How Virtual Models are Reshaping Specialty Care
Q&A with Sam Holliday from Oshi Health
Specialty care is undergoing a transformative shift, influenced by the convergence of technology, patient demand for personalized and convenient care, and the imperative for cost-effective healthcare delivery. As traditional models of specialty care evolve, there's a noticeable trend towards integrating digital health solutions to enhance access, improve outcomes, and optimize patient experience. This transformation is particularly evident in the rise of virtual-first specialty clinics. These innovative care models not only promise to democratize access to specialized medical services but also aim to address the holistic needs of patients through multidisciplinary teams and evidence-based interventions. To learn more about these changes, I spoke with Sam Holliday, co-founder and CEO of Oshi Health, a company at the forefront of redesigning care for digestive health conditions. Sam is also a 2009 graduate of the Wharton MBA Program in Health Care Management.
Tell us about yourself and your career journey
Upon graduating from the Wharton Healthcare Management MBA program in 2009 (where we were classmates!), I wanted to work in healthcare technology (now called digital health) in New York City. But amazingly, there were few companies at that time and even fewer that were interesting, so I went into investment banking for a few years where I got to work on several digital health deals. I joined an EMR company, Greenway, after helping to take the company public and that started a series of leadership roles across healthcare technology and tech-enabled services companies focused on improving population health.
After working on several startup ideas, in 2019, I co-founded Oshi Health as CEO with initial funding from Takeda Digital Ventures. Our mission from day one has been to free millions of people from the burden of living with digestive conditions, allowing them to gain control over debilitating and isolating symptoms, and get back to their life and work. We are doing this by democratizing access to high-value digestive care proven to achieve unmatched clinical outcomes, member engagement, satisfaction, and cost savings.
Today, we’re working at the intersection of payment innovation and care transformation, having negotiated national-scale specialty value-based care contracts with commercially insured plans that serve as a model for how to pay for outcomes that both matter to patients and drive significant cost savings for purchasers.
Beyond Oshi, I am passionate about the future of healthcare and calling out barriers to innovation that need to be eliminated if we are serious about improving outcomes and lowering the cost of healthcare. I love speaking to critical topics such as redesigning care delivery to truly solve patient needs, bringing value-based care into medical specialties, how health plans need to modernize to fully incorporate virtual-first care, the regulatory barriers to next-generation care models, and more. I’ve been honored to speak on these topics at leading industry conferences and events including HLTH, American Telemedicine Association, Virtual-First Care East & West, the Wharton Health Care Business Conference, and more.
Can you tell us about Oshi Health and would inspired you to start the company?
As with many innovative healthcare companies, the original ideas behind Oshi Health grew out of personal experiences – for me, it was watching my mom and sister who both live with GI conditions. My mom had found success managing her condition using dietary changes, but largely had to figure it out on her own without expert guidance and support. My sister has struggled with the mental and cognitive side of living with a GI condition. Hearing what they both went through and how the support they needed was not really offered by their doctors, I wondered why.
We started looking into the existing evidence of how to achieve outcomes that matter to patients and control healthcare costs in digestive conditions. We found that dietary and cognitive/psychological interventions were well researched and proven to achieve outcomes, but GI clinics did not staff clinicians who were experts in delivering these interventions and instead only really could offer medications as the solution.
We asked why GI clinics didn't staff dietitians and psychologists. The answer was simple: They couldn't make the economics work because the reimbursement was not available or adequate for these interventions for GI patients. Talking to GI patients, we found many had to pay cash out-of-pocket to get the support of expert dietitians or psychologists, if they could even find one nearby, which was unlikely given the short supply of these experts who know GI-specific interventions.
We then found a study that proved that putting all the GI-specialized clinicians a patient would need in one physical clinic, working as a team to support each patient, was able to drive better experience and outcomes at lower cost. We realized that we could scale this proven multidisciplinary care using telehealth to deliver the care model.
We were fortunate in 2020 to work with a national health plan to run a clinical trial of our care model in their fully-insured commercial population across 3 states over 12 months. The results were better than even we expected – with 98% patient satisfaction, +80 New Promoter Score, 92% of patients achieving symptom control in an average of 4 months and significant improvements in quality of life and workplace productivity. Importantly we were also able to measure cost savings against a matched control group that went to traditional care and we showed over $10,000 of total cost of care savings in just 6 months, which widened to over $11,000 savings in 9 months of care.
Running the trial was a big investment of time and money, but has led to our rapid growth in insurance coverage, and gaining funding and support from leading GI medical societies. I often urge founding teams to do the hard work of generating robust evidence and a clear story of how a new solution delivers meaningful outcomes and creates value for the purchasers of healthcare. Our clinical study unlocked major momentum for Oshi with health plans and employers.
“We were fortunate in 2020 to work with a national health plan to run a clinical trial of our care model in their fully-insured commercial population across 3 states over 12 months. The results were better than even we expected – with 98% patient satisfaction, +80 New Promoter Score, 92% of patients achieving symptom control in an average of 4 months and significant improvements in quality of life and workplace productivity.”
How do patients typically find Oshi?
Today, over 30 million Americans have in-network covered access to Oshi’s care through our contracts with innovative health plans and employers. That's step one, make sure this care is covered by insurance.
Step two is to make patients aware of Oshi Health as a care option. We use three types of partners to build this awareness.
Employers: play a unique role in designing and offering health insurance and benefits. Employers promote Oshi Health as a new benefit offering to employees through a wide range of tactics and channels, often alongside other innovative benefits. This has proven to be the most effective approach to date.
Health plans: some do co-branded communications to members letting them know Oshi Health is an in-network GI care option, along with listing Oshi in provider directories and the virtual care section of their member apps. Plans are also making introductions or connections to at-risk primary care groups in their networks so they are aware of Oshi's care and can partner with us for referrals.
Provider partnerships: building and expanding partnerships with great local gastroenterology and primary care groups, as well as health systems, to provide hybrid collaborative care with bi-directional referrals. Oshi is scaling access to multidisciplinary care that typically is not available via local providers, so we are complementary to and do not compete with their services. A patient may hear about Oshi through their trusted local physician who refers them for our multidisciplinary care and Oshi can refer patients needing in-person procedures, diagnostics, infusions or exams to our local partners.
Ultimately, we believe that members should find Oshi via referrals from their trusted doctors and/or promotion by their employer, while our care is reimbursed by their health insurance.
To date we have not done much direct-to-consumer advertising, because we have not had enough density of insurance coverage in states. This is rapidly changing now as we scale and we will be investing more to build our brand awareness among patients in the coming year.
What types of GI visits can be done virtually and how do you connect patients with in-person care when they need it?
Diagnosing and finding successful treatments for many GI conditions requires a lot of detective work in the form of extensive history taking, discussion of symptoms, discussion of past workups and then an iterative approach to identify the root causes of symptoms and test a combination of medication, dietary changes and cognitive/psychological techniques to figure out what keeps symptoms controlled. Many GI conditions cannot be accurately confirmed and have root causes identified via diagnostic testing. Colonoscopy or endoscopy can detect cancer or more serious and structural or autoimmune GI diseases, but many patients leave these procedures with the good news that they don't have cancer or IBD, but with a more challenging-to-understand diagnosis like irritable bowel syndrome (IBS) and without clear answers about what will work to keep the symptoms controlled.
Oshi's care model starts with tracking down prior medical records and then having a long, 45-60 minute initial appointment with the patient, during which we ask extensive questions about the history of the symptoms, what treatments have already been tried and more. We ask about potential root causes that are often not questioned, including a history of trauma and other potential psychological triggers. Our clinicians can order diagnostic testing, make diagnoses and order medications, as needed. Our patients love the longer visits and not feeling rushed...they often give us the feedback that it's the first time in their GI care journey that they feel seen, heard and understood.
Patients are then given an initial care plan that often includes meeting with our GI-specialized dietitians and gut-brain psychologists every 2-3 weeks to iterate until symptom triggers are identified and effective treatment is implemented to control symptoms. This would be impossible and inconvenient to do with in-person visits. Between visits, patients can track their food intake, bowel movements and symptoms which are viewed by our clinicians to inform next steps in care. Again, telehealth is the only way to enable this high-touch, high-frequency care model and connecting expert clinicians in short supply with patients in different states that need their care.
When our medical team identifies that a patient needs in-person care (colonoscopy/endoscopy, imaging or infusions), our team of care coordinators helps the patient find a high-value in-network local provider, get an appointment and ensure records are transferred to and back from the local provider. Our medical team can talk to the local provider to answer any questions and collaborate around patient cases. We work hard to ensure a smooth experience for both our patient and our local provider partner.
Oshi Health is currently seeing patients in 24 states and will be launching in the remaining 26 states plus DC throughout 2024. Over time and as our patient volume is rapidly growing, we are establishing more formal partnerships with health systems and provider groups across the US.
“Our patients love the longer visits and not feeling rushed...they often give us the feedback that it's the first time in their GI care journey that they feel seen, heard and understood.”
Can you talk a little bit about the virtual care specialty space and where you see it going in the future?
I’m seeing acceleration on two fronts. First, there is the next frontier of value-based care, which is specialty care – 60% of low-value care is delivered outside of primary care. Value-based kidney care and oncology have shown significant progress and I believe we’ll see this expand into gastroenterology, musculoskeletal, and cardiometabolic care this year. This will include broader recognition that virtual specialty care clinics like Oshi Health and our peers in other specialties are key partners with both health plans and local provider groups to enable scalable access to care that can drive great outcomes and lower total cost of care across the healthcare ecosystem.
In parallel, we expect to see more employers and health plans seeking accountable or value-based care in the commercial insurance market. With greater economic pressures, employers are seeking ways to lower healthcare costs and questioning traditional networks and solutions from health plans, and finding providers able to improve access to primary care and specialty care for highly prevalent and costly conditions. More employers will offer virtual-first primary and specialty care with value-based payment models in 2024 and 2025, ideally integrated via their health plan or TPA for ease of administration compared to buying traditional point solutions.
While these are both exciting trends, I also want to call out the key limitations. So many aspects of our healthcare system and regulation and technology systems were built with the assumption that healthcare could only be delivered in-person, in the local market. This is no longer the reality. But many unintentional barriers still exist that prevent virtual care from making the impact that is possible on outcomes and value. I am hopeful that health plans will continue to invest to update their processes and technology platforms to enable virtual care as part of their networks and that regulators, lawmakers and state medical boards will take a fresh look at all laws and rules that place constraints on enabling providers to see patients across state lines, allow advance practice clinicians to operate at the top of their licenses, and to bring innovative new care models to patients in need across the US.