Rajeev Singh is the CEO of Accolade, the market leading personalized advocacy and population health solution for employers health plans and health systems. He was also the co-founder of Concur, the global leader in travel and expense management.
Rajeev Singh: Employers in this country cover 170 million people. They have the purse strings and the capacity to change the healthcare journey for the people that are under their remit as it relates to people working at their businesses. They have to flex that muscle.
Bill Frist: You’re listing to A Second Opinion Podcast, your trusted source engaging at the intersection of policy, medicine, and innovation, and rethinking American health. Rajeev Singh is the CEO of Accolade, the market leading personalized advocacy and population health solution for employers health plans and health systems. He was also the co-founder of Concur, the global leader in travel and expense management. This is the third in a three part series on innovation in medicine and health. I’m your host, Senator Bill Frist. Welcome to A Second Opinion. Accolade, it’s a word that a lot of people haven’t heard of, yet I get called every day. Every day.
Bill Frist: Having been a physician, people know my life has been around this whole healing world, from people getting advice and advice on finances, on deductibles, on what doctors to go to, and my child is sick. Those questions come to me and I figure it out. But even with me being in the center of all of that, it is tough to help patients, individuals, navigate this chaotic, overwhelming, disjointed system, you can call it a system, sector of health today. Open up just with what patient navigation is, advocacy, personalized advocacy, because that’s the sweet spot for Accolade.
Rajeev Singh: At our core, we’re solving exactly the problem that a lot of doctors in this country are solving for their friends, which is how do I navigate through, you’re exactly right, through a very complicated healthcare system, understand what benefits are available to me that have been provided by my employer, take advantage of those benefits, including my healthcare benefits in the best possible way to get to the best possible outcome? We employ people we call health assistants who become the ally or advocate for that individual and their families to manage through and understand what’s available to them, where they should go next, what the right path is for them to journey on through that healthcare journey, and to get to the right outcomes.
Rajeev Singh: We surround those health assistants with nurses, doctors, pharmacists, claims specialists who understand all of those components and help give them really good advice all the way through the journey. Best part of that story though, Bill, is that not only do you get them to the right place in their healthcare journey, you lower costs. We sell predominantly to self-insured employers who are looking to lower costs while driving satisfaction levels way, way up. People are used to getting really poor service, unfortunately, in healthcare and benefits management and our service really drives incredible satisfaction levels.
Bill Frist: This sort of assistance of walking through this chaotic system, we all feel, we all know we need it, but why hadn’t anybody done it before? Why was Accolade created to do that? If so, why are aren’t there a thousand accolades out there?
Rajeev Singh: I think it’s the biggest and most stoop question as it relates to what’s different about the way Accolade is trying to solve the problem, and therefore why isn’t everyone else doing it? I think it starts with the company was founded 10-11 years ago with some contrarian principles that didn’t exist in healthcare and that to some degree I would argue still don’t exist. Start with first, the industry has unfortunately taken a view on cost containment that says, “Let’s wait until someone’s spending $20,000 a year or more on healthcare and then we’ll try to help them. But until then, we’re going to ignore them,” as it relates to building relationships with them and understanding their needs.
Rajeev Singh: Accolade’s fundamental founding premise was, no, we need to build a relationship with the entire population, acknowledging that two-thirds of the people who are high cost claimants this year were not high cost claims last year, that we need to build a relationship with them on a long-term longitudinal basis, acknowledging that at some point they will have healthcare needs and we want to have a relationship with them when that occurs. That’s part one of our contrarian principles. Part two is the industry is really forever been organized by condition, siloed by managing a particular condition and figuring out what the costs and the best outcomes are, for example, diabetes management. Accolade acknowledges at our core that an individual is more than a condition.
Rajeev Singh: That they may be wrestling with multiple conditions and that you have to understand the broad context of their journey, where they are in their journey, what the obstacles are for their journey, and then help them resolve those obstacles. That contrarian principle maybe is extended by the idea that your healthcare journey is also a part of your family’s healthcare journey. Those two big principles, have to build a relationship with the entire population, have to treat the individual in the context of that individual and their family, not the condition, are so contrary to the way the majority of the industry works today. That everything we’ve built, the technology, the service, the capabilities are all geared around those principles in a way that I would argue today managed care hasn’t quite figured out.
Bill Frist: My dad, who died about 20 years ago was an internal medicine family practice, beloved in the community. People trusted him. They went to him whether it was financial, physical, spiritual challenges, mental challenges, and they trusted him. I want to come back to that word trust because I think it’s important for our listeners to understand how you establish that trust, how you earn that trust because you’re basically saying you leave me through this system, you expose me to the sort of decisions that I and my family have to make. That’s pretty intimate. That’s requires trust. Before that, set me up with a little bit, just an example so I’ll fully understand and our listeners will understand, just an example of a phone call that might come in and what can be provided.
Bill Frist: Because we’re all there. We all get sick. We all have these questions. We don’t know who to call. Set us up.
Rajeev Singh: Start with this, we’re selling to self-insured employers, fully insured employers, who are delivering healthcare and benefits to their employees, who are oftentimes paying for the healthcare benefits for their employees and their families. We take something everyone can relate to. There’s an insurance card in your wallet right now. There’s an 800 number on that card for you to call anytime you have a question. We take that 800 number and we make it us. If you have any questions, for our customers, there’s a phrase they get to use that says, “If you have any questions about healthcare and benefits, ask Accolade and that number is on that card in your wallet.”
Bill Frist: It’s medical, financial, deductible.
Rajeev Singh: You got it. You got it. I understand your benefits programs. I have your claims. I understand your medical journey from where you’ve been. Importantly, I think this is a really important thing that is a part of why we’re so different is 60 or 70% of those first interactions, Bill, are really tactical. People are calling because they lost our ID card. People are calling because they’re thinking they want to go see a chiropractor, but they don’t know if it’s covered in their benefits program, or they have this thing that’s called an EOB which they think is a bill and they’re trying to figure out, what is this? Does it mean I owe money or not, or somebody said something about a copay and co-insurance and a deductible and I don’t know the difference between what any of those things.
Rajeev Singh: The industry has traditionally taken those signals. When someone’s lost their ID card and calling to get a new one, it’s because they’re about to go see the doctor. The industry has traditionally taken those signals and handled them in a call center fashion. Let me get you on and off the phone in 30 seconds and answer your question. Accolade fundamentally rethought that with the idea that says, look, I’m going to take that signal and turn it into something. I’m going to ask some questions, what we call fearless probing questions, to say, “Oh yeah. Happy to get you a new ID card. Why do you need it? Are you about to go see the doctor?”
Rajeev Singh: As that conversation unfolds, we can engage a clinician, a nurse who can get on the phone with that person to help them understand what type of doctor should you go see. Oh, by the way, we can book that appointment for you, and then we can prepare you for the care before you go. Our mission is to take these tactical moments and turn them into strategic relationships. Because we’re so helpful, because we deliver such high net promoter scores and satisfaction, and because unfortunately consumers are used to not getting that type of service in healthcare, we developed an incredible amount of trust and we become that single point, that place that people think, “Oh, if I have a question, I’m just going to go call my health assistant and I’ll get my answer.”
Rajeev Singh: That is profoundly powerful as it relates to our capacity to ultimately impact clinical decisions down the road.
Bill Frist: The employers, how many employers out there, companies, do you deal with roughly?
Rajeev Singh: Call it in the neighborhood of a hundred.
Bill Frist: About a hundred. The plans, because they all have their plans that they’re providing, how do they view you? Because you’d like to think, and historically we were led to think, that plans do that and do that well. Traditionally, they haven’t done that as well as a lot of people would like, or it’s time. There’s multiple phone calls. Some do it very well, some don’t do it well. But how do the plans view an Accolade who’s coming in and really built around this service with the trust and the range and the depth and the access to information, a lot more information than a plan might have?
Rajeev Singh: I think without question, plans view us as somewhat disruptive, and yet in many respects we are augmenting where we think they’re really good. We think plans are graded at claims adjudication and doing so at an effective price per unit and delivering value to the customer. We think they’re great at building networks and finding doctors that can service their customer’s needs. We can drive better utilization and engagement of those programs. I think five years ago when the company was really finding its traction and growing really rapidly, the market was a little… Maybe looked at us and scans a little and thought, “Are these guys replacing core strategic services?” Today, we work with almost every major carrier. We’re partnering with them at all of our accounts.
Rajeev Singh: We do real deep integration with those carriers, and I think carriers are understanding our mission is consistent with driving better network utilization for them, consistent with driving better capabilities on behalf of their customers.
Bill Frist: Your patient, individual customer satisfaction and net promoter scores, and most of our listeners know what that is, but you can elaborate a little bit, but how satisfied are the patients that are using the system?
Rajeev Singh: This is the best part. This to me is the best part of my job is we get to listen to or read customer satisfaction surveys. Very rarely do any of us have jobs where our customers proactively seek us out to tell us how great the service is. I feel blessed in that regard. Net promoter scores for us if you were to think about traditionally the industry, averages net promoter score is below 10. This is what percentage of the population is going to be a raving fan and tell people about your service and refer you? Our net promoter scores are in the sixties and seventies.
Bill Frist: Sixties and seventies?
Rajeev Singh: Exactly. Comparatively, you would compare us to companies like Apple and Amazon and USAA with extraordinarily high satisfaction and retention levels. That satisfaction is why. At the core, and you said this earlier, Bill, and I think it’s really important to come back to, the human relationship and the trust we build with that individual is where the core of all of our value comes from. We use an extraordinary amount of technology to then extend that value and scale it on behalf of the customer, but it starts with the human relationship and trust.
Bill Frist: The technology, to extend that a little bit, and we’ll come to your background shortly because I think it really does play into the success of Accolade and its tremendous growth both in the past and in the future, but how important is the technology? The health arena has so much information. Its claims and it’s the electronic health record and it’s the social determinants and it is consumer behavior. All of those things. How does it get aggregated? Is it mainly a technology assimilation and aggregation that makes a company like Accolade possible?
Rajeev Singh: To feasibly deliver this value consistently across millions of people, you have to do a whole suite of technology work that starts with aggregation of data. You’re exactly right. It always starts with the data. We’re pulling together health claims, RX claims, behavioral health claims, biometric information, pulling in data from the HRIS system so that we understand. We can intuit some things about social determinants of health from where you live and how much you make, and pulling all of that data together in a way that allows us to be really smart. That as we build these relationships, we can in fact make recommendations using machine learning and data to our own people.
Rajeev Singh: Those recommendations to health assistants, to nurses, to our medical directors saying, “Hey, you know what? Bill just called. Here’s three things we know about Bill. Maybe try to uncover the following two things. Here’s two questions we want you to ask and here’s an objective for this call,” that come from our understanding of other people in the cohort who look like you, who’ve had similar experiences. That’s how technology can lead each interaction to be extraordinarily efficient. It starts with data.
Rajeev Singh: It then extends to how do I turn that data into value, machine learning, and then turn that machine learning into recommendations that our people have the ultimate right to say yes or no to, meaning our nurses on the phone or interacting via mobile device with messaging with our members can look at our recommendations engine and say, “Nope, I’m not going to do any of that because right now this person…” Our machine learning engine can’t hear a tone of voice. They can’t hear anxiety in someone’s voice. They can’t hear children crying in the background. That nurse has the ultimate responsibility of making a decision, but that machine learning and recommendations engine is a nice vehicle for exposing to them the things that we really want to achieve for that patient.
Bill Frist: That really just come to your background. You mentioned the whole Accolade history goes back 12 years? 11-12 years? 11-12 years? How long have you been running Accolade?
Rajeev Singh: Four years. A little bit more than four years.
Bill Frist: Four years. Then your history does play very much into this and our listeners are very interested in this intersection of policy and medical and clinical care, the sort of delivery that we’re talking about with innovation. I think you provide that in terms of your persona experience in running Accolade as much as anybody we have on this show. But go back in 1993, you founded a company just a couple of years after college called Concur. Review a little bit what Concur is, although most of our listeners know exactly what it is, and then how that experience has played into coming into healthcare and really revolutionizing this whole patient navigation experience.
Rajeev Singh: That was a very nice prelude. I wish more people would ask me questions that has a nice prelude. Yes. My background is… Really fundamentally I started in the technology business, started a company called Concur that, you’re right, a lot of your listeners will know because they’re filling out their expense reports or booking their travel using it. Lucky enough to start a business with my brother and a very close friend and spent 22 years building that business to 25,000 customers and $1 billion in revenues. Before we sold it in 2014, we learned a ton in that journey. Amongst the things we learned is a customer’s orientation towards ROI. You may want something that’s really simple for your people, but it has to deliver ROI every day.
Rajeev Singh: That you have to be able to deliver easy to use systems for people to embrace or you’ll lose the end user and you don’t get your core business value. Both of which are lessons that apply really nicely to the Accolade story. Let’s be honest, travel and expense reporting and healthcare are two totally different things. What we loved and my co-founder at Concur, Mike Hilton, has actually joined me on the journey at Accolade as the chief product officer at Accolade. What we learned when we looked at Accolade was here was a company that had solved at some level a problem that no one else in the industry had solved. How do I build relationships with consumers, this human trusted relationship?
Rajeev Singh: What really needed to be added to the story was don’t replace that, which is too much of the industry today in my view, Bill, is saying, “How do we get self-serve for everything, but high cost claimants? Accolade fundamentally didn’t believe that. When we joined, we joined with the acknowledgement that Accolade was right. Don’t try to replace the human relationship. Augment the human relationship with technology. If you can do that, you can find incredible scale opportunities. Today, 45% of our interactions are via mobile. People messaging their health assistant, our nurse, and talking to them that way. But that you don’t sacrifice the human relationship. You extend it. That’s where you use technology.
Rajeev Singh: We feel like our background coupled with the expertise that existed at Accolade, the healthcare, the deep healthcare expertise that already existed at Accolade was a combination that hopefully allows us to achieve results that are different than a lot of technology entrepreneurs have achieved in this space so far.
Bill Frist: Well, I think that that narrative, that whole storyline of Concur, you’re sticking with it, developing it, technology-enabled, applies very directly in your description of really keeping that human touch at the core is what in large part explains your success, which is important, but more important to all the beneficiaries of people with frustrations and real problems and loved ones who are sick to be able to get those in real time answers is hugely, hugely powerful. As you look ahead, what do you see for Accolade being the biggest challenge? You’re pioneering of field in many ways that’s really fundamental to every person listening to us. What do you see as the biggest challenges? Again, I’m coming back to my intersections.
Bill Frist: Is it a policy world, or is it the medical clinical world, or is it the innovation, keeping the technology going? What’s your biggest challenge?
Rajeev Singh: Let me tell you the things I’m, one, most excited about, which are the new opportunities we continue to invest in and build on. We invest a great deal in identifying the best clinical pathway for every single person that we’re dealing with and then measuring how well we’re guiding them down that clinical pathway. It’s a huge part of our focus going forward. It’s hard work, the number of permutations. The reason why so many technologists get into healthcare and then leave it is because the permutations are endless. It is hard work. You can’t build anything in this segment without some mass. Today, we’re serving a million and a half or so people. That mass gives us data. That data gives us an opportunity to learn about those clinical pathways.
Rajeev Singh: Then patients, you have to work, you just have to keep cranking out the work. We’re really excited about that. I’d call it a big challenge and a big opportunity and something that our customers will in turn be able to really discern, are we improving the clinical outcomes for every single person we’re serving? We’re excited about that. Let me flip to the challenge part of the story because I know the listener base of this podcast has an enormous amount of influence. This is my plea to the world. Employers in this country cover 170 million people. They have the purse strings and the capacity to change the healthcare journey for the people that are under their remit as it relates to people working at their businesses.
Rajeev Singh: They have to flex that muscle, they have to demand innovation. They have to demand change. They have to actively look past the status quo that’s kind of delivering a 6% trendline and poor outcomes and find new ways to exercise their muscle as the buying power for more than half of the country. Inspiring that change. We’re a long ways on that journey, Bill. I mean, it’s a heck of a lot better today than it was in 2015. More and more buyers are understanding they have that capacity, but we’re not all the way to the meat of that bell curve. I think the world’s a better place when this very rational buyer who wants to control trendline, but also wants happy, healthy employees starts to take a way more active role in how this ecosystem works.
Bill Frist: Yeah. I think that’s really well said. People as we think of this intersection between delivery, working through the system, innovation and policy, it seems that for the past 10 years we’ve looked to policy. We looked to federal government. We look to Romneycare, Clinton Care, Obamacare for the answers. We’ve had demonstration projects with CMMI and Medicare and Medicaid Innovation Center and the federal government. When I was majority leader, we had six demonstration projects. When I was in the Senate, probably 10. People look to innovation there, and I think people realize now that the innovation in the health of the next 10 years is going to be very much by the private sector, but within the private sector.
Bill Frist: We all know the consumer and ultimately that’s who we serve, but also the fact, as you said, there are 170 million people who do depend on their employers to help them choose a plan, and then a company like Accolade helps you go much deeper in that. I think it’s really well said. But also, as you prefaced all that, it’s a real call to action because it means more than just a passive choice of plans and passing it on to your consumer.
Rajeev Singh: I agree. I agree. There’s no doubt, Bill, that public policy, that things like value-based care or things like Medicare Shared Savings, those opportunities to drive changes in behavior are very important. But if I were thinking on a macro level, there’s hundreds of billions of dollars to spend being controlled that maybe we need a little bit more engagement from that group to really change the way things work.
Bill Frist: How responsive have the employers been? Obviously you’ve pioneered a lot of this in this evolving new field. When you walk into an employer’s office, do they seem to get it, to understand about the concept, but a willingness to participate?
Rajeev Singh: Yes. The last three or four years we’ve seen really a significant phase shift. I think it was always true that employers thought, I have a trendline problem. This costs more. When I walk into the CFO’s office once a year and tell them how much it’s going to cost, he or she’s not very happy with me. They’ve always had that problem. They’ve always had the problem that none of their employees are running to them and saying, “I really love the service I’m getting out of the healthcare industry.” I think what they’re acknowledging today, and this is in part, Bill, I think unfortunately due to some of the futility of some of the past things they’ve tried. They’ve tried technology-only solutions like mobile apps that will give their employees all the answers.
Rajeev Singh: That didn’t work. They’ve jacked up their deductibles and still didn’t get the value that they wanted. That didn’t work. I think we’re finding now that employers having tried a number of other things are for the first time really focusing on value, focusing on understanding where that value comes from. For us, the positive nature of that means we’re acquiring a lot more customers every year.
Bill Frist: Makes it really encourage. We went from Concur sort of travel expense and cost. Again, very individualized focused to health and well-being. That’s not a jump. People always say I jumped from being a transplant surgeon to politics. I get this jump question a lot.
Rajeev Singh: Right.
Bill Frist: Was there a pivotal moment in your life, in your decision-making to make that job that you point back to or you cite in terms of moving to healthcare?
Rajeev Singh: We were fortunate. Concur was a positive outcome for everyone involved. I think what Mike, my co-founder at Concur, and I knew was we love building businesses. We love building teams. We love leading teams. Building businesses with people that we care about really is the most exhilarating thing professionally I can do, but we wanted this journey to be about helping people and that we wanted it to be more tangibly touching some element of human good. Healthcare in the United States aspires to do good. It doesn’t always do the good that we want it to, but it aspires to do well. What we found in a company like Accolade was this early stage company with no…
Rajeev Singh: Not beholden to any of the existing entrenched interests of the industry and an opportunity to say, “What if we could just do it right from the beginning.” I feel incredibly fortunate that we stumbled upon Accolade and Accolade stumbled upon us. That journey started the day after Concur was sold really for me thinking, okay, what am I going to do with the last 15 years of my career?
Bill Frist: We’ll wrap up here in a second. Have grown up in health and healthcare starting with dad, and so I went on rounds with him, medical school, internship, residency. He’s a heart transplant. Stayed in it for my whole life. You’ve come from the outside and I think most people from within the healthcare recognize that real transformation, what needs to be done, is going to require a different sort of approach than what we on the inside have brought along. I think Concur and you are a good example of that. It applies to engineering a more systems approach to it.
Bill Frist: Is that a correct way of thinking that ultimately these big transformations, some of it can be within, but it is going to take people such as yourself with a totally different background coming in and helping engineer a system in ways that those of us who’ve been on the inside just haven’t seen
Rajeev Singh: Actually the way you phrase that is really interesting, Bill. That systems orientation is I think at some level when you think about building a technology company, you think about scale and you’re disappointed if you’re not achieving scale really quickly. But everything you design is sort of designed with these Google, Amazon principles of, well, how quickly can I get to a billion users? That orientation is I think somewhat different than the orientation of healthcare, which has largely been a local or regional or segmented industry. That I think in part is sometimes why technologists struggle in the industry because they want one answer to fit all, the entire population, and it doesn’t. But it is an orientation that says, okay, let’s think about this.
Rajeev Singh: Let’s think about everything we build with the idea that it’s got to serve 20 million people. That is I think can be when married with an understanding of the ecosystem as it exists, you really have to have both, Bill. You have to have I think the thoughts around scale and what I’d call the idealism of technologists who believe that one day everyone’s going to use what they build, coupled with the pragmatism of, here’s where the industry is now. That’s what we’re trying to put together as we build the business.
Bill Frist: You’ve clearly done that. As you say, you got this 12 year history or eight year history when you’re coming in building on that and get the good out of that. The personalized part of it, the intimacy part of it, all that you can learn, and then putting the technology to enable it to be extended and amplified to a large population. I think it’s a great example for our listeners. One last question, what advice would you give? We’ve got a lot of people listening who are early policy makers out of Washington and in state government. We have a lot of people who are in medical school right now and interns and residents who are listening to this brave new world of healthcare that we’re talking about. We have experienced CEOs.
Bill Frist: I always hesitate to give advice to anybody, but what advice would you give to the young aspiring person who does want to have the same mission of making the world a little bit better place in the healthcare sector?
Rajeev Singh: I think it can be done. I encourage people… I had an experience. When I was telling people I was going to go into healthcare from the technology business, almost to a T everyone said, “Don’t do that. Do not do that.” I’m going to stand here four years later and say, “I’m thrilled with the choice I made, and I believe it can be done.” I would encourage people to give this a run. We have to. It’s an imperative that we change the way things work today. That’s one. Two, we have to think about innovation in new ways as it relates to how we collaborate, how we share, how we don’t think about customer ownership. This is not an industry where we should try to aspire to own the customer. What we should do is help the customer.
Rajeev Singh: We need to collaborate to help the customer and to walk in with a mindset of collaboration as opposed to a mindset of domination or winning, and then really focus on tangible value quickly. This is a industry where you have to prove everything you say, which is very different if you’re a technologist. Certainly from where I grew up, a technologist get away with saying a lot of stuff that they don’t always have to prove. In this industry, whatever you say, you better be able to back up with data, with numbers, and with results. Focus on demonstrating tangible results quickly. If you’re starting something new, collaborate, go after it aggressively with that idealistic mindset that you have hopefully, but get to value quickly.
Bill Frist: I mean, I think all three of those perfectly fits together. Traditionally, medicine was not collaborated very well. As a doctor, I was trained initially, and that’s not the way doctors are trained now, is you don’t need to collaborate. You got that information. You got in your head. You got your experience. You got a patient and give them the best. It’s one thing that we’ve learned, the collaboration, that is really fundamental to making great companies today. Ultimately translates into much better and great care for the patient. Raj, again, an amazing story and one that I know is unfolding as we speak, which is very exciting because as we started, my first opening lines were that we all need it no matter who you are.
Bill Frist: A former majority leader, a former cardiac surgeon, all the way down to my sister right now who’s in the hospital and trying to decide what that next step is in terms of rehabilitation to get through it. We all have it. But congratulations on building a great company and sharing with our listeners and viewers a really evolving, exciting, energizing story. Appreciate it. Thank you.
Rajeev Singh: Thank you very much for having me.
Bill Frist: You bet. Thank you. This episode of A Second Opinion was produced by Todd Schlosser from the Motus Creative Group and Snapshot Interactive. You can subscribe to A Second Opinion on Apple Podcasts or wherever you’re listening right now. Be sure to rate and review A Second Opinion so we can continue to bring you great content. You can get more information about the show and our guests and sponsors at asecondopinionpodcast.com. A Second Opinion broadcast from Nashville, Tennessee, the nation’s Silicon Valley of health services, where we engage at the intersection of policy, medicine, and innovation.
