Episode 16: Avoiding algorithm bias and worsening health inequities in ML/AI technologies (with Dr. Vik Bakhru of Circulo Health)
This lively conversation is one you won’t want to miss if you’re an artificial intelligence or machine learning innovator, a provider, a startup founder, or a healthcare tech investor.
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In this episode you’ll discover:
What algorithmic bias is—and its impact on health inequity
What the economic case is for investing in DEI/prevention of algorithmic bias
How technology can address so many of these societal inequalities
What the Medicaid of the future looks like
How he defines success for Circulo and for himself as CEO
Keep scrolling for a transcript of this episode.
Learn more from Carrie and Rebecca:
Healthcare insights (monthly email) | Telehealth/Virtual Care Mgmt Update (biweekly LinkedIn update)
Website | Carrie on LinkedIn | Rebecca on LinkedIn | NGL on LinkedIn
“I’m seeing so much innovation around how to get providers oriented around gaps in understanding between themselves and the people they serve.”
Learn More Here
Connect with Vik Bakhru on LinkedIn
Find out the mission and direction at Circulo here.
Read about the $50M Series A funding for Circulo here.
Read about 2022 Trends and Opportunities for Healthcare and Life Sciences Businesses and Investors here.
Read the transcript:
Vik Bakhru (00:00):
We have had structural issues in our society that have driven, unfortunately, the wrong pattern of behaviors in serving those who need it.
Speaker 2 (00:09):
You're listening to Decoding Healthcare Innovation with Carrie Nixon and Rebecca Gwilt, a podcast for novel and disruptive business leaders seeking to transform how we receive and experience healthcare.
Rebecca Gwilt (00:25):
So today I'm here with Vik Bakhru on Decoding Healthcare Innovation. Vik is the founding Chief medical Officer and head of Mosaic, which we're going to talk about a little bit at a company called Circulo, which is a really exciting new company. I'm going to ask him about it in a little bit. He's the former COO and CFO of another health tech company called ConsejoSano. And both companies are focused on the needs of underserved populations in alignment with I know what's so important to you, Vik, and that you write on a lot, which is health equity. So welcome. I'm glad to have you here.
Vik Bakhru (01:03):
Thank you so much. It's an honor to be here and I'm so excited that we get to have what hopefully will be a great chat.
Rebecca Gwilt (01:08):
That's right. That's right. It'll be a continuation of our last one. Delightful as always. So I want to start with a little bit of background. So I'd love for you to tell me about your journey to where you sort of are today, and I'd love to hear you say a little bit about what is really exciting about what you're doing right now.
Vik Bakhru (01:29):
I get asked this question a lot and I'm going to change it up a little bit today, and I'm going to say that it's really been a journey of lots of stumbles and falls. I could not have predicted 20 years ago that I'd have the great Fortune A of sitting across from you virtually through camera and through other medium but I never could have predicted that we'd be where we are in digital health and in healthcare and the incredibly rapid evolution that we're seeing around us. My background is as a clinician, it's how I identify first and foremost in all settings, usually including family at the dinner table, looking out for people choking, <laugh>, all the way to group forums where you know, look among the crowd to see who's falling asleep because maybe last night was a bit rough or what have you, but clinic, my clinical identity is pretty strong.
(02:16):
And I've done a number of various business ventures and mostly in the digital health realm over the last decade and a half or so and dabbled in the nonprofit realm as well. I'm really passionate about pediatric global health and have done some work there. So in a nutshell, that's who I am. That's what I'm about. And as you've already noted, I now work at a company called Circulo Health, which we say is building the future of Medicaid. Medicaid has been ignored for too long. It hasn't received the level of attention and investment that it should have given that the needs in this particular area of our society are most profound. We have a lot of unmet need in among patients or people covered by Medicaid and it's time that we finally address that need. And so at Circulo we're starting to do that.
Rebecca Gwilt (03:07):
Absolutely. So this is what I want to dig into. So we talked about this before and you've sort of positioned Circulo as the Medicaid plan of the future. What is the Medicaid plan of the future?
Vik Bakhru (03:20):
It's anything but a plan. The truth is that what really needs to happen in the ecosystem is vertical integration between those who are taking risk and those who are providing health or driving health. And in our case, we try not to say that we are going to deliver care. We try to say that we're going to drive health outcomes and we're going to do it in a very multidisciplinary way. So when we think about the foundation of our efforts, it's technology married with a vertically integrated approach to meeting the needs of our members. We're still figuring out what that means for ourselves. We're less than a year into this venture. We started with about five folks and we have just under 250 on the team today. So it's been incredible, an absolutely insane year. Incredible. Yeah, really, really crazy.
Rebecca Gwilt (04:07):
Yeah. So, well, one of my questions is why doesn't this exist already? Why has Medicaid been sort of underserved by the kinds of innovations we're seeing on the commercial side?
Vik Bakhru (04:18):
Well, in large part it's because the reimbursement models and the incentives that exist in our ecosystem don't really drive individuals and institutions to cater their offering to those most in need. In fact, it actu well also that depends on how you define most in need. So those most in need of cancer care might receive the level of support that they need if they have the right type of insurance. And that's really the challenge that Medicaid as a particular some call it a line of business, we tend to call it more of a segment of our society groups of individuals who are covered by this type of insurance, whatever the right nomenclature is. The idea is the same, which is that over time we've not provided the range of services including addressing social determinants, including addressing cultural determinants, including addressing behavioral care needs or behavioral health needs, and similarly physical health needs. We haven't done it as an ecosystem. And a large part of the reason is because the reimbursement for those services hasn't been a part of the equation in any substantial way. In fact, it's been the opposite. Providers only have a few appointments per day on their schedules for people covered by Medicaid and the rest of the schedule is filled with people who might have other types of insurance, Medicare, commercial exchange or what have you.
Rebecca Gwilt (05:45):
And is that changing as many states move toward Medicaid managed care?
Vik Bakhru (05:51):
It is. I think it's changing favorably from the standpoint of the adoption of value-based care will enable new ways of thinking about how to improve health outcomes and how to solve for some of the needs that exist among the people we're really trying to serve.
Rebecca Gwilt (06:06):
So I find this really interesting because I always wonder whether there's a structural issue that sort of will get in the way of these sort of equity missions being accomplished. And I'm really excited to watch Circulo as you all sort of move through that journey. One thing I know that is important to you, that is a key part of this is health equity. So certainly the Medicaid population is a very particular population, but even within that population there are differences in both outcomes and how individuals are treated based on the particular group that they are a member of. Recently, Blue Cross Blue Shield of Massachusetts published a report that included lessons that they had learned after implementing sort of equity metrics and then tracking them that revealed that even that plan, which obviously had a deep commitment to health equity and continues to do so, saw some pretty alarming problems in how their member physicians treated particular groups of people. And certainly we've seen this before in what the outcomes were. So I would love to hear your initial thinking about how you get at that problem.
Vik Bakhru (07:31):
The first step is what you've just done, which is spreading awareness about the fact that we have had structural issues in our society that have driven, unfortunately the wrong pattern of behaviors in serving those who need it. And so we're starting to have a more open national conversation about IT platforms like ConsejoSano and others that are out there that are doing really important work to solve for those gaps in understanding. Another one that comes to mind is Violet Health. I'm seeing so much innovation now around how do you get providers oriented around some of the gaps in understanding between themselves and the patients or people they're trying to serve. Similarly, how do you meet people where they're at? How do you bring some of that engagement literally in a convenient way? Sometimes it's as easy as a text message in a native language. In other cases it might be more of a preference driven interaction, but there is a lot of attention being paid now to how to solve some of these issues that have existed for quite some time decades even. And it's unfortunate that it has happened, but it's really fortunate that we're finally starting to see some innovation, some major investment around it, some platforms that are going to drive technology focused solutions, which is exciting. We're in a good time, we're moving in the right direction for sure. Lots of work to be done, but we are moving in a positive direction.
Rebecca Gwilt (08:56):
So I heard you say my favorite word, digital health technology. So it is the case that so many commercial payers in particular have really in the last 10 years embraced the use of not just telemedicine, but other sort of AI, ML driven data analytics tools to segment patient populations and really dig into where they can intervene at the right time. We're seeing a tremendous explosion in remote patient monitoring and the blurring of the lines between the hospital and the home and all of that. And you're a tech guy, you've spent a good amount of time in tech, and I know we first were talking about circulo, you said this population deserves all those innovations just like everybody else does. What are your thoughts about bringing tech solutions into Circulo as a sort of foundational part of who you guys are?
Vik Bakhru (09:53):
I come to work on a daily basis and I come to work, I mean walk from my bed to my desk, but by and large I come to work every,
Rebecca Gwilt (10:00):
I need to find the legs. Butum, bump sound.
Vik Bakhru (10:04):
Exactly. Whatever happened to the clap on, clap on.
Rebecca Gwilt (10:08):
I can find it. Oh yeah, yeah.
Vik Bakhru (10:11):
Anyway, so I digress. But a lot of every day I was trying to say every day I come to work, and I'm so incredibly inspired by the roughly 60% of our product, of our team at Circulo is product and engineering. These are some of the foremost minds in not just healthcare, but in the world as it relates to building product and engineering product and technology that makes sense for the end users. For too long in healthcare, we have had two people on either side of a fax machine arguing over payments. The provider's office has a tremendous amount of hassle, and the insurers have a tremendous amount of administrative burden. And in some ways you could argue one creates it for the other, whether it's errors and filling forms or whether it's policies and procedures.
Rebecca Gwilt (10:59):
Well, it's, it's the future now. We've got e-fax.
Vik Bakhru (11:04):
The number of times I've been made fun of for actually liking my fax facility. We won't get into it here. It's embarrassing even. I actually have interesting views on the role that fax plays. I mean, 30 billion transactions in healthcare, 15 billion of them are still done by fax machine. So we've got a long way to go in automation and in removing some of the use cases. So anyway at Circulo, I think one of the reasons why technology is being brought to bear is because the pain points have gotten to the point where it's just not sustainable anymore to do business the way we've always done it. It's causing physician and clinician burnout. It's causing patient abrasion and frustration beyond belief. Where now, even if you look at some of the news from this past week, care is being deferred and care is not being sought because of some of the issues around how payments are handled and how the uncertainty around what you might have to pay or perhaps even just the accessibility is not there. So whole host of reasons why technology automation, the work that Circulo and the team here, the world class team here is doing is really, really important in automating as much as possible. And our founder and CEO Sean Lane has a long track record from the NFA to Olive AI to now Circulo in getting these solutions to market. So I couldn't be more encouraged that in Medicaid, much of the gap will be addressed by some of the platform that we're building.
Rebecca Gwilt (12:30):
Yeah, sounds like you're building and buying. I would love to hear what tools you're thinking are really going to move the needle so much out there between the AI solutions and platforms and any number of things. We walk the floor together at HLTH, so we know it's there. What is most exciting to you at this point? And I guess a related question is how do you have to think about this differently when you're talking about the Medicaid population versus the non-Medicaid population?
Vik Bakhru (13:04):
A few things come to mind right away. First, there's so much innovation that's needed in certain segments of Medicaid. So home and community-based Services, long-term services and support. These are areas that have really been underinvested in when it comes to how is technology used to improve the data collection, the analysis of what's happening perhaps in the home environment, perhaps in a group home environment. But there's a lot of opportunity in that space for understanding what the daily workflows are like of caregivers, of family members, and how to optimize some of the care delivery pathway, pulling in the right resources, avoiding more terminal or end states to certain disease conditions that have just really radically poor health consequences. So how do we intervene much earlier in that cascade and how do we do it so that the clinician in the clinic may not have awareness? We've really got to drive a more comprehensive sort of understanding of what is happening in the health of that particular member or patient. And then secondly, sorry, go ahead.
Rebecca Gwilt (14:10):
Well, I was just going to say I served four years on the Virginia Medicaid Board, and that's right. I had been a healthcare lawyer before that, and one of my big lessons was how incredibly complicated Medicaid is versus how complicated Medicare is even and the specificity with which they created structures around each individual Medicaid population and that each state had all of these waivers and that you bring up home and community based supports and long-term serVikes and supports. And I think like, oh, those are those things that I had no idea about when I started looking at Medicaid. And I wonder whether a fundamental inability to understand how Medicaid is paid for administered who the populations are play has played a role in the lack of innovation around those populations.
Vik Bakhru (15:11):
Some of it is awareness, some of it is a commitment of resources still. Some of it is the responsibility of the frontline individuals who are participating in pathways that they have historically, in some ways felt powerless over controlling. And so there's just a whole host of reasons why we have to do better and will do better because we're starting to really chip away at some of the frameworks that have just proven to be not the right frameworks, even including some of the regulatory protections that are in place. They really need to be rethought around putting the patient or the person at the center of the equation. We've really optimized around other entities in the ecosystem and I'm seeing so much person-centered innovation that it is encouraging.
Rebecca Gwilt (16:00):
Yeah. I guess the other thing on my mind is how many clinicians I talk to on a regular basis who are just totally uninterested in serving this population. I think that's not because they're terrible people, but it is a complicated program to navigate. And as you said, the reimbursement rates are bottom of the barrel, which seems to me is inverted. If we were to tear it all down and start from scratch, we'd pay teachers more and we'd reimburse better for behavioral health and Medicaid. So anyway, I'm wondering, we can create great benefits and negotiate with states to convince them of the merit of the Medicaid plan of the future. How do we get doctors on board?
Vik Bakhru (16:57):
A lot of it has to do with the efficiency of how we transact our work together. And so if we think about the ecosystem as a whole, it's not just that we need more resources that we need to be really be thinking along the lines of how do we efficiently transact our work together? For me, that means, and for Circulo, that means we don't need prior authorizations as a component of this ridiculous puzzle in being able to serve the needs of a member. If a clinician on the front lines identifies a need, they should be able to address that need in the way that is the standard of care. And we have today some of the most advanced technologies to allow us to do the data analytics that catch the fraud waste interview. We don't need to put everyone through a ridiculous forms process that ends up delaying care and ends up frustrating all parties involved. The other thing we don't need to do is have,
Rebecca Gwilt (17:51):
That seems like a, that seems like a big deal. No, in Medicaid world, that seems like a pretty big difference.
Vik Bakhru (17:57):
It's a heavy lift to pull off, but I'll tell you, if we can get it right, we can remove 16 cents on the dollar of administrative overhead. So that's what it costs the system to do. Prior S claims, adjudication, utilization management, and some of these other areas that just absorb money out of the system. And so what we're thinking about at Circulo and with our sister company, Olive, is how do you really take cost out of the system, make it more efficient, reduce the burnout and frustration of the clinicians providing world-class care and incentivize patients to more easily engage with the system? Because now it's not as much of a hassle. There's not a delay that you'll have a sort of waiting period for some of the care that you rightly deserve. I believe healthcare is a human, and so we ought to act like an ecosystem that looks after the needs of the people who present to us.
(18:50):
So prior is one part of it. It's also silly that a provider would have to do all of the heavy work to engage a patient, schedule an appointment, handle the insurance process on the front end eligibility, and so forth, actually see the patient in clinic. For the hospital, fill out a clinical note and then fill out a form to get paid a claims form. That's right. That claims form part of the equation. And also some of the front end stuff, by the way, has to be more automated going forward. So we are building a end-to-end framework around which you can get paid seamlessly by filling out your clinical note and having the medical record number, the date of birth, the name port over into the claims form. We don't have to have data entry issues. We don't have to have a human doing that. Some of this work, they can be reallocated to do the patient facing, person facing. Sure. Interactive component that is so vitally important in offices. I mean, we need at some point that compassion to come through. And if I'm distracted data entry into a form, I'm not able to pay the right level of respect and attention to the patients in front of me as a team. I mean, it's not the person who's distracted by these efforts.
Rebecca Gwilt (20:04):
I mean, you, you've seen the bowels of all of this. I think that the normal person assumes that it couldn't possibly be as inefficient as it actually is, but I assure you, a dear listener, <laugh> it. Absolutely. It can be. So I'm interested in how you know have been successful. So if you want to move the needle on outcomes, you want to move the needle on equity, which is a bhag, big, hairy, audacious goal, even for 2022. We're at the close of the year. We're all doing deep in planning stages. How will you know have been successful?
Vik Bakhru (20:48):
That's a loaded question. And the truth is, you may not know in the early stages, especially of what you're building, how successful you've been, but the way some of the metrics are structured for our team is around how many manual processes did we displace? How efficient were we in solving some of the burden, some of the administrative burden that our partners across the ecosystem feel and that our patients experience. So some of that is through satisfaction scores. Some of that is through feedback from the various stakeholders. So it's a combination of quantitative and qualitative, but a lot of this can actually be quantified very easily. It's really about the number of human hours that have been displaced, and it's really about the number of humans served that we can show that with the same level of resources we've been able to drive X, Y, Z health outcomes, X, Y, Z experiences. It's a staged approach. It's not going to all happen at once. Naturally.
Rebecca Gwilt (21:44):
Yeah. I guess I'm also interested in you in particular, you have done some incredible things in your career. You're still such a young guy. You have,
Vik Bakhru (21:56):
Oh, tell that to my sister. She's old. Every chance that she gets.
Rebecca Gwilt (21:59):
It's her job to give you shit about that. No. Why <laugh>? Like what will you call success? I'm very big into setting intentions right now. What will make you feel like you've done, you've fulfilled your mission.
Vik Bakhru (22:16):
That's a tough one for sure. And I'm a pretty ambitious person, and I have big goals for what I want to see happen but a lot of it has to do with happiness. And a lot of that is driven by what kind of experience can you offer to the people you are trying to serve. So some of that comes through matching and providing the right culturally relevant care settings. Still, other sort of definite definition points come from feeling like we added capacity to the system. Right now, when a patient calls an office or when a person calls an office, they're not given the type of reception that you would want for your mom, your dad, your brother, your sister, your spouse, your partner. They're given, unfortunately a cold shoulder in many cases just because of the way the system functions. And so success for me is how do I drive a better experience?
(23:13):
And I haven't yet myself figured out how to measure that on a daily basis. I can tell you on a monthly, quarterly, semi-annual basis, the metrics are there and the proof points are there for how many clinics did we open? How many mobile health serVikes did we bring to market? How many members served did we achieve? How many providers shared feedback around the tools that we developed and that they were able to adopt and implement? How many clients, and therefore, how many revenue, how much revenue did we generate? There are a lot of proof points for this, but personal success for me is really smiles on faces. Happiness, the ability to return from worrying about a health need to being with family and enjoying a holiday, which is also a hard thing to do in a pandemic when there's such an overhang around sort of visit safe to go out this day today, this week, or not sure and so on.
Rebecca Gwilt (24:04):
Sure. Yeah. Yeah, it's powerful. I mean, the work you and other folks that are sort of in the healthcare innovation field is really outsized in terms of impact because our health is so central to our happiness and to our aliveness. <laugh>,
Vik Bakhru (24:23):
Quite literally. Right?
Rebecca Gwilt (24:25):
Yeah, exactly. Quite literally. Yes. So, okay. So I really, really appreciate your time today. I'm going to, I'll be thinking about a lot of the things that you said for a while. I hope that I wish you the best success personally and in slo. I will be watching you carefully. And do you have anything else to say to our listeners?
Vik Bakhru (24:48):
No. I just want to say thank you so much for the privilege of being here with you and to your listeners for listening. Of course. Happy New Year as we embark. Yes. But thank you so much, Rebecca. I really appreciate it.