Ep 11. Reimagining Home-Based Care: Insights from Dr. Vipan Nikore

In this episode of Value Health Voices, Dr. Vipan Nikore discusses his journey as an entrepreneur in the healthcare sector, focusing on the innovative concept of Home Care Hub. He shares insights on the challenges and opportunities in home-based care, the importance of metrics in measuring outcomes, and the regulatory hurdles faced in the industry. Dr. Nikore emphasizes the need for policy changes to support alternative care models and advocates for a future where smaller care homes provide dignified and personalized care for the aging population. He also offers advice for aspiring healthcare entrepreneurs, highlighting the importance of mentorship and networking.

Takeaways

• Dr. Nikore's journey from software development to healthcare entrepreneurship.

• The importance of home-based care in improving patient outcomes.

• Home Care Hub aims to create smaller, community-based care homes.

• Metrics such as decreased readmissions are crucial for success.

• Regulatory challenges vary significantly across states and provinces.

• Advocacy for policy changes is essential for funding alternative care models.

• The future of healthcare will involve more personalized and accessible care options.

• Data collection from home care can drive better patient outcomes.

• Entrepreneurship in healthcare requires resilience and adaptability.

• Mentorship and networking are key for aspiring healthcare entrepreneurs.

Introduction and Guest Welcome

Welcome to episode 11 of Value Health Voices, where we're going to be speaking with expert and innovator Dr. Vipan Nikore about reimagining home-based care and the value proposition. So let's get into it. Dr. Nikore and I have known each other for over 20 years now, when we attended business school together at Yale. In fact, we have three MD MBAs on this call at the same time, so a first for Value Health Voices.

This is great to be here. And don't call me Dr. Nikore.

That's all right. I'll call you VIP.

Guest Biography: Dr. Vipan Nikore

So VIP is the Chief Medical Director of TD Bank Globally, the CEO and co-founder of Homecare Hub, and a practicing internist at Trillium Health Partners and Cleveland Clinic in Ohio and Toronto. He is an investigator at the Institute for Better Health and previously was course director for MIT's Global Health Informatics course. He has worked clinically in Haiti, Peru, Ghana, Nepal, and India. He is a former IBM software developer, led projects at the WHO in Switzerland, UNICEF, Sun Microsystems, and Citibank. He completed his internal medicine residency at Cleveland Clinic, his MBA from Yale, and he was the former winner of Canada's Top 40 Under 40 award. Welcome, VIP, to the podcast.

Thanks, Amar. Thanks, Anthony. Great to be here.

Thanks for joining us. So VIP, maybe you could just tell us a little bit more about yourself and what got you inspired to be an entrepreneur.

Early Entrepreneurial Roots

You may remember some of this, but my life before business school—and I did business school before med school—was a little bit non-traditional. I was a software developer. I was a student during the dot-com boom out in Silicon Valley. For me, it was such a formative time, programming away when there was so much innovation happening with the Internet.

I remember in undergrad, my team and I built this MP3 player that locked down. It was on the front page of our student newspaper, and people were asking me, "Are you guys going to commercialize this?" I'm talking to people, and my cousins are like, "Well, you're gonna have to go against Apple. Are you ready to do that?" And I'm like 20 years old, right? But it was so exciting to me at the time. This is way before Spotify or the Napster days.

For me, it was just such an exciting time to think about, can we create the next Microsoft or whatever it might be? Thinking about how technology can have such a great impact in a positive manner on people, I've known I've wanted to be an entrepreneur since those undergrad days. I knew I was going to go to business school during those days. What I didn't know at the time was my path towards med school, which as time went on, I really gravitated towards and have been very happy about.

But I've known early on, and then of course during business school, with a lot of the lessons and teachings, I was thinking about entrepreneurship then. So I knew the day I stepped into med school, I wanted to start something up. During med school, I started a nonprofit called uFLOW, and we empower underserved youth to start their own service projects. We expanded that to five cities.

It was a really meaningful project for me from an impact standpoint and from a youth mentorship standpoint. But it also got me away from the med school books and a lot of the rote memorization and the science-based stuff, back to thinking about our Yale days—how can you build something to change the world? That was very exciting for me, and I built new skills. I've kind of been waiting a long time for this moment, let's just say.

It's funny you bring up those days because you're right. I remember talking to you back then being like, "Are you crazy? Why would you go back to med school?" You were down this path, but I guess you used all that knowledge and skills you learned not only in med school, but also residency and practicing, to create new ideas to be an entrepreneur.

That was the plan. Here I am.

You brought me back. I remember, unlike you, I did the MD and the MBA as an integrated program. I remember very acutely that tension between the two kinds of thinking. And also the two crowds. The med school crowd I was with, the MBA crowd I was with. You brought me back as if it were yesterday with your comment.

Totally. We all recognize that difference. Amar was one of those MD/MBA integrated people, and I was one of the MBA people wanting to join on the inside back then. It's two very different ways of thinking, no doubt.

Career Path and TD Bank Role

So that pivot then, after you decided that you wanted to get back into this, why did you focus on home healthcare? And also, there was this bit where you went and became the Chief Medical Officer at TD Bank, and you continue to do that. How did all that play out for you?

When I finished residency, I went out to MIT and was teaching out there a bit, and then I was at Lux Capital doing some venture work with them out in New York. I was doing some clinical work in Brooklyn and also at Cleveland Clinic, our main campus, and some other locums. It was really almost like this made-up program because I knew I wanted to go back to Canada ultimately. I'd been in the U.S. 12 years and kind of wanted to get back to Toronto soil.

I went back and was doing 42 weeks clinically at first, really getting my clinical chops in. I'm a hospitalist, so I'm discharging lots of patients. Pretty soon after, I actually had an opportunity to become Director of Medicine in my department. So I took on some hospital admin work for a while at Credit Valley Hospital at our Trillium Health team. I was still working at Cleveland Clinic, and then we were still seeding the idea of Homecare Hub.

At the time, our CEO of Cleveland Clinic Canada, Mike Kessel, asked me if I wanted to be the guy we bid on for TD Bank's Chief Medical Director role. At first I was like, well, I'm kind of starting to move towards this startup thing and I'm already busy. After some conversations, we went for it. We got it. So my role at TD Bank is through Cleveland Clinic. It's a program we've developed where we service over 15 different large organizations as their Chief Medical Director. A lot of the big companies out in Canada and now some in the US as well.

So I've been able to straddle a few different hats. TD oversees their 100,000 employees. It's really interesting, Amar. Back during business school, I went to some of these Net Impact conferences and I remember meeting a Chief Medical Director of Coca-Cola of Africa, I think. It was a really interesting role. I'd always had that in the back of my mind. So when this came up, it was pretty cool to be able to pursue that. I've been in that advisory role eight years. It was really unique during COVID, as you can imagine, and has stabilized since then. That's kind of my journey. Ultimately, I left my operating role as Director of Medicine and went pretty much all-in on Homecare Hub from an operational standpoint.

Supplemental Care in Canada vs. the US

VIP, maybe you could set me straight on this because I might have this wrong. I have some ideas in my head about interacting with people in similar roles in Europe, but in Canada, are you functioning—and is your relationship between your role at Cleveland Clinic and TD Bank and perhaps other firms in Canada—as a supplementary program on top of the access that people have to healthcare through their provincial health service? What exactly are you doing there above and beyond the care that everyone has universally in Ontario and elsewhere in Canada?

It's a bit of a mix and unique to each client because Cleveland Clinic has so many different services, from actually providing care to providing strategic and advisory insights. For my role at TD, it's largely on the medical advisory work. So for the 100,000 employees, we focus more on strategic healthcare advisory as opposed to providing medical care for the patients themselves.

Now, we have 30,000-plus people in the United States. So from a policy perspective and advisory perspective, it's quite different. My role in Canada versus the US is all integrated, but there's more we can do as an employer-based health plan in the US compared to Canada where the government's already paying for that. It's a different type of insight there.

I can only imagine during the pandemic they would all probably turn to you to find out about masking policies, vaccinations, lockdowns, return to work, all that, right? You were the only one who knew all the answers.

I was trying to figure out the answers. It was quite the time. I had just launched Homecare Hub in February 2020. I'm an internist, so I treat COVID patients. I was trying to cut down on my clinical work, but obviously I couldn't do that when we didn't have enough docs, so I was actually doing more. Between it all, it was a pretty crazy time.

Just to flesh out your question, Anthony, on supplemental care: Cleveland Clinic does this for Air Canada. They have already had a longtime Chief Medical Director, so we provide an infectious disease doctor who serves as a supplemental chief medical advisory team to them. I gave a talk to Air Canada not too long ago as part of our Cleveland Clinic team. So the relationships vary in many ways and customize towards different clients.

My question was motivated by, for example, in the UK, where a lot of executives or director-level folks are provided with private insurance coverage on top of their public access. They have the NHS, and then there's a relationship with perhaps someone in a role like you overseeing that product and how those folks access care through that private care on top of their public access.

There is. We have TD in the UK and Cleveland Clinic in the UK. So I've actually been involved in some of those conversations overseas as well.

The Genesis of Homecare Hub

Great. Well, maybe let's talk a little bit about your startup then, Homecare Hub. Tell us about it.

So you were asking how I got into it. Early on when I was a full-time hospitalist, I have a couple of old friends of mine who are really sharp lawyers and they were in the home health space. They called me up and we started talking about innovative disruptions in the home health industry. I quickly brought on my co-founder, Rahim Lalani, and my other two co-founders, Brian Kwan and Jay Vaghela on the legal side. We had a pretty good breadth of discussions on what we could do. We spent a lot of time brainstorming, figuring out the best path forward to improve the system.

But for me personally, the drive was as a hospitalist. I came back from the US to Canada working in both systems, and we had about 10 to 15% of people just sitting in hospital beds with nowhere to go. I thought, in what world does this make sense? People are waiting in the highest cost place to go to a place, generally a nursing home, that they don't really want to go to, which costs the payer—in our case in Ontario, the government—quite a bit of money. In what world does this make sense?

Then I started peeling back more and more layers and recognized that the problem is really universal across North America, even globally as well. Obviously, we know about the aging population. I think I didn't notice it as much in the US because we have so many SNFs (Skilled Nursing Facilities) that we can discharge patients to in the hospitals. We're kind of just kicking the problem down the road. There are people stuck in hospitals in the U.S. no doubt, even back then, and it's only worse now. A lot of SNFs aren't even accepting patients, but half the problem is also in the SNFs and getting people out to a community-based center.

My first internal med rotation in Chicago, I was at the VA. I remember my first patient said, "I'd rather die than go to a nursing home." I'm a medical student, so I'm spending half an hour just trying to convince him. Some of those memories really stick with you, and you realize there's got to be a better experience for older adults to have in their life. Nursing homes are going to have to get better, and I hope they get better, but ultimately, what are some alternative paths that we can create? That's sort of the beginning.

The Distributed Small Home Model

So just from 10,000 feet, for a layperson, I'm kind of like, okay, so you're talking about nursing homes, like just doing the same kind of stuff at home? Am I missing something, or is it just that, or is it something else?

It is something else. I realize I haven't even got into what we do; all I did was sort of tell you the why in terms of why I got into this. Ultimately, what we do at Homecare Hub is assemble networks of small care homes on demand as alternatives to nursing homes.

Instead of having 150 people go into a 150-person big nursing home, which is one extreme, the other extreme is you have everyone in their own home—150 homes. We know virtually 100% of people want to stay in their own home. But the reality is that's obviously not happening because people are going to nursing homes, and there are thousands, millions of people across the world going into nursing homes. So obviously there needs to be a place outside of their own home.

Our hypothesis is instead of those 150 people in a nursing home, you can create this distributed network of smaller homes—3 to 5 person homes, 10 to 15 person homes—and create them quickly, more efficiently, with better outcomes on demand. We basically run a platform that helps create these homes and we run them in tandem with other partners. We run some ourselves as well. We built that entire technology platform to create that, and we partner with payers and health systems to help expedite hospital discharges.

Metrics, Outcomes, and Cost Savings

What are some of the metrics that you demonstrate that this is a better solution? Could you get into that a little bit?

Metrics is key. We launched in the Toronto area initially. Then in 2024, we launched in the US in Wisconsin, and by August, about seven months after launch, we had already started to show decreased length of stay and decreased readmissions when we were involved compared to when they're going to a non-Homecare Hub home. I presented that to the Wisconsin Hospital Association in tandem with our health system partner, the Froedtert Health System, which is the Medical College of Wisconsin, last year. So those are a couple of key metrics.

I'd be interested to know if not only Froedtert, but perhaps other interested clients that you talk to, ask about what you could do for them in the context of their value-based care contracts. If you are materially reducing readmissions, then that's typically one of the metrics in those kinds of contracts that are the most weighted in terms of the bonuses that the provider side can get.

Absolutely, and that's exactly where we're going. Measurement is key. Being able to take care of really hard patients is really what our focus is. A lot of times people will almost lie to us when they refer a patient to us, or they'll leave out information. This happens a lot in the post-acute world because it's hard to get people out. So sometimes there's not always transparent information, nursing assessments, et cetera.

We encourage people: just tell us. We're not going to reject this referral just because they're hard, because we're designing a system to take really hard patients. We have some of our partner operators on our platform who take the hardest people coming out of jails, and they've had no readmissions in two years. We want to take that, but we need to know so we can make sure the supports are in place so that we can put them in the right environment where they will thrive.

We have to have all that information. When that happens, we're measuring all this out over the next couple of years and we'll have more and more data to show. To your point, there's a significant savings for all these health systems and payers if we continue to provide better care and better outcomes. But what we've done is we've created the system so efficiently that even if our outcomes were the same, we're still going to save them a tremendous amount of money because of the way that we've set up our system in terms of our operational efficiencies. Our cost tends to be about 30% lower than a traditional nursing home or traditional assisted living.

And that's just because you don't have to deal with as much overhead and you're using economies of scale?

It's almost like if you ask Amazon how they are so efficient. They're looking at every little piece of the supply chain. Even one of our partner developers who build houses at a very low cost, I was asking them how do you do it cheaper? And they're like, it's every little detail in the whole stack, in the whole system, being able to aggregate economies of scale. To your point earlier, Amar, the technology that we have built—all these little things add up more and more. We're not building any infrastructure either, which also makes it low cost.

I'm curious, you're talking about all these efficiencies that your company creates, which obviously help reduce costs. But in terms of the care gap that you're filling that allows for the readmission rates to be lower, are you helping with issues related to social isolation for some of these patients? What is the care gap you're filling?

A lot of it is these smaller mom-and-pop providers that run these homes on our platform. They don't necessarily have access to their own activities coordinator, or to really good nurses that we have on our team who can do the assessments and provide oversight medical care. So there are all these layers that we can bring in to say otherwise this person would not have been able to stay in the community, but in partnership with Homecare Hub, they were able to now stay in the community.

Patient Risk Stratification and Safety

I gotta ask you a question about patient risk stratification. For your own purposes, for figuring out how complex a patient is for the right fit and placement, do you have an extensive set of variables or characteristics of that patient that you look at to say, "Okay, this is a high-risk patient"?

Yeah, we do. We have a variety of different intakes that they have to go through. It often depends on the state because there are certain regulations. For example, in some states, the operators of our homes have to do their own intake, but we'll often do a supplemental one instead and get extra information. If it's a behavioral patient, we do an extra layer of review as well. We're integrating our health record into hospital health records so we can get more seamless information. The deeper the partnership we have with the hospital, the more we can even get some of this other information that's sometimes not captured in the notes.

It's getting all that information, talking to families, and getting all that to be able to risk stratify properly. And it's hard. We're over five years old now, but we've got it wrong at times too, where we missed information and thought maybe we should have asked this or done X, Y, and Z. It's not easy getting maybe someone who has significant mental health challenges out of a house when that's not the right environment and they're living with others. It's really important to try to get it right before they go in the home because it's not easy once they're in the home.

Navigating Regulatory Barriers

You were talking a little bit about the regulatory environment. Maybe you could comment a little more about that. What are some of the barriers you're facing in terms of regulatory licensing?

It's a common question I get as the CEO of a company trying to create a scalable company in an environment where every province and every state is so different. For example, most states have some structure for these smaller homes, but they vary significantly. In Wisconsin, they're called adult family homes if it's three or four people; five and above is a community-based residential facility. They have different regulations for each. But generally, Medicaid does pay, and at reasonable rates.

Like Pennsylvania, they have personal care homes, but Medicaid doesn't pay for the personal care homes. So the strategy is quite different. It's hard to create a scalable strategy when it's so wildly different—whether they're paid, how much they're paid, what they're called. It's quite complicated.

But ultimately, we know there are only so many different templates. Matt Atkin, who helped scale Uber—he was employee 100—is a board observer on our Homecare Hub team. I speak to him quite a bit. They had so many different ways of thinking about it at Uber, and they really distilled it down to different playbooks. We do believe that even amongst the complexity in every state and province, there are only so many different ways you could do it. That's why we believe we're getting strong in certain urban areas, rural areas, and areas where Medicaid pays versus doesn't pay.

I think that's the biggest policy challenge. At a bigger picture view, Medicare largely doesn't really pay for housing, which is a challenge. That's a whole different discussion. If we could get them to pay, that would be amazing.

I'm struck by what a virtually perfect analogy there is between what you're doing and the variability in regulation that you face and what Uber faces. In certain countries, they can just do Uber Eats, and in another geography, they can do Uber X all the way through Uber Black. It's really a beautifully aligned comparison.

It really is. We're lucky to have that insight from Matt on our team. But it's a challenge, and we've definitely learned a lot over the years in terms of which of those templates we want to go after in the first certain number of years. Which ones do we want to start conversations with? Because we know that's more of a policy change that we have to work on, and that becomes more of an advocacy exercise. Doesn't mean we don't want to start those conversations, but there are only so many hours in the day and so many people. You can't be in every state and province at once. You gotta pick certain ones that make the most sense.

Policy Advocacy and Alternative Care Models

Along these lines of advocacy, is there a dream scenario? What would you wish CMS or the states or payers could do to help allow for innovation like this?

There needs to be more of a focus and funding on alternative models of care outside of nursing homes. The Green House Project is a nonprofit out of D.C. that we work quite closely with, and they've been proving out these smaller home models for over 20 years and really advocating for alternative models. There's this newer Einstein option and others who are really fighting for the same thing—to say let's get dollars towards smaller care homes.

Whether it's through Medicare or whomever, there has to be options that provide that. Because in smaller homes, you can have more personalized care. When it's done right, it's even been proven to have better outcomes and cost savings on the system.

I think about locally here, where I am in southwest Ohio, but we really have a bottleneck in terms of LTACs (long-term acute care facilities) and SNFs. I really think that it would be a tremendous solution. I don't know what the situation is now in terms of funding here in the state of Ohio for these smaller home solutions like you guys are doing.

It's interesting you mentioned that because as a hospitalist, you're kind of taught that when someone gets discharged from the hospital, here are their options. Obviously, our great discharge planners and social workers really dive into the weeds with our patients, but we're taught the same decisions: you go home with home care, you go to a SNF, or if they're more complex, an LTAC. Or there are typically expensive assisted living options. That's kind of it. No one ever mentioned anything about these small homes both in the US or Canada.

Homecare Hub's goal is to create this really standardized common path to say there is a world where you can go to a smaller home, and it's seamless and it's going to be a great experience. For us, it's all about choice. People can go where they want. I want to see nursing homes do better. I want to see more home health. It needs to be an all-out approach. When we look at the number of beds that we need in the decades ahead, it's just math—it's not even close. We have to do something.

My goal is to create this main path. Even things like adult day programs—I didn't even know what that was till I got back to Canada. Day programs are amazing. Drop off your loved one at nine in the morning, be able to pick them up at five, and they get programming and socialization. These alternative paths need to become more mainstream.

That's true. So in the US, as I understand it, we don't have programs like that on any large scale. We see more and more the epidemic of loneliness. To name the state that I live in, we have an aging population here and not a whole lot of young people moving in. So that problem becomes more acute with the passage of time.

The former Surgeon General said it was an epidemic of loneliness. He's one of our alumni from our program. He's talked a lot about social media isolation. We know it's equivalent to smoking a pack of cigarettes a day in terms of the harmful effects.

There actually are some day programs in the US as well. They're again just not as mainstream as they all should be. PACE programs, if you're familiar with them, integrate a lot of day programs. The core of what they do is often around a day program. These are basically alternative models to nursing homes. That's another wonderful program that's starting to get more and more traction. These are the models that need to become accelerated as fast as possible.

Leveraging Technology and Data

Are you using any AI or any other technology right now in your models to help create some of these efficiencies?

Yes. With my background being software, we have a team of pretty awesome developers and they've been building software for years on this. Really the stack of software for small care homes to run their operation, to software that if you took a hundred thousand people, it would tell you where to put a home, who should live together, et cetera.

So we've built a lot on the tech side, and we have a lot of technology that we're not even using yet because we're not at that scale yet. But we're building. It's pretty exciting to watch it happen.

We're also part of the AARP AgeTech Collaborative. It is a really great incubator program, and then they ended up investing in us as well. So we get to have almost first access to all these other AgeTech Collaborative technologies because they want to be the leader in AgeTech out there. We're layering in lots of technology created by others into our homes as well.

It sounds like you're really onto something, really filling a massive need both north of the border and here in the U.S. From a standpoint of policy, are there things that we should be advocating for or lobbying for that would be helpful to the success and the scalability of solutions like you're offering? What should we be talking about when we interact with the government?

To distill it down—and I always say I'm not the policy expert; there are people who've been doing this for 30 years—my belief is generally more funding you can put towards housing is always going to be helpful. Healthcare and housing are linked much more than we often give credit for. So the more you can fund housing, you're going to get better outcomes for patients. Whether that's through Medicare housing, et cetera.

Being able to fund alternative models to traditional nursing homes, that's going to be really important as well. When I say that, that's broad—that's PACE programs, that's small home models. So just as a small example, Medicaid not paying for the Pennsylvania personal care homes.

Number two, putting a more seamless process to creating some of these smaller homes. There are some homes we've created or we're working with some states where they make it nice and simple. You create this home and you follow these directions and it makes it nice and prescriptive. And then there are some where it's so hard to find the information. I'm getting fingerprints, doing a million different things. I've got to fly down to the state. Our team has to do a hundred different things.

Imagine we don't mind doing it; we're a growing company. But what if you're a smaller mom-and-pop and you have to jump through a million different hoops to do this? They're just going to say, "I don't want to do this." How are you going to seed that infrastructure? Those are sort of the big ways I would say could help. But from a housing perspective, I think is the big picture.

One of the things you mentioned I thought was interesting. You were using technology and these learning models to potentially figure out where opportunities for your company are and to improve access for some of these seniors. But then the other thing with the data that's very interesting is you're collecting data from people at home getting this care, which is very unique. Not many people out there have that kind of data. I feel like that data would be very valuable to payers and health systems. Can you talk a little bit about what you're thinking in terms of that?

For me, I'm a clinician that wants to drive outcomes. So I see data as an opportunity to drive better outcomes. Also, as I mentioned, I'm a clinician, so my goal is to protect people's data. From a HIPAA perspective, people should be able to know that their data is safe and we're a reputable company that's going to be just using whatever information we have as a way to serve them better. That's the way I look at it.

The Future of Home-Based Care

Very noble approach. What do you think the space is going to look like in five to ten years? Home healthcare in general and how you and your company would fit in?

I think the future is going to be this distributed network of smaller care homes called Homecare Hub. Of course I got to say that—that's the goal and that's what we want to create. It's the idea that things get really challenging maybe with your parent or a spouse passes away, and they're otherwise about to go to a nursing home 20 minutes away. But now, maybe they can walk to see them. We've seen this happen with some of our own stories where now they're literally five minutes from their son or daughter because we popped up a Homecare Hub home in that area.

Having these in every little community, we think that is going to play a key role. But I think there's going to be day programs that pop up more and more. There's going to be better nursing homes—they have to have better nursing homes and nursing home reform. Even at the large scale, I think caregivers themselves are going to be more empowered. There'll be more live-in caregivers, I think from overseas, et cetera. There's already some of that, but I think there's gotta be all these different layers that you have to hit to solve this crisis. We gotta hit them all.

That's a beautiful vision. Really what you're talking about is from both the commercial side and the governmental side, a demand for and a delivery of dignity for people. Different countries take different approaches to try to deliver that, and different countries have different valuations or prioritizations of how important delivering dignity is to older people. The more we can talk about it and come back to it here in the US and keep it front of mind is important because, with all the myriad focuses that government has, it can get lost in the shuffle.

It's a great point. Dignity is something we've lacked for a population that deserves probably the most respect in society. It's unfortunately not always been the way. It's hard; you need a lot of patience. It's not an easy thing to do, but we have to invest the time to make that happen.

Just from an economic standpoint, I'm an internist. We care for most of the admissions; most of the patients are 80 and up. We like to glamorize a lot of wearables for young people—that's great, all really important—but the people who get sick and drive up costs in healthcare are generally older adults. So not only is it the right thing to do, it makes the most economic sense. I do think we have to generally, as a society, accelerate on this faster. From health systems to payers to governments, everyone's gotta move quicker to solve this problem because we're going to be in big trouble if we don't. That vision of mine 10 years from now is not going to be reality if people don't move quicker.

The Challenges of Healthcare Entrepreneurship

I also wanted to ask you, one of my favorite podcasts is How I Built This. I'm curious, what keeps you up at night in terms of being an entrepreneur having to deal with funding this operation and constantly looking for new rounds of financing? How do you handle that?

Well, before I get into that—great podcast. I was on stage at CES, on the AARP AgeTech Collaborative stage, and Guy Raz from *How I Built This* was right on before me. He was like two talks right before me on stage.

Maybe this will be your entry level podcast, and then in the ten-year plan, you'll be talking about your success on *How I Built This*.

This is the place to be, Value Health Voices. But keeping me up at night—I mean, one thing I can tell you, entrepreneurship is really hard. I talked about how I've always wanted to do this. I have a cousin of mine who had gone to Harvard Business School, much older than I am, and he started multiple companies. I remember when I was getting this going, he's like, "Are you sure you want to do this? You'd be a great VC. Why don't you do that? It's such a grind." And I'm like, no, without a shadow of a doubt, I'm going to do this. But I get it.

It is all-consuming and very hard. Everything from raising capital to the things that come up every day. If you're creating a truly disruptive, innovative model, you're going to encounter things that no one else has come up with. Something even happened today with my team, and I remember just thinking, you can't even write this stuff up sometimes. You're dealing with really hard patients and people living together and working with the hospital environments and healthcare—it's really hard.

Keeping me up at night is everything. But obviously the big thing is fundraising and acquiring customers. When you start becoming a venture-backed company, you have metrics and targets you've got to hit, and you need to show scale and growth. We're lucky all our investors are really exceptional, pushing us at the right point but not toxic in any way. Getting the right people who understand healthcare and the long sales cycles is important.

But hitting those growth targets and all of that is stressful. Making sure we're taking care of the patients is key. I love seeing the outcomes, the day-to-day stories that we see. We have someone with ALS we got out of the hospital who had been there for a very long time, and we were able to get them out in relatively short order. Their family, everyone's so happy. I stopped by the home the other day. Those are great stories. But I also want to see more and more metrics. I want to see these metrics blow the status quo out of the water. We're not creating this for average. We want Cleveland Clinic level of care in the post-acute world.

Advice for Aspiring Physician Entrepreneurs

For those who are listening to you and saying, "VIP's story is a story I want to make my own," and want to be a physician entrepreneur or build their own thing in healthcare, where would you direct them? Is there any tip you would give them to start to test their mettle?

That's a great question. It kind of depends on what path you want to go—whether it's entrepreneurship, consulting, venture capital, or policy. But I think you do need to talk to a lot of people and immerse yourself in that world and just get a realistic understanding of what it's like to be in that world. Even if you do some things just for free—I had to do those things in my life a lot just to learn—you just got to do that sometimes for that learning.

You're one of those people who is the epitome of saying yes to any opportunity that comes your way because you never know where it will take you. And look where it's taken you. You've done so many things across so many spheres because of it.

For me, I've often thought about finding somebody who is a success in a given pathway and asking, "Would it be success for me? Would I want my life to look like that in 10 years?" I've always felt that was the helpful test.

That's a great point. Seeking out people and opportunities when you can is key. I remember in med school, one of my mentors was Dr. David Mayer. I was assigned a mentor, and then I learned about Dr. Mayer, and I'm like, "Can I switch?" No offense to my old mentor, but this guy had started a company, worked in venture capital, was teaching patient safety, and teaching leadership courses. Just a super guy still doing clinical work.

I made some calls and talked to some people, and he ended up letting me teach the leadership course to the first-year med students when I was at the University of Illinois for med school. Now I've been teaching 17 years. I teach at the University of Toronto. It's all because that mentor gave me an opportunity and I sort of sought him out. Sometimes just finding the right people who might be able to give you some of that advice or get you involved is the way.

Closing Remarks

Well, this has been great. VIP, we thank you so much for coming on the episode. Is there anything else you wanted to say or plug in closing?

No, just your podcast I want to plug because I've been listening since you guys got going. I was doing it as a friend at first, but now it's an awesome podcast. So I plug your podcast because I swear we did not pay him for this endorsement.

Well, you know, VIP, I'm motivated now. We got to find through probably you another colleague in Canada with an interesting story to tell about Canadian healthcare and have them on the program.

I know lots of them in Canada. We'll do that.

Well, thank you, VIP, and thank you to our listeners. Have a good night.

Thanks, everybody.