This is the transcript from my recent podcast with WorldDoc CEO Rahul Singal transcript.

Matthew Holt: Hi. It’s Matthew Holt, at The Health Care Blog, and we’re back with another podcast. This time, I’m talking with the C.E.O. of a very interesting company, which has its fingers in multiple pieces of the health-care system. I’m talking today to Rahul Singal, M.D., who is the president and C.E.O. of WorldDoc. Rahul, how are you today?

Rahul Singal: Doing fine. Thanks, Matt. Good afternoon.

Matthew: WorldDoc is based in Las Vegas, just to let the people listening know. I saw Rahul there at a conference a week or so ago. I’d kept tabs on WorldDoc a little bit in the last couple of years, but I wanted to find out a bit more about what was going on. But a number of interesting health care stories are coming out of Las Vegas. I suspect that both those stories and the roles of WorldDoc are not so well known. Anybody going to your website would see that you’re involved in a bunch of different things: strategy analysis, software, personal health records, pharmacy benefits management. To tell the people listening, what does WorldDoc do and what are your main lines of business?

Rahul: WorldDoc is in its seventh year of operations. We started with 14 board certified specialists. We now have 20. We have the single vision of trying to educate and empower consumer end users about their health before seeing a doctor. So we created a web based software system that helps people understand their acute care problems, things like a cough or red eye or stomach pain, "What’s wrong with me? What can I do to make myself better?" Acute care is one of the things. Preventive health. "Hey, I just turned 40 years old. What tests do I need? How can I maintain a healthy lifestyle? Am I at risk for a heart attack?" Then chronic conditions, things like when you know you have high blood pressure or diabetes or high cholesterol. We teach people about their goals, how to talk to their doctors, how to get to their goal.

We do this all in a software based system, created by the 20 board certified specialists.

Matthew: That’s one part of your business. As you know, there have been plenty of companies over the last decade or so who have created software programs to do some parts of some of that, but you guys seem to have made a real business of it. So what have you been selling, who are your customers, and what kind of services are you selling?

Rahul: Our core customers are self insured employers and their payers. The self insured employers are the true purchasers of health care. Their payers are independent third party administrators or regional health plans, which market to these entities, and then their consumers and end users use them.

Our core web based system comes with a 24 hour nurse line. One of the things that we’ve been able to do is import pharmacy and medical claims into our care engine, so that the pharmacy claims can be done within 24 hours of a claim fill. That means that, if I have diabetes and you have high blood pressure, and we each fill a prescription, then, the next day, the WorldDoc system might message you and say "Hey, for your high blood pressure, do you know what your goals are? Here’s the medication. You may want to talk to your doctor about this alternative, which will save you $1,000 a year."

Matthew: Let’s get down to a more granular example. Let’s say I’m one of your customers who is an employer, and I’m working with a TPA to administer a regional health plan or a TPA to administer my employee benefits. Maybe you want to pick a real example, of one of your employer customers. How does it actually work? What are the pieces that you’re supplying to them? What are the pieces that they’re really looking for?

I understand that a smaller TPA may not have done what some of the larger health plans have done and created their own online consumer health experience, as it were. Perhaps they’re looking to you to provide that. What is the value proposition? What are the reasons for which they will engage WorldDoc?

Rahul: On the health risk assessment side, where organizations profile a population’s risk, there’s a lot of examples in the industry in which an employer or a health plan will incentivize a population to fill out a health risk assessment. We do that as well, it works great.

However, we go a few steps further, so that, if, on the basis of pharmacy claims, we know that 500 people may have diabetes, and we’ve done this with Coast Resorts, a casino here in Las Vegas. These 500 people that were on a diabetes claim file, out of a total population of about 7,000, were sent one letter, which invited them to come to the WorldDoc website and fill out a diabetes report card. About 150 people did that.

What’s fascinating is that these 150 people, whom we taught to know their numbers, put in their cholesterol levels, their hemoglobin A1c, and blood pressures, and we created a profile of "Hey, am I at goal?" Simultaneously, we sent this to the employees’ doctors, and we had that in our database. What we showed, within six months, was that these people that participated, that their blood sugars improved to the same degree as they would have if a nurse had phoned them at home. So, we believe, for working age people, commercial people, "Get on the same page with your doctor, reach your goal." This study was published in the Journal of Managed Care about a year ago, and really empowered end users to take better care of themselves.

Matthew:
Let me ask you a bit about that, because, obviously, there have been
these programs that have been introduced, and there’s been a fair
amount of evidence that, if you can move diabetics in one way or the
other and make them behave better or work better with their physicians,
you can actually improve outcomes and reduce costs. There have been a
lot of different ways to that waterhole. We haven’t really figured out
how to do it systematically. Of those 500 folks you write to, how many
are you getting to come to the website? How many does it take getting a
nurse to call them and convince them to do that? How are you engaging
that population?

Rahul:
Adoption and engagement are one of the secrets that we often know how
to do very well. Our customer experience team works closely with the
human resources team of an employer, and with the executive team, to
say "Hey, this needs to be a core strategy for the whole organization."
We do an evaluation their food habits, their cafeteria habits, their
vending machines, the hidden messages, and try to change the health
culture of an employer. Then, to get more tangible, with the WorldDoc
product itself, we’ll have posters in the breakroom, we have paycheck
stuffers, we have monthly newsletters that go out. It’s a whole
organized campaign. Then, with a small incentive, as little as $50 for
getting on and doing your health risk assessment, we consistently have
more than 70 percent adoption of WorldDoc. About half of our
organizations choose not to have an incentive. So, on a strictly
volunteer basis, we’re at 35 percent, which is phenomenal in the
industry.

Matthew:
So, if you go back to your 500 diabetics out of a population of 6,000
or 7,000, is it 35 or 70 percent of that population that’s adopting,
or…

Rahul:
No, because this was a mature client for us, in the first 18 months, we
had already engaged almost 3,000 of the individuals to participate on
WorldDoc. In the second year, we did the focused diabetes program for
those 500 diabetics.

Matthew: You actually had 500 diabetics coming online and interacting with the system?

Rahul: 500 diabetics are the amount in the population. 150 of those worked with the system. .

Matthew: OK, so you’ve got a pretty good proportion. What’s your sense of how you’re going to reach the other 350?

Rahul:
It’s interesting, that’s a great question. We did this as a pilot
program, as a kind of one test pilot. You know, repeated mailings to
the group. Nurse callouts by some of the local nurses might help, but I
think repeated mailings, communication with their doctor, those kind of
things. When we look at the populations, the non participants, the ones
that did not participate in WorldDoc, they still went to their doctor
in the following six months. They still continued to take medications.
They did not achieve their diabetes goal at near the amount, and so
more promotions needed.

Matthew:
Right, I’m with you. I think anyone who’s looking at disease management
information in any of these categories knows that it’s very hard to
move the needle, especially on the folks you can’t engage very easily.
There are some things you can start to think about doing. Now, on the
flip side of that, what is your relationship with the physicians in the
communities, what actually nuts and bolts happens for a doctor who’s
got a patient in one of these programs?

Rahul:
These programs work best when the physicians are notified in advance
that a program for large employers is occurring. That way they have a
chance to at least have heard about it prior to being blindsided by a
report card that shows up in their file, in the patient’s chart. We
went ahead and did that, and we got buy in as well as from the office
manager.

That’s important, because, we’re trying to get their
buy in, get them to help the physician and patient get the goal, get
the member to goal. When you’re doing specific peer intervention, the
physician relationship is important. We’ve done this in places where
it’s purely member driven, and it works, not to the same success rate,
but it’s been effective. We’ve done it with some cholesterol programs
on a smaller scale.

Matthew:
Right, it’s one of the things where it obviously helps if you can get a
decent concentration, I assume, with the local employer, and some local
physicians have noticed it, it’s more than just one or two of their
patients. Is that how you marketed this, are you basically metro based
programs? How are you actually going out and selling this program to
employers so you can get more attention from doctors?

Rahul:
I think, primarily, when we’re able to concentrate lines in a region,
for example in Montana we have over thirty five thousand members that
have access to the WorldDoc system, so they’re an organized effort to
go out and educate the medical community. We’re undertaking, with our
third party administrative partner there, and that’s more successful.
We have a similar concentration in Columbus, Ohio and Cleveland, Ohio.
When you’re able to achieve pockets of concentration, you’re able to
get better usage of the system. Then when people use it, the physicians
get a little more comfortable with it.

Matthew:
Is your strategy then to basically get a big employer client or a self
funded employer to be a client in one market, and then either market
back via the TPA to their other clients, or market for the next door
neighbors and try to cluster around customers you already have? Is that
how you’ve done it, or has it been more simple?

Rahul:
I guess that we’ve done it. I mean clustering is, I think, important.
One of the things early on that helped us grow. It’s that old gas
station thing, right? If you want to build a gas station, build it next
to the most successful one in town, and people will come to yours. When
you’re in a new market, even if you have some large national type
customers, a lot of people don’t like being the first to try something
in a newer market. We’ve got quite a few employers in the Northwest, in
the Southwest, Midwest, and just starting now to go out more in the
East.

Matthew:
In terms of the products of the sort you have there, which is the
personal health management record thing which they might have 24/7, and
then the PBM—WorldDoc RX—and then also, maybe you’ve already described
it, but tell me a bit about the WorldDoc TX, please, the care
management tool.

Rahul:
The TX is amazing, and that’s where because our care engine can import
data, especially pharmacy data within twenty four hours, medical claims
data, in a batch format, and laboratory values. We take direct feeds
from Lab Corp. Because we’re able to import data into this engine, we
have a very robust electronic health record. We’ve only talked about
the member using this data, and the system communicating with the
member, however we do have a separate interface whereby a nurse could
use this.

We have a health plan in Texas, where there’s about
sixteen of their medical management nurses who use this as their care
management software charting system. This is their Microsoft Office for
the day. What will happen is, each nurse has about two thousand members
that they’re responsible for. Each nurse is responsible for their own
population. What our system does is segment those individual two
thousand members into risk groups. The system automatically displays
the different care gaps that are needed, so it’ll display a hundred
diabetics on one spreadsheet electronically and say, "Hey, these twenty
five diabetics don’t even have a hemoglobin A1C. The the next twenty
five may, hey, the A1C’s overnight."

It gives that nurse
something to focus on for the day, and gives a measurement of
accountability back to the manager of all these nurses. It’s a
phenomenal system for efficiency, and what we’ve been able to show over
a couple of years is that when you measure and track the productivity
of a nurse, and Heritage Health is the health plan. They’ve realized
tremendous efficiencies in their care management department, and they
believe it’s a big reason for their low medical loss ratio.

Matthew:
If you’ve got the engine system, your core database, you’re showing the
views of the member, you’re showing another view potentially to a nurse
care management system, it’s the same sort of data, and then you’ve got
also information there on the drug database you’re analyzing
separately. Tell me a bit more about how the PBM works? Do these
products or services tend to get purchased separately, or did they just
all get purchased together, and how does the PBM piece work in that
compared to some of the big national PBMs or regional PBMs that they
can be using?

Rahul:
A big part of our PBM is transparency. Transparency of price to the
consumer, to our employer clients, and to physicians if need be. What
we try to do is to teach people to take appropriate medications, so
that if you’re on a $130 per month Nexium for heartburn, think about
that $20 over the counter Prilosec and our PBM benefit will cover that,
with or without a prescription dependent upon how the employer client
wants that. That’s a savings of fifteen hundred dollars per year on one
prescription.

Now, our PBM, again, we’re all about transparency,
communication, education, and so the members realize this difference
when they go up on our website. Our entire care engine is built on a
PBM architecture, and it has that national center for prescription drug
plan standards, the NCPDP standards. What actually occurs with most of
our customers is that WorldDoc, we can work with other PBMs and display
the information. So we work with multiple large PBM’s including
MedImpact, the country’s fifth largest PBM, Pharmacare, and several
others. What we’re able to do is to show the real accurate pricing and
transparency of each of the medications to the members.

Matthew Holt:
OK, so, if I’m a TPA, or more likely I am an end payer, I may actually
use that service in conjunction with a PBM contract I already have….

Rahul:
That’s right. We don’t have to be the PBM, you know, it’s there…We
have a few clients that use it, and with our personal WorldDoc, our
clients were able to roll out new, innovative programs and to
demonstrate the success and then go ahead and take those to some of our
larger customers who are comfortable and happy with their current PBM.
The pharmacy data is just critical. It’s critical to be able to get the
data within 24 hours, and to be able to show the actual price. If you
stripped away the conflicts of interest and all the behind the scenes
things that occur in pharmacy.

Matt:
Right, and there’s—I’ve written a fair amount about that—the typical
stranglehold the large PBM’s have on both employers and then state
governments in many places, and then some of the games that have been
going on that more organizations are starting to chip away at.

Rahul: Governor Spitzer, we’ll see what he does as governor now, right? The New York governor.

Matt:
That’s going to be very interesting. Have you been following the
University of Michigan situation? Where university keeps out all of the
PBM’s in the heart of the organization just to run the claims and
they’ve been doing the renegotiations and they found out they should
have been saving a load of money by getting rid of Caremark or Medco.
Pretty interesting story.

Anyway, let’s talk just a little bit
more about the progress of WorldDoc as a company. Give me some rough
details. You’ve been there seven years, you have seen a decent client
base, you said so, regionally. How many people have you got, what can
you tell me about the revenues you have and what your plans are. Just
give me a sense of the scale of what you’re likely to be doing next.

Rahul: Sure. Well, it’s an exciting time for us, Matt. January 2007, we earned our first dollar and we actually turned a profit.

Matt: Woo hoo! [laughter]

Rahul:
Yeah! There seems to be a lot more pressure in the office nowadays
compared to a year ago, and it’s a lot easier losing money sometimes,
but when you are growing. It’s exciting now, we’re just south of half a
million dollars of software revenue a month, so we’re on a run rate of
six million, and we’ll likely do eight to ten million this year. Where
we’re headed, we have perfect relationships with our clients, we enjoy
what we’re doing, we’re constantly learning.

I think our product
road map, the direction we’re going is to try and automate care
management and to empower members, empower people to make decisions,
and the right decisions in collaboration with their doctor. That’ll
take us the next year and a half, and then afterwards, I think what
we’re moving towards is almost facilitating or bridging care. True
care, where if I go see my primary care physician, and I have something
wrong with my shoulder, and my exercises at home that I tried on
WorldDoc aren’t helping me, well that primary care physician, they’re
not, "Hey, OK, I’ve got a shoulder issue, what’s needed?", they’re like
"Well, I need to see an orthopedic surgeon."

Well, why can’t
that primary care physician have a plasma screen with a video and get
the orthopedic surgeon visually on the TV and he can see me as a
patient and he could diagnose me over the internet? That’s
telemedicine, and bridging all of that, and bridging the data and
information.

Medicare the last fifteen years will take care of
that. It’s a very efficient, effective service because then the
orthopedic surgeon in two minutes can tell me what’s wrong with me and
suggest, "Hey do I want surgery? No. OK, well, try physical therapy.
This is what you can do." Well, great, I’m happy. Those are skills and
sculpt that are outside a lot of a primary care physicians’ purview.

Matt:
Actually, interestingly enough, I was yesterday down at Cisco, and they
were showing me they have a new room called Telepresence, which
essentially is like… I’ll put a picture or two of this up on the
blog… It’s essentially a big conference room sliced in half and the
other half of the table is a sort of bank of these big 5" plasma
screens arranged in a sort of a circular shape where the other half of
the conference table would be, and literally you’re seeing this
incredible video. Full-sized, life-sized video, where they’re seeing
you and you’re seeing them. We’re very close to getting that, but all
over IP. We’re very close to getting that kind of thing to be pretty
much available, and so it’s in the Cisco display room. Now it’ll be
everywhere in a year or two. I think you’re dead right, there’s a lot
of options to actually get telemedicine and that kind of care
integration much more on the forefront of general care. So I think
that’s pretty interesting.

Rahul:
Yeah, just one quick comment. I think it’s especially critical for the
rural population and then, in many ways, the inner city Medicaid or
underinsured. Those rural and inner city function very similarly, in
that access to specialty care is very difficult. Telemedicine can
greatly improve the efficiency, because the specialist is trained for
procedures, but many times they’re just needed for a two-minute
consultation.

Matt: Right, and then of course the other thing is that they don’t necessarily have to be in an expensive city in America, right?

[laughter]

Rahul: That’s right!

[laughter]

Matt: There’s some little ways to go before we have that done.

Rahul:
I’m confident there’s probably a few thousand doctors in India that are
Board certified in American medicine and already have licenses in the
United States and they’re sitting in India because they’re like,
there’s less paperwork there, and they’re happier their families are
there. This is a few years out, but hey, if I could see that person
right away for five dollars or ten dollars, I’d love to do that, right?

Matt:
Right. That’s sort of foreign trade in specialist consults and online
second opinions, you know, it’s not so far away. People already started
talking about that, and you can already get the Cleveland clinic to do
an online second opinion and theirs is only five hundred bucks or
something, If I could open a place in Thailand to do it for fifty bucks
or twenty bucks or ten bucks, yeah, you might be able to do
it. Naturally a possibility.

Anyway, let’s come back to the real
life, to the short term. Just to wrap up, who do you regard as your
major competitors in what you’re doing? Using some of the same
terminology as the folks at Active Care Management and some of the
other people, looking at the sort of care management angle Click4Care
has been using. Do you think of them as your competitors, too?

Rahul:
Yeah, I think Active Health Management, they have a very, very robust
care engine built over years. I think their main model is to
communicate with physicians or nurses to influence and manage a
person’s care. We’re much more member-centric. I think the large
insurance companies United, Aetna, Cigna, Anthem they’ve developed very
robust, personal health records and some nice tools on their web tools.
Certainly, we’re not going to sell insurance, but we do compete against
them for the presence of the portal, to the same client base. Then
certainly, WebMD. Still, the majority of their revenue comes from
advertising, but an increasing percentage is coming from employers,
that purchase employer type portals that have a lot of the same
functionality as WorldDoc. I think we’re still quite a bit stronger on
the pharmacy and the chronic conditions. Certainly, I think, in many
ways, that’s good for the industry. I’m excited to see that.

Matthew Holt:
One of the things I say in my general stump PHR speech is that, when
you start getting some serious businesses involved and companies you’ve
heard of, it means that the people have been there for a while and will
probably get more validation. When it’s only people that no one’s ever
heard of, then it’s much harder to sell something.

Rahul:
That’s right. People understand, I think, more and more, that you must
focus on goals, on getting consumers to have healthy behavior,
body-mass index, weight loss, fitness, exercise, diet, all these
different manifestations. It’s all a good thing.

Matthew:
Let’s push this out a few years, not so much on the telemedicine,
though I think that’s one clear area, what kind of changes do you think
that this kind of chronic-care management and member communication,
whether it’s TPA members, health-plan members, however you want to
define it, what kind of change will that make to local health-care
markets? And you were at Sierra Medical Services before you were at
WorldDoc, right?

Rahul: Sure.

Matthew: I think Jerry Reeves was there, involved with WorldDoc at the start, is that right?

Rahul: Sure, Jerry Reeves was our first C.E.O. We recruited him from Humana. Absolutely.

Matthew:
There have been some very significant changes in how care is delivered
in the Las Vegas market, inspired partly by him and some of the work
you’re doing at Sierra. My sense is that there’s a link between the
kind of work you’re doing and the kind of peak things that they were
doing. Can you talk about that?

Rahul:
I was a medical director at Sierra Health Services. Seventy percent of
their members choose to go to Southwest Medical Associates, which is
their staff owned clinic. They have excellent processes, they were
among the first to adopt electronic medical records, years ago, before
hospital lists were a common term, Dr. Reeves, who was chief medical
officer in the early ’90s, put together a hospital-list program.
They’ve all been very innovative, from a hospital management approach.
When I was there, in the late ’90s, we had a full department dedicated
to population-health management. I’m not sure where that stuff is going
now.

Many of the ideas that were there early, "How can we improve medical care delivery?", came from my years at Sierra.

I
guess in the local Las Vegas market… Las Vegas continues to grow.
There is a lot of consolidation of the casinos, which are still the
major employers, but there is quite a lot of other employers. With the
consolidation, and many of the casinos now having properties
nationwide, we’re starting to see the United Healthcares here, the
Sierra Signets here, with much larger size than before.

Matthew:
Would you say that you think that the impact of a WorldDoc type system,
whether you or anybody else, but this care management system, with the
employers or the TPAs or some third party, essentially a payer, using
the data to oversee the chronic care and look at transparency of drug
costs and many other system costs, do you think that that’s going to be
a driver behind some of the increased efficiency in the way care is
delivered? We don’t have to blame the point here, but everyone knows
that care is delivered in a wildly varying manner in most American
states and [indecipherable], that there’s much potential for increased
efficiency. Are you part of that movement, or are you thinking more
about just the chronic care services and quality improvement?

Rahul:
I think that, big jobs on every level of care, if you think of
preventative health, if you’re female, "Hey, you need a mammogram, you
need your blood tests", get that stuff before your doctor’s visit. Get
it done before the physical exam. Well, that can be enabled with
automated ordering, a tool that WorldDoc can communicate. WorldDoc
Recorder sends you your personal health summary, and, when it’s time
for your annual checkup, it gives you the map, the locations, tells you
to call the mammography place, get that done, and then see your doctor.
That’s much more efficient, much more effective.

I think for
acute-care problems, if it’s a Sunday afternoon and you have a
four-year-old kid at home who has a fever, you have a presentation to
give the next day, and the child may need an antibiotic, then you phone
a nurse, who goes through a WorldDoc algorithm that says "It looks as
if the patient has a sinus problem. An antibiotic would be helpful",
and that nurse gets your doctor’s name and number and calls the doctor
and says "We will authorize $25 to you if you think these symptoms are
consistent with sinus disease, and here’s the symptoms", and, boom, you
have an antiobiotic. That’s much more efficient.

For chronic
conditions, it’s the relentless effort to get people to a goal. A
physician is needed for the initial diagnosis and the initial visit
management. After that, you should have to see the doctor just two or
three times a year, for hypertension, for high cholesterol, for well
controlled diabetes. But, every four to six weeks, there should be
communication with a nurse or an electronic system to relentlessly get
you the goal. Many times, you just need to increase your medication
dosage, which could be done by an electronic algorithm.

So,
then, doctors are taking care of sick people, they’re in the hospital
as needed, they’re preventing and doing more education, rather than,
say, the routine hypertensive follow up, which is a waste of everyone’s
time.

Matthew:
I think it was one of the heads of quality care at Geisinger at the
Information Therapy Center conference in September who said that we had
too many $200 an hour physicians doing $20 an hour work. I think what
you’re talking about, and everyone is on this same idea, is how we can
drive some efficiency into the system by taking that work out of the
hands of highly expensive people and putting it into cheaper people or
no people. The flipside of that, of course, is that much of the stuff
that goes on that’s unnecessary is being charged $200 an hour for… If
you start taking it away, you might be looking at people’s livelihoods.
In some ways, that’s the flipside of all of this. But, on the other
hand, there’s always more stuff to be done. So I don’t know whether
that would be the end of the story. It’s been great chatting with you,
very interesting to find out a lot more about WorldDoc. So, unless you
have any overriding final comments, let’s end it there. Do you have any
last messages about WorldDoc?

Rahul:
No. Thank you for the time. It’s an exciting time, I think, to be
involved in health care. There’s a lot of change happening, many very
progressive organizations are trying to improve health and reduce costs.

Matthew:
Yep, and it will be interesting to see how you and all those other
competitors and other players we’ve mentioned will work out in the
future. I think it’s a very interesting piece, and I’ve interviewed
several of the others. Active Health Management, Click4Care, and some
of the other players. I hope I’ll keep being able to do that. So, with
that, I want to say "Thank you very much" to Rahul Singal. He’s the
C.E.O. of WorldDoc, a Las Vegas based care management player. Thank
you, everyone, for listening, see you on the blog soon.