Neil Batlivala, Pair Team, on putting primary care operations on autopilot

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Neil Batlivala is the CEO and Co-Founder of Pair Team. Neil Batlivala and Cassie Choi, RN founded Pair in 2019 after experiencing how critical a high functioning administrative team is to provide high-quality primary care by building out operations together at leading tech-enabled practices of Forward and Circle Medical. The majority of healthcare is local and fragmented, and no solutions were built to enable existing clinics. Pair came out of that need and provides a simple yet comprehensive solution that covers the front, mid, and back-office. Their automation, along with a human-in-the-loop approach provides end-to-end operations of patient outreach, scheduling, e-forms, care gap reports, record requests, referrals, lab coordination, etc., to offload the traditional job functions of the front desk and medical assistants. Pair Team (“Pair”) came out of stealth in December 2020 and raised $2.7 million in seed funding backed by Kleiner Perkins, Craft Ventures, and YCombinator, along with other prominent funds. It is also part of the inaugural cohort of 1501 Health, an investment and incubation program in partnership with Carefirst BCBS, Healthworx, and Lifebridge Health.

Neil is an engineer, YC alumnus, and co-founder of Pair Team. He has spent the majority of his career in healthcare and had the honor of working with some exceptional people while building remote medical teams at Pair Team, opening primary care practices at Forward, designing medical devices at Spect, training machine learning models at Noxon, and researching pneumonia at UCSF. Neil completed his undergraduate studies in Computer Science at Carnegie Mellon University. In his own words, he is 50% thrill seeker, 40% dad jokes, 15% math.

In this episode, we discussed:

• Neil’s background, his story of meeting his cofounder Cassie at Forward Health, and pivoting from being a direct primary care company to a provider enablement and service automation company focused on the Medicaid market
• Today’s tech-enabled Medicaid services market and untapped opportunities in LTSS, CBOs, and primary care
• The “death by a thousand clicks” problem and how it is possible to scalably address this through automation and trust, with high rates of provider adoption and 20% improvement to independent clinic margin
• How Pair Team’s solution is more defensible because of its business model, payor-provider alignment, and focus on technology in service of patient engagement, as compared with other RPA companies
• Personal leadership principles that Neil swears by, including executive coaching and journaling, reading (e.g., 15 Commitments of Conscious Leadership), and being aware of his own biases

Start — 14:30: Neil’s background, meeting his co-founder, and starting Pair Team

• Experiences abroad that shaped Neil’s interest in healthcare and equity: Though born in Florida, Neil moved at two years old, and spent most of his life in Singapore and India. Growing up abroad nurtured Neil’s sense of mission today — specifically, observing the socioeconomic disparities that surrounded him. His school was across from a slum, from which kids would join Neil’s school every day for snacks. There was a nursing station at the school at these times, and Neil would help the nurses hand out bandages, ointment, etc. This experience around witnessing inequity and the power of simple healthcare actions set Neil on his path. While he was pre-med in college, he found a passion in engineering and started his career in Silicon Valley focused on bits and bytes, operating systems, databases, AI and machine learning. He also started a small consulting firm focused on machine learning, including a project with UCSF detecting pneumonia with sound.
• Meeting his cofounder and realizing a deeper mission at Forward: Neil got involved in health tech at Forward, which Neil describes as what would happen if One Medical and the Apple Store came together and had a baby. Forward is concierge, high-end primary care. He focused on building technology from its very core, and creating great patient experiences. Forward was also where Neil met his cofounder Cassie Choi, a registered nurse. Together, they got to build out clinics from first principles, from the ground up. This experience taught the pair a lot about how to scalably engage patients and how to integrate technology into clinical workflows. However, Neil realized he wanted to step back and work on things that were more accessible beyond people who could afford a service like Forward.

“Forward aimed to start at the Tesla Model S and work our way down. Unfortunately, just due to how the business grew, we locked into a more affluent patient population. I wanted to build something more accessible. That’s what sparked Pair Team.”

• Starting a new venture as both a technologist and an optimist: The week that Neil knew that he wanted to start Pair Team, his to-be co-founder got proposed to on a Friday, and I was like, I need to work with Cassie, who’s a registered nurse. He met her on Sunday to celebrate, where Neil proposed to her to be a co-founder (Cassie got proposed to twice that weekend!). They mutually believed in a mission to bring the technology of Forward and other tech-enabled primary care leads to underserved communities and rural clinics, and that the way doctors are supported and how primary care clinics can function can be moved offsite. The vision behind Pair is to empower the provider with a virtual executive assistant, give them automation tools, and help them focus on what really matters: patient relationships and patient care. The U.S. has many primary care deserts, and many individuals with low health literacy through no fault of their own.

“I asked myself: should someone be responsible for all of their own care needs? Yes, in some cases. But, in many cases, the underlying infrastructure should still be there to support them. We’re missing that.”

14:30–30:00: Tech-enabled services across Medicaid

Why is Medicaid so fragmented?:

• Medicaid is the largest single financier of healthcare in the U.S., and it has the largest population of members — and thus it has one of the highest program spends in the country (in parallel with Medicare spend). That is so many people depending on Medicaid, and yet Medicaid is given such little attention by our infrastructure. It is highly fragmented. Unlike Medicare or Medicare Advantage, there are no national standards for Medicaid, and innovation and financing is distributed at the state level.

“While we’ve seen surging enrollment post-pandemic, we’ve seen state budget shortfalls due to COVID-19 that are expected to surpass those of the Great Depression, one of the large driving factors here being Medicaid enrollment within a state. Very few are focusing on this problem.”

• Managed care is eating the healthcare industry: 70% of Medicaid is in managed care, which surprises some people. That is just the way that it is trending. You can see the explosive growth of Medicare Advantage, as a corollary. There are about 300 Medicaid managed care organizations (MCOs) across the U.S. Less than 5% of them are multi state, meaning that 95% of them are local to a single state. This is one of the fragmentation issues that makes it very hard to coordinate care across other MCOs.

“The issue here isn’t incentives. Everyone’s heart is in it for the right reason. Any clinician who serves the Medicaid population could go across the street and get a much higher paying job at the local hospital. They do what they do because they care about the community. So we want to support them, because the underlying issue is their operational capabilities.”

• Even at the clinical level, you have about 50% of the provider network deliver care through federally qualified health centers (FQHCs) and independent rural health clinics (RHCs). Here, a provider is taking 50 visits a day in a good location, sometimes to 70 visits per day — yielding only seven minutes per visit. They have half the staff of a Medicare Advantage clinic or Medicare commercial clinic, but they have twice the patient panel. These folks are very overwhelmed. This is what Neil is focusing on with Pair Team. Neil sees a lot of parallels between this problem and Ben Lee’s concept around the passion and creator economy.

“The creator economy — via platforms like YouTube or TikTok — exist to empower the individual, while the individual focuses on content creation. If you think about this one of these clinicians at a Medicaid-focused clinic, aren’t they doing what they’re passionate about? But are getting taken advantage of by the system because they aren’t receiving proper compensation or proper resources to care for these populations. We need to be enabling them to do what they love. At the same time, this goes back to your point on why not just build a full stack provider, why not just take over and become a primary care office and build your own clinics? Well, that isn’t going in the path of enablement of these folks as passionate creators in the healthcare industry to serve their community’s population. And I think that is ultimately going to improve the entire infrastructure of the healthcare system at scale.”

• Opportunities in the Medicaid space, from Neil’s point of view:

1. Recently, Neil was speaking to someone at Commonwealth Care Alliance who has been treating Medicaid dual-eligible patients for 50+ years. Her take on the most impactful programs was long term supports and services (LTSS). LTSS programs help patients who need help with activities of daily living. It might involve helping someone who has back issues or spinal issues get a new bed for $500, saving the downstream $25,000 that would be incurred from a surgery. Those programs make the biggest dent in Medicaid costs and quality of life for the Medicaid population. However, the issue underlying lack of supply within cities. Companies like Cityblock are directly tackling this issue by increasing supply.
2. Then, there are community based organizations (CBOs). Healthcare is local. Even with virtual care, when things get serious, you will need to see a doctor locally. CBOs understand their community, where patients go, how they operate, how to build trust, etc. For example, one organization, LiveChair, puts clinicians inside barbershops. Organizations like these are redefining what CBOs look like.
3. Finally, there is primary care. The goal of primary care is to connect patients to these local resources, because a patient may not know where to go. For example, there was a plan in California that had spare capacity for their LTSS program — not because there weren’t enough people to join the program, but because people didn’t know it existed. Ultimately, Neil believes it’s the PCP’s responsibility to inform the patient and get them enrolled. That could make a huge impact on patients and the overall Medicaid program right away.

• On building full-stack versus wraparound platforms: Billions of dollars have gone into the new era, full stack, primary care companies (e.g., Oak Street Health). If you look at the actual percentage of patients they touch, it’s a drop in the bucket — maybe 1–2% of the total eligible Medicare or Medicaid population, at best. So, full stack primary companies are very hard to scale with high capital expenses (building brick-and-mortar facilities), even if they achieve depth by going full stack. Secondly, provider recruitment is a massive rate-limiting step. On the flip side, full-stack companies are able to control the experience, provide high quality of care, ensure care coordination is never an issue internally, have better oversight into patient management of care plans, etc. Ultimately, Pair Team chose to go the route of enablement via wraparound services. Here, you can scale much more rapidly in an asset-light way, and benefit from existing infrastructure.

“There are tens, if not hundreds, of billions of dollars that have already been spent on existing primary care infrastructure. There’s already the local office, your rural doctor’s office — are they going to just go away? We might as well take that infrastructure and build on top of it, as opposed to eliminate it altogether. This kind of scale is kind of cheap, as opposed to building de novo. It has its own challenges, for example, getting adoption across these clinics. The key piece here is integrating into the clinical workflow such that you’re not adding overhead to the doctor’s day. A provider just cares about the patients coming in. And that’s exactly what they should care about. They shouldn’t care about logging into another app or system and documenting something here, clicking buttons there.”

• What exactly needs to be augmented for a PCP?: Taking inspiration from companies like Oak Street, ChenMed, VillageMD, even at Forward and One Medical — one thing Neil noticed is that the way work is done at the front office, mid office, medical assistant, back office, and on the billing side, is mostly centralized patient engagement or logistics. The first question that comes to Neil’s mind is: if a task doesn’t have to happen at the clinic, why should it be? In fact, it could probably be done more efficiently remotely, because you can give that person the tools and automation to help them scale their work and be really high touch. Clinicians and staff should own patient care, patient engagement, and patient trust.. Everything else should be automated. You have data management, scheduling and outreach, evidence-based care recommendations — e.g., the US Preventive Services Task Force has been building out best-in-class care plans based on a patient’s health — and post-visit care coordination.
• On the perils of “change management” with adopting wraparound services: Neil recognizes it takes a lot of sweat and tears to achieve full adoption when introducing new technology to a provider. But aside from being embedded in the EMR, from an onboarding perspective, Neil and team focus on telling the provider what they no longer will have to do.

“We say, ‘You never have to go and look for what these codes are, because we’re just going to automatically surface them for you.’ Right there, we get the provider to see this is additive, not a nuisance. The technology should be creating that kind of magical experience for the doctor. We also invest in meeting with our provider customers, and asking them what their key challenges are. In that way, we serve as partners to providers. Lastly — and I think this is where a lot of other tech companies fall flat — we clearly describe the ROI to the clinic, because the value has to be achieved right away. For example, the front office staff see immediate value, because we start scheduling patients on day one. That is one less call that they have to make, one less person that they have to reach out to. Ultimately, we say, if you had to do five clicks in your EMR, do one click in ours. What’s ironic is that Medicaid clinicians are actually pretty amenable to changes, as long as they ultimately are the best thing for the patient, going back to the passion economy concept.”

What are different targets of wraparound services?: There are tech-enabled MSOs (e.g., Altais, which got acquired by BCBS California). Then there are companies like Circulo, who are approaching the same problem from the actuarial and health plan side first. Maybe they will eventually spread into providers, but to Neil’s knowledge, they are sticking to automation of the actuarial services first. There are two issues here:

1. The first issue is that for decades, health plans have been good at two things: data analytics, and contracting. What they’ve done historically is give clinics financial incentives, but the problem boils down to operational capabilities, which would be provided by an MSO. Neil has yet to see a tech-enabled MSO focused on the Medicaid market because of low margins, and you can’t let a lot of the work live in human labor. Pair Team’s margins are inherently better.
2. The second issue is that the level of automation you can provide is rate-limited by the data you have access to. Because Pair contracts with both plans and providers, they have access to both sides’ datasets. Using these data, Pair is able to get more buy in with both parties than either party, and allows them to build more robust remote assistant-type products as a result.

30:00—44:00 Pair Team

• Pair Team’s business model and go-to market strategy is initially focused on quality incentive payments: On average, Medicaid MCO providers receive on average ~$450 PMPM. About 5% of that is locked in state quality withholdings, meaning the payment is withheld until certain quality benchmarks are achieved. The exact quality metrics vary by state, but the usual suspects are things like childhood immunizations, mammography, preventative care, blood pressure and blood sugar control, etc. Pair first is helping these clinics drive revenue through quality incentives since many of these providers are overwhelmed right now. By taking certain tasks off these providers’ plates — things like data management, scheduling, etc. — Pair Team helps providers outreach to patients, get them in the door for their visit, and unlock quality incentive payments for providers, driving revenue by at least 20% just through quality payments for the practice and quality for patients.

“Overwhelmed providers haven’t been able to pull their heads out of the sand because — due to visit volume — they are forced to react to who comes in the door and who is sick at the time. They don’t have time to figure out which patients to prioritize for outreach. We’re able to do that for them, and thus help increase their quality scores, which helps drive revenue. It’s low margin. But what is interesting here is that any improvement is actually a stark 20%, 30, or even 40% improvement over baseline revenue, because these providers’ margins are so low as-is. So any improvement is massive, and actually makes a huge difference to the clinic.”

• Risk adjustment trends for Medicaid: As a next phase, Pair Team is working with a health plan to start looking at risk management. Ultimately, Medicaid is going to be moving into risk management in the same way that Medicare Advantage has moved into risk management: including risk adjustment factors and new risk-adjusted payments (e.g., larger players like Optum and Inland Empire Health Plan in California have started to implement risk adjustment). Medicaid clinics are going to have to build that competency. Pair Team wants to be ahead of the curve there.
• On meeting his co-founder, Cassie: What Neil respects the most about Cassie is the way she learns and grows as an individual. She is a cardiac care nurse used to providing highly intensive ICU care. If someone has a heart attack, she reaches her hand back and expects her teammate to put epinephrine or something in her hand, and she will fix the situation. Now, here she is in the tech world, thriving, learning how to do things that she was never trained how to do. She is such a curious, hungry individual that wants the best for patients. The other piece Neil would say is that they say you should have a co-founder that you could envision being a roommate. Neil and Cassie could. Neil hopes that Cassie can become a driving force to pull more nurses and clinicians into product development and building the tools to support their patients.

“At Forward, Cassie, a registered nurse, taught me how to draw blood on an orange. I taught her how to debug the JavaScript console. We’ve been two peas in a pod from the very beginning. I remember one night where I was coding something and I turned around and Cassie was there stocking inventory for the clinic. It’s those moments where you build the camaraderie in the trenches with someone.”

How Pair Team differs from other RPA RCM solutions: Pair Team has two differentiators: their business model and how they use robotic process automation (RPA).

1. Pair Team goes at-risk with their clinic and health plan customers. Since their customers are low-margin, it’s unlikely any clinic would pay them upfront. On the adoption front, it also makes it easier for providers to say yes.
2. Pair Team is not just RPA, but they use RPA for provider adoption so that they can easily integrate their technology into clinical workflows. But, ultimately, patient engagement is going to be the defensible aspect of their business, because that’s the hard part. Anyone can build tools — there is nothing stopping anyone else from building out this RPA functionality. However, once you’ve established trust with a patient, that’s when the dominoes begin to fall to make full use of the functionality: the patient is open to giving their phone number to a clinic white-labeled version of Pair Team’s interface, and the patient interacts with a text thread with a care navigator that looks and feels like the clinic but is powered by Pair Team.

Editor’s note: Pair Team was recently announced as part of the first cohort of CareFirst BCBS’s incubation partner, 1501 Health (in conjunction with LifeBridge Health). These entrepreneurs rose to the top of a very competitive applicant pool because of their passion, innovation, and commitment to changing healthcare. This cohort will receive selective access to and advice from leading investors, payers, and health systems.

• Chicken and egg growth strategy: sell to plans or providers first: Initially, Pair focused on contracting with providers directly to prove out value creation: reducing workload and burnout for providers and driving clinic revenue through quality incentives. Referring back to the 5% quality withholds, this is actually paid out at the plan level, and only a portion trickles down to the provider. With that info, Pair Team can go to plans and sell on the value prop that Pair can help unlock a greater percentage of the withhold and align provider operational capabilities with plan priorities, in return for warm leads from the plan to providers of interest. A good managed Medicaid plan is operating on slim — sometimes just a single percentage — margin. Bumping this margin up with quality-linked payments, and across a growing number of their provider base — is a big win for plans.
• Product and feature roadmap: Pair Team’s solution is not very sexy, but its elegance comes in its simplicity. There is no single thing taking an inordinate amount of time at a clinic — it is death by a thousand cuts. Pair’s platform is focused on automating all of the single clicks a provider takes over the course of a day. For example, California has a vaccine immunization registry. There is no API for information here. However, providers have to report when vaccines were delivered at the clinic, but there is no silver bullet solution here, but Pair automates that entry. Each of these small fixes are wins that aggregate into more provider adoption as their days get easier. Right now, Pair is very focused on administrative services. However, in the future, Pair Team wants to involve more parts of the care team, like offering virtual pharmacist or virtual NP/RN services to improve care for a patient panel.
• Pivoting from DPC to Medicaid clinic automation: From Neil’s perspective, there is a massive market in direct primary care (DPC). The space is full of rebellious clinicians who are sick of the system and just want to provide patient care. They do it on a total out-of-pocket reimbursement of $50-$100 per month per patient. Contrary to popular opinion, they are treating very needy patients that really need that care. There are many things attractive about this DPC market from an entrepreneurial perspective:

1. The providers are risk-takers by nature, since they have decided not to go the traditional route of working with a health system or going FFS
2. They are also single decision owners at the clinic, so you have alignment as a vendor that as long as you are doing what’s best for the patient, there is more customer interest

• So, Pair Team actually started out as a DPC company. What they learned is that while the DPC market is small and growing fast, it has yet to be determined whether the market takes off or not. DPC gets an unfair reputation for offering concierge services to wealthy people. However, Neil, Cassie and team found a lot of chronic and Medicaid patients going to these direct primary care clinics. In our current healthcare ecosystem, if you see a doctor 2–3x per month and your insurance plan isn’t great, then your out of pocket costs exceed $50/month. In its DPC phase, Pair Team ended up treating a variety of sick patients that really needed high touch engagement, which translated nicely into focusing on the Medicaid market, much more than Neil’s intuition would have initially guessed. Then, COVID-19 happened, and it became clear that there was a more focused opportunity on enabling providers serving vulnerable populations.
• What’s on the commercial roadmap?: Pair Team is currently piloting with a health plan in California and another on the East Coast, and will be launching soon with a national health plan. All of this happened very quickly in the span of two months, especially as there is growing Medicaid enrollment and spend — states are demanding more from their MCOs because of financial pressure and growing focus on systemic inequities. Pair Team has a playbook of going state-by-state to help these Medicaid MCOs prove themselves out in the eyes of the state, addressing unmet care needs, and ultimately achieving quality payments. Pair Team has about 70,000 patients in its pipeline that it has yet to deploy its solution to.
• Is it really possible to scale 1000s of interactions across providers?: In Neil’s mind, the set of things that happen in a clinic can be described as “death by 1000 cuts”, but they also fall within a set of core building blocks that a clinic needs to do: scheduling, patient outreach, follow up appointments, referrals, imaging, coordination, lab coordination, medication coordination — though long, there is a finite set of those core modules. Those tasks might be done in different ways across states or clinics. This is where Pair’s solution is defensible: you have to implement standardized modules that are still configurable by clinic. It comes down to being the interoperability layer underneath this complexity. Pair is going to be growing the number of interactions that its platform bots need to take, but the overall problem set is well-defined. It might be different across each state, but ultimately, at an operational level, there are a set of core things that Pair Team needs to do well.

44:00 — End: Personal Leadership Growth

• The 15 Commitments of Conscious Leadership: This book describes the notion of a line. You want to be above the line, not below the line. Above the line, you are curious and are okay with being wrong. When you’re below the line, you’re closed, defensive, and care more about being understood and being right than understanding the other person. The book gives Neil, Cassie and their team a nice framework with which to give feedback — it’s easy to tell Neil, “Hey, I think you’re under the line right now.” When building a company, especially when you have a co-founder, there will be differences of opinion no matter how much you care about each other. But you can also hate each other to death at certain points. The above/under the line concept has been a guiding principle for Neil in those moments.
• Making hard decisions vs. wanting to be liked: One of Neil’s other failure modes is that he can be very empathetic and a people pleaser. But, he recognizes this is in pursuit of his own need to be liked. In those situations, Neil imagines his company as another person sitting at the table — how would that entity feel if Neil was looking out for himself and not the company? This has helped Neil and the team at critical junctures with disagreement — they ask what is the best thing for Pair. During conflict, this helps remove the individual and orient towards a higher goal.
• Executive coaching, saboteurs, and journaling: Neil calls out his own saboteur (a tendency that is self-destructive) which is hyper-vigilance. Neil is always thinking about the next step, which allows him to feel prepared as the company moves forward. While hypervigilance and controlling anxious energy can be good when directed the right way, it can burn out both himself and his team members. Hypervigilance can create an intensity in a conversation if the other person isn’t thinking about a topic, but Neil is. In those moments, Neil can start using anxious energy or jump on the other person to get them to think about something that Neil feels is important, but actually doesn’t convey that point well. Plus, it is difficult to work with that. Neil has what he calls a “hypervigilance journal”. Any time Neil finds himself being hypervigilant, he will write it down, and apologize afterwards. The act of journaling has made it easier for Neil to learn and grow.