Why Risk Adjustment Matters More Than Ever: Sunil’s Journey From Medicine to Health Tech

[00:00:19] Welcome to Episode 1 of Care Decoded with Sunil. Today we're going to be talking about why risk adjustment matters now more than ever and his personal journey with his business. So let's get started. I'm eager to learn all about you and your beginning and how you really started. So where were you born and raised and were either of your parents doctors?

[00:00:41] Yes, I was born in India in a little town called Mau. But after that, we moved around every few years. I had an interesting, you know, growing up. My parents are not doctors. My father, as I said, was a judge and my mother was a lawyer, although she never practiced. So in that sense, not a medical family, but my sister is a physician. Oh, nice. And how did you end up becoming a doctor? Was it something that you wanted to do your whole life?

[00:01:11] Hmm. It's a more of a prosaic reason, I would say. So, so, you know, back then in the 80s, growing up in India, you basically, you know, if you wanted to do well in life, you either went the engineering route or you went the medicine route. And I was a bit scared of mathematics, to be perfectly honest. So, so, so I went into medicine. That's it, you know. So no highfalutin reasons.

[00:01:40] I also am not a fan of math, though. I'm scared of mathematics as well. So I'm right along with you. And I know that most physicians tend to retire into more tech advisory roles if they go that route. Now, you jumped into building a tech company from scratch. So what was that moment when you knew this is a broken system and I have to fix it?

[00:02:06] Yeah, I mean, I think the motivation was, so I'll tell you a little bit of background there. So growing up, you know, my father always used to say, you know, aim for the stars and you will at least reach the treetops. Okay. So I always had this thing in me that, you know, I wanted to make a big impact on as many people as possible. Right. So, of course, you know, going into medicine, you are sort of helping people one person at a time. Right.

[00:02:31] Right. But, you know, when I was in practice and we started using these electronic medical records. So just the idea that came to me was that, you know, we are doing a lot of work in these EMRs, but we are not getting full value out of them. Right. And at the same time, the care that patients get does leave something to be desired in the sense that really it depends a lot on the physician's knowledge and competence. Right. So half the time patients don't get the care that they should be getting. Right.

[00:03:01] So the idea was that, OK, you've got all this clinical data now in electronic format. And can you apply, you know, some good evidence based, guideline based algorithms to it and, you know, help physicians make better decisions at the point of care in terms of the care of the patient? So that was the original kernel of the idea, which I thought, well, this is something I need to give it a shot in one life to live. Let's let's see what we can do with this. So that was the beginning.

[00:03:29] Yeah, that's a wonderful mindset. I know I have worked in health care companies and I agree there's so much that is broken with it. And there's so many things that need to be fixed. And working with EMRs and EHRs, the complexity of it, it can be overwhelming. It can be cumbersome. So I definitely can see wanting to fix that system overall. And when you were in practice, what kind of physician were you?

[00:03:56] So and I still am in practice internal medicine and gastroenterology. So I was seeing patients at the time five days of full time. Now I'm seeing patients three days a week, but internal medicine as well as gastroenterology. Wow. How do you find a way to balance both? Both being founder and a physician. Those are two very hard roles.

[00:04:19] Not easy. And a lot of weekends, evenings and then, you know, you have to obviously like what you do, a passion. Right. In terms of so it doesn't feel to me most of the time that I'm being overworked or anything because I like doing what I'm doing. So and I have control over it. That's awesome. They say if you like what you do, you'll never work a day in your life. It's it's actually something you enjoy. So that's amazing that you found that not only in one realm, but in two.

[00:04:49] So let's talk honestly. What was it that frustrated you the most about the tools you were expected to use in practice, like pop ups, endless clicks, zero context? Was there a specific thing that really frustrated you? Yeah, I think all of the above, I would say. Right. And the majority of the EHRs are pretty, very clunky, I would say. Right. And that's not anything that is news to anyone.

[00:05:17] Right. So, yeah, the workflows where you have to go to, you know, multiple places, click and click here, click there. And then, you know, then you have to type used to be that you had to type a whole bunch. Of course, we'll talk about where AI has helped that a little bit, I think, in terms of burnout and stuff. But, yeah, there's lots of stuff that could be better. And obviously, we will also talk about risk adjustment and how that poses somewhat of a burden on physicians. So, yeah, it's lots of things.

[00:05:47] Absolutely. And as a physician, you want to focus on helping the patient, not getting stuck in a cycle of clicking. And where does this go? And all that energy and time is being taken away from the patient. That's exactly right. What was the first breakthrough moment when you realized, wow, we're really on to something here with Infrascience?

[00:06:08] Yeah. So this was, you know, as you may know, we started with clinical decision support. We took a little bit of a pivot into risk adjustment, although it's kind of related. But anyway, so this was back in, I think, 2017 or 18 around Christmas time. We got a call out of the blue from this large medical group in southern Florida or southwest Florida who were looking for a solution like ours.

[00:06:37] And they were very happy. And we were this tiny company and we had hardly any marketing at the time. And they said, yeah, what you guys have built is exactly what we are looking for. So that was a moment where we thought that, OK, what we built here is actually of use to somebody who knows a lot about this field of risk adjustment. So that was the beginning, I would say. Yeah, that must have felt very rewarding in that moment, especially being a small company getting approached by a much larger organization.

[00:07:07] How long were you working on Infrascience prior to that moment? Yeah, I think we had been three years. Yeah, three years we had spent building the products and all that. None of this is, as you can imagine, easy stuff, right? No, absolutely not. I've worked at a few startups, so I know that it's never easy. There's a lot of trial and error. So much that really goes into it.

[00:07:33] How did you kind of go about building the team and figuring out what needed to be done coming from a different background? Yeah, that was definitely a challenge, right? Because you are starting with almost no connections, right? I mean, you are starting with an idea and now you need to convince somebody to join you, right? On the journey, right?

[00:08:00] So, yeah, I mean, I don't recall there was some kind of a startup platform where I found my co-founder. I, you know, we met in person and I convinced him. And so him and I started, then we hired a couple of engineers. And then gradually over time, we've built the team. Wow, that's amazing. How big is the team now? Is it still relatively small? Yeah, yeah, it still is. It's about 25 people. In the big scheme of things, that's fairly small. Yeah.

[00:08:30] And for, I'm sure there's clinicians listening who are very interested in how you've come so far. And for those that are listening, who may still be skeptical of risk adjustment or documentation tools, what do they get wrong? And why does it matter now more than ever before? Sure. Yeah. Yeah. I mean, I think there's a general thought, right? That risk adjustment is a pain, right?

[00:08:58] That this is stuff that takes away from patient care, which in a sense, it is slightly to the side of actual direct patient care. Right. Right. Because on the one hand, you are seeing the patient attending to all those needs. I mean, if you look at primary care, patients typically don't come with one or two problems. They come with like half a dozen or more. Right. So on the one side, you have to take care of that. On the other side, you also have to do a proper job of risk adjustment documentation. Right.

[00:09:27] So that is definitely a challenge. But what I would say to those folks is that, you know, ultimately behind the scenes, there's a big impact of risk adjustment. Right. Because that's where you are documenting what the patient's condition actually is, which predicts the cost of care and therefore also predicts the funding. Right. Right. So if you don't do a proper job of that and your patient ends up, you know, needing a lot more care.

[00:09:56] I mean, not just your patient, your cohort of patients needing a lot more care than they're funding for. Then at the end of the day, that care cannot be funded. Right. So that ends up affecting your health plan, yourself and your patients at the end. Right. So because ultimately there has to be enough funding to for the patients to get. Get the care that they deserve. So all of that comes from physicians doing a proper job of documentation. Yes, it's a little bit of an extra work.

[00:10:25] But now, you know, there are tools out there which which will help you to do a do it more efficiently. So, yeah, that's what I would say. Absolutely. And I know 96 percent of HCC codes have some kind of error. So why do you think that documentation remains such a persistent blind spot in the system overall? Yeah, I think at the end of the day, we are asking a lot of the physicians.

[00:10:53] Right. I mean, a lot of them are getting paid based on productivity. Right. How many patients are you seeing? So at the end of the day, something has to give. Right. If you have only, say, 15 minutes to see one particular patient. Right. And they come up with this laundry list of problems. You've got to take care of them. Right. Right. So so now that time is gone. Now you're also expected to do a proper job of coding. Right. Or documentation. So so ultimately, I think, yeah, something has to suffer there.

[00:11:21] So that's where I think the newer tools. So one thing that has taken a lot of traction is something called AI Scribes, which is where the entire note gets recorded while you are speaking with the patient and gets converted into this clinical note, which goes into the EHR. So that really I have found personally quite helpful that, you know, the entire encounter gets documented properly.

[00:11:49] And then because that has been done and I don't have to spend time on that, I can spend a little more time on doing proper job of risk adjustment coding. And if I have tools like we have at Infoscience, which are giving me very solid, accurate suggestions at the point of care, I can actually do a better job of it without spending that much extra time. So that's what I would say. Definitely a huge time saver for sure.

[00:12:15] And I'm sure a lot of doctors may be even perhaps intimidated by the concept. So how do you respond to doctors who say all this coding stuff takes away from my patients? Yes, absolutely. And I think that is where having an intuitive tool, which actually does not just make you the HCC coding suggestions, but actually also gives you an explanation of why, you know, in layperson language,

[00:12:44] not layperson, but, you know, physician's language, I would say, that they understand, okay, if such a code was suggested, this is the data behind it, right? Like, so I think using, and there are, you know, we have one, but there are other companies that have tools like that as well. So utilizing things like that, I think, would really lower the bar, so to speak, for physicians to do a better job of risk adjustment coding and learn as they're going along. Absolutely.

[00:13:12] And I know that a lot of doctors, like I said, will probably be hesitant or concerned with starting something new too. Like just my experience with working with physicians and working with certain systems, even though new things can be way better and way more efficient, I think it may be hard to have that transition because it's an unknown tool. It's an unknown technology.

[00:13:38] Is there something that you would tell them to, in a way, convince them or prove to them that this is the new way, the better, more efficient way of doing things? Yeah. I mean, I think at this point, most physicians are not in their own practices, right? I mean, most of them are employed by larger entities, right? So I think it behooves those administrators or the decision makers to, you know,

[00:14:07] stay up with the times and basically, you know, promote those tools to their providers. And even more importantly, do a proper job of training them, right? Educating them and training them. So I think when they do start using these tools, they are well informed about them. They've already tested them. So now they are ready as opposed to being intimidated by something that is new that they are not very familiar with. And AI is something that is currently everywhere.

[00:14:36] It's taking over the world. There's ChatGPT. There's all these various AI new technologies. And since it is everywhere right now, and it's something that you've been building, but as you've been building AI into EHRs for years, what do you think is the difference between AI hype versus AI that actually helps and changes things for the better? Sure. I mean, yeah, there's a ton of hype around AI, right?

[00:15:06] I mean, if you go to, like, I went to HIMSS recently, which is the preeminent health technology conference, and every single booth had something about AI. But like you said, there is a lot of hype. I mean, one example I would give you is that, you know, some people think, oh, AI is going to replace doctors entirely, right? Or you'll have a mental health therapist who will be purely AI, right? So I think that is very much at this stage in the game anyway.

[00:15:36] That is definitely hype because I don't think AI is ready to replace physicians yet. Maybe in five years. Who knows? But at this point, I think that's definitely hype. But as far as what's real is concerned, there are, I think, plenty of good examples of things that actually are real and actually move the needle in terms of, you can say, either physician burnout or even in terms of the quality of care. So I'll give you a couple examples. So one is, you know, clinical decision support.

[00:16:05] So an AI that can analyze your patient's chart, including, you know, vital science, medication lab, what have you, and actually give you proper suggestion that, you know, this patient has congestive heart failure. Maybe they are missing this medication, right? Or they have diabetes and it's out of control. So maybe you should do A, B, and C. So those are, I think, very real examples which are already, you know, we are seeing some impact even from a burnout perspective as we were talking about.

[00:16:35] So as physicians, we spend a lot of time analyzing and reviewing data, right, which is fairly clunky. So, you know, if you go to see a patient before that, you have to review their previous notes. You have to review their, you know, lab data, consult notes, all that. All of that takes a ton of time. So because, and the reason it takes a ton of time is because it's, you have to go through multiple documents and each document has multiple, multiple pages before you get to what you're looking for, right?

[00:17:05] So an AI that can kind of extract all of that data and summarize it and make it easy for you, like on one screen, you can see everything and see more detail if you need to. That's another example of that. So, you know, that's just a couple. I mean, I can go on and on. But the point is that there's definitely real AI out there which is helping and I think we'll continue to do so. Absolutely.

[00:17:28] And as AI is fairly new within the last few years and is already so impactful and taking over everything, how do you think that it will change in the next few years within your business? Where do you see infrascience in the next few years? Or do you have any set goals or ideas of where you want it to go? Sure, sure. I think so.

[00:17:52] We'll continue to, you know, work on the risk adjustment and, you know, quality value based care, which is where core sort of audiences or market is. But even from the AI perspective, we are going to do more and more like these kinds of things that I mentioned, right? Summarizing clinical data, generating clinical alerts and, you know, even responding to patients.

[00:18:17] And so at the end of the day, helping physicians with burnout, as we say, less administrative burden and more patient care. So that's really the goal in the coming years. Absolutely. Definitely agree that that is the center of being a physician. And I think that it's amazing that this is an AI company, a tech company that is built by a physician. Like who knows what a physician needs more than an actual physician?

[00:18:44] So being the fact that you are the mastermind behind this, I would think would put a lot of physicians in a very comfortable place in trying this new technology and feeling comfortable and putting their trust into something new because you speak the same language, essentially. Like no one can understand physicians the way physicians can understand physicians. So I think it's an awesome concept. Exactly. For sure.

[00:19:13] And I know you've done so much in your life, but what's something about you that maybe your LinkedIn profile doesn't show, but your team knows all too well? Well, I think which you might have already gotten a bit of a flavor of here is that I tend to speak my mind and I'm pretty fairly straightforward, you know. So and hopefully both, you know, so whether it's good or bad, right? I mean, I tend to give proper feedback, appropriate feedback.

[00:19:41] And, you know, when people do a good job, I definitely do that as well. So but yeah, generally speaking, I'm fairly plain spoken, I would say. Absolutely. I mean, that's definitely something that is a characteristic that is needed. And in a great position, you need to be straightforward. And I think it's something that's very important being a founder and being a CEO. You need to be able to be straightforward and direct in order to really move things along and have success.

[00:20:10] So I think that's actually a great quality in both of your roles that have now combined. And I would hope. But, you know, you sometimes do rub people off the wrong way. Right. Right. You can't win them all, right? That's true. That is true. And what do you hope Care Decoded does for the industry? If there's just one listener that walks away with a new mindset from listening today or listening to our future episodes, what would you want that to be?

[00:20:40] Yeah, I think it's I would say it's sort of multiple things that hopefully we will be addressing or helping people with. One is, you know, and largely, you know, this is the audience is very much a health care audience. Right. So and I would say primarily physicians, but obviously health plans and people who work there, I would hope will also get some benefit. But at the end of the day, yeah, helping physicians understand one is risk adjustment.

[00:21:10] That is not the pain entirely that you think it is and that there are ways of doing things in a more efficient way. So that would be one thing. And then second is, yeah, same with technology that, you know, most of the time, you know, when we talk about EMS, most physicians will tell you that they have a very negative view of those. Right. Right. Because it has added a lot of burden compared to even when we used to do paper charting. Right.

[00:21:36] So, you know, I think hopefully they come away with the fact that, you know, technology done right with the right lens, with the right focus and on usability more than anything else. Right. And with the right sort of end goals in mind, I think it can it can truly help and actually help them in their daily lives. So that's what I hope they come up, come away with. Absolutely.

[00:21:59] And it's obviously a lot more efficient than EMRs and EHRs and very different. But what would you say are the key differences that do make it more efficient? I know you touched on the fact that there's no taking and things like that. But what are some other key differences that make it more efficient? So so I think there's something that is going into effect that you need to follow certain rules related to I forget the name of the law.

[00:22:29] But, you know, any imaging stuff that gets ordered needs to have proper justification. So if you can have an application which can sort of do that for you, that as soon as you order something, it looks to the data and say, OK, this is medically necessary or not. So that's one prior authorization is a big one. I mean, if you hear talk to any physician today, specialist or primary care, they'll tell you the biggest bugbear is prior authorization. Right. That insurance companies are in the middle of the patient and the physician.

[00:22:58] So, you know, the tools that can help with with that where, you know, it's already that the tool knows that, OK, these are the insurance companies criteria for this particular test, for example, this particular referral. And it can actually help nudge you at the point of care that, hey, maybe you are missing this or that. And therefore, it's likely to be denied. So things like that, I think, would would truly, truly help physicians. Absolutely.

[00:23:26] Are there any things that you're that InfraScience currently doesn't offer that product wise or feature wise rather that you think you would like to incorporate in the future? Yeah, I think prior authorization would be would be definitely a big one because there's a there's a crying need for it. Clinical decision support. I think we have transitioned away from our rules based system.

[00:23:49] So we are actually working on, you know, LLM or AI based decision support for, you know, care plans, I guess I should say. So those are things we are actively working on and will continue to enhance it, you know, again, from the same lens of helping the providers at the point of care.

[00:24:07] Absolutely. And I know that this is obviously a tool for a variety of providers, but do you have a particular type of provider that or a particular set of providers that use InfraScience more than others? Or is it more popular in one? Yeah, I would say typically your adult primary care physician. So that would be, you know, internal medicine and family practice, for example.

[00:24:34] Of course, you know, it can be used by specialists as well, but mainly those physicians who are into value based care. So, you know, whether it's ACOs or Medicare Advantage, which is more than half of the Medicare population at this point is in those. Actually, I would say if you include ACOs, that probably 70, 80 percent of patients are in those. So I think anybody who is in adult primary care would probably benefit from our tools.

[00:25:02] Absolutely. And in addition to them, you said other providers can use it as well, just mostly. With specialists as well. Yeah. Yeah. And as we keep working on these tools, like for when we are about to pilot for data summarization, I think that that can be used by specialists as well. So we have had good feedback from our initial users. So, yeah, I mean, ultimately, you know, I think it should be able to be used by any physician.

[00:25:28] And, you know, the risk adjustment is at least in the form that we see it is very much American concept, U.S. concept. But, you know, as we go into more of these other tools that we are in the process of building, I think anybody in the any provider in the world who is using electronic records should be able to benefit from this. Absolutely. And then I might be putting you on the spot with this question, but I'm curious.

[00:25:54] So, so far in in this journey that you've been working on in for science, is there a particular client testimony or feedback that you've received from someone that really made you feel rewarded in the sense of like, wow, this is really helping people? And if they've come to you and said, wow, like this is really helping my business, this is helping my patients. Or is there anything like that that stands out to you? Yeah, I'll tell you.

[00:26:22] And it may seem a relatively mundane example. It's funny. I was this was a few years ago. I was interviewing a nurse practitioner. I think it was to hire in my office, if I'm not mistaken. And she worked at this other this big medical group that I was telling you about from 2017, 18. So she worked there. And when I asked her, hey, what do you guys use for risk adjustment? She did not know who I was in terms of infrascience.

[00:26:49] And when I asked her, she was she went all gaga over it, like how it had improved her life and how it had helped her. So that was gratifying from, you know, neutral personally. Absolutely. Yeah, those things must feel gratifying to know that you are helping people, because I know when you're working on the back end of things to really have that experience with the consumer and or the client rather and have them really share how you are helping with them.

[00:27:14] I feel like it must make everything feel rewarding and also make you want to keep going. Were there any moments so far that you felt maybe overwhelmed or stressed out about pursuing this business? And if so, like, how did you deal with that? Yeah, I mean, you know, like any other service business, right? Clients can sometimes be demanding unreasonably. So, right. And that stresses out everybody. But, you know, you know that that's part of the game, right?

[00:27:44] That's part of the business. So I can't say that I felt overwhelmed, stressed, obviously, on certain occasions. That's just, I think, normal. I can't say that I've ever been overwhelmed. Wow, you must have very good stress management, especially dealing with so many different things simultaneously pretty much between. I tend to be calm. Yeah, I would say by and large, I don't panic easily. Absolutely.

[00:28:11] Well, thank you so much for speaking with me today and telling our viewers more about you and more about Infrascience and how you got here today and more about you being a physician. And this was a great episode. And I can't wait to talk to you next week on episode two. And thank you, everyone, for listening to episode one of Decoding the Why and Why Risk Adjustment Matters now more than ever. Thank you. Thank you, Leila.

[00:28:39] And I'm hoping also that in future, as we get into more specifics, that we can actually help people, especially providers in the risk adjustment world, help them in their day-to-day lives. And hopefully they will learn from our podcast. Absolutely. Definitely. We'll make sure to share a lot more of that next time. Thank you. All right. Very good. Thank you.