Vineet Singal, co-founder and CEO of CareMessage, a messaging platform for health safety net organizations, joins Dominique and David to share why he created CareMessage out of his original work in San Francisco’s Tenderloin neighborhood. He talks about why he turned down a scholarship to medical school to continue this work, and why he is so passionate about helping underserved populations manage their conditions and take responsibility for their health. Vineet describes how CareMessage grew from a Stanford undergraduate project to become the largest patient engagement program in the United States and discusses the types of data held by CareMessage and other healthcare clinics, as well how as how they ensure their HIPAA compliance. Vineet also explores how the COVID-19 pandemic has been a critical component of CareMessage’s growth in ways he could not have anticipated when he started the company in 2012.

Listen to “Vineet Singal: CEO of CareMessage | Using Data to Help Underserved Populations – Episode 47” on Spreaker.

 

Episode Transcript

Dominique:

Welcome everyone to Decrypted Unscripted. My name is Dominique Shelton Leipzig, and I do this podcast with my partner, David Biderman. This gives us the opportunity to really sit down with luminaries in the data space. Really excited to welcome our guest today, Vineet Singal. He is the Co-Founder CEO at the widest reaching patient engagement platform for underserved populations nationally.

David:

Yeah. Hey, Vineet. Thanks for joining us. Yeah. Dom, the one thing you didn’t also mention as the topics we cover, social good. That’s something Vineet does a lot of, so we’re glad to have you, Vineet. Thank you for joining us.

Vineet:

Thank you. Great to be here.

Dominique:

Can you tell us a little bit about your journey? How you came to creating your company, and getting into the space of helping underserved populations?

Vineet:

My story is that I grew up in four different countries. I came to the US when I was 15 years old, in New York City, where I went to high school. One of the things that had been consistent throughout my life was that I had a lot of health issues when I was growing up. I struggled with being extremely overweight, to the point of developing metabolic syndrome, or pre-diabetes, when I was a teenager in the Bronx, in New York City where I went to high school. I still remember this conversation to this day with my endocrinologist at the time. I was just 16, 17 years old. He sat me down, and he said, “If you don’t change X, Y, and Z about what you’re doing, and how you’re eating, and your exercise, and a lot of other things, this is what can happen to you by the time you’re 30.” That was definitely a wake-up call for me.

Vineet:

Thankfully, I had a great support system. My parents are both physicians. I went to Stanford, which has amazing resources. I had a great provider network of doctors helping me, a nutritionist and personal trainers. Over the course of my first two years in school, I lost over 100 pounds in the process of reversing my pre-diabetes. In the last decade since then, I’ve not needed to take any medication. I have kept my hemoglobin A1C under control, but it was only possible because of that level of support that I had, and this support system ecosystem that was around me. This experience that I had was really contrasted and juxtaposed with experiences that I had as a premedical student at Stanford, where I spent quite a bit of time working at free clinics and clinics that were serving uninsured patients that were affiliated with Stanford, called the Cardinal Free Clinics.

Vineet:

Then I also spent a few months at a free medical clinic, after taking a leave of absence from school in Texas, where my parents were working at the time in Galveston close to Houston. The experiences that I had in those places really were eyeopening. My experience as somebody who grew up in a fairly privileged environment was different from a lot of the patients that I was seeing every single day, that maybe had five or 10 minutes with a provider, with a doctor a couple times a year, but were dealing with issues that were far more significant than what I had to deal with, and with a fraction of the support that I had.

Vineet:

It was very, very clear that there was a lot of motivation and a lot of interest in getting better and managing these chronic conditions that are really big drivers of morbidity and mortality in these populations, including obviously type 2 diabetes, hypertension, even some preventable cancers. Yet at the same time, because of the healthcare ecosystem and infrastructure that exists in underserved communities across the country, and the lack of resourcing and the lack of support that’s available, these organizations that are doing incredible things for tens of millions of people are not able to provide the level of care and the level of support that I think is necessary in order to really make a dent in the chronic disease burden that America, and especially the underserved population in the US experiences.

Vineet:

That experience for me was extremely powerful. I probably remember spending time with 300, 400 patients throughout my time in undergrad, one-on-one having conversations, helping them to the best of my ability in terms of what I was able to do at the time. Not having a medical degree, obviously, but having some personal experiences, and just being there to listen and have a conversation. Came back to school, obviously was still on the pre-med path, but had this idea for helping the population that I had experienced working with in some way that could them better manage, better control the consequences of chronic conditions, and feel more empowered to take their health into their own hands. What are some ways that we could do that in a way that is scalable?

Vineet:

Obviously the one thing that immediately came to mind, and being at Stanford, I think there’s a proclivity to think about the use of technology, obviously. We tried a couple of different things. We looked at, could we put iPads in waiting rooms in clinics, and provide patient education that way, and provide more coaching and support that way? But these initial ideas really did not work. Eventually, we tried out using SMS and using texting as a method of communication. This was back in 2012, so nearly a decade ago. A couple of things had happened at the time. The first was that obviously mobile utilization had dramatically grown in the five to 10 years preceding 2012. Then the second thing that had happened was that the Affordable Care Act had passed a couple of years prior. That act, amongst many things, had a huge impact on the digitization of patient records in the US.

Vineet:

Those two factors made it really interesting for us to explore if there was a way for us to use patient records and really medical records to help drive text-based interventions for patients to help them better manage their chronic conditions. To remind them about appointments, to help them manage the process of taking their medications, and for there to be this tech driven communication channel between providers and patients. I still remember the first clinic that we piloted this at, that was a free medical clinic in the Tenderloin in San Francisco. The Tenderloin is one of the most underserved parts of San Francisco. It has the highest percentage of unhoused homeless individuals in the city. This clinic was providing mammograms to women that were unhoused, and they had a 50% no-show rate for this mobile clinic that they had that was providing mammograms. They were at risk of losing funding for this clinic.

Dominique:

At first.

Vineet:

Being poor and living in poverty is extremely difficult, and health is often not the top priority. It’s rarely the top priority, especially if it’s not an acute situation. If it’s something that’s chronic, if it’s something that’s preventable, if it’s not hurting at the moment, there are plenty of other things like putting food on the table and finding a place to sleep. Many, many other things, childcare, that are much higher up in the priority list for all of us, but in particular folks that are living in poverty. That’s one of the main drivers of lack of engagement, or lack of effective management of these chronic conditions. Obviously, if you have diabetes, it’s not going to kill you right away, but five, 10, 20 years from now. If you can make incremental changes, if you can even change the trajectory of your condition and your management by a couple of percentage points every year, that could have huge consequences 10, 20, 30 years from now.

Vineet:

That’s one of the reasons why. It’s, again, a function of the circumstances that a lot of our patients live in, where it’s not even a difficult choice to figure out like, am I going to work today so I can put food on the table for my kids? Or am I going to go see the doctor for something that I don’t even know if I have, such as breast cancer? It’s unfortunate, but that’s the reality of what a lot of our patients experience on a regular basis. Just to finish the story, when we piloted the first version of CareMessage for helping reduce appointment no-shows at the clinic, and reminding patients about that, obviously we know that because of what I just mentioned, it’s not going to cut it down completely, but the clinic saw that the no-show rate went down from 50% to 5%.

David:

Wow.

Vineet:

That was incredible. This was at a time when the clinic was telling us that, “We don’t even know if our patients have cell phones. 20% of our patient population is homeless.” But what we found was that over 80% of the population not only had cell phones, they had unlimited text messaging on their phones. This was in 2012, so that’s already grown since then. We think about mobile technology as being a luxury, but it’s really a necessity. It’s really something that not only is important and helpful for folks to access healthcare related things, but just to access life and connect with friends, family, employers, potential employers, the broader world. That’s really what has made CareMessage so scalable, is we’re leveraging an existing technology that people already have access to. It is a tool that they are using on a regular basis already to connect with lots of other parts of their life. We are just leveraging it to help improve their health.

David:

How many users are you serving through CareMessage?

Vineet:

We are serving just under 10 million patients across the country.

David:

Wow.

Vineet:

Through partnerships with about 400, a little bit over 400 safety net provider organizations in 42 states, 43 states across the country. Our primary customers or partners are community health centers. These are organizations that are set up that have a mandate to serve underserved populations specifically. They are specifically serving people that are on Medicaid, that are on CHIP. This is the Children’s Health Insurance Program that specifically serves low income kids that are uninsured or underinsured. That’s predominantly who they’re serving. They get funding from the federal government through what’s called the Community Health Center Fund, but then they also get reimbursements from Medicaid, from CHIP to serve this population, so they can effectively serve this population. There’s about 1,400 of these organizations that serve about 30 million patients across the country. One in every seven community health centers in the US uses CareMessage to reach their populations.

David:

Wow.

Vineet:

Then we also work with what are called free and charitable clinics. These are similar, but smaller organizations than CHCs, in that they specifically serve or almost exclusively serve uninsured patients. Rather than serving uninsured and Medicaid or CHIP eligible patients, they predominantly serve uninsured patients, especially in states that did not expand Medicaid. Where I am in Texas, we have a robust free clinic network here in Texas, because there’s so many people who are uninsured. There’s about 1,500 of these organizations across the country, and roughly about one in seven free and charitable clinics in the US uses CareMessage as well.

David:

We’re all about data, right? What kind of data do you maintain on these 10 million users? I mean, do you have all their medical records in some sort of system?

Vineet:

We don’t have all their medical records, but we have information for these patients that ranges from things like obviously demographic information. So things like their age, their gender, their ethnicity, race, those types of things. Obviously their name and phone number, which we need to reach out to them. Then we also have information on scheduling. That’s a big part of how clinics use CareMessage is to actually improve their no-show rates, and to reach out to patients and remind them, or even do rescheduling. What we have seen is it’s made a huge difference in their ability to not only reduce their no-show rate, but actually improve their ability to serve their population. They don’t have to double book appointments, because their no-show rate has gone down. Provider experience has improved. That’s the other piece. Then in certain cases, we’re greatly expanding this.

Vineet:

We also have access to clinical data. So we have data on, for example, which patients within the clinic are overdue for a mammogram? They’re overdue for a colorectal cancer screening. Or they’re overdue for an A1C test, because they are diabetic and they have an A1C greater than nine, and they haven’t been seen in the last six months. A lot of that data is really what drives the interventions. Then there’s self-reported data, because CareMessage is a two way communication platform, and patients respond to messages. So we actually use that data and we have a patent, actually a couple patents which Perkins Coie helped us prosecute for some of the underlying technology. That helps us create more personalized communication for patients using automated sequence of messages, based upon how they respond, based upon other data that we have for them to create a more personalized experience for the patient that’s almost entirely automated.

David:

Wow. Is there an app in addition to the text or SMS, or-

Vineet:

Nope.

David:

No app.

Vineet:

No app. This is purely SMS. We have now facilitated close to 300 million messages between our patients and their clinics in the last nine years since we launched in 2013, 100 million of which actually in the last 18 plus months around COVID. COVID has been a really critical component of our growth in terms of utilization, but also our ability to serve patients in ways that we never anticipated when we first started CareMessage back in 2012. Whether it’s getting patients to get vaccinated, to facilitating testing, to facilitating telemedicine appointments, to helping people find food and housing, it’s been an amazing opportunity to have impact in a horrible pandemic. But yeah, all of that communication has happened through SMS.

David:

So basically what you’re taking is, there’s an infrastructure already in existence of healthcare providers and doctors and treatments, et cetera. But it’s just not getting utilized efficiently. I mean, is that what you’re basically saying?

Vineet:

Correct.

David:

Okay, got it.

Vineet:

Yeah. Yeah. It’s not being utilized efficiently. There’s also not, I think there’s ways in which what we call, the buzzword is patient engagement. It’s essentially this idea that by providing more information to patients, by improving their ability to understand what they need to do and why they need to do it, and giving them the right alerts and the right kind of prompts at the appropriate time, you can actually help drive changes in behavior. That’s really what we have demonstrated through the research that we’ve done, and the studies that we have done in partnership with academic medical centers, and the publications that we have in various peer reviewed medical journals, that demonstrate that this type of intervention actually has a direct clinical impact. It actually improves things like colorectal cancer screening rates, or improves hemoglobin A1C for diabetics and other types of clinical metrics, in addition to obviously the operational things like no-shows.

David:

Wow. What would be an example of a text? If you’re in, do you call it the network? What do you call your group?

Vineet:

Yeah. If you’re a customer or you’re one of our patients. A customer is like a clinic, and a patient, obviously our end users are patients. Typically, customers have access to our web-based application, which we provide software as a service. Our customers have access to our web-based application, which is HIPAA compliant, which has access to the database of information about the patient. Typically it’s directly connected to the electronic medical record, and it’s a two-way connection in a lot of cases. So if there’s a change that’s made in the patient’s record, it automatically gets reflected in real time in CareMessage. Then any kind of communication, or a lot of communication with the patient flows back into the EMR. That’s something that really helps make things efficient on the clinic side.

Vineet:

Then on the patient side, typically these messages are either transactional or conversational. Transactional messaging is things like, “Hey, you have an appointment next Thursday. This is to remind you, are you able to attend? Yes or no?” Then they respond. Based upon their response, they get a follow-up response automatically. Or something like, “Our records indicate that you’re overdue for a cervical cancer screening. This is why it’s important. Here’s a video on cervical cancer screenings that you can watch, that explains the screening in a fourth grade reading level or below. If you want to schedule, click on this link or call this number.” Those are more of the transactional messaging. Then-

Dominique:

Is that the kind of message that you did in the Tenderloin? I was just curious what moved the needle so significantly in that.

Vineet:

Yeah, that was even more simple. That was just a simple appointment reminder message that went out. It was really, really basic at that point. The application was one 100th of the size and complexity that it is right now, but it’s kind of the same thing in terms of the transactional messaging. I think where we have seen probably the most success, or I should say the most differentiated impact for our patients is really on the conversational messaging. Really a lot of the patents that Perkins Coie has helped us prosecute have really undergirded that work. It’s really around like, how do you create a conversation with a patient around a health topic in a way that feels personal, and in a way that feels helpful and is helpful, and drives behavior change? But does not require what I think is the most precious resource in these underserved settings, which is time?

Vineet:

It does not require time from staff, because staff, there’s few and far between in terms of the number of staff that a lot of these organizations have, especially in the aftermath of COVID, or I shouldn’t even say aftermath. As a consequence of COVID, there’s incredible burnout in healthcare settings. People are leaving healthcare, understandably, because of the impact of the pandemic. Automation is critical. Being able to automate things, being able to make things require fewer and fewer staff resources, and only bring in people, bring in staff when they’re absolutely needed is really important.

Vineet:

When we have conversations or we facilitate conversations, they’re things like we have a smoking cessation program, for example, which is a several month long intervention for smokers that are trying to quit smoking. That is educational. That is fun. That is interactive, so that they are able to interact with the messaging. Based upon how they respond, there’s algorithms built in so that they get different messaging based upon how they respond and based upon other factors. The idea is that this intervention is meant to help increase the number of quit attempts that somebody has. So that over the lifetime of that person, obviously it takes anywhere between five to 10 quit attempts for somebody to actually end up quitting smoking. That conversation would require a staff person hours and hours of time to manage on a regular basis for their patient population.

Vineet:

But we can get something that’s maybe not the same as a person interacting, but we can get close with technology and with automation. And use that to help scale that intervention to tens of thousands of patients beyond what a single individual can do. I think that’s sort of the idea behind that conversational communication. We have built those types of interventions for things like cancer screenings, and diabetes management, hypertension management, maternal health, so pregnancy and beyond. Those are the kinds of things that we have done that enable us to have impact more on a transactional basis, where we’re trying to help somebody take an action, as well as on a conversational basis where we’re trying to help change behavior for the long term.

David:

Yeah, so on the transactional side, what do you have? You have like stopping smoking. Do you have like a chat function or something, or how do you implement that over basically a text message?

Vineet:

Yeah. It’s essentially, you can think of it as like, not necessarily a chat bot, but essentially a conversational interaction where you’re getting a series of messages delivered to your phone. Some of those messages are one way messages, that are essentially giving you tips and recommendations, but others are interactive. It’s all part of a structured curriculum, part of a structured program that you’re getting. Week one might cover a specific topic. Week two might cover a different topic in terms of smoking, like handling cravings or those types of things. The idea is that you’re essentially trying to replicate the experience. Obviously it’s going be very, very hard to replicate the experience, but you’re trying to get close to the experience of a health coach.

Vineet:

Communicating with you, giving you recommendations, giving you tips, giving you advice, answering specific questions, or asking you questions and giving you feedback based upon your answers. That is really what we’re trying to do. Obviously we have a long way to go before we can even get close to a health coach experience. But it’s still been extremely helpful, especially in environments where patients are not used to getting this type of communication from their doctor. And they’re not getting it even in the clinic setting, because of how overworked and understaffed these providers are.

David:

Oh, yeah. I can imagine. Tell us about what it was like during the, well let’s hope it’s in a rear view mirror, but during the height of COVID. How did that change the way you guys worked and operated?

Vineet:

It changed it significantly. I mean, we had to not necessarily pivot the entire organization, but really retool a lot of things that we were doing. Because our clinics, for them, the number one issue was not diabetes, or hypertension, or any cancer screenings or anything. It was COVID. They had to transition overnight from a lot of in-person visits to virtual. It was an incredibly difficult, but also incredibly fulfilling time. A couple of things we did during that time, number one was we allowed CareMessage to be utilized as a communication channel for COVID-19 specific use cases. We helped facilitate messaging around testing. You could actually not only schedule a test, or figure out how to schedule a test through CareMessage, we had organizations communicating test results through our platform.

David:

Oh, wow. Okay.

Vineet:

We had a lot of partners that used CareMessage to distribute food and housing related information, and actually get patients to come pick up food at the clinic, because they were distributing that for their patient population. We had clinics that said, “This previously would take us hours to get the food out. We sent one message through CareMessage. It was gone in 20 minutes.” Just an incredible opportunity for us to have impact in areas. Then more recently, we’ve been really, really focused on driving vaccinations. We’ve had organizations that have improved their ability to get vaccines out to patients by a factor of six to 10X. We’ve had organizations that have been able to really understand vaccine hesitancy within their population.

Vineet:

Understand why patients are hesitant, and use that data to inform programs that their providers can run. For certain populations, maybe they have concerns about… If you have a immigrant population, for example, they might be concerned about citizenship status being a barrier, which obviously it’s not. Or cost being a barrier, or safety, or efficacy or other types of things. Then also being able to deliver that information or accurate information to this population, that obviously just like all of us is very susceptible to misinformation and things like that. Having that accurate source of information come from their provider has been extremely helpful and valuable.

David:

Wow.

Vineet:

We don’t have any metrics on that piece of it, but I do know that our work has helped drive at the very least hundreds of thousands of vaccinations, if not more, in direct and indirect ways. Everything from making it easier for people that wanted to get vaccinated to figure out how to get vaccinated, and making that access piece easier for them to find the information and know where to go. As well as for people that maybe had doubts or had hesitancy, for them to get that direct outreach from their provider, because all this communication is coming from somebody that they know. They don’t know who CareMessage is. This is all coming from the local health clinic, the local provider-

David:

Ah, got it.

Vineet:

… that they’ve gone to for years, and their parents went to, and their grandparents went to in a lot of cases. That is really who is communicating with them. We’re behind the scenes. We’re the engine that’s facilitating that communication. That’s been really powerful to help facilitate that for people who are on the fence, for them to get that direct outreach for them. We had a clinic in Wisconsin which serves primarily Native American populations. The clinic director created a video that he sent through CareMessage with a personal appeal to the patients.

Vineet:

Most of the patients know this individual, this person is an icon in the community. They were able to see a significant increase in vaccinations through that. That’s really what we I think helped facilitate around COVID, is really that communication. Plus our recommendations on best practices of how to communicate, and what are some things that you can do around vaccinations and testing. But really a lot of it was that personal connection that’s really important, especially for something that’s a controversial decision for some people, like getting vaccinated.

David:

Do you guys, in terms of funding, I mean obviously you get all kinds of grants and things like that. Do you also get paid by the clinic? Is it like a subscriber model too? How does it work?

Vineet:

We do, yeah. We have a sliding scale software as a service subscription model. For organizations that get reimbursed from Medicaid or from other sources like our community health centers, they pay anywhere between $1 to $2 per patient annually to use CareMessage. Then our free and charitable clinics that are serving primarily uninsured patients, that are serving the population that is in terms of need extremely high on the list for us from an impact perspective, they pay a fraction of that amount. It’s negligible to us from a revenue standpoint. But it’s extremely important for us to treat these organizations that are providing very little revenue, but providing extremely valuable patient impact for us. And reaching the population that, to me, is the most underserved in the US.

Vineet:

For us to treat them just like we treat any other customer, and to have them be a core part. Unlike a lot of other companies, for whom, without naming names, obviously their dot-org or their nonprofit arms are secondary to the main thing. For us, it’s primary. Every single one of our customers is important to us, regardless of whether they pay us $100 a year or $100,000 a year. Our nonprofit structure is what allows us to do that, and have that equity between our customers, and how we work with them and how we treat them.

David:

It seems like it’s kind of localized by either clinic or groups of clinics. I mean, are there any sort of national messages that you deliver to like, everyone who’s in CareMessage is going to get this one message one day?

Vineet:

No.

David:

No? Okay.

Vineet:

We don’t, no. We don’t, because I think we want to be thoughtful and respectful of our clinics, and the kind of messaging that they want to send.

David:

I got it.

Vineet:

But one thing that we do, and one of the things that’s really unique about us is that we are not just developing technology. We’re also developing messaging content and recommendations, and leveraging our data to help inform. We have 300 million plus data points. So we know, for example, like what are some of the things that help drive the most engagement, and help drive the most benefit to a population in terms of things like, what’s the right length of the message, what’s the right frequency, what’s the right timing, what’s the right tone?

Vineet:

Those types of things we can slice and dice the data and figure out, okay, this is a message that’s 100 characters versus 200 characters, it gets this response rate. We have millions of data points to be able to demonstrate that. That’s something that we do. Then we also obviously develop a lot of messaging, like around COVID we developed hundreds of messaging templates that our customers utilize. So they definitely look to us as an expert when it comes to messaging strategy and best practices, but ultimately it’s their call in terms of what they want to send to their patients.

David:

Got it. Got it. Yeah, in terms of messaging strategy, Dominique asked about vaccines. What kind of messaging works to encourage vaccinations, and what messaging doesn’t work?

Vineet:

It’s really a lot of different things that work for a lot of different people. For some people, it is sufficient for them to get a message from their provider saying that the provider recommends that they get vaccinated. That’s a decent portion of the population. Even just getting that initial message saying, “This is Temple Community Clinic, and this is Dr. So-and-so from Temple Community Clinic. We recommend that you get the vaccine.” For some people, that’s sufficient. For others, they have questions, they have concerns. So what we help clinics do is ask patients what concerns they have. Actually, based upon if they say, “My concern is about costs,” or, “My concern is about immigration status,” or, “My concern is about safety,” or, “My concern is about efficacy,” there’s tailored messaging that we can help facilitate based upon the specific concern that somebody has. For some folks, that’s sufficient.

Vineet:

Then finally you see that layer of folks that really want to have a conversation with somebody. In some cases, that conversation happens in person. But in other cases, that conversation happens over text message, and we actually help facilitate one-on-one conversations between providers and other clinical staff and patients around the COVID vaccine. We have seen many examples of situations where people have changed their minds, or have become convinced to get vaccinated through those one-on-one conversations.

Vineet:

What that funnel that I just described really helps organizations do is figure out, “Okay, which patients are ones that I really need to have a conversation with? Versus which patients might be okay with just the information that we’ve put out, and we don’t need to spend one-on-one time?” Really being able to triage essentially your population a little bit, and figure out where your limited time and limited resources are most needed and most valuable.

David:

Oh, yeah. That’s pretty interesting. I guess iteration by iteration, you kind of learn. This is a Dominique’s question, but I always have to step on Dominique. It says here, “What kind of data do you keep, and what kind of data does the clinic keep? You mentioned that your software’s healthcare HIPAA compliant. Then what kind of protections do you have to put in place, and safeguards and things like that?”

Vineet:

In terms of the data that we keep and the clinic keeps, it’s essentially the same. Because the data that we have access to for CareMessage is the data that the clinic has access to.

David:

Got it.

Vineet:

The clinic has access to all the data that we collect, and they have real time access to that data. They have accounts on our web application, as I mentioned. It’s a lot of the things that I mentioned, demographic data, scheduling data, some clinical data. We’re starting to experiment with what’s called social determinants of health data. Which is essentially things like housing status or food insecurity and those types of things, which are obviously becoming more of a factor. Were always a factor, but even more of a factor in the COVID era. Then in terms of security, we have almost 10 million patient records and information for patients on our systems, so our security practices, encryption have to match that, and they do.

Vineet:

We have a lot of just really, really strong security practices and systems in place, obviously encryption being one of them. Different things that we do to ensure that malicious code does not get into our code base, and lots and lots of firewalls. Obviously using best in class hosting providers that host our data, and HIPAA compliance servers. Using tools that allow us to further strengthen that security that are available, that are used by all the modern web based tech companies. We’ve implemented that, and continuing to improve that is a big priority for us, because we want to make sure that that data does not get in the hands of the wrong people.

David:

Oh, yeah. Do you have privacy officers and security specialists?

Vineet:

We do internally, but also externally we have obviously resources that we leverage, including Perkins Coie, for some of those things from a legal state endpoint. Our engineering team is the largest team within the organization in terms of size. There’s functions within that team that handle DevOps and handle security, and handle those things that are specifically tied to the protection of the data that we store.

David:

Okay. Okay. Got it. You’re in Austin. Is the whole organization in Austin, or how do you guys-

Vineet:

No. We went fully remote at the end of 2018. We used to be in San Francisco. Our corporate headquarters are in San Francisco. We went fully remote at the end of 2018, because we were seeing just a lot of growth in our people outside of San Francisco. We have people now in three countries, in US, Brazil and India. In the US specifically, we have team members in 15-20 states, something like that.

David:

Oh, so you went virtual before COVID, people to go virtual.

Vineet:

Absolutely.

David:

That’s really cool. Just going back to your history, because I was looking at your bio and things like that. It said you started something called, I’m going to mispronounce it, A-N-J-N-A patient education. Was that basically CareMessage 101?

Vineet:

That was the previous name.

David:

Okay. Okay.

Vineet:

That was the previous name of CareMessage. Yeah. We changed the name in 2014, I believe. That’s my mom’s name, actually. The initial idea was to name it after her, because I definitely owe a lot to her in terms of my own health challenges, and things that she had done to help me. Yeah, it definitely was not a very pronounceable name. So we settled on CareMessage, and I’m glad that we did.

David:

Did you start it while you were a student at Stanford, or did you wait till you got out?

Vineet:

Yeah.

David:

Oh, no kidding?

Vineet:

It was actually, initially it was a student organization at Stanford. It was a student group before it became an actual legal entity, and we received 501(c)(3) status for it in 2012. I had plans to run it as like on the side where I was in medical school. That was the initial idea. I was very fortunate to have been accepted to my top choice medical school at the Mayo Clinic. I had told them that I would come, and then I kept deferring. Then eventually I said, “I’m not going to come to medical school.” That was not a fun experience for my parents, who are both physicians, but I think they get it now.

David:

Wow. Okay.

Dominique:

You work really closely with the physicians in terms of… I know it’s their messages, but in terms of some of the intuition that you were talking about in the conversations that you’re trying to get to, the health coach status, are you consulting with factual physicians and health coaches to get ideas about how to message things?

Vineet:

Yeah, we are. We have clinicians that are not necessarily on our team, but they’re people that we contract with that are advisors to CareMessage. But it’s not just physicians. It’s also folks that understand human behavior. It’s folks that have more of a anthropology or user experience kind of background, that can help draw insights. A lot of the things that we do, I mean there’s clinical basis for it, of course, and we want to be cognizant of that. But a lot of it has to do with people making decisions, and what goes into, what are the circumstances that they’re dealing with. When we’re recommending recipes, of course for somebody with diabetes, we know that there are certain things to avoid from a clinical standpoint.

Vineet:

But from a human behavior standpoint, if somebody’s living in a apartment with 10 people, and they don’t have access to a kitchen, from a human behavior standpoint, they’re not going to cook healthy meals. How do you help them do that? How do you help inform somebody who is unhoused how to create a meal that does not require access to a kitchen that they can have, that’s diabetic friendly? That’s less of a clinical question. That’s more of a human behavior question. It’s really that combination of the clinical piece with the user experience design component that really is what has informed our product development strategy.

David:

Tell us about what you did in terms of… I think there was a project that you started relating to basically the inequalities associated with COVID treatment. Maybe you can elaborate on that, and tell us what prompted you to do that and how it works?

Vineet:

With COVID, we have been obviously focused quite a bit on things like testing and vaccinations, and helping with food distribution. We’ve done less so on the treatment side. I think we have really focused on the prevention piece, that’s primarily obviously testing and vaccinations. And obviously a lot of other public health guidance around mask wearing and social distancing, and reinforcing those. Particularly in communities where the overall state level or county level or city level guidance might indicate that it’s one way, but then from a provider standpoint, there might be specific populations that might be at greater risk. Like folks above 65, or folks with underlying chronic conditions, folks that are immunocompromised. For all those reasons, I think having that be the emphasis is really where we found the most success, is in that prevention and management piece.

Vineet:

Then the other piece has been the second order or third order impacts of COVID, particularly on the economic side with basic needs and basic necessities being really challenging for folks. Even to this day, but certainly in the first few months of the pandemic. The number of messages and the number of communications that we help facilitate, helping people find food, helping people find rent relief, helping people figure out how to get health insurance, if they had been knocked off their employer covered health insurance. I mean, those are the types of things that for us were really moving and motivating, to see the product being used in situations and for use cases that it really wasn’t ever designed to be. But we’re glad that it was, and we’re thinking about ways that we can support those things in the future.

David:

Yeah. I saw something that basically said you all launched Project Equity, to address racial disparities in COVID-19 infection and death rates amongst black, Native American and Latina communities. What was that about?

Vineet:

Yeah, that’s sort of the same thing that I’ve been talking about. It’s just making more of an emphasis on supporting organizations with, in many cases, free access to our technology. Which is something that we launched back in 2020. We have now partnered, we called it CMLight, CM L-I-G-H-T. It was a product that we launched that’s essentially a COVID specific version of CareMessage that could be implemented within 48 hours, versus a typical CareMessage implementation takes eight to 10 weeks. It was just something that organizations could utilize right away if they weren’t already using our product. They could send out messaging. They could reach out to their patients. They could ask them questions. They could figure out what was going on with specific subpopulations.

Vineet:

We had populations that were predominantly impacted by the pandemic, disproportionately impacted by the pandemic, which included black, Hispanic and Native American populations in the US, and organizations that served them. Did a lot of work obviously with community health centers, and free and charitable clinics that serve these populations. But also did a lot of work, and continuing to do a lot of work, with organizations like Native American tribes. Working with tribal health clinics and organizations that serve that population in different parts of the country.

David:

Got it. Got it. You mentioned the Tenderloin. I lived in San Francisco. You obviously lived in San Francisco. One big issue obviously in the Tenderloin and everywhere else is substance abuse. Is that part of your mission, separate and apart from what you’re doing with respect to the clinics, or do you sort of interface it with the clinics? How do you all help address substance abuse issues?

Vineet:

Yeah. Substance abuse is an area that we have not done a ton of work around, just because, as you just mentioned, there’s just so much complexity. The issues are so much, not that the other issues are not challenging, but there’s just so much more that I think is required. Particularly on the human level that I think is hard to automate, and it’s hard to figure out what role technology can play in helping address. I’m sure there is a role, and I’m hopeful that we can get there. But I think that technology in general, but also our technology infrastructure needs to take a significant step forward in order for us to even start to attempt to address some of those issues. The complexity level just goes up by so much in those types of situations.

Vineet:

Also with things like severe mental illness, we definitely support patients that have mild to moderate depression or anxiety, and there’s tons and tons of applications of the technology that have been very successful there. But substance abuse and SMI, severe mental illness, I think we want to be thoughtful and we want to be considerate of the circumstances that surround some of these challenges. And be very, very thoughtful and careful in terms of how we approach them, to make sure that we’re adding value and we’re having an impact on the patient. There’s a lot of ways in which technology can go wrong, can have a negative impact in these types of situations. We don’t want to do that.

David:

Okay. So basically your mission really is, let’s fulfill the basic needs first here. When I say basic, I mean sort of like the ABCs-

Vineet:

I think there’s lower hanging fruit in terms of health needs that can be addressed through what we’re doing, and that still is enormous, enormous impact in terms of patient-

David:

Oh, yeah.

Vineet:

Clinical value to the patient, and morbidity mortality cost to the healthcare system. I mean, just lots and lots of things. I would love for us to tackle some of these more complex issues, but there’s so much that we can do just with the things that we’re already focused on.

David:

Got it. How would you rate the current state of the healthcare system in the United States, particularly for those that are underserved otherwise?

Vineet:

It’s certainly lacking in a number of ways. I would say number one is, certainly the infrastructure as it relates to data sharing, I think can be improved quite significantly. I think there’s a lot of times that data lives in silos. Somebody who’s going to a clinic, versus then they might go to a hospital, and they might get admitted for something. The clinic has no idea that that happened. They might go to a food pantry, because they don’t have access to food. I mean, there’s all these different things where people are going to these different places, and are experiencing different aspects of their care, but there’s not a lot of coordination between those organizations. We’re in some ways trying to address that ourselves, and trying to bridge those gaps a little bit.

Vineet:

Then the second I would say in terms of the things that I think can be improved, is really health insurance I think can be a really big driver of change. The simplest thing that a lot of folks can do, a lot of states, a lot of communities can do is just increase access to health insurance. It doesn’t necessarily mean Medicare for all, but it could be something as simple as making Medicaid easier to access for people. Making it easier for people to even apply for some of these benefits, or even know that these benefits exist. A lot of times they exist, but people just don’t know about them, or people just don’t know what to do.

Vineet:

That’s, again, a lot of what we’re trying to solve. I think those things can have a huge impact. Not only a huge impact on patients, but they can have a huge impact on healthcare costs. They can actually be cost efficient for organizations, whether it’s states or whether it’s the feds, or both to do. As we know, people who are insured have better health outcomes, and they are less expensive for the healthcare system in the long term. Because they have fewer health needs, and they’re able to more effectively manage their health concerns over time. So that investment is extremely warranted and beneficial from a cost efficiency standpoint as well.

David:

You know, it’s funny. We spoke to a Stanford physician who was talking about the CARES Act. Basically his comment was that at least… Now this is maybe among the insured or among those who are not in healthcare clinics and things like that. But he said that the quality of the data sharing is really increasing exponentially, because of the new statute that basically tells the physician at Cedar Sinai that somebody went to Stanford Medical Center, et cetera, and got such-and-such treatment. Are you seeing that in your world too?

Vineet:

Not as much because, again, we don’t work as much with hospitals or health systems. Our work is primarily with clinics. I think with clinics, what we found is that the incentives are really aligned. These clinics are evaluated on clinical quality measures that are really directly tied to health status and health outcomes, that ultimately have obviously the right in terms of ROI for the healthcare system. Obviously all of this is aligned with the patient.

Vineet:

The patient wants to be healthy. The patient wants to make sure that they’re not at risk for certain things, or if they are at risk for certain things that they get screened and they get the appropriate treatment sooner. That just really aligns all the incentives for the patient, the provider and the payer, in which case is primarily Medicaid, but other payers as well. That’s why we like working with these types of organizations. Not only do they reach our target population, but they also have the right incentives that are aligned with the things that we want to achieve as an organization from our mission.

David:

What do you think the next step is? I mean, you’re doing what you’re doing now. If you were to say the next stage of your mission, what do you see that as being?

Vineet:

A couple things. The first is we definitely want to get better at data integration. This is one of the things that one of our funders, a big pharma company has funded for us this year, is really helping us deepen the integrations that we have with our partner systems. EMRs, electronic medical record systems, and other systems that we have, including clinical data, including social determinants data, things like that. That will just allow us to have better insights into the population, to be able to automate things even more.

David:

Oh, yeah.

Vineet:

To be able to have data that we’re collecting put back in the patient’s chart more efficiently, so that there’s a single source of truth for all data. The second thing is really thinking more about, what can we do? We’ve done a lot in terms of helping support some of the clinical needs that patients have. What can we do to help support some of the social needs? Obviously leveraging the experience that we had with COVID, what are some of the ways in which we can help people navigate the maze of social services? Realizing how intimately tied social needs and basic needs, like food and housing and health insurance and employment and transportation, are to health status.

Vineet:

If you’re living in a food desert and you don’t have access to healthy food, and you’re trying to find housing and you can’t find housing, it’s very hard to imagine that you would do a good job of managing your diabetes or managing your hypertension. I think those are some of the things that need to be solved first or in concert with the health needs. That’s a lot of what we’re thinking about, and have received some major funder support to help us think through and solve using technology.

David:

Oh, that’s amazing. You see your mission as expanding beyond healthcare into-

Vineet:

We do.

David:

Ah, ah.

Vineet:

We do. Very aligned with what our clinics are looking at as well, and what their vision is. So it’s highly aligned with the things that they’re thinking about.

David:

Alrighty, this has really been great. It’s been a great conversation. What you’ve been doing is great, and that you started doing as an undergraduate at Stanford is pretty amazing.

Vineet:

I really appreciate it, and thank you for all your support of CareMessage over the years.

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Photo of David T. Biderman David T. Biderman

David Biderman, a partner in Perkins Coie’s San Francisco and Los Angeles offices, focuses his practice on mass tort litigation and consumer class actions. He heads the firm’s Mass Tort and Consumer Litigation group. He has represented a wide variety of companies in…

David Biderman, a partner in Perkins Coie’s San Francisco and Los Angeles offices, focuses his practice on mass tort litigation and consumer class actions. He heads the firm’s Mass Tort and Consumer Litigation group. He has represented a wide variety of companies in state and federal courts in California for 30 years.

On consumer class actions, David represents packaged food companies, coffee companies, dairy companies, footwear companies and others whose nutritional or health claims have been challenged. He also has represented search engines and other online companies. He has a record of favorable results for clients. He successfully tried a major consumer fraud class action on behalf of one of the world’s major search engines in a case involving online gambling advertisements. For that same client, he negotiated a favorable settlement of a class action challenging its online advertising pricing. He represented a major coffee retailer in defeating a class action on standing grounds. He also has litigated pre-emption defenses arising out of food labeling and obtained a dismissal for a client whose nutritional statements were challenged.

For fifteen years, David managed the firm’s full-service product liability team responsible for defending over 1,000 toxic tort cases pending in Los Angeles and Northern California state courts. These cases entailed ongoing trial activity at various levels for several trials set each month. The highly experienced and well-coordinated team has handled thousands of asbestos toxic tort cases for a variety of clients, including FORTUNE 500 companies from such industries as consumer products, aerospace manufacturing, household goods, dry cleaning and industries that generate electromagnetic fields, such as electric utilities and operators of wireless communications systems.