Making Healthcare More Equitable

Dr. Alan Roga helped lead Teladoc Health through the COVID-19 pandemic as its Chief Clinical Operations Officer. Now he's the founder of Trulite Health, a health equity platform dedicated to reducing clinical bias. In this episode, he shares his entrepreneurial journey, what led him to tackle disparities in care, how healthcare systems can embrace technology, and removing bias from AI.

Make sure you like and subscribe to "For Startups, By Physicians" wherever you get your podcasts. And keep up with us on LinkedIn, Twitter, and Medium at @InflectHealth, and on the web at InflectHealth.com.

Transcript

[00:00:00] Lindsay Kriger: Hey everyone. This is Lindsay Krieger, director at Inflect Health, the innovation hub of Vituity, where we strive to be a catalyst for better care. I'm thrilled to be hosting "For Startups, By Physicians" where we share insights and guidance to healthcare startups and technologists looking to create the future of health.

[00:00:18] Lindsay Kriger: As a physician-founded firm, we have connections with clinicians and intimate knowledge of what they need and how they work. We will be interviewing our executives, frontline providers, and industry leaders to help your business be effective and scale. 

[00:00:31] Lindsay Kriger: Thanks for joining and let's get going.

[00:00:42] Lindsay Kriger: On today's podcast, we have Dr. Alan Roga, the founder of Trulite Health, a health equity platform focused on reducing clinical bias and providing multi-level interventions at the point of care for health systems. Prior to Trulite, Dr. Roga was Teladoc Health's [00:01:00] President of Health Systems and then Chief Clinical Operations Officer where he was responsible for the strategic direction of the organization, notably through the pandemic.

[00:01:10] Lindsay Kriger: He has a medical degree from the Renaissance School of Medicine at Stony Brook University and is a fellow of the American College of Emergency Physicians. 

[00:01:20] Lindsay Kriger: Alan, thank you so much for joining today and welcome to the podcast. How are you? 

[00:01:24] Dr. Alan Roga: I'm doing great, Lindsay. Thank you for having me, and I'm looking forward to today.

[00:01:28] Lindsay Kriger: Us as well. I'd love to start off by talking a little bit about your journey as an entrepreneur adjacent to being a clinical physician. 

[00:01:38] Dr. Alan Roga: It's interesting as many things in life. It's a journey. I would say the unifying theme is that constructive discontent is a powerful motivator, which is a fancy way of saying, get a little upset about something that you think you can fix in the world, and an entrepreneur is born.

[00:01:55] Dr. Alan Roga: So while throughout my clinical career, I always had [00:02:00] some entrepreneurial and administrative components, whether it was being a department chairman or leading practice management groups, really the point that accelerated and became the catalyst of true entrepreneurship was back in 2009, I was at a conference that was talking about computers and technology — and I'm not a technologist, nor was a big technology fan, which is ironic that now this is my fourth technology-based company — and the speaker was talking about computers and technology, and I had an urgent care business plan that was the fifth or sixth one we had looked at. I had a bad debt report from my CFO and I saw how many people we were sending to collections that were, in a pretty nice area of the world in Scottsdale, Arizona, and as a poor kid from New York, that would've bankrupted my family. 

[00:02:48] Dr. Alan Roga: So constructive discontent took over, which is, I just got tired of charging someone the amount we were because their child ended up having pink eye and ended up in the ER, not because they didn't have insurance, but because [00:03:00] they couldn't get see their primary care doctor because of the challenges of the system and really thought through technology, could we increase access to care, improve cost and outcomes? 

[00:03:11] Dr. Alan Roga: And so back in 2009, telehealth and telemedicine were not cool to do. It was very new and novel and all the companies were pretty young. And really the galvanizing component was simply getting a little bit unhappy with the status quo and thinking there was an opportunity to make it better. Not to say startups are being entrepreneurs are easy, but started on that path back in 2009 and through a challenging financial crisis and market, raising capital and getting people to see the beauty of virtual care and I think it's ironic now that thankfully myself and other companies did so because, during COVID, that was number one way people engaged with their healthcare. 

[00:03:51] Dr. Alan Roga: And in fact, in my most recent exam, my primary care doctor forced me to do a telemedicine visit. So I think it's interesting how far we've [00:04:00] come in that not a lot of people want us to do it back then, and now it's ingrained part of our system. 

[00:04:05] Lindsay Kriger: And it's only less than 15 years ago, right? That's not all that long ago considering how slow some innovations do take in healthcare. So that's really admirable and one thing that I know we've always connected about and you've connected with our other physician leaders about is just this need to make healthcare better. And we know that being a practicing clinician is key to that because you see the challenges and struggles of families and systems and payers.

[00:04:36] Lindsay Kriger: I just commend you for having that, not only desire to make the change but then the guts, the willingness to put yourself out there and make that change for others. I think that's really beautiful. 

[00:04:47] Lindsay Kriger: Obviously, you worked your way up as an executive and leader at Teladoc, and during the pandemic, as you mentioned, that was one of the critical ways to connect healthcare [00:05:00] and the population. Tell us a little bit about what that was like as a leader, as a physician, and what you learned from that before we move on to your next journey. 

[00:05:09] Dr. Alan Roga: It was great fun being in a public company that started as a young public company and then grew to be a very large public company. And I think it's the same foundational things, which is not only as constructive discontent, a healthy attribute to have for entrepreneurs, but to stay curious.

[00:05:24] Dr. Alan Roga: So really coordinating and working on clinical operations during COVID, and prior to that, building the health system division from a ground up startup, I would think staying curious and looking at things and not accepting the status quo was a foundational component for any successful person. Not just an entrepreneur, but physician leaders, and physician executives. 

[00:05:49] Dr. Alan Roga: And really for me, the second moment in there during COVID was, we all saw what happened at George Floyd and saw a lot of social unrest [00:06:00] in the world, and so curiosity around health equity became important to me. A thousand doctors and millions of virtual care visits to manage during a challenging time during the pandemic. 

[00:06:11] Dr. Alan Roga: And with all the discussion around health equity — I'm an inner-city kid from New York. I did my residency in the Bronx — I didn't really know much about health equity and disparities in care. I figured that they treat everybody the same way, and that's not the case. There actually are a lot of disparities in the United States and health inequity, whether it's race-related in black or Latin patients, or whether it's white Americans in rural America or people with physical disabilities. Our system needs to evolve. 

[00:06:40] Dr. Alan Roga: I had a very enjoyable role and really did derive great satisfaction coordinating care for our patients during COVID. Found another mountain to climb with health disparities. So proud of the work that we did help bring virtual care to the market. And now looking at the second legacy, if you will, around really addressing care at broad [00:07:00] scale for diverse populations and making sure we make things more equitable.

[00:07:04] Lindsay Kriger: And do you remember ever having a formal curriculum in medical school or residency and even other jobs you had at health systems or Teladoc for that matter, that ever attempted to or tried to bring up some of the inequities in the healthcare system or even address race relations or any sort of differences?

[00:07:30] Dr. Alan Roga: One of the best advice or a piece of advice I ever had was the first day of medical school when there was an anesthesiologist giving the kickoff to all the future doctors in the room. There are about a hundred of us, as I said, I went to Stony Brook. And I'll never forget, he said, "Listen, about 75% of what we're gonna teach you is wrong. We just don't know which 75%." 

[00:07:49] Dr. Alan Roga: And there were probably never more prophetic words issued because we're constantly evolving in healthcare and learning in a positive way. Clinicians are amongst most dedicated people you ever find in the world [00:08:00] to their craft. In medical school there was none. In fact, most of the teaching was wrong.

[00:08:04] Dr. Alan Roga: ACE inhibitors are contraindicated in the black population and there was a lot of race-related component differential things, and now we've learned. So whether that journey is revisiting some of our science or cultural bias training, or really looking at clinical outcomes, I think similarly of looking at how we're doing things and how do we make them better.

[00:08:25] Dr. Alan Roga: Again, staying curious is foundational. I saw some of the cultural bias training, which was good, important foundational elements, but not yet moving the needle on outcomes, social determinants of health work that's important, foundationally, but not yet moving outcomes, and then really going back to, "Okay, some of our teachings are wrong clinically. How do we focus on that and bring that to the equation to address disparities?" Just became a natural evolution for me. I'm not a complex thinker, so staying simple with, "Okay, there are social factors, there are clinical factors. How do we address that as a best [00:09:00] practice?" became really the galvanizing moment to say, "all right, time to do another startup."

[00:09:06] Lindsay Kriger: Why do you feel technology is important in that startup world, and how do you see it accelerating hopefully the rate of change that we need to see in this industry? 

[00:09:17] Dr. Alan Roga: And the most ironic part of that is, again, I'm not a technologist. In fact, my kid, my kids make fun of me. They say, there's no way you can actually be doing this.

[00:09:25] Dr. Alan Roga: I'll never forget the CIO of one of the hospital systems I used to work at who I don't think I was his best friend because I did not want to go to EHRs. And I ran into him at a conference and he said, isn't it ironic what you're doing now? And I said, "like the Dalai Lama says sometimes what's standing in the way is the way."

[00:09:40] Dr. Alan Roga: So I think for healthcare and clinically, we do need to embrace technology for its positive attributes, especially in how do we impact the populations at scale. So I think as you look at technology and how it addresses not only healthcare but our healthcare system, right? One of the things I really [00:10:00] like about startups is what you do is you gather a group of like-minded people who think there's a problem worth fixing in the world that have the talent and attributes to do and you appropriately incentivize them with equity and compensation plans so that everybody extracts the value, both personally and professionally for the efforts.

[00:10:16] Dr. Alan Roga: The other part while you're embracing that journey is you have to realize that feedback is a gift, and you have to have very thick skin as an entrepreneur, especially at the early stages. So the magic is iterating on your solution and your technology-based by market feedback to make sure it aligns with your user's goals.

[00:10:32] Dr. Alan Roga: And in healthcare, we have a lot of different stakeholders, right? We have clinicians, not just physicians, nurses, care coordinators, social workers. We have patients, we have administrators, we have insurance plans, we have a lot of stakeholders, which adds complexity. So the other part of it is not only gathering like-minded people and ensuring that feedback is a gift, but you have to have confident humility, which is you are reconciled to a certain path that there's a mountain worth climbing and a [00:11:00] problem worth fixing in the world, and you're starting with a certain well designed, thought through solution, while you're ready to be humbled every single day by your multiple stakeholders so that you can garner their feedback, take it as a gift, not take it personally and then iterate on your model and technology.

[00:11:18] Dr. Alan Roga: What it really does is bring scale. And it brings scale quickly, it brings incredible leverage and it really impacts lives on a much greater capacity than we can necessarily individually as clinicians. So that's been my migration from not a technology embracer to a technology person in many ways. 

[00:11:39] Lindsay Kriger: I'm gonna take advantage of the fact that I know you interact with health system executives and leaders on the regular. 

[00:11:47] Lindsay Kriger: For folks listening to our podcast who might not have any access or hungry to have one, two, or even three conversations with someone to lead to eventually having a conversation with an executive [00:12:00] at a health system, what would be your advice to them as an entrepreneur, as someone who has been through this uphill battle of trying to get technology into the healthcare space? What would you say to them? 

[00:12:12] Dr. Alan Roga: So first off, I love health systems and I think that every great company and great product and, really, entrepreneur, you have to love your clients. Now, much like your children, that doesn't mean to that, and not that I'm equating a health system to my child, but they don't always have to be right.

[00:12:32] Dr. Alan Roga: So you have to love them while accepting that they're not always right along the way, and you have to have the patience to get through the process. So working with health systems is complex. It's like working with the government in many levels. There's a lot of people involved and there's a lot of people who get involved in the decisions.

[00:12:50] Dr. Alan Roga: So when you're working with health systems, I think my advice for entrepreneurs would be the following: Number one, be very clear on your value proposition. This is a very busy [00:13:00] person on the other end of the line. They're overwhelmed right now. And why are they dedicating part of their day to you when they can be doing other things?

[00:13:07] Dr. Alan Roga: And you have to get that out quickly. And if you don't understand your value proposition for the health system, you shouldn't be having that conversation because you probably get one chance. 

[00:13:15] Dr. Alan Roga: The other part is you have to gather a broad-based consensus buying process. So there usually isn't one purchaser inside of a health system. There are multiple. So you have to be ready for consensus-based buying. You have to be a very crisp on your articulation of your value proposition and be ready to meet with multiple stakeholders. 

[00:13:36] Dr. Alan Roga: And the third is polite persistence is always a great attribute to work with health systems, which is you have to continue to be in front of someone who is very busy while being respectful of their time and understanding that you are one of many priorities — this is your priority, but this probably is not their priority. Now, if the priorities align, you have an accelerated process. 

[00:13:59] Dr. Alan Roga: [00:14:00] There's a lot of tactical things I can give every entrepreneur about getting to yes is probably just the midway point. That's not the end zone for working with a health system. You still have to contract and you have to cultivate the relationship and you have to get through all the review processes. But at the end of the day, I find them just the most phenomenal people to work with who are so passionate and dedicated to their care. You can't let the process get in the way of the end goal.

[00:14:25] Lindsay Kriger: For you and Trulite, you decided to go the health system route as the customer, as opposed to going a direct-to-consumer route. The scale at which you can impact through health systems and national payers is obviously very great, but a lot of people are taking this consumer route. Tell me a little bit about your thoughts in that arena. 

[00:14:43] Dr. Alan Roga: Back to general entrepreneurship, not only understanding your value proposition but also going back to really what is your go-to-market strategy is so key: What problem do you fix? Who cares? Why? What's the value they garner from it? [00:15:00] There is certainly an approach to go direct to consumer in healthcare, which is admirable and people have done that successfully.

[00:15:07] Dr. Alan Roga: There's also a lot of challenge is going to direct to consumer, right? Most people are... economic climates are tough right now. People already spend a lot of money on healthcare. To get them to pay more for their own healthcare is a challenge, not only again, financially, but just operationally with the way the system of design with payer reimbursements and eligibility claims and files and all of those sort of components, but it's direct access to an end user.

[00:15:33] Dr. Alan Roga: The reason why we ended up going this route with Trulite Health is that we have several end users, the consumer being one, but also understanding our value proposition. So we really think that addressing disparities in care and health equity is not only morally obligated, but it's financially obligated.

[00:15:53] Dr. Alan Roga: It has a cost of over twice the entire federal government spending on all of healthcare. So who holds the financial [00:16:00] risk often is an insurance company or a health system. So I like to go what's called B2B2C, so business to consumer, because then you can scale both audiences. That's just the decision that every early-stage company needs to make.

[00:16:15] Dr. Alan Roga: The reason why I like, again, B2B2C models and health systems and payers and self-funded employers, is because that ultimately ends up allowing you to reach the greatest and broadest numbers of the population, much like we did it at Teladoc, where before I left, we were servicing 70 million Americans. One in five Americans were being touched by Teladoc's virtual care products and getting people the care they needed, especially during a time like COVID.

[00:16:40] Lindsay Kriger: I appreciate that. It's a really systemic approach to problems. We see companies sometimes say, oh it's just, the physicians were more educated, or if the clinicians only had better materials or better workflows. But we all know the pressures on an individual clinician. Just like the pressure on a health system executive is overwhelming at [00:17:00] any given moment of the day, and so trying to get one level up to really understand the systemic opportunity.

[00:17:05] Lindsay Kriger: I wanna get your thought on some of the, in the news, so to speak, content around AI and what its potential is for healthcare, but also the unconscious bias, the concerns about data sets that have not been diverse enough to really power a natural language model. 

[00:17:28] Lindsay Kriger: What is Trulites thought about this? How do you hope to engage with AI and technology in the future to ensure that there's a more level playing field and a more equitable opportunity in AI? 

[00:17:40] Dr. Alan Roga: This is a very important point, and as you touched on, look, this is getting attention at all levels, including the federal government level. On one hand, we have the incredible power that AI can bring to accelerate processes and lead to better outcomes.

[00:17:56] Dr. Alan Roga: On the other hand, we don't wanna introduce bias. And what we've seen [00:18:00] already is there's been studies already published on scheduling modules that are introducing bias through their AI. So the no-show rate is thought to be larger in certain populations. So people will get double booked and then they can't get a hold of their clinician or the AI algorithms for sepsis introduced by.

[00:18:17] Dr. Alan Roga: So this is a real issue, unintended. Well-intended people. Technology introduced some biased, it's getting addressed. But that doesn't mean we should get rid of the whole segment of AI. It means we need to, as I said, feedback is a gift. That's the first attribute of every entrepreneur and every innovation.

[00:18:36] Dr. Alan Roga: So we're iterating on that. Trulite, being of course, very sensitive to introducing bias as a company who's trying to address clinical bias, we did not want to do that. So our AI is really on the deductive reasoning level. So we want to introduce no bias to our process by making it very simple, it is deductively reasoned through our AI algorithms.

[00:18:58] Dr. Alan Roga: Now as we continue to amass [00:19:00] data and additional data sets, we will evolve and enhance there, but we've taken the approach to say, there's no introduction of new bias in a system that already has some bias. 

[00:19:10] Dr. Alan Roga: And you touched on before in the prior segment around how this is a systemic issue. That's why going to the channel partners and the distribution partners is key. So whether it was virtual care on how do we improve access or Trulite now with addressing clinical bias, this is a system-level issue. This isn't an individual issue. 

[00:19:29] Dr. Alan Roga: It's not that doctors and nurses go to work to do a bad job. In fact, they'd go to work, do a great job. It's how do we evolve the system to provide the right tools so that clinicians can do their jobs more effectively than they could yesterday? 

[00:19:42] Lindsay Kriger: I'm sure there'll be more thought leadership from your team and more collaboration with like-minded individuals around this opportunity to continue to make better. As you said, it was an unintended consequence of strong technology, but we do want to continue to [00:20:00] strive and push the industry to do what's right for our patients and we will. And we will. That's right. I love the optimism and we stay optimistic. And that's of course what we love about you and your team is the optimism to tackle a challenging opportunity.

[00:20:14] Lindsay Kriger: Dr. Roga, thank you so much for joining us. I'm sure we'll have more conversations soon. Good luck to Trulite. And if people wanna know more about you or the company, where can they find the information? 

[00:20:25] Dr. Alan Roga: Yeah, so it's Trulitehealth.Com. T-R-U-L-I-T-E — a little play on words there — health dot com. You can find me on LinkedIn. My parents weren't that smart. Two four-letter words, A L A N R O G A. I am happy to assist any of our audience, especially those physicians who may have some entrepreneurial desire. 

[00:20:46] Dr. Alan Roga: I seem to be a magnet for some of them and actually do advise a few of them on their journeys and my compliments to the team at Inflect Health, the support you're giving to founders and companies, while it's [00:21:00] not my first one, it is appreciated. It's always warranted, and it's the Entrepreneur's Code, which is you help each other. So you've got a great group there too. 

[00:21:07] Dr. Alan Roga: And my appreciation for everybody's time there and for your efforts, Lindsay. 

[00:21:11] Lindsay Kriger: Thanks for joining us, and again, I'm Lindsay Krieger, director at Inflect Health. Here at Inflect, the future of medicine care and health delivery is not just right for disruption. It's increasingly personalized, accessible, and human. 

[00:21:25] Lindsay Kriger: Make sure you like and subscribe to "For Startups, By Physicians" wherever you get your podcasts. And keep up with us on LinkedIn, Twitter, and Medium at @InflectHealth and on the web at InflectHealth.com.