Gladden longevity — Episode #30

Speaker 1: Welcome to the Gladden Longevity Podcast with Dr. Jeffrey Gladden, MD, FACC, Founder and CEO of Gladden Longevity. On this show, we want to answer three questions for you. How good can we be? How do we make 100 the new 30? And how do we live well beyond 120? We want to help you optimize your longevity, health, and human performance with impactful and actionable information. Now, here's today's episode of the Gladden Longevity Podcast.

The Gladden Longevity Podcast is provided for informational purposes only. It does not constitute medical advice. This content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of a physician or other qualified health provider with any questions you may have regarding a medical condition. The use of any information and materials linked to this podcast is at the listener's own risk.

Dr. Jeffrey Gladden: Welcome, everybody. On this edition of the Gladden Longevity Podcast, I'm going to be speaking with Michael Brombach. Michael is the Chief Operating Officer for Recuro Health, R-E-C-U-R-O. Recuro Health was started by Michael Gordon, who founded Teledoc a number of years ago. And Michael Gordon is now very interested in trying to bring proactive care to the masses. Michael Brombach started a company called SupDoc, was powered by AI as a platform for convenient, efficient healthcare services. He has a long history of working in a traditional “sick care” industry trying to transform that and now is teamed up with Michael Gordon at Recuro to try and change the way employees and employers engage around health.

I think you're going to find this a really interesting conversation. We go into some really interesting topics. It's not a long podcast. It's about 30 minutes, but it's quite fascinating. I hope you enjoy it.

Welcome, everybody, to this edition of the Gladden Longevity Podcast. I'm your host, Dr. Jeffrey Gladden, and I'm here today with Michael Brombach. Michael is a very, very interesting person. He's good friends with... Not even good friends, but his company was bought by a good friend of mine, Michael Gordon, who you may have heard of. He founded Teledoc, subsequently sold it and is now started a new company called Recuro Health. Michael was brought in to be the director of operations, COO actually, for Recuro Health. What's interesting about this is many times in our podcast, we're talking about “sick care” versus true healthcare and things like that. Michael Gordon and Michael Brombach are actually working to try and transform “sick care” and make it more proactive, more preventive, and things like that. So, I think you're going to find this an interesting conversation. So, Michael, welcome to the show.

Michael Brombach: Thank you for having me.

Dr. Jeffrey Gladden: Yeah. So, why don't you fill people in just a little bit on how you got to be here working with Michael Gordon and Recuro. Give them a little bit of sense of your background. And it's not so much where you worked as kind of the thought process that got you to want to be working in this particular space.

Michael Brombach: Yeah. It's a great question. My background really focused for a long time within the traditional healthcare system. So, I worked with most of the major health systems, provider systems, and health insurers. And a lot of the work I did was focused on what the future of care delivery could look like. I set up some of the bigger accountable care organizations in the country. I set up some medical groups with some of the larger health systems. And then I worked with a lot of major payers and health systems on what that next generation of virtual care could look like.

How would you set up care that's more focused on cost, focused on better outcomes, focused on customer experience, and then moving those big systems towards different types of technology or care delivery models that really put this patient at the center of those care journeys.

Dr. Jeffrey Gladden: Let me just interrupt for a second. When we think about traditional medicine, let's call it, “sick care”, healthcare traditional, we tend to, in my experience of it, when I practiced it was it's very reactive. Nobody came to see me if they weren't sick, right? They had to work their way through some sort of hierarchy of referrals to get to me. And so it sounds like what you're doing is... And it seems like the entire industry is set up that way. The insurance payers are set up that way. They'll only reimburse for CPT diagnoses of a disease, a process, a problem, if you will. Doctors are kind of trained to take care of problems. And so it sounds like inside that system, you're trying to do something different. Is that true?

Michael Brombach: Yep. I think that's exactly right. I think that's why it's such a challenge to change sometimes is you're changing completely both the care delivery model, the payment model, the incentive structure, and then as a whole stakeholder management for these systems to redesign how they're approaching patient care. And these are some of the largest organizations in the world focused on healthcare. They know they need to change, but there’s so much working against them from a legacy structure perspective that it's really difficult to do things differently, at least within these systems.

Dr. Jeffrey Gladden: Yeah. That's what I would think. Every time I had a conversation with a large health organization or with an insurance company, you just had the feeling that there was just so much momentum in a particular direction that it was almost difficult for them to even conceive of something different that could possibly work.

So, I'm curious to know, in your working with those people, did you feel like you actually made some inroads with them? And if so, to what extent were you able to make some inroads?

Michael Brombach: I'd say the biggest thing we were able to do was to set up more value-based care or accountable care structures within these systems.

Dr. Jeffrey Gladden: Okay. Describe that for the audience, if you would. Sorry to interrupt, Michael, but just describe that accountable care structures so that people have an idea what we're talking about.

Michael Brombach: Yeah. So, basically, if you have a big health system, most of their payment focuses on fee for service. So, basically, paying doctors or practitioners or counselors for the things that they do. So, if you have a visit, you get paid. If you have a lab visit, you get paid. If you do surgery, you get paid. And so, as you set up these different types of accountable care organizations, they were more focused on paying physicians and care providers based on cost reduction and outcomes.

And so, they would get better compensation if they kept people healthier, if they kept costs lower, if they used care in a more efficient or structured perspective. So, I was trying to realign the incentive, so the providers and the patients had a similar subset of incentives.

Dr. Jeffrey Gladden: It's an interesting concept because as I think about it, just intuitively, it seems like physicians and healthcare systems are really set up for reactive care, right? To go in and do something when there is a problem. And now, you're financially incentivizing them to keep patients healthy, but they're not trained in keeping patients healthy, they're trained to act when there's a problem. So, taking that toolkit of "I have tools that can get you quote unquote better if you're sick” and trying to use that tool set to keep someone healthy seems like kind of an inherent mismatch, right? Because it's a completely different set of tools you need to keep somebody healthy than you need to take care of them when they're sick. So, that seems like a big challenge.

Michael Brombach: I think you hit the nail right on the head. It's a different set of tools and it's a different set of problems because the things that keep people healthy aren't necessarily in the four corners of that doctor's office. Sometimes it's care coordination. Sometimes it's lab. Sometimes it's genomics testing. It's a lot more that goes into that. It's social determinants of health and food scarcity and living situation. And so, if you look at just what happens in those four walls of the doctor's visits, the tools are different, but the problems that surface during that visit are different than the problems you would need to solve if you're really looking at whole-person or proactive care.

Dr. Jeffrey Gladden: You could almost make the argument that the current healthcare force is not really up to the task of providing that kind of care.

Michael Brombach: Yep. I think there's a very strong argument to be made that the healthcare force, the healthcare systems, the reimbursement, the technology, even the lab tests aren't set up for that sort of care. It's been built around years and years and years of practicing and training and perfecting that very four corner model of in-person care. It's a very different mindset.

Dr. Jeffrey Gladden: Yeah, exactly. So, anyway, it's interesting that the world sort of needs, it knows to change, but I can see even in their trying to change, they're kind of stumbling over do we even have the right tools to change even though we might want to change and that's... So my heart kind of goes out to them. It's one of the reasons that I've decided really not... People have asked me many times, "Why don't you talk to the insurance payers? You're doing such great work. You're making people so healthy. Why don't you talk to the insurance payers?" And it's like: "Those are the last people I want to talk to. I don't want to talk to the hospitals because they're not going to get it. They're not going to understand it and I want to stay out of their world."

And you get that intuitively also. Out of all this, you ended up starting a company, right? And it sounds very intriguing. You were just utilizing some AI and genetics testing, other testing. Tell us a little bit about that.

Michael Brombach: Yeah. So, I left a large consulting company working with these big health systems and payers. So, I saw a gap for a platform or technology that could help make care more proactive, that could take the right data, could take the right tools and allow physicians to be more efficient with these different types of care models, something that's more proactive. So, I left to build this technology company called SupDoc that was eventually acquired by my current company, the company I'm the Chief Operating Officer for, Recuro Health. And so, we took that platform technology and scaled it across Recuro to do a lot of things very differently. And I can go into a lot more detail there.

But it's taking something that's a lot more efficient, something that's a lot more customer-centric and allowing the doctors to actually have the tools to practice differently because it's not just a patient experience side, it's a physician experience side too.

Dr. Jeffrey Gladden: So, give us an example of that. What would be some examples of that, so people could relate to what you're talking about.

Michael Brombach: Yeah. So, I would say the biggest thing that we do with Recuro is we try to catch things early. We try to have care that's focused on preemptive care, proactive care. And the biggest way we do this is we take the right data about you. So, we take risk assessments. We take in wearable data. We take in lab data. So, we create a more complete picture of the patient. And so, when you're actually going through onboarding and enrollment in our process, we're getting the right information about you so that we can then tailor your care or the actual physician you get based on your problems.

So, it's not this shooting in the dark of saying: "Oh, I might need to talk to a primary care doctor. I might need to talk to behavioral health, or I might need a counselor." We know enough about you to say: "Okay, we're going to give you these lab tests, these genomic tests. We're going to set you up with these providers that are going to create this type of care plan to manage your health on an ongoing basis. And then we're going to retest you on an annual basis and we're going to keep monitoring that data on an ongoing basis, so we have a snapshot in time of your whole-person health. We have a doctor and a care team that's helping to manage that care, and then we're able to check in on an ongoing basis to see if there's improvement, to see how we can tweak that care plan."

So, it's really about bringing the right data, the right tools, the right labs, the right doctors to each person's unique needs because everyone's extremely different. Everyone has different needs across this space. And so, it's really tailoring that care model to a person.

Dr. Jeffrey Gladden: Gotcha. And then the Recuro model, you're working with employers, I believe. Is that true, primarily, with employers? Are you reaching to the general public too? Or how are you doing that?

Michael Brombach: Right now, it's primarily through employers. And so, we're working with a lot of innovative companies, both in the small, medium and large size groups that want to offer a different type of virtual care benefit to their employees. And so, the companies that typically come to us, they're still funded which means that they're managing the risk of their population in some sort of way.

And so, they have a far better incentive to offer tools that actually keep down costs, but then keep their employees healthy. And so, their incentives are far more aligned with how healthcare should work than sometimes traditional insurance providers might be.

Dr. Jeffrey Gladden: So, just so the audience understands, there are companies out there that have self-funded insurance plans essentially is what we're talking about here. So, basically, they're the front end and the back end, so to speak. And so, they're directly in the line of fire if their employees get sick for the healthcare costs. But, obviously, there's a major win for a company keeping its employees healthy because companies invest a lot in terms of training and recruiting and all these kinds of costs that go into it.

It's like training a Navy Seal. How many millions of dollars go into training a Navy Seal, right? It's not quite the same, but you get the idea. These companies have a lot invested in these people. And then when they get sick or they die suddenly, it's kind of a massive loss on two fronts, right? Both the healthcare cost side, but then also the personnel loss. I can see how they would definitely be the perfect fit for this kind of model, right?

It's upside on both ends of that. So, what are some of the pushback that you get from those companies? Are they skittish about it? Are they jumping all over it? How's that coming forward?

Michael Brombach: It depends on the company a little bit. So, the more innovative companies understand that they need to take more control and more responsibility for people's health, and people's long term health, because right now it's typically more of a cost issue for some companies where the typical employer benefit is just on demand virtual care.

So, think of you get sick, you call a doctor through like a Teledoc or an MDLIVE. And those one-off visits are typically what's been offered. It's a bit of an education for groups to know that there is a different type of care service out there and that we can actually provide it at a cost that's affordable. But it's always going to be more expensive than on-demand urgent care, because you've actually got an ongoing primary care doctor. You're using genomics testing to catch for cancer. You're using PGX to better tailor medication.

So, there's more tools in that toolkit. And so it's a bit of a [inaudible 00:15:02] issue. It's a bit of an education issue. And then there's always a little bit of hesitancy anytime you're doing something different in healthcare. There's data concerns, there's privacy concerns, there's deployment concerns. You don't want to disintermediate your traditional primary care doctor. You want to make sure those things tie together. So, there's a lot of just change management from that standpoint.

Dr. Jeffrey Gladden: So ,for the employee, that's working at a company like this, let's say Recuro Health is contracted with or whatever to provide services. Does the employee kind of have a team that they can go to on-demand throughout the year or is it set up in a very regimented fashion where they get testing once a year or if they have certain medical conditions, maybe they get tested, I don't know, four times a year or whatever it might be.

But do they feel like they start to have their own team there that's actually looking after them, whether there's mental health involved, physical health issues, whatever it might be. Is that how it works?

Michael Brombach: Yes, that's exactly how it works. So, we don't necessarily have a lot of control over when people start to use the service. But once they do use that service and we're actually able to take in that data, understand their risk, and tailor a diagnostic and testing plan and doctor care team, then they've got a care team that's assigned to them.

So, they get to choose. Well, assign sounds like we're dictating it. They get to choose from a list of doctors. "Oh, okay. Dr. Smith or Dr. Gladden looks fantastic. Let's go with that physician." They get to choose a doctor. They get to see their bio, a picture. They get to choose that doctor on an ongoing basis. And so, they really feel like they have a connection with that care team member on an ongoing basis. And then we add in things like: "Okay, you need counseling or you need a psychiatrist on top of that for medication management."

We'll always add to that care team, but you're going to have a quarterback of that person's care on an ongoing basis. So, they have someone to go to at all times.

Dr. Jeffrey Gladden: For the employee, employees are used to paying premiums. And then the employer many times will match some element of that or whatever to get the healthcare coverage. So, are these premiums higher for the employee or they’re lower for the employee, or they start off higher and go lower as they stay healthy? How do you manage all that?

Michael Brombach: It typically stays the same to start out. So, premiums typically don't change to start. The long term premiums will go down as we reduce costs and we can show data and better outcomes. They can bring that back and actually lower premiums for patients. So, typically, it doesn't go down right away, but it's something that they incorporate in terms of their long term medical cost planning.

Dr. Jeffrey Gladden: Right. Okay. So, that's reasonably attractive. I mean, if you come in and say: "Okay, your premiums are going to stay the same. You're going to have access to a team. We're going to be working with you to optimize your health." And then the employer is happy about that. The employee, interestingly enough, not all employees are all that concerned about their health, quite honestly. Some of them just want to go home and drink their beer, drink their wine, drink their scotch, whatever. So, they're not necessarily into it. They don't want to get sick, but they're not really focused on being healthy.

But then over time they have the opportunity for their premiums to go down. I suppose that's an incentive for them too, if you're able to do better, your premiums go down. Now, what happens if they do worse? What happens if their lifestyle choices are running counter to their genetics and everything else we know, and things are getting worse, so their premiums go up. Is there that kind of scenario here?

Michael Brombach: We haven't done anything like that directly. There are some employers that are looking at both a positive incentive and a negative incentive. If you're not following that care plan, if you haven't done your annual visit and your testing, then usually the way they do it is you don't get a reduction on your premiums, so it would stay the same. I haven't seen an employer raise it yet, but that negative incentive that you're still not going to save money is something that a lot of employers are exploring. Because if you look at the key to aligning incentives is everyone shares in both the risk and the reward of programs like these.

Dr. Jeffrey Gladden: Correct.

Michael Brombach: And you're seeing innovative employers structure these programs very differently than you would've even a couple years ago.

Dr. Jeffrey Gladden: Right. Okay. Well, that's interesting. So, then tell me a little bit about AI. I know there was some AI involved in your company that you ended up selling to Recuro. And how is AI factoring into this? I'm hearing about care teams headed up by a physician, may include other healthcare professionals, I'm assuming. Does it include things like PT and nutrition people and all that. I assume it probably does.

Michael Brombach: Yeah. It's a really good question. So, from a care team perspective, what we have today are pediatricians, primary care doctors, psychiatrists, and counselors. We have a suite of integrated specialists.

Dr. Jeffrey Gladden: What's a counselor? Is that a mental health person or is that a...

Michael Brombach: Mental health. Yeah, like a behavioral health.

Dr. Jeffrey Gladden: Got it.

Michael Brombach: We do cognitive behavioral therapy through our counselor network. What we're looking at next is we have integrated specialists like nutritionists and some other genetic counselors and other groups, but they aren't necessarily directly in our network yet. It's something we're exploring right now is what are those next set of services we want to pull in tightly into our model versus which sort of services we want to refer out to because, I'm sure as you see too, the groups that you have tighter integration with from a care model side, the more control you have, the better care plans you can create together. So, it's a big source of investment for us from a care team.

Dr. Jeffrey Gladden: Yeah. Understood. It ultimately determines a lot about the product because any professional, typically, the way we were trained and if they're still working kind of in that mindset, I mean, they're kind of in their lane. Right? And anything outside their lane, they're not comfortable with. So, anyway, back to the AI, so how does the AI play into all of this?

Michael Brombach: Yeah. So we use AI in two ways, and I'll talk a little bit more how we want to grow it. Our philosophy on AI and clinician support is there's a lot of very simple tasks that are not necessarily worth a clinician's time. If you see XYZ flags, you'd want the system to say: "Hey, maybe this is something the physician should pay attention to." And so, we don't make medical decision-making through the AI, but we take in claims data, we take in clinical data, we take in lab and pharmacy data. We take in wearable data. We take in questionnaire data from a patient.

So, what the AI does is it looks at all those different data sets and those different potential risk factors and it runs them against a normal set of data and looks for variances. It looks for abnormalities. And if it sees something out of whack, what it does is it triggers that for a clinician to pay attention to it. And so, it's more like a kind of pre-nudge on a proactive set.

Dr. Jeffrey Gladden: Got it. Now, is it actually doing it against a normal whatever that means, a quote-unquote normal group. And I assume if there is a normal group, that's age, sex, height, weight matched, or some demographically matched group, I suppose. But then there's also value, of course, of tracking somebody against themselves in their state of health. Right? And so is that also a piece of the pie? Like their respiration rate jumps up by 50%? It's like: "Oh, well maybe we need to think about COVID or an infection or something. Right?"

Michael Brombach: That's exactly where it's going where we've got some rudimentary components that are looking for abnormal. And a lot of those are rules-based and those aren't as AI robust as they could be. Where it's going is looking at those trends and adjusting for what's actually normal. It might be normal for a patient to have this A1C level and that's not actually a risk factor. So, we don't want the AI triggering it. So, really what AI does is it looks at... It's a statistic set of rules of, if you see something, what does that actually like [inaudible 00:23:09] physician. What does that do and how do you resolve it? And so, what we need a lot more of is that feedback from the clinician to say: "Okay, this is normal, or this is not normal? Or this is the diagnosis.”

So, then we can match those results with that data structure, so the algorithms can get better on what's out of normal or what's out of whack or what's not.

Dr. Jeffrey Gladden: Got it. Got it. Okay. So, it sounds like you're still in the very much in the building phase per se on this whole approach. Okay, cool. And then in talking with Michael Gordon, who's the founder... And just so people know, he and I are writing some white papers together actually, on behalf of Recuro and Gladden Longevity. Actually, we're both kind of purposing those white papers. So, we work together pretty closely. Working on the inside, what's next on the list for Michael in terms of where he wants to go with this?

Michael Brombach: Two things. The biggest thing that we're doing is adding in more genomics and lab tests. And the right genomics and lab tests based on your risk factors. I know we've got a lot of really great insight from you, actually, Dr. Gladden on some of the right tests to look at. But right now what we do is we look at some hereditary cancers. We look at some different diseases that you can test on the genomic standpoint. And then we do some PGX pharmacogenomic testing. There's a whole set of other microbiome and epigenomics and other tests that we can layer in based on a lot of other risk factors. So, building out more of a library about a patient to tailor the right set of tests for someone is a big piece of what we're doing next in a big way.

Dr. Jeffrey Gladden: Okay. So, I'm imagining, if that's the case, that maybe not everybody that signs up for the program gets every test, but there's some sort of an intake called history or history slash physical or however it's set up. And then based on that testing family history, et cetera. And then from there, there's a core bit of testing, but it can fan out into other areas is kind of what I'm imagining, you're imagining. Is that right?

Michael Brombach: Yup.

Dr. Jeffrey Gladden: Okay.

Michael Brombach: That's exactly right. Because what we have in market right now is there's a lot of standard diagnostic tests. So, based on risk factors, we'll send you an A1C or a lipid or at home lab for a lot of services. And pretty much everybody needs something like that once a year. Then there's a very small percent of the population right now that gets those genetic tests. It's usually about 5% based on the risk factors, but we know there's a lot more based on hereditary risk and social risk and other things that require different types of tests. And that's what we want to tailor next. You're exactly right.

Dr. Jeffrey Gladden: Okay. Interesting. That's actually giving me some ideas in terms of interfacing with just from the standpoint-

Michael Brombach: As much input as you want to give us on that, yeah.

Dr. Jeffrey Gladden: Well, just because I have some things that would be very beneficial in that regard. We were talking a little bit maybe even before the podcast and in terms of what we focus on, but what I've found is that all the biochemistry in the world at an individual, whether it's around longevity, health or performance, but it's really what their mindset is, right? What their mental health is. Those things are critical because there's so much self-sabotage.

People don't really, truly love themselves. They beat themselves up all the time. They're trying to [inaudible 00:26:40] from the past. There's addiction. There's not feeling safe, anxiety to factor in. And I think those have a much bigger impact on health, longevity, and performance than even knowing somebody's genetics, if you will. And I'm sure you're aware of that, which is why you probably have psychiatry and things already in the mix.

Michael Brombach: Yep. You're exactly right. And actually that's the second big piece. So, the first big piece is tailoring those testings better. The second piece is what we're doing around behavioral health. And you touched on some of it. There's a lot more that you and I need to design together on how we support correctly. But what we've noticed right now is that behavioral health as a standalone service or even as a tightly integrated care team service isn't necessarily enough for people to actually feel supported and feel engaged.

There's other ways people want to interact with the behavioral health space, whether that's behavioral health coaches, whether that's peer to peer, groups, therapy sessions. So, there's a lot of other types of behavioral health and support and engagement, we have not cracked the code on yet, but that's a big source of investment for us next because, again, I think you're spot on when you said earlier, it's about people wanting to change and people being a power to change and having the right tools and resources. And that comes down to behavioral health in a big way, but not just the clinician, but it's tools, it's how you set up the gamification of a lot of these things. It's how the tech works. It's when people reach out to you. It's just the tip of the iceberg for a lot of these things. And that's the biggest, second piece that we're working on.

Dr. Jeffrey Gladden: Yeah. Well that makes perfect sense. That makes perfect sense. I've always been a big fan of the fact that we're all on a journey, so to speak, but many times for a lot of people, it's easier if they're not on a journey by themselves. So, if there are groups that kind of naturally amalgamate around a particular thing, which is group therapy, so to speak, but it's beyond group therapy. This is more like you're part of a team and the team is encouraging each other and holding each other accountable and some things like that.

There's a lot to be said for that kind of feedback and encouragement. I know people try to get them to exercise and they won't exercise, but if they have a buddy they'll exercise, right? Or they have a trainer's appointment. Well, I've got a trainer's appointment, so I go exercise. But the day I don't have it, I can't get myself to do it. Right? So all that kind of stuff too.

Michael Brombach: Yeah. I'm sure you've seen the gamit of all those different things and that's exactly what we're running up to do.

Dr. Jeffrey Gladden: Oh, yeah. I've had all the conversations I want to have with people that don't really want to change, which is kind of why we're working where we are with people that are really motivated which makes it much more fun. Well, cool. It's interesting. I think it'll be really interesting to see how Recuro moves forward. And actually this conversation has given me some further insight into the company. Are there other things that you would want to talk about here before we wrap up a little bit?

Michael Brombach: No, I think the other thing that we're working through from a long-term strategy perspective is the more we can do from a proactive standpoint, the more we can put in a virtual care model because there's so many different types of tools that are being developed all the time. There's all sorts of different science. There's all different sorts of research. And it usually takes a long time for that science and research and those therapies to actually enter physician care.

So, what we're trying to do from a long-term perspective is make sure we're getting the best science, the best therapies, the best approaches and we can actually put those into a care model that's scalable because we have a virtual net, we have a national network, we have a virtual care platform. We can hard code and embed a lot of these things into physicians practices. So, we're hoping to take a lot of the great things that you produced, Dr. Gladden, and all these other groups do from a care practice side as you've perfected your art. But how do you scale that across a larger population? That's what we're really interested in from a long term perspective.

Dr. Jeffrey Gladden: Got it.

Michael Brombach: So, that's just where we're going as we evolve this model.

Dr. Jeffrey Gladden: Yeah. It's perfect. I mean, really the democratization of preemptive care versus reactive care is really, it's just a massive need. So, I really applaud that you're working in that space. Cool stuff. Well, it's been great chatting with you, Michael. We'll need to have you back and get an update as things progress over there. So, thanks so much for being with us.

Michael Brombach: Yeah. Well, thank you for the time. Really appreciate it.

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