Aristotle Mannan graduated from the University of Michigan in 2011 with a degree in Cellular and Molecular Biology. After college he moved to Cambridge, MA to begun his career in the biotech/pharmaceutical industry where he worked in early-stage drug discovery and genomics.
To get a broader perspective of healthcare and work more directly with patients, he left his work in 2014 to pursue opportunities working with community-based organizations in the greater Boston area. It is through his experiences working with frontline, safety-net organizations that he was inspired to develop bosWell and address some of the inefficiencies involved with coordinating care for the most vulnerable individuals.
Hello everyone, this is Ray Pedden from Center for Care Innovations. We are thrilled to be joined by Aristotle Mannan who is the founder of BosWell. BosWell is a digital health company that improves coordination of care for Medicaid patients and and guides decision making for their health plans. BosWell’s platform leverages front line community based organizations to individuals at the point of care, assess them for social and environmental health determinants and triages the highest risk patients for cost effective interventions.
Ari welcome to the show and thank you for joining us on Health Pilots today. We would really like to hear a bit about yourself and your journey and what you’ve gone through as you put together Boswell. And how you thought about the platform that BosWell is interested in offering in the safety net community and broadly throughout the industry.
I started out in a totally different part of health care. I studied molecular biology in undergraduate. I was into biomedical research and biotech. When I got out of college I spent three years working at the Cancer Research Institute. We were involved with early stage drug discovery.
I learned about data analytics and predictive models. But I wanted to get out of my comfort zone and see another part of health care and have a direct impact on what I was doing. So in Spring of 2014 I quit my job and started volunteering with community based organizations around Boston. These were mobile health clinics, food pantries, shelters, churches, detoxes, really any of those touch points in the streets for those in need. In the course of doing this I opened my eyes to a lot of aspects in healthcare I really hadn’t seen before.
In June 2014 I was working with a mobile health clinic in East Boston run by first year medical students. Every Thursday night they went out to East Boston and provide food, toiletries, and clothing to about 50 individuals. Most of these were low income and on Medicaid, hanging on by a thread. East Boston is geographically isolated and it has the highest liquor store to grocery store ratio so it’s a metric for a medical hot spot. A lot of audible people are out there.
The first person I met was this guy named Hughie. And Hughie is an inspiration for BosWell and taught me about a lot of things at the safety net level. Hughie was 57 years old, he was sitting on the bench drinking Listerine, he was wearing a green hospital gown because he was a frequent flier to the Boston Medical Center, he was homeless, had food poverty and probably some depression or mental health issues as well.
Every Thursday night I would see him and he was stuck in this vicious cycle. Bear in mind there are 40 to 50 people who come through each night but a handful of people are like Hughie – caught and just can’t escape. For six months I knew Hughie and then one night he passed away in the parking lot. That was shocking to me because it was the first time I experience that. What was even more shocking was that it didn’t take long for Hughie 2.0 to emerge.
Another guy sitting on the bench, drinking Listerine, also a frequent flier to Boston Medical Center. I guess as far as social disparities exist, that vicious cycle will also exist. BosWell started because I noticed all the organizations I was working with were pen and paper record keeping or not at all. There are a handful of larger nonprofits that had electronic record keeping but for the most part these were mission driven impact oriented nonprofit organizations. The initial aim was to address record keeping needs.
So really then, you are talking about BosWell as an application platform in the hands of the front line social worker. As a person in front of the patient, in the streets, in East Boston, who is interviewing people like Hughie. So you think of a platform and you are doing the interview. What kind of barriers exist in that conversation with the Hughie’s of the world? Are they afraid to talk, are they willing to talk, will they share? How difficult is it to learn what is going on and how much repertoire does the clinical worker need to have with the Hughie’s?
I think one of the hallmarks of the safety net community based organizations is the relationships that are built and the trust that is built with the client and the social worker that is doing the intake and provides services. I think that trust diminishes as you get further along into the healthcare system into the subspecialties.
Hughie went to the emergency room maybe 150 times a year but they didn’t really know about his back story. Until the point he crashed and goes into the crisis mode, they aren’t really witnessing deterioration in his life. Those touch points, the clinics and shelters are seeing this day in and out and so there is a lot of trust there. We leverage that trust to collect a lot of information, particularly social risk factors, that would otherwise be missed or not collected at all.
In a sense, you have replaced the paper system with an electronic system that we hope is user friendly for the health worker. And you have replaced the memory system. So is it that simple to implement? Do you simply hand the person a smart phone and have them tap on an app or hand them a tablet and say open an application? Is there a training? How difficult is it for the community health worker in the street? What is the reaction of the patient? Of the Hughie?
In the Fall of 2014, I approached a few of the organizations I’d been working with and asked if they’d be interested in piloting an application. Interestingly enough, my neighbor is a software engineer so he was able to build a few prototypes of the applications. We vetted those prototypes with the organizations and got their feedback.
We saw a few initial advantages initially. One is that efficiency is compromised when you use pen and paper. You lose a lot of information and under report information. The other thing is they are required to transcribe information into an electronic form at the end of the fiscal year or the end fo the quarter.
So they were willing to adopt our application. The other thing is we offered it for free and said it is always going to be free. There’s no need for us to be charging organizations that are doing so much on so little resources. I think that was the catalyst for us getting pilots. As we’ve continued to do this, we have realized how different many of the organizations are and different intake needs, sometimes the services they provide and data they report are very different as well. So we are continuing to modify data accordingly.
You’ve had experience collecting data, you’ve had experience in the street and community health workers seem to be happy with the ability to collect and aggregate the data in reported health. What benefits have now come from that for the Hughie’s?
We envision the data we collect to be really valuable in helping forecast. I think there is a big disconnect between the health systems for delivering care and the community organizations that are on the streets doing this every day. There is growing evidence that social risk factors are indicative of outcomes and costs for a number of patients in particular the Medicaid population and the Hughie’s of the world.
We envision using the data we collect at the front line to risk stratify the population in real time and triage people for earlier interventions. That is something that can be acted upon through a health plan or system that has care coordinators and social workers. It’s really hard to find a needle in a hay stack. As for folks like Hughie, it takes a while for them to even become a blip on the radar.
A lot of the analysis that is being done is retrospective analysis on claims data. Given the lag time in claims data which can be up to 4 months, when you do a retrospective analysis on someone like Hughie, in the span of 4 months you issue the first claims, he may have already been to the hospital 30 or 40 times. It’s crisis that folks go to when they end up in the hospital. Unless you can stop or identify the risk pattern of behavior early on, any sort of intervention isn’t going to make a change. That’s what happened to Hughie.
At a certain point, a guy that has been in the hospital 150 times and has hit his head on the pavement even more than that, there is not as much you could do as you could have done a few years earlier. That’s where we want to have an opportunity to treat earlier for better outcomes.
How are things coming along in your ability to predict future high utilizers based upon the data that are collected by your community health workers?
It took us some time to figure out the value of the data we collected. Initially we just wanted to address the record keeping needs. We realized in order to make this sustainable and scalable and offer it at no cost, we needed to figure out the value chain and who benefits the most from this data layer.
We approached hospitals initially. Their incentives are a little bit different in the sense that they are very much fee for service – especially the emergency departments. There are a lot of folks that flood the emergency departments (the Hughie’s of the world) but they still get paid, especially the Medicaid population for the Hughie’s that come through the emergency department. It’s kind of a catch 22 to go to them and say well we are going to keep Hughie out of the hospital. It turns out they still get paid 60% of the bill 100% of the time if Hughie does come to the hospital.
So I think the top of the value chain are the payers. In the place like Massachusetts where I’m based, you have Medicaid managed organizations that receive capitated upfront payments from Mass Health, the state Medicaid agency. They might receive about $3,500 per patient per year on a number of patients. It’s up to them to risk stratify the population.
It’s that inability to identify a patient like Hughie early on and reroute him out of the hospital that is very costly to him and them. I think that’s really the target customer depending on what state we are in you have- Medicaid ACO’s, FCO’s, intersect our data layer with the claims data layer that they have and show that the predictions that we make are correlated to outcomes.
So as we think about this in a provider community (and you bring up hospitals as a good example – their community health centers, their clinics, the for profits) as we get into a provider organization everyone seems to be focused on innovation in health care. Given your experience and given that your actually doing work in Boston and getting traction in what your doing in this particular space, what advice would you give to the provider community about innovation in health care in light of your experience this far?
I would like advice from the provider community as well because we are trying to learn more about the challenge and pinpoints they have in coordinating care for this complex population. I think it comes down to seeing the problem at the front line. I think often times the provider, patient relationship is confined to the four walls of the clinic. The reason why the community based organizations are so important today is because there is a deficit of providers.
In East Boston a number of folks may have Medicaid or might be covered by expansion, but they don’t necessarily even know who their primary care physician is. The reimbursement rates are really low, so a lot of primary care doctors don’t take the vulnerable Medicaid population as patients. Its estimated that there is 30,000 deficit of primary care physicians that’s going to double in the next ten years.
These safety net community organizations are all the more important. That’s where you can really learn about the vulnerabilities of the patient population and the things that contribute to there complexities: why they might not be able to adhere to a certain medication, why they can’t make an appointment, why they are caught in this vicious cycle. Just going out there and seeing it has a lot of value.
There are a lot of other entrepreneurs out there like you and Boswell and really trying to address some of these needs. What advice would you give to your fellow entrepreneurs out there? They aren’t providing care but they are very interested in trying to help facilitate the change in health care. What advice would you give to the entrepreneur?
I would say keep an open mind in evaluating an area or problem that you want to go after. Don’t pigeon hold yourself into one specific issue and have a preconceived notion of what your solution might be. It’s similar to what I said about the providers, just kind of going observing and seeing what is out there. I just stumbled into this but I was observing what was happening at a community based level.
I noticed there was an obvious issue where data was being captured but not in a formal way. It’s not in an electronic way. It also seemed obvious that these folks had preventable issues. At the front line there was limited bandwidth to take care of the Hughie’s of the world.
I spent a lot of time observing, and asking as many questions as possible, and speaking the language of the community based organization (it’s a relationship building component that’s important to understand how they interact with their patients and also to get more insight from them too.)
If our listeners want to learn more about you and your journey and BosWell and how they want to take advantage of things you’ve learned thus far, how should they get in touch with you to learn more?
I’m always happy to meet. My email is Aristotle at boswell.io. We should have a website live in May. You can also tweet us at BosWell_io. I’d be happy to connect with anyone that has questions.
Do you have anything else for our listeners?
It’s been a pleasure to be part of the podcast. We are an early stage endeavor now. We are just starting to launch some of the pilots with ACOs and MCOs. We are intersecting our data layer with claims data to show that we have a predictive model. So hopefully we’ll have some more updates in the next few months.
Thank you very much for taking time today Arti. I think everyone listening will be inspired by your journey. I think they will also appreciate some of the insights you’ve shared on BosWell and what you’ve learned being on the streets of Boston. And we really do appreciate your time.
Thanks for having me.