Pre-Sell the Thing That Doesn't Exist Yet: Dr. Alison Curfman on Building a Pediatric Powerhouse

What does it take to leave a steady hospital job and build a value-based care company for the most medically complex kids in America?

In this episode, Dr. Adam Brown and Dr. Lara Zibners sit down with Alison — pediatric emergency physician, mom of 4, host of Startup Physicians, and co-founder of Imagine Pediatrics — to trace her path from clinician to telehealth pioneer to founder of a company that now takes full risk for children on Medicaid.

Along the way, they get into the realities of homeschooling four kids through COVID, why complex pediatric care has been ignored by investors for so long, and the analogy that finally explains the broken math of insuring only the sickest kids (hint: it involves teenage boys and car insurance).

Alison also delivers the single best piece of advice we've heard for physician founders: stop polishing the pitch deck and pre-sell the thing that doesn't exist yet. It's how Imagine Pediatrics walked into day one with thousands of patients already under contract — and it's the playbook she now teaches other doctors who want to build.

Transcript

SPEAKER_00 0:00

Unstable Vitals is the podcast that takes the pulse of American healthcare. And the prognosis is critical. Dr. Adam Brown and Dr. Lara Zibner, physicians turned entrepreneurs and business leaders. Expose why the system is unraveling before our eyes.

SPEAKER_02 0:17

And welcome to another episode of Unstable Vitals here with my good friend Dr. Adam Brown. How are you doing, Adam? Oh yeah, I'm Lara Zibner's.

SPEAKER_03 0:28

What's her name again?

SPEAKER_02 0:29

Lara, Lara Zibners.

SPEAKER_03 0:31

Yeah, yeah, yeah. We all know. It's a it's in the title. I think it's kind of like on the on the Spotify thing.

SPEAKER_02 0:39

But it says Dr. Lara Zibner's. And I like when I was a if I didn't introduce myself as doctor, I would pick up the phone and go, it's Lara Zibner's. And that sounds like Lara the nurse.

SPEAKER_03 0:50

Well, I mean, it I guess it happens quite a bit, right? When like you walk in as the doctor and people are like saying, No, I'm ready for my doctor.

SPEAKER_02 0:58

And oh, we've been in this hospital for five days and we have not seen a doctor. You've seen many doctors many times a day. We're just all women.

SPEAKER_03 1:07

Anyway, how are you doing? It's good. It's really hot in DC. I you know, I'm back back stateside. Um, I go back to London in a couple weeks, but um, but uh it's uh yesterday it was 96 degrees here in Washington, DC. Yeah, ooh gross.

SPEAKER_02 1:23

Ooh, that's like when the like the the the sewage in the street starts to really get yeah, hot trash days.

SPEAKER_03 1:30

That's not a really good day. Um temperatures run uh for those on the on the other side of the pond, that's like 36 degrees, you know. So they're like, oh my god, that's a lot. So and it's May, you know, here.

SPEAKER_02 1:42

So like um it's it's it's quite I'm in London and it's kind of nippy. Yeah, kind of glad.

SPEAKER_03 1:48

I mean, I'm ready for that again.

SPEAKER_02 1:49

It's a typical London day.

SPEAKER_03 1:51

Yeah, hey, we've got a really cool guest. I'm really excited about it.

SPEAKER_02 1:54

This is like our shortest banter, like that was the least fun banter.

SPEAKER_03 1:57

Well, we'll go back into it, you know. But okay, fine.

SPEAKER_02 1:59

Okay, so now I get to introduce this guest.

SPEAKER_03 2:01

Okay, go ahead.

SPEAKER_02 2:02

So, you know, I was at Health Vegas, not yeah, Health Vegas last October, and I had a booth, and I had my octopuses because I was on a panel called Women Are Not Octopuses, and I'm standing at my booth after my panel minding my own business, and this lady comes up to me and is like, Hi. And we start having a chat, and then it turns out she's also a pediatric emergency medicine doc. And it turns out that she also has a podcast, and it turns out that she also enjoys going to conferences to get away from her children. She has more than me. And so we became friends, and I was on her podcast, and it took some scheduling issues because you and I have calendared handicaps, but we finally have brought on Dr. Alison Kerfman.

unknown 2:57

Thank you.

SPEAKER_02 2:58

Physicians is the podcast. Allison has a wild background ranging from pediatrics right through the money side of it, and is now one of the biggest supporters of physician entrepreneurs I know. So, hello, Allison. Tell the world your story.

SPEAKER_01 3:14

Thank you. Thank you so much for having me. I feel like I need to clarify that I don't only go to conferences to escape my children. It is a perk, but um, okay, yeah. I mean, I guess we all might do that a little bit.

SPEAKER_02 3:27

Let's just, I got that right, right? There's a lot of.

SPEAKER_01 3:29

Yes. I have four, um, 13, 11, 9, and 6. Um, they are amazing. Um, they are currently homeschooled. We do kind of like a world schooling, we do a lot of traveling, um, and they they go to a special co-op program. So I'm not their teacher, but they don't go to traditional school.

SPEAKER_02 3:48

I was just gonna say, did COVID not turn you off from the concept of homeschooling forever?

SPEAKER_01 3:55

You know what? COVID was rough. I, you know, was working full-time in the ER and had a newborn who had just gotten out of the NICU during COVID. So, and then I had a kindergartner and a second grader and a preschooler. And so, yeah, I was rough. Um, they thought that our ridiculous whatever that year was, uh schooling-wise, they thought that was the best year of their lives. Um, pretty much taught them how to like make grocery lists and do their own laundry, um, which is life skills.

SPEAKER_03 4:24

It's like home economics, right? Exactly.

SPEAKER_01 4:27

From back in the day, and we got a ninja course in the basement, and they got really ripped doing like pull-ups on the ceiling. Um, so we had these like muscular little kids that knew how to buy groceries. It was great.

SPEAKER_02 4:38

You know, I sometimes I talk to people and I'm just like, I'm a really shitty parent. Yeah, like I started out, I put a map of, I was like, I'm gonna, I'm gonna rock this. So I got a map of the world and I put it on the wall and I was like, okay, guys, let's mark all the places we've been, right? So that took an out five minutes. So then I was like, okay, reverse, let's mark all the places we haven't been, right? By day three, I was done with every single activity I could think of. My son was using the school iPad to download pictures of Peppa Pig holding AK 47s. That was first grade for him. He just my children were being told by their teachers to make mosaics out of lentils and beans. So, you know, I'm going to the grocery store, but they're spreading legumes around that.

SPEAKER_01 5:22

It was it was a weird, it was a weird time. I um I remember being incredibly stressed in 2020. And I'll when I share my career story, it'll come a little more full circle of why it was such a rough year. Um, but at home, we were trying to hold it together. Again, we didn't know what COVID could do to to babies, to newborns, to, you know, and I remember like, you know, coming home from work and like, you know, you'd like strip in the garage and wash your mail and all the things. And um, but somehow I know I oh we washed your mail, man. Wash your mail? Yeah, because other people that touch it. I mean what? I I know you like take it. I I don't know. We I it's it's such a blur. I barely remember that period, but I do remember being scared all the time. Um, but I do know that I worked on New Year's Eve that night, uh that year, and my husband was home, and my oldest, who was in second grade at the time, um, they stayed up till midnight, and um he was sitting alone with him on the couch and was like, So what did you think about this year? Like we're going into 2021 and 2020 is wrapping up. And he was like, it was awesome. It was the best year of my life. I got to be home. I got to hang out with mom and dad all the time. It was so great. We had a baby, it was amazing. Like he's a very positive kid. But they apparently had a great homeschooling experience, even though David and I, it was very stressful for us. Um, but we did put them back in regular school. Um, we ended up moving to Nashville. Um, I'll talk more about that. Um, they did go to regular school here in Nashville. And then I believe in like signs from the universe. I think sometimes the universe is like telling us something. I spend a lot of time focusing with entrepreneurs on how do you design your life? How do you design your career and your interests and your time? Because the time is the one asset that you cannot get more of. And I spent all this time talking to adults about this. And then my kids approached me and they were like, we raised a lot of time at school. Um, and we had literally in one week, completely unsolicited, four different conversations. It was like bombarding us from every angle of families that homeschooled or did non-traditional schooling. And my kids were like, Remember when we did that? That was so great. And I was like, Oh my God, like, I cannot be your teacher. I have so many jobs. You can't be home all the time because I mainly work from home. Um, so they actually I gave them some AI tools. They did like a deep research report to find um uh options in our area. And they they found a program and they like wrote a proposal to us. They're like a little democracy. They like all work together to like figure out how to convince us of things. So they made a pretty good proposal. So we allowed them to leave school. Um, so I guess that I guess shows my willingness to be very open-minded and pivot. Um, they had an amazing year. They spent you know half their days in a creek and they went to school a lot less than anyone else, and we did a lot of world travel. And um yeah, I'm coming over your way this this uh summer, Lara.

SPEAKER_03 8:41

So I you know, I want to jump into kind of the career sort of things because it's really interesting.

SPEAKER_02 8:46

Um, and you know, I I all of us I know we do have a it this is a podcast about healthcare, and here I am just like feeling like a crappy mother, and I'm like back over here in the creeks.

SPEAKER_03 8:55

Yeah, I don't even have kids, so I don't know what you guys are talking about.

SPEAKER_02 8:58

But like, you know, um Well let me let me explain to you where you live where in your world, weekends are enjoyable. In my world, weekends are the days that the teachers don't go into work.

SPEAKER_03 9:12

Oh are you are you talking about for me?

SPEAKER_02 9:14

Yeah, like when you're I'm working non-stop.

SPEAKER_03 9:16

I don't know about it.

SPEAKER_02 9:17

No, I know, I know, but I just like like days when schools are closed, like I just find that offensive.

SPEAKER_03 9:23

Oh, I find it l lovely because then my my neighborhood is not completely chock full of tons of cars, you know, trying to get at 7 30 in the morning when I'm trying to just spring back to healthcare. Anyway, back to Allison. So tell me about your career journey because you know, very much like the three uh the two of us, uh all three of us have a non-traditional kind of career pathway, and and it's informed by, I think, as you were saying, like signals from the universe of like you should do certain different things. So, what was your career journey?

SPEAKER_01 9:56

So I'm a practicing pediatric emergency physician. I still practice medicine. I worked in the ER this weekend. I love taking care of kids and their families. Um, but I always saw this unbelievable brokenness in the systems. And I think that we as physicians carry the emotional burden of when the system fails our patients. Um, we can do everything in our lane and in our capacity to make things better for the patients, but we're still operating in this system that is unbelievably complex, has all of these different layers of influence. And in it very frequently, the losing party is the patient and the family. Um so I remember feeling a little stifled by the traditional system because I would see a problem and I'm I'm a very creative and visionary person. I'd say, what if we did this differently? What if we created something that could do this? And I it was just like, no, no, no. Like we that doesn't work that way. Um and I was like, oh, okay, that doesn't work that way. Um, and early on I would take that answer and be like, oh, bummer. Um and then I started to have some, I actually had a case when I was a fellow of a patient that, you know, a rural hospital called and they were panicking. They said, we have this kid, he's really sick, we don't know what to do. Um, we're gonna get him to PEADS as fast as possible. That's what he needs. Um, and they put him on a helicopter, but we had no information, we had no history, vitals, physical exam, and I really couldn't provide any sort of guidance to them. And he had an unrecognized head injury, and on that helicopter flight, he herniated and died. And um, someone lost their toddler because they didn't know what to do at this rural hospital. And and I don't fault them for that. This is a very, very challenging case. But at the same time, I thought, I look over, my husband is adult neurology, and they have these networks that they're starting to build for TPA, for stroke, for doing telehealth to outlying facilities. And I was like, I know it's possible. Why are we not providing more support to um, you know, help help children in outlying ERs? This would be an incredible use case of incorporating technology as a tool in our practice to give better care to kids. Um, very quickly got shut down. It was like, nope, we are not gonna take on liability and there's too many operational things. Oh, and we don't get paid for it, all of this stuff. And so then I started looking at telehealth more broadly. This was 2014. Nobody was doing telehealth well. Um, there were no best practices or standards or policy or payment. Um, so I ended up starting my first venture, which was a nonprofit research network for um pediatric telehealth. I wrote the AAP's policy statement on telehealth, which conveniently came out in 2020. Um, and again, was just very much a thought leader for how do we, as clinicians, take technology that may not be part of our day-to-day practice, but we set the standards. We say these are the cases that it would work well for, and these are what you should absolutely not be doing via telehealth. Um, and that was an uphill battle up until 2020 when all of a sudden everything changed. But um, I ended up moving into a role as a medical director, overseeing all the virtual care programs for a large hospital system, and our foundation program was for children with medical complexity. Um I had a very strong interest in population health. I was running this program for the sickest of the sick kids in our hospital system. And our hypothesis, which um is really not rocket science, was that these children who are make up a very small percentage of pediatric patients, but account for a massive amount of spend and utilization in PEDS, that if we just supported their families more with more of a proactive wraparound model of care, that we could keep them healthy and out of the hospital. And so I ran that program for a couple of years. We reduced their hospitalizations by 35%, cut their ER visits in half. It really worked. It was all a virtual intervention. We were just, again, supporting these moms and dads. Like there are so many things they have to navigate. It's so challenging. Um, and it it really was a great um evidence of how you could use this sort of a tool in a new way. Um, but we were not in value-based contracts. So we were in a fee-for-service system. It was a pilot study. Um and during COVID, the budgets changed and uh we lost all our funding, basically overnight. Um, and so that program, despite being really clinically successful, was not financially successful and it was shut down. And I moved into an operational role and was really questioning, what am I doing here? You know, I don't want to build workflows and and oversee a bunch of, you know, reporting. And um, I I really like working in the ER, but I was going again, this was 2020 when I had a new baby at home and all these kids running around doing pull-ups in the basement. Um, and I was every shift I worked in the ER, all of these kids that I had kept out of the hospital for two years, every shift, at least one of them, was either in the ER or had just been admitted. And that's when I decided to build it on my own. I I decided, I actually, who am I kidding? I did not decide. My co-founder, who had a lot better view on what the startup ecosystem was like and what it takes, she was like, we have something valuable. We absolutely know how to care for these kids. We have a model, we know who they are, what they need, how we provide this intervention, and we have the data. And you're a doctor and I know tech. Like, let's go do this. And I thought she was crazy. I was like, I don't, I work for a hospital, I don't know how to build a company. Um, but I did agree to apply to this um local incubator accelerator program. We got some coaching. And then again, universe, serendipity, whatever you want to call it. The day that I actually called her and told her, I am willing to quit my well-paid job to go out on a limb. I believe in this. I'm so unhappy doing this operational work that is not the mission that we set out to do. I will quit my job and come work on this and we're gonna build this as a startup. Um, the day I told her that, I actually got a LinkedIn message from a very prominent uh private equity firm in Nashville that has a venture studio. And they said, we're interested in investing in complex care peeds. We found your paper. We'd love to talk to you about it. And like within a few days, we actually flew down to Nashville, met with the whole firm. Um, we both called our husbands. We're like, hey, you know how we were gonna quit our jobs to start this company? Can we actually like all quit our jobs and move to Nashville? So um thank God for supportive husbands. We moved, you know, my whole family of six and all of her kids to Nashville. And so I had the experience to basically incubate this company within a very well-resourced firm, um, which led to the creation of Imagined Pediatrics. It is a phenomenal company, uh, value-based company for children with medical complexity. Um, we work directly with Medicaid MCOs. And as of today, I mean, we reached a multi-nine figure valuation in less than two years, and I we're close to having about a hundred thousand patients that we take full risk for. So this whole experience, I took something out of my brain, out of my clinical experience, out of my uh relationships with these moms and dads and families, and created a model that now lives on beyond me. And, you know, all of these children that otherwise were not getting this sort of care are receiving unbelievable care.

SPEAKER_02 18:28

So can we back up there for a second? Because the idea originally came, because I had this experience too. You know, I trained at the Ohio State, right? Nationwide children's, and you one of the fellows was just constantly on the phone talking to other hospitals. And and it was amazing to me how sometimes I'd even be talking to somebody I had trained, and they were a very, very competent, comfortable physician, and they were comfortable with children when they were at children's, but take them out of children's and put them somewhere else, and the uh the uh lack of uh infrastructure for children uh left them feeling uh unsure about all their decision making, right? So I that's definitely a recognized problem. But the issue with the pediatric um, you know, emergency care being available to children uh, you know, even in rural environments. But then there's a pivot here because that was the original idea of how do I support these emergency cases? That was a trauma incident, but you very smartly pivoted to chronic care kids. And as you were saying that, I'm like, I learned very early on that when it came to these chronic kids, it didn't matter what I thought. I wasn't coming up with any ideas, I wasn't even gonna bother dealing with the complexity. I just would ask mom or dad, you know your child, please tell me what you need. And they'd be like, I need this antibiotic and I need this trait, blah blah blah, blah blah blah blah blah. And I'm like, great, done. Because these parents know their kids so well. How do they get the support? So I think that was kind of a brilliant model because those are, as you said, the children that the the local environments maybe don't like mom and dad know better, but how do they get anyone to listen to them?

SPEAKER_03 20:08

Yeah. You know, one of the one of the things that strikes me, so in my class that I teach, we talk about you know the cost of healthcare, how how how much it's um continuing to rise, and that less than five percent of the of the healthcare population are actually driving 50% of the costs. And so, you know, your your thesis around we can help support Medicaid MCO totally makes sense for those that own a Medicaid, is for lower income individuals. About half of the um women are on Medicaid at some point in time, and then there's managed Medicaid, of course, for the purpose of um that it's oftentimes run by private companies that help take Medicaid, Medicaid dollars, and then um leverage those dollars to take care of patients underneath the Medicaid plan. Sorry, I'm educating, just putting my professor hat on for a second, just for those that don't know the difference between Medicaid and Medicare. Um, but anyway, so um, but it's an area that's really challenged in Medicaid because reimbursement rates are typically very low. Um, the patient population, if Lara remembers from class, it was one of our case studies we talked about um in Memphis, Tennessee, actually a Medicaid class, but that may have been the one you missed. I mean, I don't know.

SPEAKER_02 21:16

But um No, I missed one class. And can I just in my defense remind our listeners that I did my MBA at one o'clock in the morning?

SPEAKER_03 21:25

She did, and she still got a high pass.

SPEAKER_02 21:27

I would set an alarm, and the one class I slept through ever in two years was Dr. Brown's class on the difference between doctors and nurses and ACPs. And he was like, That's cool. I think you got that one.

SPEAKER_03 21:39

Yeah, I think it was APCs. But anyway, um but uh I just keep kind of needling her a little bit.

SPEAKER_02 21:45

Well, but see, my husband, we're in the UK and they're called ACPs.

SPEAKER_03 21:47

Oh, they are?

SPEAKER_02 21:48

Oh, okay. They're advanced care practitioners.

SPEAKER_03 21:50

I'm now learning. Um but no, so going back to the Medicaid population, I think one of the one of the biggest challenges is um is uh many. Many companies find it hard to engage that population for several reasons. One of the reasons being that there's not a lot of income. And so when people are working and have to work, they don't have the availability of going to the doctor's office at 10:30 for the appointment, you know. Um, because there's not child care, there's not transportation, there's not those type of infrastructural type of benefits that sometimes people are more well off. So it's you, I it's so fascinating how you you tapped into several problems with your solution. One is you tapped into a very challenging population because of all of the socioeconomic and social determinants of health issues. But secondly, you tapped into a population that, um, especially from a chronic disease, is a really high cost driver or cost driver for health care. And so being able to get patients engaged, number one, is a huge feat. But number two, driving down the cost of care for those patients is massive. So there's no doubt in my mind why a value-based care type of private equity firm that would be focused on that would be like, hey, this is a great opportunity here.

SPEAKER_01 23:06

Well, I mean, I thought it was just bizarre that somebody was like, hey, you know what? We want to do complex peds because there's not a lot of firms that are like, hmm, where do we see there being great investment? Oh, pediatrics. Like there must have been a personal connection. There was. Well, I'll tell you why. So the firm, I mean, they they had experience with building other um complex chronic programs for seniors. So one of the first uh value-based companies for complex seniors um was founded by the CEO of the firm. It was his first company. And he was always asked, could you expand this into the pediatric population? And it was always interesting to him because he's like, not with this business, but is anybody looking at that? Um, and I see a lot of children's hospitals trying to address this with, you know, a complex care clinic or something to really provide services for those patients. But when you think about it from a population health perspective, if you only take like the tip of the pyramid and try and build a funding model for that, um, if you were to take risk on just complex chronic kids, that would be like starting a car insurance company that only insures 16-year-old boys, right? You can't build a model that works that way because it would be too expensive. And so I um I actually think that what we had to create with our model is understanding um it's actually more children with special health care needs. It's not just children with medical complexity, although they drive a lot of the cost. Um, you have to have other people in the population. And so we built an algorithm based on uh ICD 10 codes that we used to do do a healthcare economic evaluation. Um and basically everyone in the population is someone who has some form of a chronic disease and they have um some form of uh you know other other things leading to um higher risk factors to utilize more. And so your point about Medicaid engagement is well taken. And it's honestly why I think some people shy away from this and why people would look at, you know, there are other companies that have tried to address uh full risk in Medicaid more in an adult population. And it's a challenge, it's very challenging. These people might not have a consistent address or phone number, or you know, there's all these things that are contributing to them not having um consistency for contact. On the flip side, these kids with chronic conditions, the vast majority of them have had some interaction with the healthcare system in the past 12 months. Um, the vast majority of them, a lot of them are on Medicaid because of their chronic conditions. Um, and the fact that they've had interaction with the healthcare system, and they have parents who are just desperate to get help. They are it's actually a very engaged audience. I I think that the parents of this population, it they are um they're it's a superpower to be able to tap into their their knowledge and their drive. Like these these parents would do anything for their child. Um and so it in some ways is an easier population to engage.

SPEAKER_03 26:27

You know, that's a really good point. Because when I when I typically have been talking about, you know, when we talk about the Medicaid population writ large, it's much that is a much harder nut to crack because you're talking about people that get in the mail a card one week and your their new doctor is X and it says United Healthcare, and you find out it's a Medicaid program, you know, like you don't just depending on the state. And so I used to have patients all the time in the ER here in DC that would come in and say, like, I don't know who my doctor is, I have no idea. Right. And then you'd look on the card and they're like, oh, I just got this new card last week, and or um, but your point is a really is a great one. And going back to my my, I mean, I'm not a pediatric ER doctor, I'm a generalist, but like um doing the the rotations at CHOP and Philly and stuff, I you are a hundred percent correct. Like those patients that had chronic diseases, um, their families were like stuck to them like glue. You know, they they were the most engaged individuals, irrespective of their insurance plan that they had. Um that said, it's outside of that population, the Medicaid population is quite challenging. And so for any VC or PE firm to be like, hey, let's fund um a Medicare target, a Medicaid targeted MCO kind of solution is is quite quite astonishing. But also it's taking a risk.

SPEAKER_01 27:51

I was given a really clear uh directive when I was hired at the firm. It was that we were going to basically do our discovery process and de-risk the concept on paper before putting capital in, and that we had to prove a pathway to a billion dollar valuation before they would fund the company.

SPEAKER_03 28:10

I want to pick on that really quickly. So one of the big areas No big deal, right? Just No, no, that's a huge deal, but it's so smart. So one of the big challenges that I see with innovators, because my company, we work with innovators from the US, Europe, UK, etc., um, in commercializing. And one of the challenges that we always see is that their focus is like, I want to get through the FDA regulatory process, and that's it. They are like, that's what I want to do. They are not contemplating the commercialization strategy, which is exactly what they were forcing you to do. It's like, how are you going to let's mitigate the risk, let's de-risk this, let's think through who are the stakeholders, who are our buyers, what are we going to do, and then how are we going to actually make money on this? And this is where I see a lot of both sides, doctors who are innovators, and then innovators who are not doctors have a problem with not having a wide aperture of what is the commercialization process going to be like, who are the critical stakeholders, who are actually the buyers? It's oftentimes not the patients. And um, and then how are you going to actually make money? Because if that dog don't hunt, you don't take a hunting, you know.

SPEAKER_02 29:22

And I I think this is also an interesting example of where private equity can approach healthcare in a positive way, because you know, there's really two models. One is to build value, and the other one is to cut costs. And we all know what happens when private equity comes in and tries to cut costs, they cost lives. But the the ones who go in and see how we can roll this up into something that's scalable, and now we have economies of scale, and we're actually creating and driving value, that's a different model. And I think it's a good example of how we can't just walk around saying PE needs to keep its nose out of healthcare.

SPEAKER_01 29:59

It's I honestly, I I did this exact program in a nonprofit setting, and it got shut down because it wasn't, we couldn't make it profitable, and they would never ever have had the resources or the know-how to negotiate value-based contract. I mean, it's a big deal to take full risk. You need a lot of capital. You have to be willing to take it's literally called taking risk. You are taking risk. Like, for all I knew, if the model didn't work, we could owe them like $50 million at the end of the year. That did not happen. But um, you know, it working with a PE firm that had done this sort of uh really complex negotiations and building our business model of our like how we contract, I was able to focus completely on the clinical model. And you're right, it is building value because it's something that we aren't cutting costs. All of the, all of the revenue that we generate comes from a shared savings of reducing hospitalizations, which the families are thrilled, they don't want to be in the hospital, the payers are happy, they would love to cut costs, and they are not in a position to deliver any sort of programming like this because they that they just don't know what to do with these children. So I think the de-risking process is a huge part of what I teach physicians today. So I do work with a lot of physicians on, you know, becoming advisors for startups, or also I run an incubator program for physician founders, really teaching them the process of how do you take a concept of wouldn't this be nice to have and actually build a business model around it where you can assess essentially the go-to-market plan, the initial proof point of how you're gonna get to a pilot in a short amount of time, and and building a forward-looking financial model that can look ahead and say, could this be a hundred million dollar business or a billion dollar business? Um, and and and then you get just a ton of feedback. So we were we were pitching to MCOs constantly and getting all sorts of reasons why this number is wrong, or why that won't work, or why we wouldn't want a contract for this, and why we'd want to add something about this. And did you include our equality metrics and all these other things? And every time you're having those stakeholder conversations and you're doing it based off of a forward-looking model, you you then go back in, you assess it, you it's all about the unit economics. What are all the revenue streams? What are all the potential costs? This is a very, very complex model. So our um our our model was, you know, many, many tabs on Excel, but it all boiled down to one number. What is the unit economics per patient per month to deliver this model? And what is the amount we will get in revenue? And so you don't want to scale something unless the unit economics are positive.

SPEAKER_03 32:50

It's it's so totally true. So we operate off of the total product lifecycle type of concept and coming going from the point of ideation all the way through the point of commercialization. And I think that your your point there too, I love it around, you know, when you are sitting in the uh the we'll just use incubator space, thinking through kind of the process of how you're going to put your product out of the market, you do have to think about like, okay, great, we've got this. If it's a medical device, we've got to get this through the FDA. Cool. All right, well, Laura can speak to this. I mean, she's got a device out there. So, like, um, you've got to get through the FDA if you're going to be in the United States, cool. Okay, but you've also got to get it paid for by payers. And so, and their economics are very different than safety and efficacy. They're look or their endpoints and their studies are very different. They're looking at economics a lot of times and outcomes versus safety and efficacy. And so, your point around getting to the point of a pilot. Well, you have to get it oftentimes to the FDA to get to the point of a pilot, but at that pilot, you need to make sure your study design is organized in such a way that your outputs or your outcomes that you're studying are going to be able to kind of tickle the ears of the CFO at the hospital or of the plan administrator, or you know, depending on who your potential buyers are, it's not just about does it make clinical sense? It's got to make financial sense too. So I really love that you're teaching that. And it's it's really, really aligned with what the we all have been talking about here.

SPEAKER_02 34:18

And I think that's something that people don't understand is that when you're approaching healthcare systems, you have to convince a lot of different people who have a lot of different like one no derails you, it doesn't matter, and you need the clinicians, even if it's paid for, then to adopt it, right? It has to like be easy. People don't like change. Change is hard, it hurts.

SPEAKER_03 34:39

Well, it's beyond that, too. You said something the the liability word. How many times did we hear as we were in training, we can't do that because I'm worried about my license or not on my license, or I'm worried about the liability. And sometimes very valid, but sometimes just as a throwaway statement to get you off of to avoid change.

SPEAKER_01 35:02

Well, I one thing that I found to be really um clear is that I believe physicians need to be at the design stage. I see how much value I was able to bring to the I mean, I I I actually ask this of physician audiences all the time. I say, um, what is a problem in healthcare that affects your patients that you know the solution to? And I tell them, like, do you want some developer or some uh investment banker trying to figure that problem out? Um, you understand all the edge cases of this scenario. You know how to approach this. So I you have to have the confidence to realize the clinical knowledge itself is incredibly important in the design stage. Um, and I I deeply understand what I was able to bring to the table, but you are not the end all be-all. You have to make a business case around it, you have to be able to work with other stakeholders. It's very easy for doctors to throw their hands in the air and be like, oh, payers are so evil, or admin is so evil. Yes, every and it's it's hard because we are again, it goes back to, I really do feel like we carry the emotional burden of like, you know, private equity doesn't feel the pain of like having a mom crying on your shoulder and you're trying to comfort them and you just can't figure out how to get them what they need. Like they they see that as a line on a spreadsheet or something. They don't we carry the emotional burden of when the system fails our patients. And so it's easy to point fingers and be, or, or to say, you know, that this is the healthcare, you know, your your tagline of healthcare is unstable and it's it's not sustainable. And maybe I should get out. And um, I want doctors to become part of the solution. I think that we have good ideas, we have to feel empowered to use them. Again, I was told over and over and over again, you cannot fix that. That is just the way things are. Um, and maybe I couldn't fix it there or in that setting, but I could go somewhere else where where I was able to contribute that sort of innovation.

SPEAKER_03 37:07

You know, this notion of I tell this to other doctors I talk with all the time, and again, we're three examples of it. No one would ever say to an attorney or an accountant, you can only do that, and you can only do it from that type of desk and that type of scenario, you can only do that forever, and if you stop it, you're going to be shamed by society, you know? No one would ever do that. But for doctors, it feels that way sometimes. It feels that way that, like, if we decide to step out of the clinical space, even part-time, that we're somehow um some of our d duties and shun. But let me just finish this quick point. But what I tell people is that the, and this is Allison, what you're getting to, or what you're saying, is your impact, the amount of impact that you could actually have on the system can be so great beyond seeing one patient every 10 to 15 minutes in an emergency department, you know, and not that that should be demeaned in any stretch of the imagination whatsoever. I'm just saying that like the scalable impact that I potentially have by working with device manufacturers or working with healthcare systems or working on strategies of improvement, same with you. I mean, you're an example of this with the thousands upon thousands of people that you're, I think it's all something over 100,000 plus um pediatric patients in your company. That's massive. And if you were, if you were just always in the ER the whole time, you wouldn't be able to do that.

SPEAKER_02 38:35

You know, this is this is when I retired from clinical medicine, it was because I'd reached that point where due to COVID and life circumstances, I hadn't touched a patient in a year. But I've been involved with advanced trauma life support, and I'm currently the national educator for the UK, and I was educator for Africa and Europe. And and so I told myself the word for this is Ponzi scheme. Uh, you know, as a physician, I might have been able to care for X thousands of patients over my lifetime. But being teaching on six courses a year where I teach 16 doctors how to then go teach 24 doctors each on how to care for an injured patient, I've now cared for. So I retired with sadness, but I told myself it's okay because I ran the greatest Ponzi scheme in medicine ever. I've cared for more patients than I ever could have physically done on my own.

SPEAKER_01 39:24

Well, and I think it's important to note that you don't, you don't you can do both. You can you can leave clinical medicine, you can stay. I I think being in pediatric emergency medicine has been a great benefit that um we we are either there or we're not. So I can I can work shifts when I'm and when I'm there, I'm I'm working and seeing patients. And when I'm not, it's not like I have like an in-basket to keep up with. Um so it's been very amenable for me to kind of dial it up and down at different points in my entrepreneurial journey to, but I I do it, I I love seeing kids, but it would take me, I just calculated, it would take me 10 years of working 365 days a year and seeing 40 patients a day to reach 100,000 patients. And um, I think by by creating something, creating value, creating a model, um, and and putting, I mean, I think there's like 500 people that work at Imagine Pediatrics today. And um, and I believe that the care that people are getting is is exceptional. And it's uh you you talked earlier about how, you know, in Medicaid, oh, it can be hard to like take off work or whatever. I mean, well, then maybe we have to design care models that actually work for patients. So we have 24-7 support wraparound care that like they can access on their terms and we make sure that um every patient is we we really want to make sure that nobody is ever limited by their technology access. So we built it into the business case to say, hey, if they don't have you know a smart device, we will provide one. You know, we will make sure that we're providing care in a way that people can actually access. I mean, the actually navigating the healthcare system is so hard. I I know more than most people about how to navigate the healthcare system. And I can't do it. So I think that our models need to be um, they need to be solid business models, meeting a real clinical need. They need to have the right clinical input from the beginning, and they need to be very focused on like what do patients actually need and stop dealing with these archaic, bureaucratic, we've always done it this way, sort of systems.

SPEAKER_03 41:32

Absolutely. So we only got a couple minutes left. This has been fascinating. It's gone by so fast. Um, I I do want to ask two questions. Um, one is so we talked a bit about like what you do when you're talking with physician founders or innovators and things, but what is the one thing that you think that physician founders should do before they raise money? Um, before they get out there to raise money. What should they be doing? They should pre-sell their product. Explain.

SPEAKER_01 42:02

So I um I learned this by again working at a firm. They basically like put us in a room for a year and they were like, make this worth a billion dollars. Um, and so what that means is yes, you need your forward-looking financial model, you need a product roadmap to tie with that to assess what are we building and when, when are we offering these different options um and what's it gonna cost? So you can really see what the capital requirements are. Um, but then beyond that, you are not just gathering stakeholder feedback on a one-pager or a high-level pitch deck. You are actually getting, go try to sell it. Like, I I feel like I don't even know what we were pitching in like January of my first month working. I I mean, I would love to go back and look at like what did our deck look like? I do remember the formatting of it because it was really ugly. Um, I don't know what we were pitching. I mean, it was like here's V1 or V0 of the idea. Go talk to an MCO, have them tell you all the reasons why they won't buy it. And then go fix it. And and and the the leaps and bounds of progress you make from actually not just like, hey, do you think this is a cool idea, but like, will you buy this? Um, and and I think that um anyone can make a pitch deck in like five minutes on Claude these days that can be beautiful, but it's what's on that's the tip of the iceberg. It's the foundation underneath it. Um, do can you actually build a financial model and a roadmap that has like a real data room that you could sign an NDA and give it, uh, give them access so they could go in and they could test your assumptions. Um and and go get that stakeholder feedback. Try to sell it because it's uh it's almost like Kickstarter, right? Like you would you buy this, would you buy this? And if people will buy it, right? Yeah, if if people will buy it, then you. They can pre-order it. Um, now that's a direct-to-consumer thing, Kickstarter, but we were legitimately able to negotiate down to the detail of what these contracts would look like with MCOs because we had so much of their feedback because we were trying to sell it before it existed. So then when we signed a contract in, I don't know, August or September of 2022 to go live January 1st of 2023. And it was like, oh my God, we're starting with 20,000 patients. Nobody works here. We got to go hire some people. We got to do some work. Um, but it's way easier to fundraise and have a ton of leverage when it's like, and I have a contract.

SPEAKER_03 44:42

Contract, absolutely.

SPEAKER_01 44:44

So that's what you need to do as a founder. If you don't know how to do that, find someone who does. I teach people how to do this. Um, it seemed bizarre to me. I was like, no one's gonna buy something that doesn't exist yet. That's not true.

SPEAKER_02 44:57

I I think that, and I was just gonna say that that that it makes everything easier because just having those letters of intent or letters of support from those stakeholders that convinces your investors that people will do this. It convinces everybody along that whole chain. So I think that's great, great advice.

SPEAKER_03 45:15

So, last question is um, and that's such great advice that you just gave. I absolutely love it. Um, last question, and I'm assuming I know the answer to this of what you're gonna say, but I'm gonna ask it anyway. Um, you know, the call our our podcast is called Unstable Vitals, and we called it unstable because healthcare is unstable in the US. And so are we and sure, we are too, a little bit. Um, so but is healthcare so unstable that it's unsalvageable in the United States?

SPEAKER_01 45:44

Oh, I'm a like huge optimist. I'm like, I'm most founders are. This is why I love working with founders. Like, we're gonna fix it, and everything is rainbows and sunshine, and we're gonna, you know, we're gonna get knocked down and get back up again. Um, but um yeah, no, I um I see so much potential. I have, you know, I experience the pain of uh both being a practicing clinician and and seeing what patients go through and being navigating as a patient myself sometimes. Um, but it's that's just opportunity. Like in my mind, it's just opportunity. And if there's ways that you can see an angle of something that could, again, not don't look for cost-cutting measures. I mean, that's like the very uh derogatory, negative way to be like, oh, they're just gonna take away our jobs and replace us with AI or um uh other types of people. Um no, create value. Find ways to create uh an outsourced amount of value by fixing a process or by providing something more or creating something. I mean, I think that um we are so starved of creativity in traditional medicine. It just like people don't even know that's a possibility that you could go be creative. So um I have high optimism.

SPEAKER_03 47:04

Good.

SPEAKER_02 47:04

You and I love that, and I love that what you did was you created value for a group of people who aren't seen as being value generating, right? We're talking about pediatrics, we're talking about children. Children don't vote, so children are, you know, pediatrics is one of the worst paid and then a lot of these kids have chronic issues. Many of them may be dependent on on social support systems in some form or another for the remainder, you know, the entirety of their lives. So you found a way to shine a light that was real value on a population that uh often gets completely overlooked. And I I think that's amazing.

SPEAKER_03 47:45

Completely agree. Allison, we really appreciate you being on. Uh it's such an enlightening conversation. I think, you know, some really great points in here just about your your career journey, the arc, it's still going, you know, who knows what it'll be like in four or five years. Um, uh, you know, your experience of of being a founder and then educating other founders, just that scaled kind of impact is so huge. So we really appreciate your time. And um, we we hope folks uh check out your podcast as well and also your website. I know there's opportunities to engage with Allison on there and also on LinkedIn. So um we will be sure to post that. But Alison, thank you so much for being on our podcast. We really appreciate it.

SPEAKER_01 48:25

Thank you. I'm I'm proud of anyone who made it through this kind of ADHD uh swarm of various concepts that we we we made it through. We we actually got this scheduled and we made it from homeschooling all the way to uh transforming healthcare.

SPEAKER_02 48:41

You can always re-watch it on half speed. You can yeah, that's also true.

SPEAKER_03 48:45

But you know, ER docs who have ADHD and you put all of them together. And my husband will say this when he listens to us all together sometimes at like dinner drinks or whatever. He's like, it's like watching a bunch of rats kind of go after a singular piece of cheese, just kind of like he's like, but somehow they make it through, you know, somehow we get it. So well, it's fine.

SPEAKER_01 49:04

Thank you for having me.

SPEAKER_03 49:05

Yeah, you guys have a good one. Thank you so much. Until next time.

SPEAKER_00 49:09

Thanks for tuning into Unstable Vitals. If you enjoyed this episode, make sure to follow us for more unfiltered conversations on the pulse of healthcare. Connect with us on LinkedIn or visit us on unstablevitals.com to stay in the loop.