trencher:
Part of that arrangement that we have a referral arrangement is that we're going to get the data back, we're going to provide data about that patient and then get data back so that there is a synchronized record between the community, bricks and mortar and the virtual record for that patient and so it's not easy. Healthcare obviously, nobody's yet solved for the universal health record that is shareable and complete across the entire healthcare ecosystem. I'm not going to tell you that we've solved that either, but I'm saying we consider it important and we're definitely following standards based and protocols and trying to make that a key part of the care model that there is that coordination and collaboration around the patient.

Todd Bellemare:
I think one thing that you had said there Dan, in terms of the convenience, right? When we talk about the continuum of care of where they could go get their healthcare, making it easy and convenient, people are very ready to take the convenient thing if it's going to get them to the next step and that kind of leads me to two points is that one, Justin, you had mentioned how do you stitch it all together and usually those questions have some degree of privacy included in there, with the California law for privacy and so other surveys have said that people are willing to give up a little privacy if it gives them more convenience and so I think that a lot out of that interoperability between systems people will say, "Well hey, if that can all work together and make it a seamless event." "Hey, I'll allow my data to traverse across that environment."

Todd Bellemare:
But again, then it comes to the convenience factor. It really has to be something where they're easily able to just say, "Yep, I'm going to get on a quick call with my doctor to get to the next step." Dan, you had mentioned about hey, when you got to go get in your car and go do something, it's got to be worth it. For me for example, I hurt my foot, I don't want to have to drive all the way to my doctor's office 30 minutes away just to tell her that, "Hey, I hurt my foot, can I get a referral to an ortho or something." Rather, I would have a 15 minute conversation with her over video conference and then she'd give me the referral from there so it's those inter active pieces that if we can insert the puzzle to make it convenient, the ability for people or the willingness for people to allow their data to traverse the internet to get there to make it worth it.

Dan Trencher:
Yeah and I think we should take an expansive view of what our data is, right? So particularly as you think about areas of healthcare with stigma attached to them, right? So mental health as an example, a barrier to care is that people don't want to in a small town go and drive and park in the parking lot outside the town psychiatrist office, right? Something as simple as that. I mean there's data in that, right? And so the privacy and the control of your presence in data I think that you can do virtually. It's particularly within an integrated system is pretty powerful and it's actually activating people to take care of themselves better and access care when they might not have otherwise and that can be pretty powerful.

Justin Steinman:
Yeah that's actually really interesting Dan, I agree with you. Mental health is a topic that's really changed in the pandemic. 10 years ago, nobody talked about mental health in the open nose, a hush topic as you just said. We're definitely in a healthier place now. People talk about mental health issues the same way they talk about their broken foot. I think that's amazing progress. I got some data that kind of would validate some of that was really interesting around it. First off, over the past two years, we've seen the overall volume of mental health visits, both physical and virtual increase by about 10%.

Justin Steinman:
So more people are out there, raising their hands saying I need to find someone to talk to, but when you look at how the outsized role the telemedicine has played, again, it's a shocking growth story, shocking in a good way. In February 2020, less than 1% of all mental health visits were done by telemedicine. By April 2020, the very start of the pandemic, that jumped to 48% of all visits we're done by telemedicine, but now in 2022, we're stabilizing in this new endemic world if you will. The percentage is stabilized up about 37 or 39% of visits each month are being done by telemedicine. Is that an area that Teladoc's investing in and what are you doing there?

Dan Trencher:
Yeah, absolutely. We've seen the same sort of pattern and I think you make a great observation and Justin, we both been in the industry long enough to know when mental health parody came out and that was a big deal. It's hard to even imagine now that was such a big deal that you have to govern mental health. Just like physical health. Well okay, that was. Now that's sort of taken for granted, but the access component, it has become such a challenge for people, that's why I think virtual care has taken off for mental health. It's obviously uniquely well suited in many ways, right? That you can have pretty much the full clinical experience for most consumers through a virtual environment and just the difficulty in finding a provider who's taking patients today.

Dan Trencher:
And as you said, just the increased need because of everything going on in the environment, right? There're just more people need help than ever before and so we've seen our volume of mental health services literally go up multiples, let me put it that way. I'm not exactly sure which number we've shared publicly, but let's call it multiples if not order of magnitude and that is continuing as your data suggested, right? It wasn't just a blip and sort of gone way down. It is continuing at a pace that really makes it an area we're super focused on, and it isn't I would say, just like we talked about before, virtual care versus telemedicine, it is in large part through live therapy visits, live psychiatry or a patient would work with psychiatrist and be able to get medication and medication management, but part of our strategy is a sort of a mixed model or a step care model that includes the self-management capabilities part of when we merged with Livongo. A part of that was also my strength which is on the leaders on the digital side.

Dan Trencher:
So we've worked pretty hard to integrate that for a full stack model where a patient can come in and get sort of triaged through the program and application and get a recommendation about sort of the level and types of care and services that might be valuable to them which could include anywhere in a mix of self management coaching therapy and sort of psychiatry, or more acute needs and a referral for more acute needs, and I think that's important because it's sort of more right care for the right person at the right time, but also allows us to be efficient with resources. I hate to say it, nobody's minting new healthcare, mental healthcare providers quickly enough anyway, right? That supply challenge isn't going away and so being able to use digital in a way that really extends and sort of amplifies what the therapists and clinicians and psychiatrists can do, I think is pretty important not just at a Teladoc level, but at a societal level.

Todd Bellemare:
Have you seen when people start mixing in, obviously the bumps that in telehealth for mental health were just astronomical for sure and I did find it so fascinating that as we look across all of the specialties, even if you break out psychology from the mental health, that is almost 50% still just across the board happening virtually, but have you seen, when you start patients who start mixing in the telehealth component for mental health, does it make it more likely that they continue on with their therapy? The data kind of shows that once someone goes in for a telehealth visit for mental health, they are much more likely to continue on seeing that therapist as opposed to when it was always in person. So hey, there's traffic, there's things to do. I can't eek out the extra hour of time to do the travel. Therefore, if I don't have to do that, I'm much more likely to stick with it.

Dan Trencher:
Yeah, I would say that's absolutely the case. Partly for the reasons you just mentioned. It removes some of those barriers of the convenience, the getting time off from work. When we look at our statistics, over half of our mental health visits, the visits themselves occur after business hours, either weekends or nights and evenings during the week and that's not happening nearly as much if it were required to be in an in person setting. The other thing I'd add is as we look at our mental health model, Better Help model, which is continued to go really well on a DTC basis, it is activating people who had not sought therapy before and probably who would not have sought therapy before, and so activating them is a good thing.

Dan Trencher:
They're getting the care that they need, but also a key part of that is messaging with the therapist, right? So sometimes a chat session, but more often asynchronous messaging and so it's really also the mix of mediums, let's call it. Between phone calls, video calls and some messaging, that can also help people through different sort of cycles in their needs, right? Sometimes when it's less intense, it's maybe more just check-ins and it could be more on the messaging side and then when more things are coming up, you can kind of mix and match and for different strokes for different folks. Some consumers, we see a lot of heterogeneity and how people are using it and it's most often a mix, meaning people are using each one of those different types of modalities.

Todd Bellemare:
I love the idea of thinking about those modalities just because I think everybody thinks oh, telehealth or telemedicine is you're getting on a video conference or even a phone call is a form of telehealth as well and then text messaging or even again, those phone calls I think is really interesting because it expands the understanding what we're really talking about and when you talk about people, then using those different strokes for different folks, right? It's going to lead to better outcomes and I think in the end, part of the story is for this of course, is that all of these different modalities we have at our disposal can eventually lead to this five years, 10 years or so, we've got people better off now than they were in 2019 and 18, 17 and so on because now they actually have access to these things and it's that great story back to my optimism. These are the things technology is now solving these problems and it's an and, and it gives them both the options there so this is exciting stuff.

Dan Trencher:
One of the things we've been focused on since the beginning, we were well known as sort of starting with the telephone, right? Because you couldn't even get high speed video 20 years ago when the company was founded, but even as the technologies in general caught up, particularly because we serve very diverse populations, we work with a lot of Medicaid populations, we work with older populations and internationally as well in different developing nations. You don't want to let now a new barrier to care come up because of technology and because of lack of access to high speed wifi, right? Everybody's got a phone, but maybe you don't have unlimited access to high speed bandwidth and so we try to avoid introducing disparities by requiring only a certain method, sort of modality to be able to access the care that people need.

Justin Steinman:
Dan, I want to come back to something that you were talking a little bit around mental health because one of the things that I'm really personally interested in is kind of the intersection of mental health and physical health and how one impacts the other, and I think a little bit about like what you all are doing with Livongo which for those people who don't know does a lot about diabetes management and coaching and stuff like that and I'd love to kind of hear some view perspective around how Livongo is helping that, right? Maybe I'm a diabetic and I eat Snickers bars because I'm depressed and food is comfort for a lot of people and it's not just I have a physical issue, I have a mental issue that's driving a physical issue, but I think when you bring them together, you actually can make a real difference in somebody's life.

Dan Trencher:
Yeah, it's a great point. There's a lot of data, right that we could cite around the value of addressing mental health needs whether it's anxiety and depression or other things that improve with comorbidities and save costs dramatically, right? But also create better outcomes for those who have comorbid chronic conditions like diabetes or hyper tension and so our approach, and when I say our, includes Livongo of course as part of the Teladoc and I know those terms used a lot, a whole person approach, and the first level of that is when we're talking about supporting, let's say a population of people with diabetes, not just treating the diabetes condition or managing that, right? It is having built in the ability to support weight management or hypertension and mental health needs as they come up and first orders, all those services are available to that consumer because that's all part of who they are. The second level and the harder level is make those services integrated, right?

Dan Trencher:
And that's really where we're focused so that the therapist who's helping with that mental health piece isn't kind of off somewhere doing their therapy. You're able to leverage the data, leverage those relationships potentially between providers. Obviously all at the patient's discretion in terms of sharing information and privacy and all of that, but that integrated clinical experience is what's super powerful, right? And it extends all the way to if you're having your diabetes managed, maybe what you also could use as a clinical consult from a physician who can order an A1C test and maybe adjust your insulin or adjust your medications, right?

Dan Trencher:
And that's part of the model too. So it's not just like general med over here or primary care there and diabetes management over there, but really thinking that is one holistic whole, that's certainly the future and where we're headed, and I'd say the clients more of the market is starting to see that whether it's bringing mental health and diabetes together or other chronic conditions, there's sort of an overwhelming number of point solutions out there and in more and more in the market from a purchaser perspective are trying to consolidate and make their lives easier, but also have more effective programs because consumers are not just a series of conditions, they're people, right? And best handled that way.

Todd Bellemare:
I think something super interesting when you look at just in your comment about the intersection of body and mind, pretty much of those treatments and then not only that, but looking at if we talk about the mental health and the large percentage of it happening in the telehealth realm, when you look at endocrinologists or even dieticians and nutritionists, those are two of the other large groups that a large specialty is really seeing a big percentage still drawing from their patients in the telehealth world as well. So for example, endocrinologists, they kind of bumped up big when April hit, but there's still seven or 8% in the winter time is a little bit higher and then you look at nutritionist and dieticians, they're in the 20%. So 20% of their visits, even still now in a year and a half from 2020 April, they're still having a large percentage of their patients coming in as telehealth visits.

Todd Bellemare:
So when you look at the sort of the comorbidity across those different arenas, the patients are going to get used to that from their nutritionist, talking to their endocrinologist and then say, "Oh, maybe there is some kind of mental issue driving some of this." "Oh hey, just do it also with your mental health, it can all be done this way." And people get used to those modalities and then goes back to that convenience. If you're used to doing with nutritionist, it's an easy step over to talk to a mental health therapist and it's easy to talk to an endocrinologist in that environment as well. So the chronic care leading from mental health to all these other sorts of things that have those connections, if people start getting used to it in one arena, it's easy enough for them to jump to their other doctor that treats their other conditions in the same modality.

Dan Trencher:
That was actually one of the interesting things we saw as you might imagine. We analyzed pretty closely how our service is getting used, particularly as we think about what we call general medical service which is what sort of remote urgent care historically, but what we saw is starting in March of 2020, it was used for a whole lot broader set of things, right? Conditions like lower back pain, hypertension, endocrine issues became a much bigger part of what it was used for and that's partly because interesting of course, when people started shutting down because of COVID as we all saw, there was no flu season last year, right? It sort of kind of shut down most respiratory infectious diseases let's call it, right? But there was all this need around chronic conditions which weren't getting managed and so it was obviously there was nothing good about COVID, but it was interesting to see the broadening out of how consumers were using virtual care even in an environment where they didn't know the doctor before, right? This was a first visit so to speak between that patient and that provider.

Todd Bellemare:
It was also kind of scary to see where that didn't happen for cardiac diseases and cardiology had a massive downturn in just overall visits regardless and the telehealth bump in cardiology was not as large as it was in other sort of chronic management so I think we saw quite a bit of poor outcomes are starting to come in the door now while in 2021 and now in 2022 of people who did not keep up with that for sure.

Dan Trencher:
It's really interesting. What part of our business when we serve hospital and health systems is traditional, like Telestroke, TeleICU, those sort of provider to provider kind of hub and spoke models and so within Telestroke, there was a lot of industry data that there were just fewer strokes that came into emergency rooms, and I think we all know there weren't fewer strokes, right? It was just that they weren't making it to the emergency room. People were just staying home because they were scared to go in. So it goes at the sort of the hidden costs a little bit in the background of care that wasn't delivered that really needed to be delivered and it's scary, and hopefully people are starting to feel more comfortable getting the care that they need in those sorts of situations.

Justin Steinman:
That's a really interesting point. As an advertiser for an upcoming podcast, we actually have a position coming on to talk from a Cedar Sinai about the impacts of the delaying cares on his patient profile and the entire hospital system out there, but I want to come back now and talk to us something I read recently in the Boston Globe, right? So your CEO, Jason told that the JP Morgan Healthcare conference and I quote now that Teladoc is gradually embracing more risk sharing. What does that mean and how does risk sharing work for a virtual care provider?

Dan Trencher:
Great question and I position it first as he said, gradually embracing, sort of evolution in that direction, right? So at the most basic level, taking risk is having as part of our economic model with our clients that some of our economics are at risk based on the value that we're providing, based on outcomes of various sorts and as you know, our historical first economic model was a PMPM and visit fees and that's all good and that hasn't sort of gone away, but certainly there's a move in the industry towards more risk based compensation, just like there is in community settings, right? And certainly with ACOs and other sorts of arrangements, and I actually see the evolution in virtual is going to probably follow a similar path to what we've seen and traditional sort of brick and mortar settings.

Dan Trencher:
And what I mean by that is you start with fees at risk and moving towards capitation, but there's a lot in the middle, Right? So maybe fees at risk based on pay for performance, right? So what are you achieving against something you can easily measure, like a HEDIS measure, right? What percentage of people are getting a screening that they need or are you impacting blood sugar and then you can move over time to actual clinical outcomes, right? So are you having fewer hospitalizations? Are you having improved outcomes around a chronic condition and then sort of the last step in that is cost outcomes, right? Are you from a total cost of care perspective or from a bundled sort of perspective around a particular condition category? Are you impacting that positively and I think virtual care follow a very similar path because you obviously can't go straight to full capitation until you've taken those initial steps, right?

Dan Trencher:
It takes time and it takes proving out the effectiveness of the programs and those sorts of settings. So we see that in chronic condition management. There's a great fit there and primary care as we move more towards into longitudinal primary care. There's a great fit there as there has been in the industry around patient centered medical homes that are taking primary care risk. I would say that we certainly expect to take on more risk and it could be plus minus, right? So obviously there could be some upside as well in that primary care space. I never want to become a health plan.

Dan Trencher:
I've been on the health plan side. I don't want risk based capital. It's great if you're in that business, but it's not for virtual care companies. That means that we're probably not taking full cost of care risk on a population so to speak. We want to take risk where we can directly impact those costs best are around the virtual services that we can provide, but I think it's a trend that's in the industry and we think because of the effectiveness of our programs and the breadth of our programs, we could be pretty successful in that kind of model.

Justin Steinman:
You've alluded to multiple times that you have an international footprint because you're virtual. Could you ever see Teladoc getting almost back into in person care delivery, building a network to challenge an Optum or an HCA or even a CVS?

Dan Trencher:
Well, certainly what I can say is our CEO, Jason who you've quoted earlier in the podcast has been fairly declarative about his allergy to owning Bricks and Mortar, right? So he has said that explicitly. I will not contradict that in any way so we don't really want to own bricks and mortar physical locations, right? But we certainly foresee having strong relationships with bricks and mortar providers and those can be retailers.

Dan Trencher:
We already have relationships with retailers as you know with providers owned by our clients. That's certainly an area that we're often asked when we work with our health plans to enable their providers whether they're owned or to just affiliated or just preferred, to be able to provide virtual care to that health plans population. We also have an opportunity because we work with 100s of hospitals and health systems around the country on that side of our business to leverage those relationships and create sort of a network so to speak or referral relationships into those facilities. We tell those clients also, we have no intention of opening up a store down the street or a clinic down the street from you so that's the best I can say.

Todd Bellemare:
I can see in 2040, Teladoc opening a robot only doctor's office where you go and you talk to the Teladoc robot and tell them what ails you and they take care of you from there.

Dan Trencher:
I love it.

Justin Steinman:
All right so let's wrap up a little bit here, telemedicine and virtual care are growth industries, right? But our data shows that frankly, more than 50% of people in this country has still never had a virtual care visit. I'm embarrassed to say that one of those people happens to be my wife, who despite the fact that I've worked in healthcare IT for 15 plus years has yet to have a virtual care visit. So Dan, what would you say to all these people, including my wife, to get them to start using virtual care as your real healthcare delivery mechanism?

Dan Trencher:
Well, I can think of three things, right? So one of them is the statistic that 80 plus percent of people would try it, like it as good or even better than what they're used to. The second thing going along with that is how excited are you about the current healthcare experience? Do you love the current healthcare experience? Are you a positive NPS on what you have to go through to access care? And so do you think it's possible that there could be a better experience out there? At least to try, and then the third is in the time we've been talking about this, you could have already accessed care virtually, right? So why not give it a try?

Justin Steinman:
I love that. I'm a big user. I have used Teladoc multiple times. I give it a high NPS on the Justin scale, whatever that matters, but hey Dan, I really appreciate your time. This is great conversation. I know Todd has been over there having a good time and chimed in a bit as well with you. So thanks for taking the time with us today.

Dan Trencher:
Absolutely, thanks for having me, great conversation.

Justin Steinman:
Thanks for listening to Definitively Speaking with Definitive Healthcare podcast. Please join me next time for a conversation with Ben Rooks from ST Advisors about mergers, acquisitions and private equity investing in the healthcare IT market. If you like what you've heard today, please remember to rate, review, and subscribe to the show on Apple, Google, Spotify, or wherever you get your podcasts. To learn more about how healthcare commercial intelligence can support your business, follow us on Twitter @definitive HC, or visit us at definitivehc.com. Until next time, take care and please stay healthy.