EP432: The Knifepoint Intersection of Margin and Mission and the Peril of Cutting Clinical “Waste,” With Kate Wolin, ScD

[00:00:00] Episode 432, the knife point intersection of margin and mission and the peril of cutting

[00:00:09] clinical and air quotes waste.

[00:00:12] Today I speak with Kate Wollin.

[00:00:22] American Health Care Entrepreneurs and Executives You Want to Know, Talking.

[00:00:29] Relentlessly Seeking Value.

[00:00:31] First of all, I just want to start out this pod and really thank everyone listening

[00:00:35] and for showing up for a show like this one.

[00:00:39] You do it and you are here because you care about patients slash members.

[00:00:45] It's just so easy to feel like we'll never be able to do enough and that's a rough

[00:00:52] rough feeling.

[00:00:53] Please take a moment to truly hear how grateful I am for you being here and for doing

[00:00:58] all that you do and that you try to do.

[00:01:01] I saw on the interwebs the other day a Marcus Aurelius quote what he said was, Be Satisfied

[00:01:07] with even the smallest progress and I think this is really important to remember because

[00:01:11] nobody working in the health care industry especially today is ever probably going to get

[00:01:16] anything close to a perfect solution so instead just aim for progress even the smallest

[00:01:21] amount and feel good about that please.

[00:01:24] This show is an important one for anybody either in the business of health care delivery

[00:01:29] or buying healthcare delivery services.

[00:01:33] It's an exploration of what works and what doesn't work and how what works can easily

[00:01:38] become what doesn't work in the face of the real world.

[00:01:42] This peril of cutting clinical and air quotes waste perilousness all starts with the whole

[00:01:49] hey let's make some money so we got a scale and be efficient.

[00:01:54] We got to do our thing at as low as possible a cost and maybe grow as fast as possible.

[00:01:59] We got to keep our investors happy or pay off our debt we got settled with or pay that

[00:02:04] giant management fee were being charged or compensate the sea suite at the level they've

[00:02:08] grown accustomed to so again the let's be efficient and get everything repeatable has

[00:02:13] entered the building.

[00:02:14] The first point I guess today Kate Wolland makes about all of this and this is exactly

[00:02:18] the same point that Rick Renard made in episode 427.

[00:02:23] Efficient to what end game now it turns out survey show only a small small percentage of

[00:02:29] healthcare delivery solution providers are measuring outcomes of pretty much any kind so

[00:02:34] how do we even know if cutting so called waste is actually waste at all I mean in the

[00:02:40] absence of any actual measures here's a hypothetical for you someone could look around hey I see

[00:02:47] these nurses they're all just sitting around chatting with patients and I don't know

[00:02:52] talking about throw rugs what is this episode of HGTV who cares if a patient with diabetic

[00:02:58] neuropathy has throw rugs in their hallway let's tell these nurses chop chop get them on

[00:03:04] the computer using AI to be efficient right like let's get rid of that clinical waste

[00:03:09] I just made a point in the most sarcastic way possible but the bottom line is this it's

[00:03:13] actually really efficient to not engage patients in these ways right patients they talk slow

[00:03:18] they ask questions that seem irrelevant and their time consuming it's very efficient

[00:03:22] to not build relationships or foster trust or I don't know assess full risks but whatever

[00:03:27] is going on is also going to fail in that model from a patient outcomes standpoint at least

[00:03:33] I'm an quote Sergei Pilevakov right now with some light edits he wrote on LinkedIn

[00:03:38] primary care is not scalable in the same way as scrub daddy or bomba socks that's something

[00:03:44] not taught in MBA and CFA programs someone should have told Walgreens CVS Amazon and Walmart

[00:03:50] they also probably should tell a whole bunch of point solutions and payers also somehow

[00:03:55] system exacts or pharmacy leaders might also want to get that memo what I really liked about

[00:04:01] the conversation with Kate Wollins today is that she retains optimism in the face of all

[00:04:06] of this she offers advice for how to navigate the balance between mission and margin in a way

[00:04:11] that's better for patients and also sustainable financially she talks about three points first

[00:04:17] she talks about founders and investors being in alignment and the essential nature of that number

[00:04:22] two the importance of having clinical leadership and a team dynamic that enables innovation but

[00:04:28] in a clinically sound way and number three she talks about how you got a measure what matters

[00:04:33] and do it in a way that inspires a mission driven culture if we're talking about relevant

[00:04:38] shows to listen to next after you listen to this one please do not forget episode three three one

[00:04:43] this is where al Lewis teaches us how to evaluate wellness vendors and health solutions

[00:04:49] but it also teaches us how to be a good wellness vendor or health solution again that's episode

[00:04:54] three three one also do come back and listen to the encore with Jerry Durham next week about

[00:04:59] front desk and the total care experience lots of really bad avoidable things happen if the front

[00:05:05] desk isn't considered and it isn't often considered for sure also listen to the show with Dr. Kenny

[00:05:11] Cole that's a must listen that was a couple of weeks ago then again the show with Rick Renard came up

[00:05:16] several times in this episode four two seven as I said before the show with Jodel and Owen also gets

[00:05:22] brought up episode four two one that's a great cautionary tale there to keep in mind for mission driven

[00:05:28] entrepreneurs and investors and then may I also recommend J Michael Connors MD he writes a lot of

[00:05:33] stuff in a newsletter along these lines links in the show notes to all of these things last last

[00:05:40] last please go to our website and subscribe to the weekly email I am planning on doing a few invite

[00:05:44] only sessions for email subscribers plus the weekly email is a really very convenient way to get

[00:05:49] the episode transcripts and stuff and if you don't get it you're making your life less efficient so

[00:05:54] go fix that Kate Wolland my guest today trained as a behavioral epitomologist and has done research

[00:06:01] in chronic disease prevention and management she launched and led a digital health startup and sold

[00:06:07] it to Anthem she's been in the digital health startup space largely at the intersection of science

[00:06:13] and product strategy ever since my name is Daisy Richter this podcast is sponsored by a Ventria

[00:06:19] health group Kate Wolland thank you so much for being on Relentless Health by you today

[00:06:23] thank you for having me if we're thinking about what works in healthcare and then how sometimes

[00:06:30] that might devolve when we start trying to make money at the same time the whole canundrum of

[00:06:38] mission margin maybe we start here if we're just thinking about what works your respective of money

[00:06:45] maybe everyone doesn't know but as someone who spent a lot of her career living and breathing

[00:06:50] journals and articles and PubMed there's a lot of information out there about things that work

[00:06:57] in clinical care in population health care things that have been around for decades in some cases

[00:07:04] the challenge is that many of those things are human capital intensive to plan to train to act

[00:07:11] the Q and to maintain those programs that get tested in clinical trials that get published in

[00:07:17] the research base they're built on relationships between people they're built on time of people

[00:07:24] and together they're built on resources being deployed and the unfortunate thing and one of the

[00:07:30] reasons that I ended up having my as good at the death moments about academic research is those

[00:07:36] things are sometimes difficult to get paid for or difficult to scale so give me some examples you

[00:07:43] said that there is a lot of information about what works relative to clinical care relative to

[00:07:47] population health and we've talked about this ending number of times on the podcast that it is

[00:07:53] at its core at its seed about relationships it's about trust it's about spending time together

[00:07:59] because you got to spend time if you're going to have relationships and trust but what are some

[00:08:03] maybe case studies of things that you have seen which inarguably work so these are things where

[00:08:09] we're deploying people into the community to meet people where they are and that's a phrase that

[00:08:14] we talk about using technology to personalize and hyper personalized to an end of one we've been

[00:08:21] doing that for decades by putting someone in the community and having a conversation with them

[00:08:28] having a conversation around the behaviors that they might be undertaking to take care of themselves

[00:08:34] the barbershop or beauty salon is a great place to have that conversation because you're talking

[00:08:40] about someone who is engaging in to use a modern tape phrase and active self-care and so to have

[00:08:46] a conversation about other things that they do to care for themselves in that moment is meeting

[00:08:52] someone where they are similarly a laundromat is an active care for yourself or your family

[00:08:58] and so to have a conversation about the things that you do as a family caregiver in that moment

[00:09:04] there are examples of that being an effective way to engage people they're places that people go

[00:09:10] regularly right so one of the challenges that we often have in health care is how do we keep

[00:09:16] people engaged and when you're meeting people in a place that they go on a regular basis

[00:09:21] churches are another example of that you're able to have an ongoing dialogue and an ongoing

[00:09:27] relationship because you're leveraging a place in a space where that happens naturally

[00:09:32] and so you're able then to engage people in ongoing conversations around supporting

[00:09:37] preventive health behaviors and behavior change those have been effective ways to do that by using

[00:09:44] relationships of trust to your point that exist and building on them in the places that people

[00:09:50] already are. And Dr. Carly Eckert did talk a bunch about this in the podcast as have others

[00:09:57] just this idea that you know sometimes we talk about access right but if you start thinking about

[00:10:02] just cranking patients through a throughput machine you might have access but you don't actually

[00:10:09] have engagement and therefore it would be questionable whether health outcomes actually improve

[00:10:15] is someone actually going to take their blood pressure medication as prescribed if they don't trust

[00:10:21] that prescription was given from a place of wholeheartedness. Absolutely, I live in Chicago so

[00:10:28] I heard about Oak Street in the very early days of them building that business and one of the things

[00:10:33] that really stood out to me is quite different was the idea of building your facility to not look

[00:10:39] like a doctor's office right but to look like a place that the community would want to come and spend

[00:10:46] time in older adult who is experiencing loneliness their community that sense of loss of community

[00:10:53] and loss of a sense of place as neighborhoods change and to create a gathering place where people

[00:10:59] would want to be then it's that same opportunity to have a conversation with Mrs. Jones about how

[00:11:07] she's feeling if she's like I'm a little uh today right you can say oh when was the last time

[00:11:13] you took your blood pressure and how are the medication working you're building a relationship you're

[00:11:20] building that trust but it also loses some of the paternalism that people sometimes experience in

[00:11:27] the healthcare system it loses some of that shame and we often know that people will tell doctors

[00:11:33] what they think they're supposed to be doing versus what they're actually doing and so if you're

[00:11:38] actually building a relationship by being part of the community and being a place that people want

[00:11:44] to be I think you give yourself the opportunity to actually deliver care in a different way or

[00:11:50] a way that maybe look like how care used to be delivered many decades ago it's not just about

[00:11:56] let's put some technology into a broken place back to the point of you have to have trust social

[00:12:02] determinants is a great example unless a patient really trusts the one that they're talking to

[00:12:09] if they're asked are you hungry? They're not going to answer truthfully so like just getting the

[00:12:15] inaccurate picture of the patient's health and then also having a comfortable circle in that

[00:12:22] that advice is actually taken really requires effort as you said it's very human capital and

[00:12:29] intensive and this also really matters this whole idea of going out into the community because

[00:12:34] as we know sometimes the individuals who have the biggest gaps in care are not the ones who

[00:12:40] are showing up in clinic right if they're showing up in clinic they are in fact engaged at a certain

[00:12:45] levels I think sometimes we make this about the clinical provider it always makes me think about

[00:12:52] the rest of the people in an ecosystem that create trust and a positive experience is thinking

[00:12:59] of it recently someone shared a clip from I think it was like a golden gobs acceptance speech

[00:13:05] and the person thanked that the people who answer the phone at her agent's office because those are

[00:13:11] the people she actually interacts with those are the people that make things happen

[00:13:16] and that recognition that yeah like I might be paying the guy in charge all of this money

[00:13:22] but I recognize that there's all these other people that make or break my experience.

[00:13:27] I think in health care we forget the best experience in my doctor's office maybe the person who's

[00:13:33] working the front desk and may not be my doctor that keeps me coming back and so I think when we

[00:13:39] think about how we build relationships and how we build trust it's not just about what the

[00:13:45] provider is doing but the entire experience. Again there was a podcast with Jerry Durham and it's

[00:13:52] a really great show and this is what the entire show is about just the importance of the front desk

[00:13:58] and the patient experience and not just relative to are you going to get a good review on Google

[00:14:04] or whatever it's actually important for clinical care I encored that show and we'll link to it in

[00:14:10] the show notes. So if we start thinking about all the things we were just talking about having

[00:14:15] community outreach and coaches and buildings and spaces that are welcoming and all the training

[00:14:20] and retraining and paying enough so that we can get quality the quality and level of people

[00:14:26] that are needed so margin is actually a required consideration here in the real world.

[00:14:32] So now let me introduce money into the conversation. The second that we introduce money and add

[00:14:39] margin to the no mission, no margin or in order to have a mission you have to have some margin

[00:14:45] equation. What starts to happen like where does this go wrong? It can go wrong in a number of places.

[00:14:52] The first one that kind of comes to mind is part of that margin is around how do we make this more

[00:14:58] efficient or how do we make it scale and I think a lot of time we have a ton of unarticulated assumptions

[00:15:06] about where we can create efficiency, where tech might be appropriate. Sometimes people actually don't

[00:15:13] do a whole lot of testing and evaluating of what is the one or two things that are key to

[00:15:21] the outcome I'm trying to drive right and maybe embedded within that is are you clear on what

[00:15:26] the outcome you're trying to drive is and then are you actually aligning to that? So okay what I'm

[00:15:33] hearing you say someone thinks to themselves okay well in order to make this profitable I need

[00:15:40] efficiency and we need to be able to scale and maybe one bigots the other right like you can't

[00:15:45] scale unless you have efficiency but then I just think to myself all right I want to make this

[00:15:50] process efficient and I don't really truly understand what might wind up on the cutting room floor

[00:15:56] as being inefficient that actually was integrated in the secret sauce. So I wind up cutting

[00:16:03] stuff exactly that is essential. Exactly because we don't actually pay attention we actually don't

[00:16:08] know what the secret sauce is right how much of this is people how much of this is processed and if

[00:16:14] it's really people are there ways to make the people better and more efficient without sacrificing

[00:16:21] the thing that makes people now doubled in the detail than how that gets implemented but to me

[00:16:27] it's a reflection of you build your business around what you believe is core to achieving the outcomes.

[00:16:34] So I'm going to dig in on that first sack because I am going to assume that you have some

[00:16:40] thoughts relative to how we make sure that actually the most essential ingredients don't wind up

[00:16:46] getting cast off but I thought the other thing that you said was super interesting especially

[00:16:51] in concert with the podcast that I did a couple of weeks ago with Rick Renard in which there was

[00:16:57] this clinical operation survey that he did they found only somewhere between 7 and 16 percent

[00:17:04] actually calculated patient outcomes either prompts patient outcomes or the clinician assessed outcomes

[00:17:14] such a small number so sad but to your point can you even optimize a process and recognize what is

[00:17:24] essential if you kind of haven't figured out what the goal is or what you're even trying to do.

[00:17:31] Oh I think this is such a great question the report that Rick put out was fantastic to me for exactly

[00:17:38] highlighting this idea people are doing things without really being clear on why they're doing them

[00:17:44] or how they're doing them it's actually not a well-documented process I think it makes me laugh as

[00:17:51] laugh cry as a public health person who was like oh my gosh people go to school and they get a whole

[00:17:57] degree in management and so they must be really great managing process and understanding it and we have

[00:18:05] these books that you know are considered bibles of management around measuring what matters

[00:18:11] and I think about Rick's report and I was like if you aren't even clear that you have a process

[00:18:16] and you aren't documenting your process you're certainly not then looking at that process and saying

[00:18:22] what are the key metrics that tell me where the process is breaking down and where it isn't working

[00:18:29] either in terms of efficiency or in delivering outcomes Rick is really shining a light into this

[00:18:35] shadowy corner where we actually a lot of times don't articulate what the measures are along the

[00:18:44] way that indicate the process is working we're not articulating what those intermediate end points are.

[00:18:50] You got to figure out the ultimate key performance indicators KPI's that we're talking about here

[00:18:56] really what are we trying to do ultimately like what does improving patient outcomes mean so like

[00:19:02] if somebody's in our program for one year they should have blah that that happens out of minimum.

[00:19:08] What I love about what you said there Stacey is you articulated a time frame the lot of times

[00:19:14] in digital health we say things like we need to get patients adherent to medication we need patients

[00:19:20] to engage in this self-monitoring behavior and I'm like every day yeah every day every day for

[00:19:27] the rest of their lives yes really like really at no point in their clinical care can we decrease

[00:19:34] that to every other day we're actually very unspecific in what we're trying to achieve a lot of

[00:19:41] times in these digital health programs. I am a fan of the smart goal Kate which is I love a smart

[00:19:49] specific measurable time constraint and doable right so you have to have a smart goal that sits

[00:19:56] at the top of the flywheel but then I what I'm also hearing you say is along the way you need

[00:20:02] leading indicators or signals that the process is in fact working because if you don't and then

[00:20:10] you're continuously improving toward efficiency ultimately what might wind up happening is you're

[00:20:18] like I don't think we need that stuff you cut the step and ultimately your outcomes go down because

[00:20:24] that was something that you're cutting into bone but you don't know it so like this is how margin

[00:20:31] starts encroaching on mission and undermining mission that's the theoretical nut of the whole thing.

[00:20:37] Yeah I applied example of this from my path life we actually do a lot of protocolized things in

[00:20:43] healthcare and like the diabetes prevention program which is the gold standard is this

[00:20:48] many-week program so week one we're going to talk about topic X week two we're going to talk

[00:20:53] about topic Y and people are going to progress through this program there's really not a high level

[00:20:59] personalization people think of these things that like one on one and of one tailoring and in

[00:21:04] many cases they're not one of the things I learned early in in working in this space of these like

[00:21:11] weight management interventions which are fairly protocolized is there's data that if people don't

[00:21:17] lose weight in the first two weeks they are unlikely to achieve the weight loss goal which in most

[00:21:23] of these programs is like three to six percent of your body weight so I'm sitting there thinking okay

[00:21:29] if I'm got someone who has a connected scale and I can actually see that they have lost no weight

[00:21:35] in the first two weeks why would I proceed with the protocol as written that's insane but the

[00:21:41] reality is that's how a lot of these care protocols work okay so now let's introduce confounding

[00:21:48] factors here when you start getting money in place so let's say that I am a venture funded

[00:21:54] digital health rpm remote patient monitoring software I've got a program and I'm getting paid

[00:22:01] PM PM per member per month or maybe I'm getting paid only for patients in the program or at a

[00:22:07] minimum someone is tracking my patient engagement and giving me reports on how many patients are

[00:22:12] engaged there is a really good reason why I'm going to continue the protocol after two weeks even

[00:22:17] though I know it won't work especially if nobody's I mean because measurement let's just say

[00:22:23] has two different sides to it one is the vendor's measurement the digital health company or the

[00:22:29] RPM company are they actually measuring their results but then on the other side does the customer

[00:22:33] even know what to do with the results as measured correct if you are a digital health vendor you've got

[00:22:39] your private equity investors squawking at you to get your ARR up or whatever the acronym of the

[00:22:46] moment is that all have dollar signs in front of them I could very much see that all of a sudden

[00:22:53] the protocol starts to change and not in a way that is going to drive better patient outcomes

[00:22:58] because the metric that we're striving for there is not outcomes it's a growth outcome of the

[00:23:03] business right it's more patients you know in the case of cerebral right the thing they measured

[00:23:08] was scripts that was the metric that they wanted to report on and when that's the thing you're

[00:23:14] measuring and not a clinical outcome that tells you what's important to that business

[00:23:20] and just to remind everybody who might be like what was the cerebral example that was the

[00:23:25] come they got a lot of trouble they're allegedly almost became a pill male for ADHD drugs right lots

[00:23:32] of things happen behind closed doors and lots of speculation has been made about what drove that

[00:23:37] but I think enough times that you start to think there's something to it there's often this sense

[00:23:42] of the business measures and the business growth measures put pressure on the business to do

[00:23:48] things in their product and in their clinical that are not in the best interest of the patient

[00:23:54] outcome it's easy to villainize the finance folks but to me it's a reflection of are you aligned

[00:24:02] at the founder as a business with your investors on the pace of growth and what is feasible and

[00:24:08] what is reasonable and what is required to get there there may be places in health care where

[00:24:15] the growth comes at a slower pace in order to unpack these questions around what is really driving

[00:24:22] the clinical outcome and can we do it in a way that scales faster or is more efficient to drive

[00:24:30] a better margin without sacrificing the clinical outcome I think what I worry about is that conversation

[00:24:38] isn't happening that there may be trade-offs in clinical outcomes that don't have to be made if

[00:24:44] we're willing to grow a little slower so that's actually probably a pretty optimistic picture

[00:24:50] that I just heard you say there because what I'm hearing is scalability and growth is in fact

[00:24:56] possible you just have to do it in a very considered way and in a slow enough way that enables the

[00:25:05] entrepreneur the digital health solution to try something see if it impacts outcomes rework it if

[00:25:12] it does try something else right like that there is in fact a path forward to profitability and

[00:25:18] maybe even to some kind of multiple but you can't do it super fast because then you're probably

[00:25:25] going to make a big mistake that ultimately is going to impact patient care I think I'm optimistic

[00:25:32] that we can achieve growth we can achieve profitability not for every business but for many

[00:25:39] and still deliver outcomes and still deliver value like I do fundamentally believe that or

[00:25:46] I think I would bang my head against the wall one too many times in frustration mic Pico spoke at

[00:25:53] the Kellogg health care conference a couple weeks ago mic is the co-founder and CEO of Oak Street

[00:26:00] health by the way what really stood out to me and the Q&A with some of the Kellogg students

[00:26:05] was this question of like well why didn't you do X to grow faster why didn't you do X to add more

[00:26:10] revenue and what stood out to me as a part of being a leader is what you say no to Mike said yeah we

[00:26:17] looked at a lot of these things but we had to say no because they weren't core to our business and how

[00:26:24] we were going to grow and how we were going to deliver clinical outcomes those are really hard

[00:26:30] things to do in my experience that this the EO when people throw ideas of how you can get more

[00:26:36] revenue more customers is to think about does that come at a cost and do I really understand the

[00:26:42] cost we're talking about here as a cost of clinical outcomes or clinical quality that may be

[00:26:48] sacrificed in the process I'm going to ask you for some pieces of advice both for private equity

[00:26:54] as well as CEOs and I'm going to put words in your mouth here and assume that your first piece of

[00:26:59] advice is going to be exactly what you just said you got a level set together and have alignment

[00:27:06] between the investors and the CEO relative to what does good look like what are we doing here

[00:27:12] and what is the pace of growth which we're going to accept first and foremost this assumes

[00:27:19] mission is measured by an actual KPI by which work is evaluated and secondly that frankly both

[00:27:27] are sophisticated enough in the healthcare industry to understand actually what that means

[00:27:32] because in fact I just had lunch with a doctor recently who had quit a startup because she said

[00:27:40] and this is pretty much a quote she said I just couldn't with the working with a bunch of cowboys

[00:27:45] her term who just were running around breaking things with no clinical knowledge or really understanding

[00:27:53] of what they were doing or the impact that they were having and she said this is really frightening

[00:27:58] and especially so because a lot of their clients were Medicaid absolutely part of what makes

[00:28:02] that a two way street is if you're an investor and you're investing in a digital health company

[00:28:08] that doesn't have someone with a scientific or clinical background in a key position of

[00:28:14] influence like why it's healthcare I think as someone who trained as a population health scientist

[00:28:21] I also get it that it's very hard in these settings to engage with someone who has a clinical

[00:28:28] background and they're like that's not how it's done and the whole point is yes because we're

[00:28:33] trying to do something different you know I've been in that position advising a clinical team

[00:28:38] implementing a new workflow that is traditionally done face-to-face and we're trying to

[00:28:44] bring it virtual and they're like this is how it's done and I was like is it done that way because

[00:28:48] there's a regulatory requirement is it done that way because that's just how it's always been done

[00:28:55] and what are the risks if we were to do it differently there are ways that those things go well

[00:29:01] and there are ways where people really don't feel heard between your clinical scientific folks

[00:29:08] and everyone else and this is one of those things that blows up my inbox and linked in from

[00:29:13] clinicians a lot or scientists a lot is feeling disrespected not heard and I think sometimes like

[00:29:20] I always say to them a great lawyer will say to me these are the 3000 risks in the contract you

[00:29:26] asked me to review because that's their job is to find all the risks that's technically why I'm

[00:29:31] paying them and my job is to say back to them okay help me understand which of these are likely to

[00:29:39] happen and destroy me which of these are highly unlikely to happen but if they do will destroy me

[00:29:46] and which of these are like you know like the impact of this is not that bit right and I think

[00:29:52] there's a lesson to be learned there in how clinical folks interact but the bottom line point

[00:29:58] is the same which is you have to have a clinical or scientific person on the team and that's a

[00:30:03] responsibility of both leadership and in my view investors okay so we've got two pieces of advice

[00:30:10] so far let me recap number one there has to be alignment between private equity or investors maybe

[00:30:15] I would say and the healthcare entrepreneurs themselves and maybe it's just a real also understanding

[00:30:23] that if you want to invest in or build an answer prize mostly for a huge exit like that's the primary

[00:30:32] driver maybe do something else that isn't going to involve grandma's getting suboptimal care as a

[00:30:37] necessary part of the business model and I just do want to do a call back to the show with Jodelyn Owen

[00:30:43] who runs a maternity clinic in a zip code rife with social determinants of how a digital tech maternity

[00:30:51] startup came in with lights flashing on a magic carpet ultimately failed and for all the probably

[00:31:00] reasons that you were just talking about but it wasn't just that digital health entity failed

[00:31:06] it actually diminished the quality of care in the entire community because they disrupted a bunch

[00:31:11] of things in their arrival that had been stable before so like this isn't just the self-inflicted wounds

[00:31:19] but actually we're talking about people here we're talking about patients we're talking about

[00:31:22] communities so what I think I'm doing is I'm understanding your advice in the sense that if

[00:31:28] you're actually going to succeed with the mission margin thing or maybe even just with the margin

[00:31:32] thing you got to do what you said that you have to have alignment between the private equity and

[00:31:36] them and the entrepreneur themselves particularly in the venture space right people say all the time

[00:31:41] that you want the right investor not just a check and I understand you know in a tough funding

[00:31:47] environment particular like the one that we're in can become a harder thing to stomach you just

[00:31:52] capital to survive as a CEO or a founder if you're not having that conversation as part of your

[00:31:59] process to really understand this and to be clear about the assumptions then it's really really

[00:32:06] hard later when you hit the struggle point and you're in a board meeting and saying we didn't

[00:32:13] hit our growth metric and being able to say and here's why but this is something we talked about

[00:32:19] right before you invested that this was a risk if you're not having that conversation before

[00:32:25] the check is written I've seen it with with founders were they're reluctant to give that transparency

[00:32:33] right because they're afraid that the board is not going to reinvest things are going to get

[00:32:38] difficult and and complicated and and so I think it's just is something that can't wait until

[00:32:44] after someone is invested to talk about yeah and I think you know if I was going to just

[00:32:50] throw something out into the universe I really feel like if there's private equity or there's

[00:32:54] venture capitalists out there who's listening to this show and probably if you feel that this way

[00:32:58] you're not listening to the show but all that is cared about is money don't invest in health care

[00:33:05] go level up dry cleaning or something you know what I'm saying this is just there are

[00:33:10] downsides that exceed anybody's wallet here the second piece of advice you offered up is really

[00:33:17] think about the composition of the team and also the team's dynamics make sure that there is

[00:33:22] clinical people experts epitomologists pop health like you've got the right clinical

[00:33:29] and epitomology expertise behavior behavioral health expertise that are on the team but beyond

[00:33:37] ensure that there are efficient and effective ways of working together such that clinical

[00:33:43] feels heard but at the same time there can be forward progress right like there has to be a good

[00:33:49] culture I get it when you're at you know seed stage start up you may not have the need or the

[00:33:55] resources to have a massive clinical team and that's totally fine right like to to have someone

[00:34:01] who is in an advisory role but what drives me absolutely bonkers is a face on the slide

[00:34:08] that you're never talking to you end up with the inclination from those folks to swoop and poop

[00:34:13] and that's not that doesn't work for anyone you have to engage your clinical and scientific people

[00:34:20] in a way that you build trust between the team members so that they can be heard and they're not

[00:34:26] just being asked to rubber stamp things okay we've covered two pieces of advice that you have

[00:34:31] for those with money and those who need money is there a third the third thing I would say

[00:34:36] is we talked a lot in the beginning of the show around how people matter right the front desk person

[00:34:41] matters the clinical staff matters and we're in an era of a lot of burnout and a lot of turnover

[00:34:48] from the workforce yes it's the clinicians but it's also the staff who are cleaning the dialysis

[00:34:54] center are turning over as well and that puts drains on businesses what I would say whether

[00:35:01] your early stage start-up or late-stage business is humans are fundamentally motivated by the mission

[00:35:08] to be in healthcare in so many cases but they are also motivated to be successful in their own

[00:35:14] journey in life they want to know that the work they are doing aligns with the success of the company

[00:35:21] if they're not clear on what success for the company look like they don't see how their work align

[00:35:26] to that success and so to me it does come back this idea of are you measuring what matters

[00:35:32] and to people know how their success contributes to the success of a business for early stage companies

[00:35:40] it's easier to see how your work aligns to those clinical outcome measures but also to the success

[00:35:46] of the business is gross perhaps it's just me and my end-of-one experience but working at a

[00:35:52] fortune five company I did not feel connected to the mission and to be honest I wasn't clear how

[00:35:59] my work connected to the stock price it's really hard to sort of feel like you're moving the healthcare

[00:36:05] business as a business or moving healthcare forward when those things don't connect and the more

[00:36:10] I think you can help people understand what is success for your business or business unit

[00:36:18] and how their work connects to that you have to be clear on what the success looks like to our

[00:36:23] a conversation around measuring what matters it also helps people see how their work connects to

[00:36:28] that well I would reframe that because I can really see exactly the point that you're making so

[00:36:35] I had asked you the original question was what's your advice to ensure that margin doesn't start

[00:36:40] to trump mission and what I'm hearing you say if everybody in an organization understands what

[00:36:46] the goal is and if that goal has a mission focus then you wind up creating a culture which can

[00:36:52] serve you very well downstream but what it also does at every step along the way is now you have

[00:36:58] an entire organization pointed in the right direction and if it starts to go off course margin

[00:37:05] starts to eat mission you have an entire company of people who potentially could be the

[00:37:13] one to raise their hand and say hi like we're going off course yeah and just also be accountable

[00:37:18] to one another and keep each other in check I think what you're saying is super important which is

[00:37:22] probably why they say culture eats strategy for breakfast lunch and dinner whatever that latest

[00:37:27] iteration of that is if what we're trying to do here is hard and we need to stay on the path

[00:37:32] then it would be great to have everybody aligned and accountable to one another yeah Kate

[00:37:37] Wolland is there any place that you would direct people to go if they would like to learn more

[00:37:42] about your work LinkedIn they will find you on LinkedIn Kate Wolland thank you so much for being

[00:37:47] on relentless health by you today thanks D C so let's talk about going over to our website and

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