Is value-based care a sure bet? Find out why Blake Marggraff is doubling down.

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In this episode you’ll discover:

• Why focusing on the lowest common denominator in technology serves the largest populations

• Why qualitative symptomatology fits alongside quantitative data

• Why getting a jump on value-based care now will reap bigger rewards as others lag behind

Keep scrolling for a transcript of this episode.

Key Takeaways

• When you're fighting the value-based care battle, you have to think about things very differently than when you're trying to check boxes to get some fee for service dollars.

• We enable chronic care management and some other codes, but we don't hitch our wagon purely or only to codes where we couldn't serve true value-based, fully capitated populations.

• We found, through studies as well as millions of patients of real-world implementations, that not only do people adopt that type of technology more readily, they stick with it long term as well. And that long term engagement is vital.

• The folks that essentially get a jump on driving health equity are going to reap financial rewards while everybody else lags behind.

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

Learn More About Blake Marggraff and CareSignal here

Website: https://caresignal.health/ 

LinkedIn: https://www.linkedin.com/in/marggraff/ 

Twitter: https://twitter.com/blakemarggraff 

Read the transcript

Carrie Nixon (00:16):

Hello everyone. I'm Carrie Nixon. And welcome to the latest episode of Decoding Healthcare Innovation. I'm so pleased to be joined today by Blake Marggraff. He is the CEO of CareSignal and CareSignal is a device-less remote patient monitoring solution. They're serving millions of high risk patients across the US. And we'll talk a little bit about how a device-less remote patient monitoring solution works and that's gonna be a great part of our conversation. Let me continue my intro and say, as of the end of November of this year CareSignal became part of the Lightbeam Health family, and Blake and I are gonna talk today about digital health solutions specifically in the value-based care realm among a couple of other things. But first Blake, I'd like to ask you to tell us a bit about yourself. I know that you have been an entrepreneur from a very young age and I'm interested into, and I'm interested as to what got you into the healthcare space.

Blake Marggraff (01:15):

Oh man. Carrie, it's a great question. Thanks so much for the opportunity to join today, as well as, as I was saying before, I, I have to shamelessly thank Nixon Gwilt for the partnership and the work that you've done. And thank you for making it so easy to introduce other entrepreneurs to you, given what you do for the industry. Right product, right time.

Carrie Nixon (01:35):

Well thank you.

Blake Marggraff (01:36):

Absolutely. It's my, my privilege. In terms of my journey, for the longest time, I was pretty intent on moving into the pure research side of healthcare. I knew I wanted to work in healthcare and had some inclination toward the positive impact, that philosophy of serving other people and adding healthy, productive lives to the world. And one of my early mentors was one of the early Silicon Valley entrepreneurs who had bootstrapped and sold his business, actually a business that used software that just made organizational charts on dot matrix printers. How early Silicon Valley is that?

Carrie Nixon (02:16):

Yeah, we look back at that now and go, dot matrix printers. What's that?

Blake Marggraff (02:20):

Right. What we whip up in PowerPoint was an entire on-prem software solution. <Laugh> And he encouraged me to look at the startup side of things as a way to focus on the areas about which I cared, but also to scale impact. I started an education technology business with some phenomenal co-founders while I was a full-time college student. And we scaled that business to cash-flow positive. That business was focused on helping keep engineers engaged in their education, especially undergraduates. It's actually a big problem. And the whole while I was looking for opportunities to move into healthcare, once again, a long, long standing desire, and started CareSignal with just a world class founding team. I'm still humbled to have started the company with the folks that I did. It was born out of research instead of going straight to market with the product that we built.

Blake Marggraff (03:16):

We built the product, actually not too hard to build health IT solutions, at least simple ones. And then we conducted really rigorous research, everything from quality improvement studies to randomized control trials. Once we had a good range of outcomes, not just, you know, in hand, but published in peer review journal publications, then we went to market and started having conversations. And as I think we'll discuss, this was right at the early tipping point of value based care. So I think we, frankly, we, we were just really fortunate to enter the market at the time we did.

Carrie Nixon (03:50):

Yeah, absolutely. So I wanna dive in a little bit to what CareSignal actually does. I described it in my intro as device-less remote patient monitoring. Talk a little bit about that. Talk a little bit about why you decided to focus on device-less. That's a kind of unique differentiator in my experience. So I'd love to hear more about that.

Blake Marggraff (04:14):

Absolutely. CareSignal uses text messages and phone calls to capture patient or member reported symptomatology, really patient-reported outcomes across a broad range of conditions or some clinical use cases like social determinants of health. And we do that because we have deep conviction that the best way to support the large rising risk patient or member populations that are the main focus these days is to meet folks where they are in a technology that they're already familiar with, as low friction and as accessible as possible. And that informed our product strategy. But we finally landed on the device-less, RPM positioning years after we'd started building the product as something that struck, you know, the best of both worlds type balance between remote monitoring—cumbersome, expensive, very effective for the patients that use it, but often it's too expensive or too complicated to be used—and patient engagement, which is a commodified, really, it's hard to differentiate yourself when, when there's a sea of patient engagement offerings that have no clinical evidence or impact.

Carrie Nixon (05:25):

Interesting. So the typical remote patient monitoring that most people think of, I believe, and certainly that that I am most experienced with is the type of monitoring that uses some sort of peripheral device. Like for example, a wireless blood pressure cuff to capture some sort of physiologic data and transmit it to the patient's provider to be sort of monitored. Did you all start out with peripheral devices or did you know right away that you didn't wanna have to mess with those types of things?

Blake Marggraff (05:56):

We never wanted to mess with devices. I think devices absolutely have a place, but that wasn't the focus and from a positioning perspective as well before we honed in on the device-less, remote monitoring messaging we would describe our offering as a remote monitoring or engagement solution for value based care. And when you're fighting the value based care battle, you have to think about things very differently than when you're trying to check boxes to get some fee for service dollars.

Carrie Nixon (06:22):

That's right. That's right. Absolutely. And that's a hugely important distinction, right? So in the fee for service realm, if remote patient monitoring is going to be reimbursed, one of the requirements that CMS put in place was the use of a peripheral device. What I'm hearing from you is that that's limiting, right. It's limiting the types of technologies and digital health innovations that can be used in a fee for service realm. And what I'm also hearing from you is that maybe your focus is broader than sort of physiologic metrics. Maybe it is the patient saying, I'm not feeling well today, right? Like I'm not feeling well, and that is relevant to care as well. Does that sound right to you? Am I getting that right?

Blake Marggraff (07:16):

Exactly. So to the first part of your observation a fee for service opportunity today, if it's not managed strategically, especially for an early stage company can become a liability tomorrow. For that reason, we enable chronic care management and some other codes, but we don't hitch our wagon purely or only to codes where we couldn't serve true value-based, fully capitated populations. And then you nailed it. It can also be a focus on pure physiologic data can be limiting because pulse ox, blood pressure, weight are absolutely valuable, but what about qualitative symptomatology like nocturnal pedal edema or dyspneic events or whether a parent reports that a child has been using a non-connected rescue inhaler more often? Opioid dependence. Maternal health. And we already touched on health equity. Most of the world does not live in a few biometrics. And I want to capture all of that to enable better outcomes.

Carrie Nixon (08:23):

I think you have a pretty unique perspective there. And it's a real differentiator for some of the other things we see in the market. So you mentioned that you generally communicate with the patients who are on the CareSignal platform via calls or text messaging. Talk a little bit about why this is. I've seen a lot of technologies in the market that require some tech savviness. Is that part of your thinking about maybe making it as easy as possible?

Blake Marggraff (08:55):

Yep. It's exactly that. By using the lowest technological common denominator, which is not a pejorative statement, right? The lowest common denominator means that it will be accessible to as many people as possible. You can help as many people as possible. And as it turns out, we found, through studies as well as millions of patients of real-world implementations, that not only do people adopt that type of technology more readily, they stick with it long term as well. And that long term engagement is vital. If you're gonna support chronic condition, I've been told that chronic conditions don't just go away after a couple of weeks post-discharge.

Carrie Nixon (09:35):

Go figure, yeah.

Blake Marggraff (09:36):

<Laugh> You have to design technology that aligns with that reality.

Carrie Nixon (09:39):

Yeah. So to the degree that you can make utilizing a technology like CareSignal a habit for the long term, I suspect you're doing better at being able to intervene early at managing problems and impacting outcomes and the overall cost for the long term.

Blake Marggraff (09:59):

That's it.

Carrie Nixon (10:00):

So you also mentioned social determinants of health. You know, we are thankfully hearing a lot about health equity these days. Talk to me a little bit about how social determinants of health play into the CareSignal platform and the patients that you all serve. Talk a little bit about maybe some of the trends that you see around particular social determinants of health and how you're addressing those.

Blake Marggraff (10:30):

Sure. Well, in case any ACO REACH participants come across this discussion—especially now, before 2023, I think it's safe to say, when folks might might hear this—there is a massive arbitrage opportunity. Folks that start investing in health equity within their communities, that are going to use geographically benchmarked performance for the preliminarily, very simple SDOH (or social determinants of health) metrics, the folks that essentially get a jump on driving health equity are going to reap financial rewards while everybody else lags behind.

Carrie Nixon (11:10):

There is a financial incentive for the ACOs and for the providers involved for sure.

Blake Marggraff (11:15):

Exactly. I think that's the crux of it. I think you and I, and pretty much everybody in healthcare knows that health equity, that improving health equity by supporting social determinants of health is the right thing to do clinically as humans. But now it's the right thing to do financially as well. And it's just gonna become more and more so.

Carrie Nixon (11:35):

Well. And having that carrot, right, is extremely important. It's one thing to want to do the right thing. It's another thing to have the financial resources and financial incentives backing doing the right thing.

Blake Marggraff (11:49):

Yep.

Carrie Nixon (11:51):

So how did you decide...you started CareSignal back in 2015, I think?

Blake Marggraff (11:58):

mm-hmm <affirmative>.

Carrie Nixon (11:59):

Did you always know that the value based care market was where you were gonna land? How did you decide to play in that space? I think particularly at that time everyone's knee jerk reaction was just to be in the fee for service space, right. Or at least to start out that way and then transition. How did you land solidly in the value-based care market before many others did?

Blake Marggraff (12:24):

It wasn't right at the start. Right at the start we were getting our sea legs, but a year or two after founding the company, my founding team and I had a conversation where we essentially said, look, should we try to keep one foot in each canoe? Should we build a product that can align with fee for service? And I could show you text messages as recently as early 2019 from investors in CareSignal asking, Hey, do you really think this whole value based care thing is for real, like I'm hearing talk that it might essentially cool down for the next five years or so, maybe you should rethink the whole strategy. Most investors of mine did not think that or see that, but you take those text messages seriously because that's how that's how CEOs get fired <laugh> is by saying no, I'm right. I'm not gonna listen to you.

Carrie Nixon (13:11):

Yeah, you gotta hear the investors for sure.

Blake Marggraff (13:13):

You gotta. Yes. Right. And they're smart, experienced people with more data points than you have. Right. We decided that it was, from a risk reward perspective, that it was optimal to take the risk that the value-based care trend wouldn't pan out because the reward, if we built the first product that could really scale for remote monitoring and engagement in a true value based care arena would make that worthwhile.

Carrie Nixon (13:40):

My suspicion is that you had some challenges in convincing some of the the ACOs that you first approached, that this was worth an additional spend. I know, for example, if you're talking to ACOs sometimes about remote patient monitoring with devices and sort of the way that that typically happens, they go, well, this is still gonna count against my spend. It's not gonna help me meet my benchmark. How were you able to get ACOs to sort of see the longer term payoff associated with actually paying to use your platform? You know, how you make money and stay in business?

Blake Marggraff (14:33):

It's such a good question. So put your, put your hat on as one of the chief physician executives of an ACO, a big ACO, maybe you even oversee multiple. Okay. I come to you and I start by saying, Carrie, Dr. Nixon, we have as a company put our roots and our bets in research first. Here are the 13 peer-reviewed publications showing that the technology that we have built has improved clinical outcomes, not just for perfect, super healthy patients, but for your patients, for folks making $9,600 a year with COPD, for patients with end stage renal disease. Here are the publications. Now forget about the publications because your ACO has harder patients has, you know, more strapped staff, right? Now let's move to real world outcomes. Here are the case studies of real world implementations showing the outcomes.

Blake Marggraff (15:27):

Okay. Forget about those case studies of your peers. Here is your exact population. If I cite the peer reviewed publications, if I cite the corroborative case studies showing real world outcomes in identical types of organizations to your ACO, to your multi-specialty physician group, to your payer that supports lots of challenging Medicaid populations, here are the projected outcomes and the exact ROI, the number of dollars you're gonna spend, the number of dollars you're gonna receive on a 6-12 month time horizon. This is not a five year time horizon where suddenly magically every diabetes patient becomes better. Okay. Now, if you don't believe me after those, after the academic evidence, after the real world evidence and after a rigorous, bottom up organization-specific return on investment model, if you don't believe me, I will take financial risk up to 100% on the solution I'm offering.

Carrie Nixon (16:22):

Yeah. That's key. That's key. That's key.

Blake Marggraff (16:24):

That's it. And that's, that's been the approach.

Carrie Nixon (16:28):

I gotta hand it to you, Blake. Taking risk, going at risk, and especially going at a hundred percent risk, that's a risky proposition. And I don't think there are a lot of folks out there who frankly, are comfortable enough with their value proposition, right, to be able to do that. So I have to say hats off. And it sounds to me, frankly, like you did a tremendous amount of work laying the groundwork for showing the clinical evidence, the real world evidence, but also building the business case, like literally building the business case for each of your potential customers, is that right?

Blake Marggraff (17:11):

Exactly. It has to be down to the exact patient. Then you mentioned that we were fortunate to be acquired by Lightbeam Health Solutions, which is a population health enablement platform and Lightbeam solves the biggest problem that CareSignal always had, which was figuring out which patients or members need help.

Carrie Nixon (17:30):

Yeah.

Blake Marggraff (17:31):

It's one of those very rare, beautiful accretive business alignments.

Carrie Nixon (17:38):

Yeah. It sounds like there's some real synergies there. So I wanna go into that a little more in a minute, but you just said that Lightbeam identifies patients that need help. One really critical factor that I'm aware of in having any technology or innovation introduced into a provider-based entity is getting clinician and physician buy-in for use of that technology that can sometimes be an uphill battle. How did you all approach getting physician buy-in? And maybe it was the ACO's job, right? Like more so to make sure that their folks were buying in, but did you all play a role in that as well?

Blake Marggraff (18:27):

Absolutely. Any implementation requires not only patient or member outreach and engagement, but also meeting clinicians, meeting physicians where they are, make sure that Dr. Smith understands that when her patients start getting a phone call from an engagement specialist, who's of course calling on behalf of her organization, that that is blessed by the highest echelons of clinical leadership. But you know what, don't worry about that. Here's the evidence, here are the outcomes. Once again, let's bring it back to, you know, to what the language that doctor speaks. The other thing that really helps to succeed in value based care is centralized care management or care coordination capability. It is increasingly necessary. And as that trend has taken off, that really started maybe 2018, we saw organizations investing in that, like Mercy Virtual and St. Louis, that was accelerated further by the very unfortunate staffing shortage where now not only is that centralized capability necessary to realize efficiencies of scale, but technology is required to accelerate the scalability when there aren't enough staff to do everything manually.

Carrie Nixon (19:43):

Yeah. I think that point can't be underscored enough. At this point, we have seen physician burnout. We've seen clinician burnout. We're seeing shortages. At the same time, we've seen some reluctance by physicians to adopt new technologies because they're afraid they're gonna be displaced, right, it's gonna displace them. To the degree that we can position these technologies as allowing physicians and clinicians to operate at their highest level of practice, right, while some of the other things are taken care of by technology, I hope we can really make that case to folks because I think technology plays such a huge role in alleviating some of this burden and frankly, just improving care overall by virtue of the fact that it's gonna free clinicians up to do what they really want to and are supposed to be doing, which is like, think about what's going on with this patient and how can I care for them?

Blake Marggraff (20:52):

I couldn't agree more <laugh>

Carrie Nixon (20:55):

So I presume you're gonna continue on in the value based care space, because I think it's a reality that value based based care is here to stay. You've been involved in the remote patient monitoring space for a long time now. What do you see in terms of sort of trends in this space? Are there any things in particular that you would call out that you're keeping your eye on?

Blake Marggraff (21:20):

Yeah. One, one has really been top of mind recently and it's the idea that even if you just focus on the provider side, the level of sophistication required to align and implement a combination human capital plus information technology solution is so sophisticated. The level of sophistication is so significant that I think we need to think about for every type of organization, maybe even every organization, specifically building that group's pathway to value. And in this case value, meaning both, you know, revenue with an appropriate level of profitability or sustainability, but also the long term path to value based care, let's say by 2030, when Medicare means value based care.

Carrie Nixon (22:12):

mm-hmm <Affirmative>.

Blake Marggraff (22:14):

And that pathway to value concept has forced me and my colleagues to reframe how we combine either the best solutions in the market or build the best solutions in the market and then augment them with staffing that is so deeply integrated into the technology that it feels like one and the same.

Carrie Nixon (22:39):

Yeah.

Blake Marggraff (22:40):

And then it gets even more esoteric and it becomes kind of sophistry, but that pathways to value concept I think is is what I've...I don't think that, you know, I don't think that it's appropriate for a Livongo to come along anymore and say, Hey, you know, for these organizations with this risk and this population and this type of staff or not, give us this money, we're gonna solve this part of the problem. It's kind of a severe shift away from anything that resembles a point solution.

Carrie Nixon (23:09):

Yes, yes, yes, yes, yes. I actually agree with that. I think point solutions are are well on their way out the door. Okay. So, the answer to this question may be sort of along the lines of what you just talked about, but before we wrap up, I wanna ask you what is next on the horizon for you, CareSignal, Lightbeam Health?

Blake Marggraff (23:34):

I would like to support one of the most impactful, if not the most positively impactful improvements to health equity across the country that has ever taken place. And we're actively working on what I believe can do that. I would like to build and support a team that is building the most robust pathways to value, to have the greatest positive impact in US healthcare. And then speaking personally, I have to say, Carrie, I've learned a lot drinking from the fire hose of starting and growing and selling a company for the past 5-6 years. And I'm learning as much if not more every day now. So feel, I feel very fortunate. I guess, keep learning is the short answer,.

Carrie Nixon (24:19):

Just little small goals, nothing big there, no big deal.

Carrie Nixon (24:25):

We can do it,

Carrie Nixon (24:26):

We can do it. I love it.

Blake Marggraff (24:27):

We can do it. Look at what we've worked together on.

Carrie Nixon (24:29):

I know.

Blake Marggraff (24:30):

It's there. CMS has lined up the dominoes. It is our finger that can push it down.

Carrie Nixon (24:37):

I love it. I love the enthusiasm. This is why I really wanted to have you on this show. I knew you would bring this enthusiasm to our listeners as well. So I think this is a great place to wrap. Thank you so much, Blake. I am looking forward to having you on the show again, at some future point in the not too distant future, maybe talking about some of those big, hairy audacious goals and how you've gotten there.

Blake Marggraff (25:03):

That sounds delightful. It would be a privilege. And thank you again, Carrie, for having me on.

Carrie Nixon (25:07):

You are welcome. All right, everyone until next time, this is Decoding Healthcare Innovation.

Outro (25:14):

Thank you for listening to Decoding Healthcare Innovation. If you'd like the show, please subscribe, rate, and review at Apple podcast, Spotify or wherever you get your podcasts. If you'd like to find out more about Carrie, me or Nixon Gwilt Law, go to NixonGwiltLaw.com or click the links in the show notes.