Taboo Health

I get asked that question fairly frequently, and the way I'd describe it is that I've had a non-linear career path. All the pieces don't seem to fit until I look back and realize the experiences actually do tie in with each other.

Going way back, I came from a big Irish Catholic family of eight, and did well in college. When it came time to apply to med school, I got an early admittance to Dartmouth Medical School. My dad said "Congratulations" — and that we'd figure out how to pay for it, because we had no money, literally. So I signed up for a program called the National Health Service Corps, which I'm not even sure exists today. What it was targeted at was paying young students' and medical students' tuition, with a monthly stipend, as long as you agreed to work in an underserved area.

I was approached by the federal government in my senior year of college, and they showed me brochures of little towns in New England with foliage and white churches. I said, "Well, I want to be a family physician and I want to work in a little town — perfect, sign me up." Of course, the first lesson I learned in life: never trust the federal government. I got the scholarship, I went to Dartmouth Medical School, I got the monthly stipend, and it was great — I was probably one of the richest of my classmates with that stipend coming in. And then, lo and behold, when I finished my residency in family medicine, I got a computer printout from the government, and there were no little towns in Vermont or New Hampshire or Northern New England with white chapels and foliage to practice in. It was all Indian Health Service sites.

So there I was, finished with my residency. My wife, fortunately, was an OB nurse, so she had the flexibility to move anywhere. We essentially picked a site to pay back my four years, sight unseen. It ended up being the Navajo Reservation in Shiprock, New Mexico. I interviewed over the phone — I didn't even go out there to look at the site. Quite honestly, I chose it because it looked like a needy area of the country, and it looked like there was great hiking and great ski areas nearby. So my wife and I packed up our one- and three-year-old and took our journey out West, sight unseen. We did not know what we were getting into.

We pulled up on the Navajo Reservation and it was very different — more desolate than any other area I've ever lived in, but it had its own beauty. We moved into our housing, part of the compound around the hospital, and for the next four years I practiced primary care. My wife was the OB nurse there and loved her work. I did everything out there. With the Indian Health Service at that time, you did operative obstetrics, a lot of OB, full-scope primary care, you were in the ICU. It was almost like doing a four-year fellowship after my family medicine residency. I loved it. The one thing I learned is that you could deliver really high-level care for an underserved population with extremely limited resources and still get great quality outcomes.

The reason I mention that is I was involved in population health before that term was even coined. We had such limited resources that when you rounded on patients in the morning and said, "You know what, I think this patient needs a CAT scan" — we didn't have a CAT scanner, and MRI technology certainly wasn't available then. You had to justify, in front of all your physician colleagues, why you were going to spend money to send them to a local hospital for a CAT scan. You had to justify every penny you spent, deliver high-level care, and be accountable for both quality and cost of care. True population health, before anybody even thought of population health.

After four years with the Indian Health Service, I settled back in Northern New England, where I'd thought I was going to be from the beginning. I practiced in Concord, New Hampshire for over 25 years doing family medicine — really traditional primary care, cradle to nursing home, 30 to 35 patients per day, a panel of 3,500. I set up a small family practice with myself and another colleague. So I really enjoyed primary care in the very traditional way: rounding in the hospital, seeing patients five days a week, hoping they didn't call at night, because we were only open Monday through Friday. On weekends you had an answering service, and occasionally you had to see someone in the emergency room.

Along the way in Concord, I took on a lot of leadership roles in utilization management, and roles at the hospital around managing large groups of patients with payers. I also took a role for two years as chief medical officer for Tufts Health Plan — a really neat health plan that had moved up into New Hampshire — while keeping my full-scope primary care practice going. So I learned a lot about primary care, about the payer world through Tufts, and about leadership, particularly around utilization management. All of those pieces fit in later in my career.

Then, back in 2009, one of my former colleagues from Shiprock reached out and said, "Pat, we'd love for you to do a two-year project with the Indian Health Service." He knew I had experience not only in primary care but in a subspecialty in adolescent medicine. He said, "We need you for a two-year project. There's a high suicide rate among adolescent youth on the Navajo Reservation. Could you come out and set up a network of school-based health clinics to screen and treat adolescents — and even younger children — for depression, and get interventions going?"

It was very interesting — back to the future for me. As my last child was going off to college, my wife and I pulled up stakes in Concord and went back to the same place I'd practiced 25 years before, in Shiprock. It was the most rewarding two years of my career. My wife went back to OB, and I worked as an adolescent medicine specialist setting up school-based health clinics. We did a lot of screening for suicidality, anxiety, and depression right out at the schools. The interesting thing was that on the Navajo Reservation, to participate in sports the kids had to have a pre-participation physical, so we ended up doing a lot of behavioral health screening as part of that physical. More important than listening to the heart and lungs was actually assessing where the stresses were, what was going on at home, and the risk factors for both depression and substance abuse. We brought out counselors, as well as a referral network to psychiatry at the central hospital if that was needed. A population-health-focused, school-based clinic network. I loved the work.

Then I got reached out to by Walgreens — an entirely different aspect of my career. This huge pharmacy company was actually getting into healthcare. They had set up 500 of these retail clinics — small, 200 to 300 square foot spaces within a Walgreens store, doing very limited-scope care like colds and flu. Customers coming into the store could get on-demand care, very convenient, available anytime the store was open. It was very well received, and it brought a lot of foot traffic into Walgreens. But the one thing I realized, once I came in as chief medical officer to oversee the retail clinics, was that for Walgreens it wasn't a great value-add other than the foot traffic. They didn't benefit from the referrals as you started screening more patients with risk factors — the imaging studies, the referrals into primary care. Health systems would really benefit from those referrals.

So I brought in a strategy to transition the retail clinics from Walgreens to health systems — think of an Advocate Aurora or a Vanderbilt. They would run the clinics, employ the nurse practitioners in the Walgreens space, and benefit from the referrals into their system. It was really good for Walgreens: they got away from the responsibility and cost of running retail clinics, still got the foot traffic, and got a closer relationship with major health systems around pharmacy programs. And it was great for the health systems, who garnered the referrals. We transitioned virtually all 500 clinics to health systems.

As I worked towards my own obsolescence at Walgreens by transitioning these clinics, I got more and more involved with the healthcare strategy, and eventually became chief medical officer for all of Walgreens. I learned a lot about the pharmacy programs, the 340B programs, and about creating a strategy that made Walgreens into the healthcare neighborhood destination. In my last year and a half we actually brought practices into the store. One of the greatest relationships I started was with a very large managed services organization called VillageMD. Village would come in and set up a primary care practice in 2,500 to 3,000 square feet in a Walgreens store, and many of the prescriptions written were captured by Walgreens. So Walgreens got the pharmacy lift, and VillageMD got the support of pharmacists to help with adherence, plus great locations. We initially did a pilot of six sites. After I left Walgreens in May of 2019, that relationship really matured and grew — I think Walgreens has now invested close to $6 billion in VillageMD. They see that the model works, so I was really proud of starting that relationship.

Then, really out of the blue, I got recruited by a telehealth startup called Hims & Hers. To tell you the truth, I wasn't looking for a new position, but it fascinated me — the startup world, San Francisco. I saw that telehealth could be the next iteration of consumer-facing care. I didn't anticipate the pandemic was coming, but I saw that you can deliver care in a virtual environment, manage about 80 to 90% of primary care conditions virtually, and do it in a very consumer-friendly way.

When I interviewed for Hims & Hers, I realized they had a very limited scope of care at the time — more around hair loss, sexual dysfunction and erectile dysfunction, some dermatology. But the company committed, through their CEO, to expand the scope of care, and they followed through: they added about 50 different lines of service, all the acute episodic conditions we treated in retail clinics, brought onto our platform. And then the thing I'm most enthused about — about eight months ago we launched behavioral health, treating anxiety and depression in a virtual environment. The reason we added all those services is that six months into the job, we found people were coming to us looking for access for things like urinary tract infections, pharyngitis, COVID screening, as well as anxiety and depression.

The demographic we serve, primarily millennials and younger, has really struggled with anxiety and depression through the pandemic — some studies show 30 to 40% of that demographic having issues. Hims & Hers is really keen on providing access to price-transparent care for stigmatized conditions. Think about sexual dysfunction and dermatology — but what's a more stigmatized condition than behavioral health? So that's what we launched, and I've been excited with the work we've done.

It's a really different model. Today we don't take any insurance — customers pay out of pocket. For, say, $30 to $35 a month, you get access to a virtual provider 24/7, 365 days a year, to treat conditions you have concerns about. Most of those visits are asynchronous — an adaptive interview based on evidence-based guidelines, with a provider. If you qualify and the provider feels you'd benefit from medications, they get prescribed and sent to you from our cloud-based pharmacy. So think of Hims & Hers as a fully integrated health delivery network — from the brand, to the virtual provider network, to pharmacy fulfillment, to regular follow-up.

I've been with Hims & Hers since May of 2019. It's been an exciting journey, and I've grown significantly. I helped take the company public in January of 2021. Today we have over 500,000 active subscribers on our platform, and we see 3,000 to 4,000 patients per day across all the conditions we offer. So — a very non-linear career path. Traditional primary care, leading a multi-specialty group, leading an integrated delivery network, leading risk-based models in Medicare and Medicare Advantage, working in pharmacy at Walgreens, and now the startup world in a virtual environment. It's one I never would have anticipated when I was seeing 35 patients a day. But looking back, everything fit in.

I think it's not that I have a vision of what's going to happen in the future of healthcare. It's that my experience in primary care really grounded me in the challenges, the needs, and the opportunities.

When I speak in front of groups — at Walgreens, or externally for Hims & Hers — fairly often younger physicians come up afterwards and say, "Gosh, I'd like to be chief medical officer at Walgreens," or "I'd like to lead a telehealth company. I'm just finishing my residency — should I get my MBA and jump right in?" And I say, don't do that. If you want to do something as a physician leader, it's really important to actually practice. I practiced for over 35 years, right up until I started at Hims & Hers — I was still practicing while at Walgreens, volunteering one Saturday a month at a free clinic in downtown Chicago. When you practice, you get a keen appreciation of all the challenges in healthcare, and you can anticipate what the issues are.

Even in the latter part of my career in primary care, I saw we were moving to a more risk-based world — payers shifting risk to primary care providers, saying "we want you to take risk on the finances as well as the quality outcomes." And I saw the challenge for the average primary care physician; it's the most difficult job in the world. I also saw this ongoing phenomenon: we have an acute shortage of primary care in this country — probably about 50,000 primary care physicians short. Coming from a primary care background, then managing risk for large groups, and then Walgreens, I realized this has to be team-based care. You have to use pharmacists as part of the team. You need social workers. You need coaches doing outreach. On the Navajo Reservation, they had folks who worked in the chapter houses — the central area in each community — who would identify the high-risk patients and get them plugged into care. You need various members to manage patients with high needs out in the community.

I didn't anticipate the pandemic, but I did see the upside of telehealth. It's a very efficient system — particularly asynchronous, an adaptive interview, where you can deliver high-quality care and a provider can see eight to ten patients per hour, far more efficiently than a traditional practice where a provider might only see two to three per hour. You can use the labor force much more efficiently in virtual care, and get out into rural and underserved communities without setting up brick-and-mortar practices where, financially, the models sometimes don't work. So it's not that I had a crystal ball — everything I've done has been grounded in primary care, seeing where the gaps are, and trying to understand how to fill them.

That's a great question. I did enjoy the personal interaction with patients, no doubt about it, and I think you do miss that with virtual health. That's the downside.

The upside is we don't bill insurance, and our EMR is home-developed, so it's very customer-friendly and provider-friendly. I practiced on five different EMRs — the land of a thousand clicks with Epic and Cerner. To me it's almost a tyranny of traditional EMRs; they're really time-intensive. In my last ten years of practice I spent more time looking at the screen than at the patients. So I was missing that human interaction even in a brick-and-mortar practice. What we've seen is that our providers love practicing off our platform — even though the interaction is virtual, they still interact with patients, answer their questions, and provide access to care. And patients are very grateful for it. They don't have to wait 60 days to see a primary care provider. Good Lord — try to see a psychiatrist today; it's really difficult, and 50% of psychiatrists don't even take insurance. So there's a trade-off. Patients love the access and the price transparency, and providers love the frictionless experience.

They can do the majority of their visits off a mobile device, fitting it into times of day that work for them. Most of them have day jobs — the average provider on our platform practices about 14 hours per week, on their own schedule, without the hassle of blocking out large chunks of time. Our churn for virtual health providers — and we only have about 350 on the platform — is really low. They just love practicing in a different modality. These are folks who work in ERs, or as hospitalists, internists, or family physicians in traditional primary care.

Absolutely — and it's happening today. For our providers, these are non-exclusive relationships. If they want to practice on another telehealth platform, we say fine. Work as much or as little as you want. We don't have non-compete clauses, which I think are so antiquated. In a way it is like a gig economy.

The challenge — and when I came to Hims & Hers, my first priority — was to put in a quality structure. I need to make sure that providers practicing 14 hours a week are following evidence-based guidelines, having positive interactions with our patients, prescribing appropriately, and referring off the platform that 10 or 15% of patients who are too complex for virtual health — while providing access to those who are appropriate. We don't tell providers how to practice, but the intake questions the customers answer are all based on evidence-based guidelines, informed by a great specialty advisor network we've brought in.

We're able to track the quality of care on those encounters — we've done over 50,000 encounter reviews. We can identify the outliers, the folks not practicing to the standard of care we've set up. We grade providers on five criteria: webside manner — do you introduce yourself, are you having a positive interaction from the start; are you following evidence-based guidelines; are you prescribing appropriately; are you referring appropriately; and is your note robust enough that when the next provider picks up that chart, they understand the treatment course and can continue the care? As virtual health explodes, we have to be able to show that the quality on a virtual platform is as good as, if not better than, face-to-face. That's table stakes for us.

I love that term AI, because it means so many different things to so many different folks. It's the buzzword out there now. Two buzzwords I hear a lot are AI and social determinants of health — I hear them everywhere, at every conference I go to. So what really is AI? It's just really iterative, informed, intelligent screening. And we do that off our platform — we could call it AI, by gosh.

Our intake forms are extremely robust. We're able to include and exclude patients who are appropriate for the platform, get a full past medical history, identify risk factors, and tee all of that up for the provider. When the provider takes the patient out of the queue and looks at the information presented, they can make a really informed, high-quality decision. So we do use AI, in fact, every day.

Will we ever exclude physicians or providers entirely from that process? I hope not. Even with great front-end questioning and AI, there's still a vital role for physicians to sort through the data. There are nuances to the answers you need an experienced physician to catch. For example, one of our more popular offerings is erectile dysfunction. If you look at how many men in this country have some form of ED, it's pretty high — for 30-year-olds it's up to 25 to 30%, and every ten years it increases by about 10 percent, so 40% at 40, almost 50% at 50. But our questions are essentially a cardiovascular screen: 70% of folks with erectile dysfunction have hyperlipidemia. So we ask, have you had a cholesterol check? We screen for anginal-type symptoms, and if they have those, we get immediate referrals off the platform. We ask about a history of diabetes, whether it's under good control, what your last hemoglobin A1c was. We're doing more cardiovascular screening than I ever did in my primary care practice, just by bringing in folks who want and need medications for ED. That's pretty nuanced — you can ask the questions, but without a provider looking at and sorting through the data, you're missing something, and you're not going to reach the quality benchmark you want.

A lot of the derm conditions are fairly low-risk, and you're right about hair loss. But even hair loss is a fairly nuanced flow. You come onto our platform and we screen whether you have androgenic hair loss; we want to make sure there's no other reason the treatments won't be effective for. Then we give customers the information to make an informed decision about which treatment they want.

That's everything from minoxidil, which is essentially over the counter — we offer it, but you don't necessarily need a prescription for it — to a combination of minoxidil and topical finasteride, which has been very well received; the efficacy is higher than minoxidil alone, probably about 70 to 90% effective. Topical finasteride is a prescription medication, so you do need a prescription for that. And then there's oral finasteride, one milligram per day. Interestingly, oral finasteride does have side effects — in about one and a half percent of folks there can be some sexual dysfunction, and there have been reports of depression on the medication. In some ways it's a fairly controversial medication because of those side effects. So we make sure all of them are listed up front, and customers can decide: do I want to take a pill every day with the risk of these side effects? Or would I rather have topical minoxidil and finasteride — I still get the benefit of finasteride, but absorption is less and DHT suppression is less, so it's almost as effective as the pill with a lesser side-effect profile? Or do I want to just use minoxidil alone and not mess with finasteride at all, with even fewer side effects?

So it's about letting customers make an informed decision, making them aware of all the side effects, and giving them a way to get back to our providers if they experience any. It seems simple — hair loss — but it's pretty nuanced, with three different types of medication, including over-the-counter shampoos we offer that suppress some of the DHT. It's not as simple as it appears on the surface, which is why I think we'll always need a provider — although we've made the process as frictionless and hassle-free as possible.

Absolutely — it's something we explore and talk about fairly often. We probably wouldn't do the trials ourselves; we'd partner with health systems or researchers. If you think about what we do for hair loss, we probably do as much topical finasteride and minoxidil as many organizations in this country — probably more than your average dermatologist. So we have a huge dataset. The studies that support the use of these treatments are out there, but there should be more, and we have that information; we just haven't taken that step yet.

Even in behavioral health: many of our visits are synchronous, face-to-face, but for the very low-risk patients we're able to identify, we do asynchronous. There aren't a lot of studies out there on asynchronous versus synchronous. We've been able to show internally that the quality is the same, but it would be great to do an academic study comparing the modalities for anxiety and depression in lower-risk patients. I think that would be hugely valuable.

I learned a lot of lessons. One is that you have to have credibility — my years of practice gave me that. It's hard to stand in front of a physician group and say, "This is how you practice medicine, do one, two, three, four, five." They'll look back at you, and if you haven't practiced or been involved in primary care for years, they'll say, "You really don't know anything about healthcare. You don't have an appreciation of how difficult it is to manage patients day in and day out." So you have to have credibility, some gravitas, when it comes to getting in front of physicians and actually incenting them to get things done.

The second thing I learned is that you have to be very clear on the mission. You can tell physicians to do X, Y and Z, but if you haven't clearly defined the mission, they'll come back and ask, "Why am I doing that? What's the purpose?"

And the third part is that you have to give providers the tools to succeed. That's anything from an EMR that's actually functional, to really incenting them financially for delivering high quality. You can't just say, "We want you to hit these measures." There has to be some upside, and you have to create compensation structures that incent them to do the right thing in terms of value-based care. And for many physicians, the currency isn't just financial — it's time. Give them time to manage higher-risk patients. Carve out 45 minutes for a visit with those complex patients. Don't expect them to manage a diabetic with impending end-stage renal disease and hypertension in 15 minutes — you're not going to make any progress on that.

So, particularly in a multi-specialty group, it's important that physicians are given the time to deliver high-quality care, with access supported by hiring advanced practitioners to see the acute episodic conditions, and a telehealth network too. If someone has a urinary tract infection, you can do that on a telehealth visit — why jam up the schedule of a high-functioning internist who needs to focus on the top 10 or 15% of high-risk patients? What I've learned is: find the mission, align incentives, give them the tools to succeed. Combine all of that and the results will follow — I've seen it.

I don't read a lot of medical leadership or "how to be a leader" type books. What I do is talk to a lot of other physician leaders — whenever I can, I network and ask them what works, what doesn't, what the tricks of the trade are. One advantage of going to a lot of conferences and speaking externally is that you meet folks and share wins and losses, and you can learn from them. I'm very open about sharing what we do, even with competitors — "How have you been able to do this?" and "This is how we do it" — just comparing notes. That networking has been very valuable in my career.

I appreciate the opportunity to speak. In summary, particularly for younger providers and physician leaders who want to get into this world: be open to making changes in your career. Just because you get trained in one specialty doesn't mean you have to stay there for 30 years and not do anything else. Be willing to step forward and take chances.

I remember when I left the Indian Health Service and started in primary care in New Hampshire at Concord Hospital, a great hospital. The CEO was always asking for physician leaders to step forward — to work on utilization management, population health projects, or evaluating potential EMRs — and I was amazed how many physicians just didn't want to do it. "I don't want to be hassled with that, I just want to see my patients, don't bother me." And then, as physicians, we step back and complain that we're not involved in decision-making. Well, that's because you never stepped forward and volunteered to take on leadership roles. So be open to taking those roles, and don't be afraid to take a risk in your career.

When I was 50, practicing in Concord at a great practice, my colleague from years ago at Shiprock said, "Come out and do this adolescent medicine project for two years." I could have said, "You're crazy, I'm not going to uproot my wife and go back out there." Fortunately my last child was going off to college. But that was the best thing I ever did in my career. It opened up a whole world of medical leadership I had no idea about — it led to roles at Atrius Health, then Hartford HealthCare, then Walgreens, then Hims & Hers. If I'd just stayed doing my primary care practice in Concord, I'd still be doing that today — which is still very worthy — but it would have closed off a whole area of professional opportunity. So be open, and be willing to pivot many times in your career.