Ami Parekh is the Chief Health Officer & Ankoor Shah, is VP, Clinical Excellence at Included Health. I had a long conversation with them about the philosophy of how we are doing population health and how we fix the system that we have today. I’m arguing for more primary care, but Ami restated it and says, you need somone you trust who is an expert who can help you make decisions. And this might not be a human! How do we change the system, and how does telehealth work now and how will it change? Defining health from the person perspective, not the way the health system wants to define it! Matthew Holt

This was such a great discussion I wanted to publish the transcript. The way I do that is to copy the Youtube generated transcript and drop it into Claude to smooth it over. I then read it and if I think it’s made an error, dip back into the video and listen to what actually happened and make a correction. This is all code therefore for me saying I think this transcript is pretty accurate but it might have a bunch of AI and human generated mistakes.

THCB Spotlight: The Future of Primary Care and Virtual Health Delivery

A Conversation with Ami Parekh, Chief Health Officer, and Ankoor Shah, VP of Clinical Excellence, Included Health

Matthew Holt: Hi, Matthew Holt with The Health Care Blog here with a special chat. I have with me Ami Parekh and Ankoor Shah — the head honchos of the clinical team at Included Health. Ami is Chief Health Officer and Ankoor is VP of Clinical Excellence. Both are MDs. Those of you who’ve been following digital health for a while know that Included Health was born as Grand Rounds, merged with Doctor on Demand a few years back, and is one of those companies straddling the line between navigation and direct care delivery. These two in particular have thought a lot about how we should be treating patients and managing their care in a modern era. We have a world in which — as those who read my work know — we have a disjointed, if not nonexistent, primary care system. We have a lot of specialists doing things in a disjointed manner, and a lot of hospitals making a lot of money doing intensive surgery, and probably none of that is the way we’d get to the best population health outcomes. So great to see both of you. Ami, we talked 18 months or a couple of years ago about some of this stuff. Let’s dive in philosophically — what are the major problems you see when you come to a new customer or a new population group? What’s wrong? And then we’ll talk about how we fix it.

Ami Parekh: Great. Well, Matthew, thank you so much for having us. It’s always fun to talk to you whether we’re doing it in person or virtually. Last time we had the joy of doing it in person, so maybe next time we’ll bring that back. So I like to start at the highest level and then work my way down. At the highest level, when we talk to a purchaser of healthcare, the problems are actually pretty basic: they pay too much money for not great outcomes. Period. Full stop. For companies in retail or technology, or a state with firefighters and police and teachers, the cost of healthcare is becoming one of the number one costs their CFOs have to deal with. It’s going up year over year. This year they’re looking at double-digit increases. And then they’re not getting the outcomes they deserve. Their employees are living shorter, less healthy lives. They’re unable to show up for work the way they want to. They’re unable to show up for their lives and their families the way they want to. If you’re paying a lot but getting amazing outcomes, maybe you’re okay with it — your people are showing up every day, engaged, able to do the things they love for their families, able to snowboard if they want to. But when you’re paying a lot and not getting the outcomes, you’ve got a problem. That’s the fundamental problem our clients come to us with. At the member level, it means that as a member you’re frustrated, you’re annoyed, you’re not living your best life. Healthcare is not something you wake up excited about for most people. You’re more like: I’m doing this because I want to lead a longer, healthier life, I want to prevent getting sick, or if I am sick, I want to prevent suffering and get the best outcome. That is not the experience of members today. If you’re a human in America, 100% of you will have a healthcare need in your lifetime — sorry for that update — and you’ll leave with a frustrating, annoying, and not great result. And with so much money now being paid out of pocket, you might also go financially bankrupt because of your healthcare need. So those are the problems. Good news — I’m an optimist at heart, so I think we can solve all of these problems. That’s the problem statement in my head. Ankoor, did I miss anything?

Ankoor Shah: It’s really around framing how healthcare is so different from every other part of our life. We’re trying to make healthcare like how we actually interact with other technology — like how I watch Netflix. What the consumer, the patient, wants — what I want, what Ami wants, what you want — is care when we want it, where we want it, how we want it, that’s affordable and very personalized, and that actually makes us healthier. That’s a very demanding consumer need. If we orient around that demanding need for the patient, then all those other sequelae that Ami mentioned around cost and outcomes actually come true.

Matthew Holt: So two things. First, we hear a lot about chronic disease — god knows we’re hearing way too much about it now from our alleged Secretary of Health and Human Services. I think it’s true that the impact of chronic disease is clearly growing, and I want to know how much you’re seeing that in your populations. And then the wider question is: when Owen started Grand Rounds back in the day, it was a company based initially on second opinions and specialty networks — figuring out where people should go when they got sick. I sat in Alain Enthoven’s class at Stanford Business School in 1990 explaining how half the surgeries being done shouldn’t have been done, and the Dartmouth research on price variation was just starting, finding that people were doing three times the surgery at double the price in some areas versus others. We’ve had people talking about that forever. So first: how sick are people, are they getting sicker? And second: are we getting anywhere with managing specialty chaos?

Ami Parekh: People have more chronic conditions, and we see that even in the commercial population. Our current area of focus is working Americans and their families. Even in that population, and Ankoor can speak to this, even in children, we are seeing an increase in chronic conditions. One of the myths out there is that people with chronic conditions won’t engage with virtual care — that they’re going to want to go in person to their clinicians. We actually found in our virtual primary care practice that a number of the people who benefit most from virtual care are people with three or more chronic conditions. That’s another trend: many people don’t just have one chronic condition. You don’t just have diabetes — you have diabetes and hypertension. You don’t just have osteoarthritis — you have osteoarthritis and diabetes, and most of the time you also have a behavioral health condition on top of those physical chronic conditions. We’re absolutely seeing that trend. And the way that’s showing up is that we all know about the delay in care that happened during COVID — people put stuff off for all the right or at least understandable reasons. Now we’re seeing trends go up a lot, medical utilization going up. Some of it is this buildup of chronic conditions that have not been managed well over the last three to four years, and now we’re seeing the implications in higher-cost needs of that population. Their needs are increasing, and if we manage them well, hopefully we can reverse that trend. I don’t think it’s irreversible in any way.

Ami Parekh: On your second question about specialty care and variation — what Included Health has said is that within a broad network, we can steer the member to the best-matched clinician for them. And that’s a lot of how we drive savings for our clients. We minimize the variation in the quality of clinicians that a population is seeing at scale, and that’s a huge driver of the value we give to our clients. If you look America-wide at those 160 million people who get their insurance from their employers, that variation is still stark — especially in PPO networks, which are just broad networks. There’s very little reason for a plan to narrow that network. And even where they narrow it in an HMO network, I’m not sure they’ve done the rigorous scientific work about who’s in the network based on quality and cost, as opposed to who signed up. There’s an inherent conflict when you’re the one owning the network and also the one measuring quality and cost.

Matthew Holt: Ankoor, let’s dive into that. What’s your philosophy on dealing with clinical excellence among the providers you choose? You’ve done this in your real life as a pediatrician and at other health systems. How are you thinking about fixing this issue of clinical variation and lack of quality in a specialty network?

Ankoor Shah: The framework we use starts with safety — are we ensuring that people are actually connected to safe care? Then you get to the quality of care they’re receiving and the effectiveness of that care, which now has two arenas. Quality of care is probably evidence-based care that is being delivered and that we can measure, and then are we actually driving toward better outcomes or reduced utilization. In our virtual urgent care practice, for example, we’re resolving over 95% of cases without the person needing to go to a brick-and-mortar urgent care or ER. That’s a metric because it solves a patient problem and delivers the right care. This is where I think we’re really pushing the innovation bubble — traditional healthcare metrics haven’t changed in decades. HEDIS metrics are frankly a little uninspiring. So if we reorient to wanting the member to actually have healthier days — adding more healthy days in your week or your month — and use that as our orientation, we can ask: what are the interventions that drive that? That’s around safety first, then quality, then effectiveness, then cost. What Amy mentioned before is what we see in the industry in reverse — it’s cost first. But value is quality over cost. We use that framework whether for the services we deliver or for how we evaluate other provider networks and care delivery systems.

Matthew Holt: I get that for the specialty network. A lot of this is about the increase in chronic illness, and obviously the demands on behavioral health and mental health have gone up dramatically — either we’re counting them better or the rates of depression and anxiety went up dramatically since the pandemic, and probably haven’t gone down since the election. On the input side, the policy vision is that if we could give everyone primary care and manage it well, it would save a lot more money in the long run and we’d have healthier populations. Given the problems we have with chronic illness, is that something we can actually do, and how are you thinking about doing it given the virtual primary care network you’re running?

Ankoor Shah: With rising chronic disease there’s a demand problem, but there’s also a supply problem. A lot of why this is happening is that you don’t actually have access to high-quality primary care that’s longitudinal in nature. One thing Amy and I and all of us at Included Health are excited about is the first-dollar telehealth coverage that was recently passed, which gives employers an opportunity to expand access while still considering affordability for the member, for virtual care services including primary care. Access is the first thing — and then ensuring that longitudinal care relationship where you’re not stuck to a 15-minute visit where you have to talk about everything. You’re actually on this journey together to manage your chronic conditions.

Ami Parekh: To what Ankoor mentioned about access as one key way to get anyone who wants it to high-quality primary care — I also think we’re at a really opportune moment where we may need to redefine what we mean by primary care. Primary care is actually a very healthcare-jargony term. If you ask five people on the street what primary care is, you’d get five different answers, and some people would just stare at you and say, ‘I don’t know — what’s secondary care?’ What it means in my head is that you have somebody you trust who lives within the highway that is healthcare, who can help you make decisions about your health care to achieve your own goals, and who comes with some level of expertise — they actually know things like which medicine to use. That’s how I define primary care. Most of the time it’s a person, but we’re really in this world of AI right now. I know you’re going to talk to Owen at some point about how we’re using AI, but could some of that be taken over by a tool that is not another human but is supported by a human? I think this is the first time in my 20 years of working in healthcare that I’m genuinely thinking: maybe there is a solution to this supply problem Ankoor was talking about. We’ve done a lot by enabling virtual access — if you’re rural, you can get access — but the next phase is maybe not everything has to go through a human. Maybe you can have a trusted relationship with an AI plus a human that actually gets you to better health. So I think it’s going to be an interesting decade of really trying to define what primary care means from the member’s or person’s perspective, not from the healthcare system’s perspective — which is always the way we try to define everything. And the proof points are in countries that have a higher GP-to-population ratio, or in places like Kaiser and other vertically integrated healthcare delivery systems where people start with their primary care doctor before going to a specialist — they get better outcomes, they live longer, healthier lives. Primary care is a major tool to get there, and now we have AI to potentially scale it better and make it more personalized.

Matthew Holt: Well, they’re all healthy and sitting in Portugal with their primary care clinics, eating sardines drowned in olive oil and drinking red wine. I’m a big believer in primary care — I wrote this piece saying we should give every primary care doctor 600 patients and $1.2 million and let them get on with it, and that would probably improve healthcare. And if you look at Humana’s data about how they manage their value-based care versus other care, they’re spending nearly three times as much on primary care and seem to be getting better results. So I think we’re all bought in on the policy side. But there are a couple of things before we even get to AI. What you guys at Included Health — and you’re not the only ones — have been doing for many years is providing telehealth-based primary care, and there seem to be a couple of issues. One is regulation: a doctor has to be licensed in New Jersey to see someone in New Jersey, and that whole piece seems gummed up by the traditional medical system. The other is that there’s still some uncertainty about what you can actually do in a virtual consult versus where you need to physically touch somebody. Are we getting better on the regulation side? And how are you working to convince people that virtual primary care actually works even if you can’t physically examine them?

Ami Parekh: I don’t think state licensing boards are going anywhere. States need money and budgets — that’s part of the whole reason this industry exists. So I think all your doctors still have to be licensed in all 50 states, or that bureaucratic process still has to happen. That said, one of our real advantages at Included Health is scale. One of the special sauces at this company is that we know how to license people. We know how to do it efficiently. We know exactly how many licenses you need when you come on board, and we get them for you. It’s a necessary but functionally useless administrative exercise — and we’ve gotten very good at it. So we assume you have to regulate, bribe, and legislate your way through, and we’ve done that. We’re not going to change that. Now, on your second question — how do you convince people that primary care can be done without being touched? I think most people believe it once they do it. There are advantages and disadvantages to both. The advantage of virtual over brick-and-mortar: frequency, speed of access, not having to wait 60 days, and you get to see things in people’s homes that you don’t see when they come into your office. You can say, ‘Open your medicine cabinet and show me your pills. Where’s that scale you tell me you’re stepping on every day?’ There’s a whole bunch of stuff we can do virtually that you can’t do brick-and-mortar. Second, remote monitoring is getting a lot better. You can listen to somebody’s heart virtually, listen to their lungs, look in their ears. Many parents have bought the little phone attachment where they can send a picture of the tympanic membrane: yes, ear infection; no, ear infection; done. Technology in the home has moved forward quite a bit in the last five years. That said, there are still things that need to be done in person — the classic example being a well-woman exam. For those we refer to high-quality in-person providers, and those are usually things that don’t have to happen frequently — at most once a year, usually once every three years. We can get that done. The issue is we want both as members — able to access virtually and in person when needed. The relationship is actually easier to maintain virtually because of the frequency of visits and ease of access. The in-person piece can almost become a commodity: you get it done when you need to get it done. I do think it’s going to take time for people to really believe that. Right now it’s mostly working when a friend tells you it worked for them, or when you do it yourself.

Ankoor Shah: What’s interesting is that if you ask doctors — even a doctor in your family — they’re providing non-office care visits all the time. A lot of our lives as doctors is actually caring for family and friends through asynchronous or virtual interactions. If we were to deconstruct a primary care visit or any visit, it’s trust, relationships, data, and decisions. We’ve been focused on getting the data part right — through in-person visits but also through wearables — and what’s the value of that data compared to other parts you have an opportunity to change, and then decisions which require follow-up and a close connection to trust. So actually if we deconstruct what a primary care visit is, you could easily deliver it in a different way. I would push the boundary even further — it’s not brick-and-mortar versus virtual. It’s: can we reimagine the care experience to be longitudinal and ask what part should be async, what part should be in person, what part should be virtual, where should technology take the lead and where should humans take the lead? A perfect example when we talk about AI: when you’re prescribed a new medicine, adherence generally drops if there’s an issue after the first week — I don’t like the taste, I have a side effect. How often does your doctor call you a week after you started a medication to ask how it’s going? Versus you could have an AI assistant reach out one week after every new prescription: ‘Hey, how’s it going? Any issues?’ And then quickly adjust and maintain adherence. So it’s really not the paradigm of brick-and-mortar vs. virtual — it’s traditional healthcare versus a new way forward of redefining what care should be.

Matthew Holt: I can recommend about 15 companies who think they can make that call for you and would happily go to work for Included Health on that basis. There’s a ton of interest there, and I think it’s generally correct that we can do a lot more. I am a little — not disappointed, but surprised — at the uptake of some of these remote tools. The folks at Tyto Care have had this device you can pass around and put in your nose, ears, and on your chest. There was a company called MedWand that won the Health 2.0 Launch — must have been 2015 or 2016 — and eventually got to market. I’m actually very surprised there isn’t more of a consumer good version of that kind of device. I know people are using the Apple Watch, and there’s Whoop and blood pressure monitoring, but I’m really surprised at how little there is of the sort of home exam accessories that could be added on.

Ami Parekh: maybe as the price of those things comes down, they’ll get more adoption. I think they were priced high, and if you put yourself in the shoes of the purchaser, the ROI might not have felt like it was there. I’d have thought people would want this for their own use and it would plug right into a video visit. 

Matthew Holt: But let’s go to the next thing — for people with long-term chronic conditions, how do you philosophically approach remote patient monitoring? The blood pressure stuff, which I’ve been recently whining about because I can’t get a consistent reading — I’ve had different readings from my doctor, a nurse at a health fair, and two different devices I’ve been using. I either have very high blood pressure or it’s too low, I’m not sure. And obviously you have diabetes and blood sugar and A1C, and a bunch of other conditions people are trying to measure including pain. How does Included Health think about chronically ill patients with those conditions and those tools?

Ankoor Shah: Right now, for conditions like blood pressure and diabetes, we have ways of monitoring outside of the virtual visit. That could be your blood pressure cuff — you take your blood pressure, you put it in the app, your doctor sees it. Your doctor says: here’s your care plan, I need you to do this. You do those tasks and have communications back and forth or a visit. Similarly, you get your labs drawn and that information comes back to the care team and you work together. So this is essentially taking what is currently a hard in-person process and removing the friction from it. But what excites us is going beyond that — what’s the future process? Two things. First, how often have you gone to a different healthcare setting, gotten your blood pressure taken or labs done, and then gone back to primary care and repeated a test? A lot of waste and trouble comes from that. Part of our investment in technology is upgrading to a consumer-grade electronic health record with real interoperability, so we can actually see other places you’re getting care and use that information for your care plan around chronic disease. Second, the future is really around integrating other data you have as a person — from your Apple Watch, your Fitbit, and more. The forward-facing vision: you could actually train an AI tool around certain parameters — I’m a doctor, I’d love for you to stay within these ranges, and when you’re out, let me know. Then you’re able to engage with Included Health in a way that’s truly transformative, that helps you stay aligned on certain metrics. And as soon as you go a little off course, you have the power of a 50-state, 24/7 practice behind you.

Ami Parekh: I’ll add a little bit of data. There’s this belief that if you’re a young, healthy person, virtual works, but if you have chronic disease, it doesn’t. It’s actually the opposite of what we see. People with chronic conditions love virtual. Why? Often they’re also seeing specialists. If you have to go in person to see your oncologist every now and then, you don’t actually want to also go in person to see your primary care doctor. And what happens is people stop doing the primary care things — they stop managing their diabetes and hypertension because they’re so focused on this really serious condition. Having a virtual primary care doctor actually keeps them healthy on the chronic stuff. We find that patients with complexity actually really prefer doing this primary care piece virtually. The second thing is case and disease management. The most complex patients need a lot more than visit-based care. They often need a social worker, because some of what drives complexity in American illness is lack of access to the right foods. They need behavioral health support. They need a couple of specialists, and we want to make sure they’re all high quality. Using our tools and that team for the most complex members is one of the ways we drive value. It’s primary care for sure, but it’s also what else beyond just visit-based traditional primary care do people need to manage their chronic illness given their situation.

Matthew Holt: I think there’s the redefinition of primary care as a bunch of different things — including navigation, monitoring, and behavioral health coming in and quarterbacking that team approach. It’s something we’ve talked about for a long time but again doesn’t happen enough. My soap box is that I built and wrote this paper five years ago now called the Continuous Clinic, which had all the bits — the telehealth doctors in the bunker at one end, and all the monitoring at the other end based on where the patient was. Going back to COVID, when people were thinking about monitoring folks in hotels for blood pressure and pulse ox — where they could be managed outside a hospital. With that kind of philosophy, there are a lot of things you can do. You have to get people to actually monitor their blood pressure, actually take their blood glucose or monitor whatever it is. And there is that division between somebody who’s basically healthy and has a problem versus somebody who now has a chronic disease. But it does seem like the future of primary care-based healthy living is monitoring people at the rate they need to be monitored. If you’re a healthy person with an Apple Watch, maybe you get into your 50s, develop AFib, and it starts getting picked up. And if you’ve developed type 2 diabetes, we can start really focusing on you. It seems to me that’s exactly where you guys are going.

Ankoor Shah: So we should just take our strategy from you, Matthew, right? It is funny — because you mentioned healthy living. That’s the words we hear our members and patients using, as opposed to the construct of ‘primary care’ that we in healthcare have created and are trying to fit everything into. Versus what a family actually wants: they want to feel secure, they want to feel confident that they’re going to get healthier, and that their mind, body, and wallet are going to be taken care of. If you start with that problem statement and build toward it, you end up creating something like a continuous clinic that actually includes financial advocacy and has nothing to do with traditional brick-and-mortar. And when you do that, you actually end up improving health outcomes, thereby reducing utilization, thereby reducing costs. That’s really the hypothesis and thesis that’s so different from how we usually see this problem being solved — because most approaches start from the cost end, or from the quality angle of specialty care, rather than from the family and the member.

Matthew Holt: I think that’s dead right. I do want to ask — we sit here and say all this, it sounds great. Ami, I want to say you have 15 million members now or something like that. How many?

Ami Parekh: If you think of our two categories: there are people who have access to our virtual services — that’s on the order of 50 million people. But if you think of people who have access to our all-included care, or navigation plus virtual care delivery, that is on the order of 15  million people. 

Matthew Holt: That’s a decent number, but there are 340 million Americans. Some of whom are about to get less care and less access than they had before given what’s just happened to Medicaid. And even if you add up all the people in Kaisers of the world and other players doing integrated primary care, it’s still a minority of Americans. The thing we’ve talked about sounds great but it’s taken a while. I always kid that whenever someone comes up with a great new way of doing primary care, I say: yeah, well, Sydney Garfield was doing this in 1937 in the desert before he started Kaiser, and nearly 90 years later we haven’t really gotten there yet. So what’s your sense for the pace at which we might get to this near-term future we’ve been talking about?

What’s your sense for the pace at which we might get to this near-term future we’ve been talking about?

Ami Parekh: I always think it’ll be faster than it is. There’s that saying: you always do less than you think you will in one year and always do more than you think you will in 5 to 10 years. Reflecting on my seven years at Included, that’s sort of how I feel. Do I always want to grow faster? Do I want to give this service to more people? 100%, absolutely, all the time — everyone in my family asks me when they get Included Health, so it’s like a constant thing. I wish it were faster. But given that’s not how healthcare works — the biggest problem in healthcare is not a lack of ideas, it’s a lack of scaling those ideas — we’ve been lucky and good enough at what we do to grow consistently year over year. This whole thing started in 2011, so in some ways we’re old and have been around for a while, but I have a 17-year-old at home so I’ll tell you we’re also still a baby. For just being a 14-year-old company, we are now serving 15 million Americans — that’s a million Americans a year. And we want to hit 350 million. That’s actually pretty significant growth. Our mission is to raise the standard of healthcare for everyone, and we’ve always said we will never be able to do that on our own. We want people to copy what we are doing, because ultimately imitation is the best form of flattery. If every health plan in the world starts doing what we’re doing for people in America, that’s great. That’s our hope — to show the world this model works, that you can get better outcomes at lower costs, and we’re going to keep doing it for more people every year, while encouraging others to do it as well. And there are some policy things — like what’s in the reconciliation bill — around employers now having flexibility to allow their members to access telehealth at low or no cost without putting their HSAs at risk in high-deductible health plans. Those are moves to increase access and make it easier for people to get the kind of services we offer.

Matthew Holt: Let’s end with you, Ankoor, on a couple of the trickier parts. We can sit here and talk about motherhood and apple pie and fixing primary care, and I think we’re all in huge agreement about that, and all going ‘why the hell does this take forever? Why don’t health plans really do it?’ I’m a member of a famous California health plan — one beginning with ‘Blue’ and involving some kind of defensive weapon — and I’m always saying: why don’t they seem to know more about what I’m doing? Why don’t they seem to know that I’ve been to a primary care visit here when they’re offering me another one over there? There’s complexity at the payer level — people move between plans all the time, it’s chaos. But you can see your way through to getting a primary care system, hopefully, especially if you add AI and more tools to support it, which I think is coming. I’ve just been playing around with this mental health AI thing called Ash, which just got released. I’ve been inventing all kinds of psychoses to see how it’s doing, and it’s doing pretty well. There’s a huge opportunity there for AI monitoring and AI-supported primary care with clinicians. But the bit we spend real money on is specialty care — expensive drugs, expensive surgeries, cancer. What’s your philosophy and what are you guys actually doing about those costs?

Ankoor Shah: I’ve spent a lot of time thinking about that. There is this idea that we could cut a large amount of these high costs by doing marginal things — but I think the first step is acknowledging that certain people genuinely need higher-cost services. Complex cancer care, multiple complex and rare conditions — sometimes they’re receiving evidence-based care that is the most cost-effective care that exists, and that is actually transformational. Gene therapy is transformational and it is incredibly expensive, and that is a problem we need to figure out at a broader level. But oh my goodness, there is so much opportunity in ensuring that people get the right type of care, the right level, and high-quality care that’s cost-effective. The way we do this is centering again on the member — what’s actually easier for the member? This is where, in our partnership and work with CalPERS and Blue Shield of California, we’re actually operationalizing these ideas. Some of these ideas are old as apple pie — site-of-care steerage, moving to biosimilars. How do you actually do it? How do you actually engage a member and show why the better option is easier and better for them as well as for the health plan? That’s really where we’re focusing our energy: how do you make the right decision the easy decision — not by creating more friction for the wrong decision, which is traditionally the approach, but by actually making the right decision much more frictionless through technology, better experience, and wraparound care.

Ami Parekh: I’ll add a couple of things. To your point about why primary care is effective — it’s actually effective because you usually avoid specialty care if you do it well. We do this today: if you’re looking for a specialist, we’ll often ask, ‘Have you already seen your primary care doctor for this?’ How do we give those nudges at the right time? Don’t go straight to the orthopedic surgeon — talk to your primary care doctor first and let them help you decide if you really need to go to a surgeon who will most likely recommend operating. That’s a big lever to decrease specialty use over time. And I’ll go back to where we started: quality really matters. High-quality specialists are less likely to do inappropriate procedures and to use high-cost inappropriate drugs. At our core we believe that by driving to quality, you will decrease long-term costs. Some people just need specialty care — let’s just call it. Many people need specialty care. But can we make sure that when you need it, you’re getting the expert opinion to confirm you’re getting the care you actually need? And when you see that specialist, you’re seeing the high-quality one who’s not going to do an inappropriate surgery, not going to order an MRI if you don’t need one, not going to prescribe a med just because it’s expensive but use the med that’s more likely to work for you. That’s still our core of how we affect specialty cost. And turns out we now have good evidence that it actually works.

Matthew Holt: On that point — there’s a lot of fuss at the moment about people being denied care by AI and health plans. There’s the great TikTok meme of the plastic surgeon cancer specialist Elizabeth Potter having to argue with some AI prior auth system — I think it’s UnitedHealth. There’s and a propaganda war which is clearly being lost by the health plan side at the moment. How do you avoid what you just said — which all sounds very sensible — being bundled in with ‘these people are just denying us care’?

Ankoor Shah: We’re solving for a different problem, and this might sound simple but it’s really true. What’s going on in the industry is AI versus AI. Large hospital systems are deploying AI for revenue cycle management and productivity. On the plan side, it’s a better audit function for coding. It’s AI versus AI, and I don’t hear a patient or family anywhere in that conversation. So it really goes to what we’re actually trying to solve for: easier, simpler healthcare experience for the member. When we think about what our member-facing AI will do — ‘Hey, how’s that new prescription going? How are those new meds doing?’ — it’s just such a different framework for building this tool that supports this broader vision.

Ami Parekh: I would just add: to me it comes down to trust. Owen’s vision at the beginning — part of why I love this place — is that everybody kind of wants a doctor in their family. A doctor that they love and trust and that’s going to do right by them. That’s why my family texts me whether or not I want them to, and it’s probably why your family does the same thing. They feel like I’ve got their best interest at heart. If I were to say, ‘Actually, you can do this at home and you don’t have to drive, or you can go in person but it’s going to be kind of a hassle and it’s not that much better’ — they’re going to listen to me. Now, that trust has to be honored. It’s not something you take lightly as a physician or a clinician or a caretaker for another human being. It’s a privilege to have that trust. Part of why we’re so excited about this third way — we’re not the health plan, we’re not the provider, we’re trying to be both things to you as a person — is because if you trust us, and it will take a lot for us to earn that trust — maybe we’re going to have to solve a bunch of your problems, maybe we’re going to have to help you battle a bill you don’t actually owe — then maybe it won’t come across as us just trying to take something away from you that you need and deserve, but actually that we’ve got your best interest in mind and there’s a better alternative path. That’s a big ‘if,’ and maybe I’m living too much in La La Land. But that’s the optimism, and that’s what we all want. And I think it’s probably going to be a third party like us that’s not coming in with a lot of baggage, that is really trying to do what’s right.

Matthew Holt: And the ultimate question is whether anybody can actually have this brand of being a trusted ally of the consumer. People don’t understand how any of this stuff works, as we said earlier on, and there’s clearly — 50 years after the Dartmouth research — still a lack of understanding about the variation and the lack of safety in American healthcare. The more that someone can be trusted to guide you around the system, the better. Mike McGee, who comes on my podcast occasionally and writes on the blog, says that the role of doctors is to assuage the fear and worry of their patients — and you’ve got to have that part. Maybe it requires hands-on, maybe it doesn’t, maybe it can be done virtually, maybe it can be a matter of trust — but that’s the part that’s so critical. You’ve got to help people feel that someone’s got their side through the system. And then you also have the harder data part of managing what’s going on at the back end of the system, which as we said is still super complex and a lot of it’s inefficient, ineffective, and in some cases harmful. Alright, last thing for both of you. We always want it done in a year, it’s always going to take 10 years — but in five to ten years, what do you think the Included Health experience will mean to the people who are part of it? What do you think you’ll be doing that is maybe not massively different from what you’re doing today, but better? And do you think you’ll be understood as the primary care provider for people you’re working with?

Ami Parekh: Yes to the second question. 10 years is an interesting time frame. First of all, I do hope more types of populations have access to our services — I think we’ll continue to offer this kind of care for working Americans and families, and I hope more people can get it through their employer or whoever purchases their healthcare. Perhaps we’ll also be able to offer these services to patients who get their health plan through the government in various ways. If we do what we say we’re going to do and do it well, you’re going to have a team — both technology and humans — that you actually trust to be by your side in managing this thing you call your healthy life. It will be through both visits and, I think, more types of visits. We already do primary care, behavioral health, and urgent care 24/7 across all 50 states. There’s probably a whole bunch of specialty care we should be able to do virtually as well — you really don’t need to go into an office for a lot of stuff people do today. We will be able to more seamlessly guide you to in-person care when you need it. When you end up going to in-person care, I don’t want you to have to repeat your story. I want it to feel integrated. You need that well-woman exam, you show up, and the person doing that knows you, knows your past results, and is really confirming things for you. It feels like an Included Health visit versus being handed off between different provider groups. When something bad happens to you or your family in the healthcare realm, you know you’ve got somebody by your side. When new stuff pops up, you can easily call us. And people don’t go bankrupt because we’re helping them manage the cost side of this equation too. It’s not really that different from what we do today, but I want to do it all better, more seamlessly, and across more things from an all-included perspective — for more people.

Ankoor Shah: It’s interesting you say 10 years. I would love it if — by doing all that — when people hear about Included Health, they think: healthcare done right, easy, and I’m going to be taken care of. How we think about healthcare now is pretty grim. How I think about a luxury hotel experience, or going to Costco, or even Disney World, is very different. Included Health can be that kind of experience — not necessarily that we’re doing every part of it, but that we’ve created a model that others are replicating. That’s why people will come to us.

Matthew Holt: That’s great. All right, fantastic. I’ve been talking with Ankoor Shah, VP of Clinical Excellence, and Ami Parekh, Chief Health Officer at Included Health. We talked about their model and a bunch of related stuff, but there’s plenty we didn’t get to — we didn’t touch on health span and longevity, we didn’t mention GLP-1s. All kinds of good stuff. So hopefully you two will come back on and we can get to that next time.

Ami Parekh: Yes! Talk to you soon.