Dr Michael Fratkin is a practicing palliative care physician and Founder of ResolutionCare, based in Northern California.
ResolutionCare is a social enterprise offering remote palliative care services via videoconferencing technology and an interdisciplinary team. It started as an Indiegogo campaign in 2014.
We caught up with Michael to learn more about ResolutionCare, and get an insight into the future of telemedicine.
How did the idea for ResolutionCare come about?
The idea was borne out of frustration with the unworkable nature of the US healthcare system, with its questionable economic incentives. The fee for service economics pushed me in the corner. I explored videoconferencing through Google Helpouts [now closed down] and discovered I could use it to provide a tech-enabled, home-centered palliative care program. Then I discovered a concept called “tele-mentoring” through Project ECHO and realized I could sort of clone myself by sharing what I know where it can make a big difference.
Can you talk us through a case study of an individual that ResolutionCare has supported?
This story was featured in a PBS Newshour piece. A young man developed a glioblastoma and strongly believed he would fight to the end, and find a miraculous cure. He regularly travelled 6 hours each way to visit his oncologist in UCSF [University of California, San Francisco], with whom he had developed strong bond with. I introduced him to the concept of palliative care using the ResolutionCare interdisciplinary team and an in-person meeting. I then followed him up remotely via videoconference on a regular basis. His oncologist from UCSF also took part in these videoconferences. That was powerful for them, we were all in tears.
Oncologists usually lose contact with their patients in the final stages of their disease as patients can’t travel to see them. So oncologists don’t actually watch the last few days of life, and they assume it is a horrific experience for patients to go through. Actually the norm when palliative care is offered is to have improved wellbeing in last few days of life.
Has ResolutionCare helped widen access to palliative care?
We maybe have 1/20 of the palliative care resource we need in the US, particularly for those in rural areas. The ResolutionCare approach has saved our patients 18,000 miles of driving since we set-up.. We have tripled capacity for palliative care in our local community in Northern California. There is now better palliative care availability in our rural community than in San Francisco, thanks to ResolutionCare.
As intelligent machines manage data better than we ever could, effective communication will return to be the focus of a physician’s role.
Though surely palliative care is better suited to in-person discussions than telemedicine consultations?
The conventional palliative care experience is impersonal as the doctor is staring at a screen to document, and not the patient for half the consultation. In addition, patients have to verify their identify and appointment details at reception by repeatedly answering a bunch of redundant questions. When a person travels to a hospital they become a patient. In a videoconferencing environment they are in a “magic window” where I am able to focus on them without distractions, and they are in control as they are in their own home where they feel most comfortable.
In some ways this even better than a home visit, where there are distractions [such as a playful dog], and people have to cope with a doctor intruding into their home. In videoconferencing consultations there feels less need for foreplay and small talk, leading to a more focused discussion. I am doing some research to improve our understanding of why telemedicine consultations are shorter than in-person visits, as I find that interesting.
The outcomes based model is the key to freedom from the misaligned incentives inherent in a fee-for-service model.
How do you see the evolution of telemedicine?
10-15 years ago Telemedicine 1.0 was used to connect large teaching hospitals with rural communities to get sub-specialty input. It didn’t have widespread traction though, as the tech platforms were not well developed.
Telemedicine 2.0, which we have seen in the last few years, works due to ubiquitous internet access and handheld devices to facilitate virtual consultations for minor ailments and sniffles. This is beneficial, but not the only value of telemedicine.
Telemedicine 3.0 is a restoration of tradition, the deep and profound engagements between doctor and patient doing what we frequently fail to do in the hospital setting or in clinic, where we medicalize people. This type of telemedicine restores personhood in the care of illness, and that’s exactly what we are seeking achieve at ResolutionCare.
You use home visits too – do you think telemedicine can ever exist without the physical aspect?
One challenge we have is that people can’t believe palliative care via telemedicine actually works. For now a hybrid model, where videoconferencing is combined with home visits, makes patients and caregivers more comfortable. Through the hybrid model we are learning interesting things to iterate our product. However, the future for ResolutionCare will be almost totally virtual.
What is your revenue model?
We have partnerships with one public health plan and one private health plan. They will pay for as much capacity as we have. These two health plan providers have 15.4m individuals between them, and a conservative estimate is that 150,000 are eligible for palliative care. The health plans know they will get a return on their investment. They understand the value proposition of community-based palliative care. When patients are empowered to choose they don’t choose the most expensive treatment, but instead the most effective.
I thought crowdfunding was about the money but it turned out to be about building a community.
Can doctors be trained to communicate effectively via telemedicine, or is it just something you learn by doing?
Yes and yes. I am sure that the same question was asked about telephones. In the past, before the industrial model of medicine brought scientific obsession and death denial, the core value proposition doctors offered was communication. As intelligent machines manage data better than we ever could, effective communication will return to be the focus of a physician’s role.
ResolutionCare uses an outcomes-based payment model – how has this worked out so far?
It has been fantastic for us. The outcomes based model is the key to freedom from the misaligned incentives inherent in a fee-for-service model. If you pay for the outcomes that the people you serve define as desirable, then that is what you get. Our two strategic partners pay us to get to the goals patients want, and almost couldn’t care less about what it takes to get there. It allows us to invest in an incredible team that thinks outside the box, and works to create value for the folks we serve and their families.
I was incredibly surprised at how creative and inspiring business development actually is.
What was your experience using Indiegogo for crowdfunding? Why did you choose Indiegogo?
That was a wild ride that yielded far more traction for our story and mission than it did gather funds. This was a surprise. We were the top trending campaign for the last three days of our campaign!
I thought crowdfunding was about the money but it turned out to be about building a community. The back story is how much social media activity and the personal communication was required to pull off the success. On midnight when the campaign began, my iPhone literally burned up…heat, smoke, and everything! With the costs of the campaign, the net gain was much less than the $137K we gathered. The real yield was a committed tribe of nearly 600 people passionate about caring for people completing life comfortably.
What advice do you have for doctors considering an entrepreneurial path?
I was incredibly surprised at how creative and inspiring business development actually is. I would have never thoughtfully gone this direction, it had to be grounded in distress, burnout, and indignation about the status quo. If you are comfortable staying grumpy and resigned about your work and your place in the world, stay put and don’t bother. If you can imagine a world where you and the folks you work with are actually fulfilled and adding value to a world in great need, start drinking coffee and get busy!
Which other healthcare startups do you particularly like, particularly palliative care startups?
Also watch Michael @ Tedx: