HIStalk Interviews Ashish Shah, CEO, Dina

Ashish Shah is co-founder and CEO of Dina of Chicago, IL.

Tell me about yourself and the company.

I started with Dina six years ago. I was previously the CTO and head of product for Medicity and was there eight years, before and after the acquisition by Aetna. Dina offers an AI-powered care-at-home platform and network that supports hospitals and health plans as they transition to monitoring patients in the home and other post-acute settings. We call this Care Traffic Control.

We’ve talked before about my father, who passed away suddenly shortly after Aetna acquired Medicity. I was a healthcare executive who had helped thousands of hospitals connect to ambulatory care sites, but that didn’t improve my dad’s situation. He had home health aides and spent time in senior centers, but those caregivers had no way to share information.

What effect has the pandemic had on the demand for at-home care as well as the company’s business?

The pandemic shined a bright light on what we need to do and accelerated it even further. Prior to the pandemic, Dina was 100% focused on organizing all of the resources outside of traditional facility-based healthcare, whether that was post-acute rehab facilities or in-home services. We knew we needed to do a better job to support the silver tsunami, the 10,000-plus people each day who are turning 65 years old. 

We would get a lot of head nods, and that was important, but COVID unfortunately accelerated that tsunami and gave us a glimpse of what it’s like when the traditional healthcare system is overrun. That cemented our place in the market. Clearly, complex things will continue to happen in the high-quality facilities. That’s never really going to change. There may be some automation and further optimization that takes place, but that’s still the right care setting for the right types of things.

Virtual care, whether it’s telehealth or some combination of remote patient monitoring, became critical. But these things need to be complemented by a third important delivery vehicle, which is in-home care. Not just traditional home health, but mobile lab and imaging, courier services, and a host of other capabilities that can be brought to you. The world was trained on things coming to you through the pandemic, not just in healthcare, but in all aspects of life. So in many ways, it made it super obvious for everyone. Now the race is on to equip the industry as fast as we can.

How do you see that shift away from the four walls of a hospital or a clinic being a threat, an opportunity, or both to the traditional health system?

It’s tricky. It’s hard to be a health system leader today because you have your feet in two different boats, two different business models. It’s hard to look away from how healthcare has been financed to date in a fee-for-service world. That creates some real challenges. Many health system operators were challenged in COVID by not having a consistent revenue flow, either through capitated payments or other at-risk payments.

It was interesting that in a industry that doesn’t have enough labor as it relates to physicians or nurses or other support staff, some organizations had to contemplate reducing headcount. I guess it was necessary to make the money work, but it was definitely challenging to witness that.

The opportunity as we hopefully come out of COVID is to accelerate health plans and providers having conversations around creating predictable revenue streams that are more based on value-based care type programs. The art is to make sure that there’s no attrition in revenue. In many ways, it’s the same type of conversation from 10 years ago when I was at Aetna. But now that we’ve had COVID, that took it from a theoretical concept to something that we need to solve as an industry.

What does the typical care network look like for a senior who has one or more chronic conditions and how do the members that participate in that care network coordinate or communicate with each other?

It’s very, very complicated. A typical senior or somebody whose health is complex could be on seven plus medications. They may need support with activities of daily living. That’s a non-medical home care service, which is different than a certified Medicare home health type service that may provide skilled nursing and physical therapy, really an extension of a service that you would get in a facility, but now being delivered in a home. So complex med management, personal care support with activities of daily living, perhaps some skilled needs that are required. That’s not even including primary care and specialty interactions as well.

A lot of what we are looking to do is to coordinate all of those logistics so that you can match or exceed the experience that you would receive in a facility. The market definitely wants it, but it’s easier said than done.

How does that care team structure or those care decisions differ for someone who is covered by a Medicare Advantage or a Medicaid Managed Care plan instead of traditional Medicare or Medicaid?

When I work with many folks on the home care side of things, they’re so passionate and they are wonderful organizations. But one of their biggest challenges and obstacles that they face is, how do we ultimately get that care financed that they know that the market needs and that creates value? I love what Medicare Advantage plans and Managed Medicaid plans are doing right now.

I’ll start with Medicare Advantage, because it’s a little bit more progressive and new relative to Managed Medicaid, which has been doing some of these things for some time. Medicare Advantage has introduced the concept of supplemental benefits — the extras, if you will, above and beyond Medicare fee-for-service — that will allow the Medicare Advantage plan to innovate and introduce new offerings like non-medical home care, nutrition support, transport, or other types of things that are not covered by a traditional Medicare plan. In the effort of delighting the member, addressing in some cases social determinants of health or other healthcare needs that can bend the cost curve, but also help that member meet their healthcare objectives. Really neat programs. We are in the early phase of this, but this is bringing online non-medical services or social determinant-oriented services that are being paid for, that are attracting members, but also change the outcome story.

Medicare, and CMS in particular, were wise to hatch the program years ago and then continue to invest in it and then allow the free markets to innovate. They have a  program called VBID, value-based insurance design, that is a vehicle for registering and testing for new types of benefits. If they work, then they ultimately graduate into the scope of things that MA plans can reimburse for. So it’s a really neat program.

On the Managed Medicaid side, in-home services, for example, are covered under what’s called LTSS, long-term support services. This is the goal of trying to meet the member in their home and community and unlocking alternatives to traditional long-term nursing home care. It’s a neat program that has been around for a while, but there’s some complexity in trying to manage that.

We’ve seen insurers that range from tech-heavy startups to Optum go big into Medicare Advantage, and some of those companies are providing health services directly. How will that change traditional hospital care, home care, and long-term care?

For Medicare Advantage plans, it’s bringing members online in a race or land grab moment that hasn’t existed before. The only option if you were a senior before was to be on Medicare fee-for-service. You could have bought your own private health plan, but now with Medicare Advantage plans, there’s a race to go manage outreach to these members, unlock a superior experience, and turn on new benefits that we know can change the arc of healthcare and the finance of healthcare.

Three years ago, 25% of Medicare-eligible members enrolled in a Medicare Advantage plan. Now we’re north of 40%, so it is growing rapidly. Many solid organizations are innovating. I think it’s wise that they are trying to establish a direct connection with the person to better understand their needs. Some go as far as delivering the care themselves, while others have invested in care coordinators or counselors who take a more proactive role in navigating that member through all of their needs. It is neat to see.

There are a lot of innovative organizations out there. Not just on the MA side of things, but organizations that partner with MA plans, like Oak Street Health, for example, or Iora, showcasing for the market a brand new community or home-based delivery model. I think we will continue to see that scale because it makes sense. Not to mention that people like it, which is sometimes hard to say about things that we do in healthcare, to get people to actually say that they enjoy the experience.

A problem has always been that outside the 9:00 to 5:00 window, people who weren’t hospitalized or in a SNF had to call 911 or go to the ED to have any changes in their health evaluated, including those that turn out to not be urgent. Have those insurers who have skin in the game addressed the unnecessary use of those services?

It’s clearly a problem that people have been studying for a long time. We’ve tried a lot of different things, from raising awareness to your health plan or the ACO to let them know that when somebody is in a emergency department. But in many ways, that’s too late, even though it creates intervention opportunities.

I’ll give you an example of a company like Dispatch Health. We know some of the folks there — we overlapped inside of the Aetna portfolio companies going back, so we are fans of them, the company, and the model. They took a new approach. They started by bringing urgent care to you rather than having you come into an ER, which was costly and had a lot of other ramifications. Not to mention that maybe you didn’t actually need to be an emergency room. They’ve started to chip away at the problem by redeployment of almost like a paramedic model to your home to manage triage for routine things, then escalate and navigate you to another site of care if it’s needed. In some cases, it may not be needed. In some cases, it may translate into something that leads to a telehealth encounter with a specialist that they bring into the mix.

There’s a lot of creative solutions that are coming into place. It’s not one size fits all. It’s not whether it will be telehealth, or in-person visits, or home care. The challenge for us as an industry over the next five to 10 years is to bring the best of all of that together with the right care at the right place at the right time. It sounds cliché, but that’s the challenge that we all have, and that’s what Dina is working on.

How do you see the company changing over the next several years as these market conditions change?

We no longer have to convince people why we exist. In the early days when you start a company, that’s a lot of the discussion. Tell me about the problem that you’re trying to solve, tell me why is it a really big problem, and tell me why it’s a big market opportunity. It was clear to many, including our early investors, when we talked about the aging demographics in the country and globally. COVID has expanded our market opportunity to include all people that are struggling with some sort of healthcare-related need. 

For us, it’s really about execution.To simplify our story, we use terms like “care traffic control” to create a visual of equipping hospitals and health plans with the infrastructure to be able to move from monitoring patients in ICU units and in hospital beds and shift that paradigm to coordinating, navigating, activating, and monitoring patients in their homes and communities. The solution we put into the market is a network of resources that are medical and non-medical in nature. We’ve got lightweight technology that allows us to engage with patients and families and understand what’s happening when a healthcare person is not in front of them. We do a lot with data. We bring all that information back to create opportunities to proactively delight that person and meet their needs on a continuous basis.

The organizations that are attracted to that today are health plans, like MA plans or Managed Medicaid, but also large provider groups that have started to go down their path to value-based care. I think that in five to 10 years, this will be everywhere. I don’t think it’s farfetched to think that every home is going to operate like a virtual primary care clinic, where it’s not just your residence, but an actual site of care that the healthcare ecosystem knows how to interact and work with.

It’s exciting. It’s what I wanted for my family before. I can see the convenience for it in this day and age. Our challenge is to make it happen now.