Nate Maslak, Ribbon Health, on the quest to simplify health decisions with better data

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In this episode, we interview Nate Maslak, Co-Founder and CEO of Ribbon Health. Ribbon is breaking the long-standing barrier of complex and challenging provider data by identifying and delivering the most accurate, comprehensive data on providers, facilities, insurance plans, and cost and quality measures through a seamless API layer. Ribbon is trusted by innovative health care companies such as Oak Street Health, Ro, and Well (Well Dot, Inc.). Headquartered in NYC, Ribbon is backed by leading investors like a16z, Y Combinator, BoxGroup, and several leading entrepreneurs.

Nate Maslak, Co-Founder & CEO, Ribbon Health

We discussed:

• How messy provider data persists and compounds to a subpar patient experience, high cost, and poor outcomes
• How Ribbon’s platform is solving this problem via provider directory, quality indicator, and cost-effectiveness products
• Ribbon’s partnerships with Ro, Lively HSA, and Alice Financial
• and more!

Start to 11:00: The origin of Ribbon

• On choosing one of the most regulatory dense, opaque industries to work and launch a company in: The problem that Ribbon is trying to solve is that healthcare decisions are being made in siloed environments without accurate data, which pains patients and adds cost to the healthcare ecosystem. This problem impacts everybody in the U.S. in one way or another. Nate started his professional career in healthcare consulting, mainly for health systems and payers in the Midwest. Nate witnessed how much impact one could have by driving structural changes at these players. Simultaneously, he was alarmed that he was owning tasks like running claims analyses in Excel to help large payers and state governments determine how to price reimbursements — which seemed insane to him as he felt that should never be done in Excel. Nate realized that as an industry, healthcare was behind analytically.
• Nate’s personal story behind Ribbon Health: Fast forward a few years after Nate met his co-founder in business school, Nate’s mom needed help finding a doctor because she wasn’t sure what was causing her joint pain. After many twists and turns to find a doctor, Nate spoke with a PCP friend who advised skipping exercise for a week to see if the pain would go away. It worked.

“There was this moment of getting lost in the healthcare system, having no clue how to navigate it, for somebody who came from a position of privilege and allegedly knew how to navigate the system. It was very clear that if we were in this situation, many folks who were far worse off, having much worse experiences are not even able to access the system from the first place.”

• The genesis of Ribbon Health: Nate and his co-founder didn’t set out to start a company. They just wanted to help their friends find appropriate care at the right time: how do you find a doctor? How do you estimate the cost of care? They first created a pretty janky forum thread of how to navigate healthcare, referencing symptom checkers or medical condition descriptive webpages. Throughout business school, they developed this navigation tool into a direct-to-consumer platform for healthcare navigation. When they graduated, the natural question was figuring out how to transform this into a self-sustaining business. The goal wasn’t to drive a venture-backed exit — it was to build something that could exist on its own. They saw early success selling the tool to employers, then hit a growth accelerant after being accepted into Y Combinator.
• Pivoting away from navigation and doubling down on data integrity: A couple of months after graduation, the navigation tool was live with Ribbon’s first few employer clients and enjoyed 90% month-over-month patient engagement. It felt like Nate and his co-founder had cracked something — it’s tough to get to that level of engagement for a digital-first healthcare solution.

“All of a sudden, Ribbon’s metrics plummeted. They went from comments like, ‘I’m so happy that we have this solution, I finally got my husband to see a doctor for the first time in five years,’ to the same person saying, ‘When we called the doctor, the phone number was wrong, and the address was wrong. The doctor wasn’t in-network when you said they were. I can’t use this thing.’”

• Nate and his cofounder realized they had a doctor data problem on their hands. They had taken for granted that the doctor information that was out there was accurate, because why wouldn’t it be? After their own back-of-the-envelope validation, they found that information was about 50% accurate (numbers that are further validated by CMS audits). They started trying to build a better mousetrap for their own internal software system so that people could actually find a doctor (wild concept!). Some of their competitors started approaching Ribbon asking if they could license that data. There was this “aha!” moment on deciding whether to (A) use this mousetrap as a way to compete, or (B) democratize access to this asset and help power different solutions. At the beginning of 2018, they decided to shut down their employer solution and go with Option B: they launched an API and became Ribbon Health. They’ve been at it for almost three years since.

12:00 to 22:00- Why provider data quality drives high costs and poor outcomes

“At first glance, provider data shouldn’t be that hard to maintain. We’ve had YellowPages forever. Still, the average provider directory website, even for a well-known health plan, is 50% accurate or less. This is just for contact information like phone numbers and addresses. That doesn’t even start to consider dynamic elements like insurance plans.”

• To Nate, the reason provider data is so hard to maintain is that the data is dynamic. Doctors move practices. Doctors will practice at multiple practices. Practices will get shut down. A new one gets reopened. Frequently, a practice will get acquired by a hospital. What happens afterwards? In aggregate, there are all these little moments during which any one doctor is probably not moving seven times a year. But across the over 4 million providers in the U.S., those small moments add up.
• Second, Nate believes there’s a problem of a lack of truth data. Many places will show provider data that pulls from another source that pulls from yet another source, and quickly we lose track of where something actually came from. A provider, even one that has the resources to maintain this information everywhere, can’t keep up with all the different places where their information shows up.
• The typical starting point for provider source of truth is the National Provider Identification (NPI) registry system. Every provider gets an NPI when they become a licensed provider. Then, they need to add a phone number or an address. This information is maintained today in one way only: the providers themselves have to go in and update it.

“As an experiment, we looked at a building in Chicago with a high concentration of providers…except it wasn’t a medical clinic. It was an apartment building. This address was in the NPI registry because that’s where a lot of Chicago-area med students lived when they commuted to school and took their licensing exams. That was just the address that they put down because they needed to list an address. There isn’t enough education of: here’s what this means for you and your patients 17 years down the line if you don’t update this information.”

• Nate believes there are really three core issues that happen because of bad provider data. First, access to care. When somebody is sick, over 70% of people will go to their health plan website first to understand which providers are in-network. They pick up the phone to get an appointment, but the first phone number is wrong, then go on to the second one, and so on. If you are really sick at a certain point, you’re going to stop making phone calls and just go where you know, like the ER. You’ll experience a 20x increase in the cost of care for somebody to write a prescription for an earache. Or you may give up on care altogether, putting off something that should be addressed. This is the basic provider data problem.
• Second, cost-effectiveness. Wrong points of care are huge drivers of healthcare waste. Nate believes the best predictor of having a cost-effective or not cost-effective health care experience is whether you go to an in-network or out-of-network provider.
• Third, outcomes. Did you go to the right doctor for you at the right point in time? Somebody might be a phenomenal knee replacement surgeon, but they’re going to show up as an orthopedic surgeon. Somebody needing a shoulder surgery should not be going to the provider that spends 99.9% of their time doing the knee replacement surgeries. Provider matching also has a clear impact on the quality of care and outcomes.

“There was a recent study showing that providers are spending the equivalent of over $5 billion a year just on maintaining their own provider data. Health plans are spending over $2 billion a year doing the same.”

• Despite this alarming statistic, Nate does believe health plans have the best intent. Putting himself in a health plan’s shoes and seeing how provider data is being sent to them built empathy. Health plans look at their contract data. A doctor can be in-network at a location where they don’t regularly practice. For example, what if there’s a patient who needs a specific provider’s help, and the provider wants to make sure they can accept the patient’s insurance, but the provider is only there once a year? The health plan gets that information directly from the provider group. Once the provider is listed on the plan’s directory, if a patient calls to book the doctor at that location, the provider may not be there for another six months. This sort of problem gets amplified as other sources begin to pull info from these sources. It’s a domino effect: you give a megaphone to this messy, noisy data.
• Additionally, insurance mappings are hard to maintain. As a patient, what you care about is seeing an in-network provider. But, network contracts are very complex. Providers themselves can be in-network but the facility could be out-of-network. To a patient, this means not everything that you’re getting is in-network. The complexity that you see roll up at the aggregate level quickly becomes nuanced. Ribbon collects data on accepted insurance for a given doctor down to the plan name, network level, and location, and making that information readily digestible.

23:00–43:00: Ribbon works with payers, providers, and patient-facing solutions

• Ribbon’s five-year vision is to power every care decision to be convenient, cost-effective, and high quality. Ribbon has four core data modules: directory, network mapping, cost-effectiveness, and quality indicators.
• Health plan directories: Ribbon ingests health plans’ provider directory data and aims to aggregate 100% of doctor information wherever it exists. Ribbon uses data partnerships, publicly available data sources, and manual validation approaches. These data are very noisy — Ribbon sees over 30 phone numbers per doctor hit their system. Ribbon’s algorithms score that information to identify what is likely right vs wrong and make recommendations for data fidelity. Ribbon’s call center runs mock regulatory audits trained the same way that CMS would. Payers leverage this data to increase directory accuracy, power member-facing care navigation solutions, and to ensure network adequacy.
• Network mapping: Ribbon’s network module is about understanding different network affiliations and being able to address anyone in the U.S. who might be using a Ribbon-powered product to find an in-network provider. This just requires additional partnerships and just driving scale.
• Cost effectiveness: Earlier this year, Ribbon launched its cost-effectiveness and quality indicator products simultaneously, as they are both most helpful with each other. This suite of products is helping folks understand when they are looking for a given procedure in a given market, what should their ballpark cost expectations be? Ribbon finds that people don’t really even have a good sense of that. Second, who are the most cost-effective providers near the consumer?

“We’ve always thought about cost-effectiveness on a relative basis. While it would be great to be able to say X procedure with Y doctor will cost $742.52, there’s a lot of variability in provider pricing. Even the best predictive model might create false precision. What we found is that a consumer is really looking for a general estimate.”

• Quality indicator: Finally, on that quality indicator piece, Ribbon is focused on patient satisfaction and experience in primary care. On the specialty and procedure side, patient experience is less relevant than other indicators that are better drivers of outcomes, such as risk-adjusted length of stay.

“We think that there’s anywhere between 6 and 10 billion care decisions being made a year in the U.S. Our goal is to be able to affect every single one of them. One way to do this is distribution power, every care decision. To do that, we need to be the infrastructure solution for every place a care decision is being made: health plans, providers, groups, systems, patient-facing solutions. In a world where these decisions are being made or affected digitally, we think there will be a clear need for provider data literally 100% of the time. Second, then, are the products we’re enabling.”

• To Nate’s knowledge, Ribbon’s provider directory solution is the most comprehensive and accurate in the industry. They have never lost a head-to-head data test. That’s still not good enough, because it should be 100% accurate. In Nate’s view, just because Ribbon is better than the industry average of 50% does not mean that that’s the kind of product experience that you want to give to your loved one.
• Ribbon approaches its cost-effectiveness products and quality indicator products the same way, but they’re still a stretch away from what they believe people are really looking for, which is if you go to the doctor, is this going to be the most cost-effective care experience? Is this the right doctor for you to see? Can you access that provider?
• Ribbon is continuing to invest on the directory front, including maintaining individual provider and disparate location directories. If a patient wants to get an MRI, they are usually not thinking about who the provider is — they just care about finding a nearby facility.

“On the network side, I want to make sure that we have coverage for 99%+ of lives covered in the U.S. so that anybody who’s using a Ribbon-powered product can find an in-network provider. We’re close, but we’re not there yet. I would say we’re probably around 85%, but in this industry, that feels high.”

• On partnering with Ro: COVID-19 forced the overnight digitization of the healthcare economy, which is great. Telemedicine is an amazing entry point into the healthcare ecosystem, but not everything can be solved with telemedicine. Ribbon’s work with Ro bridges the gap between telemedicine and in-person care: people can get referred within the virtual care platform to an-in person provider. The question is then what happens when somebody needs in-person care — how do you choose the right doctor for you? How does the algorithm powering provider selection meet your preferences? To accomplish these, you need high fidelity provider data. So much information beyond physical location and phone number is critical for provider-patient matching. This is where Ribbon comes in: being able to facilitate these movements across the ecosystem.
• On its HSA partnership: A Health Savings Account (HSA) is a financial and health care instrument that helps people plan for and save for their care. People can allocate income to the pre-tax HSA, and that nest egg grows over time (also non-taxable) and can be spent on healthcare. Nate and team see HSAs as a kind of a healthcare consumerism tool. Digital healthcare solutions really struggle to drive recurring engagement. But HSAs didn’t face that problem from the get-go. Ribbon’s HSA product helps consumers not only understand how much remains in their HSA and how to navigate that, but also understand the implications of that decision. This creates a better healthcare experience for an HSA consumer who has high intent to spend on health care.

“People go into their HSA to check how much money they have saved up. Why? It’s probably because they’re thinking about saving for health care or spending that money. Ribbon helps drive the HSA care navigation experience. If a consumer is going to spend on something from their HSA, how do we help find the right doctor? How do we find the right facility if they need an MRI? If someone has a $5,000 deductible, how much have they already used? We’re able to pull this information in real-time from the health plan, and transfer that over to these different HSA providers.”

43:00 — End: Leading through early growth and a pandemic

• On onboarding: COVID-19 threw a wrench into how Ribbon was thinking about interviewing and onboarding. Some of their prior interview processes translated well to a video screen, but the onboarding process was horrible remotely. Like a lot of small companies, pre-COVID-19, the onboarding process involved giving people ownership of a few things and unlimited access to seven people sitting in the same room to ask any questions. That doesn’t work very well in a remote setting — you can’t just ask everybody to constantly be on video together constantly. However, COVID-19 did lead Ribbon to think intentionally at the start to add more structure into their people processes early. The process and people investments happened much sooner than they otherwise would have, and they’ve paid off.
• Advice to new founders: Place a lot of value on the values of the company — early. Before making too many strides on Ribbon, Nate and his co-founder sat down and discussed what kind of company they wanted to build on the off chance the company would pop, knowing they wouldn’t have time to do that later. That conversation led to six core values that are on Ribbon’s website, written all over our office, and mentioned during every single Monday in their all-hands meeting. Those values have kept Nate and his co-founder honest while they guide the company through turbulent and challenging times.
• On meeting his co-founder: Nate and his co-founder, also named Nate, both met early on in business school. One night, they were just talking about startups. That turned into an infectious energy that made it impossible for them to not dive into new business ideas together. Both Nates deeply cared about the healthcare problems they considered and quickly found that their shared values help guide them through disagreement. Still, to this day they make sure diverse perspectives are represented as they build out the company: they want to continue the kind of respectful debate of different ideas.

“I don’t think that Ribbon is going to do this alone. I want us to be an input for many other companies that are solving the healthcare conundrum. Cost and quality are also inherently personal. It’s really hard to say objectively, this is a high-quality provider because the question is — high quality for whom? We want to be the company that is helping power decisions: for the consumer, for care navigators, referral coordinators, or doctors. Ultimately, the way that we judge scale and accuracy is, do our customers feel like our API and our technology work? Does that enable them to do their job better and faster, and in a way that is driving the best outcome for their patient?”

About Ribbon Health

Ribbon is breaking the long-standing barrier of complex and challenging provider data by identifying and delivering the most accurate, comprehensive data on providers, facilities, insurance plans, and cost and quality measures through a seamless API layer. These products together help health plans design up-to-date networks, offer members care navigation tools with deliver personalized out-of-pocket cost estimates based on their deductible, plan design, and provider prices. For at-risk providers and payers, Ribbon can provide insights on patients’ total costs of care and help ensure referrals to high-quality, cost-effective providers. Ribbon is trusted by innovative health care companies such as Oak Street Health, Ro, and Well (Well Dot, Inc.). Headquartered in New York City, Ribbon is backed by leading investors like Andreessen Horowitz, Y Combinator, BoxGroup, and several leading entrepreneurs.

Nate Maslak is the Co-Founder & CEO of Ribbon Health. After years of healthcare consulting at McKinsey, Nate built and ran the Identity Graph predictive analytics product and business at Datalogix to help drive an acquisition by Oracle for more than $1.2 billion in 2014. Outside of Ribbon, you can find Nate trying to eat his way through NYC boroughs. Nate received his MBA from Harvard Business School and BS from Washington University in St. Louis.