Entrepreneurs Rx_John Criswell: Audio automatically transcribed by Sonix

Entrepreneurs Rx_John Criswell: this mp3 audio file was automatically transcribed by Sonix with the best speech-to-text algorithms. This transcript may contain errors.

John Shufeldt:
Hello everybody, and welcome to another edition of Entrepreneur Rx, where we help healthcare professionals own their future.

John Shufeldt:
Hey everybody, and welcome back to Entrepreneur Rx. Today, I've got the real honor of showcasing someone I've known for a little bit now, his name is John Criswell. He is a multiple-time startup founder, CEO, he's a non-physician, and what I was excited about this is he's been so successful in this space that I really was excited to have him, John, welcome.

John Criswell:
Hey, thanks, John. Great to see you again.

John Shufeldt:
Thanks, good to see you, too. Hey, so give us a little bit. Give us, as I mentioned earlier, you know, we've had not all but mostly physicians on this one, and I want to start also highlighting people who've been really successful like you have, who didn't really come at this space, like, for example, I did through healthcare. They actually had some business knowledge instead of trying to figure it out in the way. So give us a little bit of your background.

John Criswell:
Sure, well, I guess, John, I'll start with I consider myself somewhat of a reluctant entrepreneur. I was working in a number of different industries from supply chain, which I consider healthcare, a complex supply chain problem, consumer products. And when I was leaving consumer products, I was enticed to get involved in healthcare. And the first thing I said to the CEO physician is, I don't know anything about healthcare. And he said, we'll teach you everything you need to know. And that really was the foundation of getting started in healthcare back in 2006.

John Shufeldt:
And what did you do before supply chain? Did you, I mean, you sound like you weren't an entrepreneur early on, would you? Did you have any inkling of that in your schooling?

John Criswell:
I did not, and when I speak with potential entrepreneurs, people considering entrepreneurs, students, one of the first questions I ask is, do you have any family members? Were your parents entrepreneurs? Have you done anything entrepreneur? In my background I did not. My grandfather and his brothers were plumbers and I think that was entrepreneurial, but I didn't really have access to that. He passed early in my life. So I was, again, really not surrounded by entrepreneurs, but always eager to do more, to do better, to solve problems. And that, in connection with some really fantastic entrepreneurs, learned a lot. With one of them, my formal kind of supply chain background, a family of entrepreneurs that I learned a great deal about, and then went into consumer products and learned a tremendous amount from the founder of Applegate Farms. It really helped build the foundation for what I've done since then.

John Shufeldt:
Very good. So what was the first healthcare startup you did?

John Criswell:
It was a turnaround. It was a five-unit urgent care in Maryland. And when I arrived, I thought, oh, my gosh, this is really an interesting problem, which allowed me to dip into this vast over a decade of supply chain experience that I had in consumer products. On the consumer product side, we had 21-day shelf life, right? Meat and cheeses and other types of products. And when I entered into the urgent care world, I was finding products that had spoiled a year, two years. I said, Wait a minute, we can do much better. And ultimately at that, at that time, taking that supply chain background, created very interesting models using data analytics. You might recall back in 2006 through '08, we had H1N1 swine flu. Some other interesting, very well, right? I felt like I was living what I perceived to be a clinical MASH unit without the artillery.

John Shufeldt:
It was the early, it was early COVID. I mean, it was the shot over the bow for COVID. At the time people were totally freaked out about H1N1, and when you look back at it, it was like, you know, that was nothing. But at the time it was, people were pretty freaked out about it.

John Criswell:
Well, as were we in practice, it's, the clinics we were running at the time were 5:00 to midnight and we were running almost till 3:00, 4:00, or 5:00 in the morning treating patients. At that same time, Google launched the flu trends, Google.org flu trend, since, removed it. And as a supply chain person, data is essential, and I found that data asset really critical to solving what patients were looking for online by typing things like flu-like symptoms, nausea, and others. And then we actually built a labor staffing model to support that so we could move patients more efficiently through the system.

John Shufeldt:
What was the name of the urgent care?

John Criswell:
At the time it was called Nighttime and we rebranded it to Righttime Urgent Care.

John Shufeldt:
I remember that name. So why did they bring a non-healthcare guy with no urgent care experience in for the turnaround? How did you get involved with that?

John Criswell:
So it's actually a lifetime story. I knew the physician CEO and founder. He was my pediatrician when, I mean, from the time I was three years old bouncing me on my knee, and had stayed in touch with him over the years and just received a call from him and said, hey, we're really having some challenges here, and I think we need a business person to help solve this. And initially, I was reluctant because I, again, had no formal clinical training and ultimately, as I have shared, just realized that healthcare can be solved with just some really solid discipline supply chain practices. But it was really, it was, I got hooked immediately, like this is, we can solve this, we can make it better.

John Shufeldt:
Was it a, it was, it sounds like it was a pediatric urgent care.

John Criswell:
It started out as a pediatric urgent care, expanded to adults, and then we ultimately expanded to 9:00 am to midnight, seven days a week.

John Shufeldt:
Wow, very good. Okay, so how long did that last?

John Criswell:
I was there for about two years. So we took it from, geez, I would say 11 million in revenue to doubled it in that time and improved EBITDA significantly. So it was a great, really fantastic business and great experience for me.

John Shufeldt:
That's excellent. Okay, so you stay there two years, you do the business turnaround, now you're hooked. You get out of there and say, My turn.

John Criswell:
I actually, I went and worked for a data analytics company. I became intrigued by what Google was doing with their search engine and the data assets that they were producing and went to work for a data analytics company doing what was, or what is called risk adjustment and quality and using data to predict certain mortality, morbidity, and illness-wellness morbidity, became fascinated by that and doing in-home programs as well as encounter facilitation. So to encourage senior populations to connect with their primary care, to receive treatment for their chronic conditions.

John Shufeldt:
Interesting, and how long did you do that for? So that was, so now I get a sense of why you are where you are. How long did that one last?

John Criswell:
Yeah, so there for a little over a year. And I decided that I needed to start my own company, which actually became a personal mission. I had, my two grandmothers, both were suffering in different ways. One was healthy and unfortunately had a condition that led to her death, and then the other was in nursing facility because the family, we just couldn't care for her and she had dementia, Alzheimer's, multiple chronic conditions. And every visit I saw the deterioration, I saw the treatment, I saw the challenges. And I said, you know, this is there's an opportunity here to predict mortality, morbidity on these populations, to help people live longer and stay in their homes healthier. And I was also very aware that the, there was no quality measure. There's no way to rate these skilled nursing facilities, these special needs. There's no real mechanism. And so one was to get out in front to do predictions on data to eliminate fall risk. Fall risks have very specific categories, and we developed a model that we could do predictions to avoid fall risk, to educate patients on what to do, how to do it. And so from that launched Pulse8 as a bootstrap, which was a healthcare tech-enabled company with my primary cause. And back then, I think I launched in 2011, back then, data was not cool. People weren't playing with data. And, I absolutely believed through prediction, you could eliminate things in healthcare that were unnecessary and wasteful and drive the dollars to the individuals who actually need it, because we spend a lot of money, whether it's care management quality that's unnecessary. And I thought if we could do this better than those, those components could drive a better solution. Interesting, we filed for patents on that in 2016 and happy to report that in July of this year the patents were approved. And so I'm a patent inventor, which was just kind of neat, but yeah, we proved that out, but dude, that journey, it was really difficult because most in healthcare didn't believe that you could be precise, that you could predict, frankly, kind of like my urgent care. When I first said we've got this massive data around Google and I think it can predict which patients we're going to see and where and we can direct which units, I got laughed at and said, You can't do that. That's not possible, you don't know what's going to see, what's going to come through our front door. And I said, I think we absolutely can. And frankly, the Google data was far more predictive than CDC data, which is essentially a voluntary reporting mechanism by providers, which, again, it's delayed, it's lacking, it's not as, at that time it wasn't as effective as Google.

John Shufeldt:
Yeah, it's funny, I thought I thought that Google, that flu tracker, was amazing because you're right, it's people in real time looking up flu and flu symptoms and where to go and what to do, and you get, you can absolutely see a trend. And I remember way back when you almost saw this wave going across different locations as the flu spread and people got sick from it. So I thought it was a great device. So that was.

John Criswell:
Pulse8, founded in 2011, my first healthcare startup. I've had others, but this was the first in healthcare, it was a bootstrap. We, once we were doing those predictions, when it was certain that the ACA or what is more commonly known as Obamacare, we moved quickly around predictions for one of the key tenets which was transfer payments, which was calculated based on the illness wellness burden rate. And from there the exchanges were delayed quite a bit. We had some contracts that we could not monetize because the exchanges weren't live. We were, I was bootstrapping funding the company personally, had everything for sale, my house everything, and raised a little bit of money from some friends, one venture firm, and we never looked back. And once the exchanges took off, we really accelerated, which was great, with primarily our data and analytics component.

John Shufeldt:
And who was buying that, who are you selling that information to?

John Criswell:
So there was primarily insurers. And at that time you had different what they call payviders. So health systems that offered insurance. So we had payviders in that mix and then expanded to value-based care. Anyone taking risk within a PCMH, MSSP, now ACO reach, those types of programs. Those were the primary customers.

John Shufeldt:
Interesting, and then, okay, so what was the outcome of that? What was the outcome of Pulse8?

John Criswell:
Well, I'll get to that. But I will tell you, when President Trump was elected in 2016, 95% of our business was on the ACA. And you might recall that the ACA was a target. And I got called the next day by a parent, a friend of my youngest. I think at the time he was probably five years old. He's like, Are you okay? I'm like, What do you mean, am I okay? He's like, Your son has come to school and told my son that you're out of business. My poor children are feeling the stress and pain of their father and what's going to happen. But we spent as a company about 60 days, I lost some people during that time. It was a real challenging period. And through that 60 days, I essentially arrived at a simple mission statement. We're not going to worry if the ACA is going to be here or not. So those that are arguing that it won't be here, let's agree, it won't be here. Those that are arguing it will be here, okay, let's agree that it will be here, but let's not worry about it. We'll create a separate financial document that will be our ACA. We know that's 95% of our business now, but we're going to launch all kinds of products and we're going to change our product mix. So it ended up being a rallying cry, and so we launched a Medicaid product, which I was very proud of, a Medicare Advantage product, and a risk and a quality program, so we became certified. Heat is reporting, engine stars quality reporting, and within 12 months completely diversified the business, and that 95% became 30% and then ultimately less. Medicare, Medicaid, and the quality products became a larger piece, which gave us, well, certainly grew, the business certainly grew the revenue, certainly grew the team, but gave us a much broader story to tell. In 2019, the business was acquired by a publicly traded company, and I left in 2020.

John Shufeldt:
So basically, Trump gets elected, you see, you see the possible writing on the wall and you proactively pivot, which is a huge lesson for, it would be a huge lesson for people, one that you did a prospectively. Before the elections, where you're thinking, okay, if it goes this way, I better have this construct, and if it goes this way, then I'm okay. And after, sounds like the election and I get into politics, but something like the election turned out to be a positive. You know, the result of election ... be positive for you because it expanded your footprint.

John Criswell:
It was, and it actually proved to me that you don't you shouldn't rely on an emergency, something critical to your business to make a change, and so that lesson will stick with me forever. But I'm embarrassed to say I was not prepared for a Trump victory with the business, and so it was a surprise. And from the time that he was elected, and I'm not making a political commentary, it was just a surprise to me. And, but from that, over that next 60 days and those next 12 months, what we did was unbelievable. And the team just got together, backs together, swords out, and we changed our product mix and we became way more valuable to our customers in what we were doing.

John Shufeldt:
I like that analogy backs together, swords out. I don't think I've heard that one before, so I'm going to have to steal it from you. I was just going to, I'll plagiarize and give you credit for it. Looking back at it, can you say that, like, how did I not see this opportunity? Why did it take an election result to open my eyes to this? I mean, did you ever look back? Not that you should, but you ever look back and say, okay, what can I do in the future to prevent this from happening again?

John Criswell:
Well, I think one of the key things as a leader within any organization at any size, having self-reflection and self-awareness is important. Frankly, I was happy with where we were. I was delighted. We took this small little idea that we would talk to customers, we would go to presentations and people would laugh at us and tell us what we were talking about is not possible and not what the industry was doing. So I felt, I don't want to say complacent, that's probably not the right word, but I was like, We are going to continue to grow. We were dominating the ACA space and this is what we were going to do, and when we're ready, we'll launch new products. That was wrong. I was, that was not the right approach. And so now I try and operate with a sense of urgency around everything, not in a destabilizing way, but in a way that anything can happen at any time.

John Shufeldt:
Right, and that's the great learning from all this is to keep your foot on the gas even when you don't need to be.

John Criswell:
That's right.

John Shufeldt:
Yeah, complacency is always potentially fatal. Okay, so your last of the estate of the publicly traded company for a year, was that your workout clause?

John Criswell:
No, I could have stayed longer. The organization ran into a number of challenges pre-COVID that ran into COVID. They had a large debt load and we're really trying to figure out what they needed to do and how they needed to do it, and they asked me to leave. And so I, asked is probably they let me go, and that was it, so onward and upward.

John Shufeldt:
And that turned out to be a blessing as well. So talk about what you're doing now.

John Criswell:
Yes, so started a company called Porter. Like my previous company, in terms of cause motivation, we want to make healthcare simpler and easier for every American. And I got to this place, I was riding my bike and had a fall, fractured my pelvis in two places, and I had to navigate it myself. And I said, Oh my gosh. Like, why is this so hard? I think this can be easier. Shortly thereafter, my father had a heart attack, was being discharged from the hospital on a Saturday right in the middle of COVID. And it was really difficult to figure out all the things that he needed on a Saturday. I then went and met with one of my good friends who is a two-time cancer survivor. I explain these two stories. He laughs at me and says, You think you have it hard? He shows up at my house a few days later with five three-ring, three-inch thick binders of his journey from medications, discharge instructions, home care, and through a very emotional three-hour meeting, tells me how difficult, not only that it was for him, but for his wife as a caregiver and how they would just cry together, trying to solve for things that should and can be made easier. And so at Porter, that's what we have endeavored to do, is make healthcare easier for every American. And there is a difference between healthcare, as you know, John, and health insurance, and bringing those two together, whether it's acute or chronic, is essential to making it easier, both the physical, emotional, and financial toll that this has on so many Americans.

John Shufeldt:
Yeah, it's amazing. So give me some perspective on what does Porter do? What's the elevator pitch for Porter? I know it makes healthcare easier, but specifically, how does it do it?

John Criswell:
Yeah, so we are helping connect people with the resources, the products, and the services that they need. So in a condition-centric way, we build kits and recommendations using data and analytics to create a bundle of those items, resources, service, and products that will help your speed to recovery. And so we believe, like supply chain, speed, cost, quality, pick two and we will serve those up for you. We will let you know what items are covered by your insurance and in your benefits and what items are out of pocket. And that's essential, and frankly, as a physician, I know you'll understand this, you can't possibly understand all of the benefit, all of the network, all of the components that exist. And in the case of my good friend, the two-time cancer survivor, for illustration purposes, he was prescribed a genetic testing and his physician didn't know, and he didn't know, and he went and had the testing done and it was $2,500.

John Shufeldt:
Yeah, I was going to say.

John Criswell:
It was a covered benefit. If he went in-network and would have cost him zero. And that plays itself out time and time again. We have a member on our platform that was, that lives in Salt Lake City, was receiving his cancer treatment at Johns Hopkins in Baltimore. And we were caring, and supporting him in Baltimore. When he went home, we helped him with all the things that he needed. And we said, when you go to your physician in Salt Lake, your oncologist, make sure you get a prescription for your $500 defined benefit for dietary supplements. He had had no idea to do that, and his physician would have had no idea. And the insurer, the payer, absolutely wants that benefit because this is going to help reduce costs and reduce outcomes, which everybody wins in that case.

John Shufeldt:
Yeah, but nobody has an idea to get it. You know, it's funny, I remark on this literally all the time. I mean, I'm in the healthcare space and I've had a couple of healthcare issues in the last couple of years. And fortunately, I can pick up the phone and call people who I knew and who really helped me. Man, if you're not in that, I mean, I call, I just literally, as you saw right before the podcast, got a call from somebody who was struggling to navigate this healthcare issue and felt like they were getting the runaround, and frankly, they kind of were. And I don't blame the physicians, they were just saying, okay, well, here's what I do in this case. But there was no connectivity between the different modalities they were trying to navigate through, and it is, it's got to be incredibly frustrating. It is incredibly frustrating.

John Criswell:
It is, incredibly, and no matter how insignificant or significant of an issue, technology can enable a lot. And under the Trump administration and now the Biden administration, under the No Surprises Act and the Transparency in Coverage, Insights, and Interoperability Rules, the government has taken an active role to drive more transparency, more visibility, more capability so companies like Porter can utilize those tools to make it easier for the member, make it easier for the patient.

John Shufeldt:
So what's your revenue model?

John Criswell:
So PMPM, we also take risk, and for those of your audience, per member per month, or per member per year. We have a risk model. We will take risk on certain cohorts of populations. We're very versed in reducing remits to the appropriate site of care, education. So those are all areas that we believe, strongly, in what we do, and so we're happy to take risks on managing certain cohorts of populations while improving quality and improving the illness burden rate for whether it's Medicaid, commercial, or Medicare Advantage.

John Shufeldt:
And then how do patients find you? Do their health plans direct and the health plans pay you and say, Look, We know you're going to reduce costs, so we're going to pay you a pmpm for their entire population of patients, I suspect.

John Criswell:
That's right. It can be done either the entire population or a cohort of a population by chronic conditions.

John Shufeldt:
Interesting, and what's your data showing to how much have you been able to reduce costs? Because it seems like even a little will go a long way. I mean, one unnecessary MRI, one unnecessary ED visit, and everything transpires from it, I mean, is thousands of dollars.

John Criswell:
It's, we're on readmissions somewhere around 43%. It's astounding, it's astonishing, really. Once we engage that patient, we connect them with their, either their primary care or their specialists. We begin the education, that concierge care guide. Once they get into that, no one wants to end up in the emergency department. But I'm most proud of our Net promoter score, which is 90%, and our engagement rates are about 77%, which is phenomenal. We're capturing at the episode. So if you're in the hospital, you're soon to be discharged or during an event, we're capturing that member at their most critical time when they need it and where their caregiver needs their support.

John Shufeldt:
Interesting, you know, just example you had about the dietary supplements for cancer patients. I mean, you know, one of the big risks of cancer is people become emaciated because they can not get enough caloric intake. But you're right, I would not as a physician would not have thought, oh, my gosh, let's give us a prescription for dietary supplementation. And the physician, the patients wouldn't know to ask until you tell them. And then, then I'm like, of course, that makes total sense, but I don't know if I would have thought of that prospectively.

John Criswell:
Well, and then you add to that, then find the vendors that are curated that you would want to purchase those products. This isn't like going to an Amazon. You have cancer. You want to trust that you're getting the right dietary supplements by an approved, curated partner that is trusted like Porter. And then you expand to that to, beyond the dietary, the right nutritional products that help support your journey as well. Meal replacement, meal preparation, all of the things that most of us don't think about in healthcare or health insurance that health insurance provides today. Many, many provide today.

John Shufeldt:
Yeah, and I would have had zero idea because as you said, no one calls you up and tells you don't forget to do this. What was the biggest takeaway as you've learned from your entrepreneurial journey thus far, and what were the biggest surprises?

John Criswell:
So biggest takeaway is, never give up. You did a post recently on It Takes Hard Work, and I've read enough books around the eight-hour work week and I'm like, that must really be good. I want to do, I would like an eight-hour work week. The truth is.

John Shufeldt:
... the four-hour workweek.

John Criswell:
Or the four hour, it's.

John Shufeldt:
Embarrassing, I remember my son read that. I'm like, yeah, that'll never work.

John Criswell:
You got to the answer faster than I did. John, I, it takes hard work. It takes grit, it takes stubborn persistence. So I think that's, what's the definition of an entrepreneur, the number one trade. I think it's grit, stubborn, persistence, never giving up, but being self-aware and self-reflective enough to know when something's not working. If you haven't figured out the marketplace, the market, the product fit, they need to change. Oftentimes change is iterative, and especially in healthcare, healthcare is typically risk averse. And so startups struggle with these great ideas. We're seeing it now play out in the marketplace. A lot of these companies do not have market fit, product fit, whether it's on the health system side or on the payer side. So I think stubborn persistence with an open mind to not falling in love with your own idea to change and to figuring out what the market needs, and then building to your ultimate goal, whatever that purpose is. And I think that's kind of number two, purpose. My last company and this company has been about trying to change an industry. And it was terrifying in those early days going to speak in front of 100, 200 people about doing things different, and the criticism, or if you were in a meeting with a large insurer and there's eight people sitting around the room and you're reading the tea leaves and you've upset half the room by what you're saying, you're walking out. They're like, I'm not sure this is the right approach, but ultimately you get those first customers that validate you, and then it begins to expand. I guess those are kind of the key parts up front. But there's a second part to your question, John, that I didn't address.

John Shufeldt:
Yeah, the biggest surprise, like what's you know, there's, frequently I say, like Mike, you know, I didn't see that one coming that was out of left field.

John Criswell:
Well, we talked a little bit about the Trump presidency, but on the, I guess when we did sell the business, I was heads down. I wasn't really paying attention to how it would feel to the team. And I'll never forget we had a, just a fantastic developer who was with us since the beginning, and he had a son who had disabilities and he called me up in tears. I was in tears. I still get choked up. And he's like, you know, this is, you have changed my life. I now have, my house is paid off. I have, I can see the future for my son. He has, we have money to care for him after I'm gone. And I just, it gives me chills every time.

John Shufeldt:
You just gave me chills. I love that feeling.

John Criswell:
That story just, you know, played itself over so many different times. And I was at war as an entrepreneur that was doing something different. And so kind of like, well, I'll just, we'll have fun later. So, and we had a good time, don't get me wrong. We had a good time, but we had the gas in a pretty, pressed pretty hard, and just the reaction from the people who didn't necessarily expect it. I spent a lot of time as a number two in different industries, and I always had the promise of equity and that never materialized and that has stuck with me. And so I have, I consider myself somewhat generous to the team. I like to be generous. I want people to have ownership and feel equity as much as it matters, and that's important because I never had that for myself. And I want my team members to know that we're in this together and we all win together. And a lot of people create separate deals for themselves, that's not who I am. I'm a member of the team. We're at the same level. Let's do this, backs together, swords out.

John Shufeldt:
Did you have trouble transitioning? From, because as I know, you know, I mean, once you're the owner, the buck stops with you, good, bad, and different. Then I always tell people, you know, I accept all the blame and give all the credit. I mean, that's how I try to lead. Was that a difficult transition for you where no matter what happens, it's ultimately your fault?

John Criswell:
I think, I appreciate, I respect, I honor kind of the buck stops here and the I believe in collective intelligence. I want everyone to be able to provide their thoughts and opinions. At some point, somebody's got to make a decision. And so if there's a tiebreaker, we can make that call. If you're reflecting in terms of from the acquisition forward, in terms of how that changed, or just more in general.

John Shufeldt:
More in general, my next question is on the acquisition.

John Criswell:
Yeah, so for six years, most of the team, we worked seven days a week, and I don't mean the figurative seven days a week, I mean I was in the office seven days a week, 6, 7 a.m. till I'd go home, 6:00 for dinner, I'd go back to the office at 7:38, worked as long as I could. If I was traveling, I'd constantly fall asleep with my laptop on my lap in the hotel. Wake up at 3:00, 4:00 in the morning, go back at it. Saturdays, outside of activities with the kids, I'd be in the office pretty much till 3:00 or 4:00, and then Sundays till noon. So we were heads down, we just kept grinding it out to prove what we were doing. Making the decision that was just, you have to make decisions right or wrong. And we had to, we had a philosophy. I have a philosophy in life. You go to a restaurant, you have a bad meal. It's like, glad we tried it, let's move on. We have choices, free choice, free will. So in business, let's, we're going to break things, things are going to happen. That's okay, glad we tried it, let's move on. So if I or somebody else made a bad choice, you know, it's important to keep yourself out of the ditch, right? But staying a course in making a bad choice or bad decisions, like let's not lament, let's learn from it, but let's move forward. There's, no nobody wins in blame game. Let's move forward and be positive, and we can learn and grow.

John Shufeldt:
No, totally. And I know you know to some respect, but I also have, I think I have a good sense from you. I suspected that you had a very strong culture in Pulse8, in Porter. Did your team have difficulty going from the Pulse8 culture to this large publicly traded company culture?

John Criswell:
Yeah, it was difficult, I think. We were probably somewhere 200 members on the team during acquisition and there was a lot of things that I think people accepted and there were some things that were difficult. We had a, not one inch, and frankly, the acquirer wanted us to maintain our culture because our growth rates were strong and they continued to accelerate even as our revenue increased. But after I left, I think they lost about 50% of the staff. Some of that was just the public challenges they had around COVID that required them to do certain things, but I think it was a challenge for a lot of people to kind of shift, and those that are still there, I think they embrace on the open culture that we had before that might be different now.

John Shufeldt:
Right, yeah, very good points. Well, any closing thoughts for all the entrepreneurs and budding entrepreneurs that are listening?

John Criswell:
I start with, what's your cause? What's your motivation? What's your purpose? I am asked often by investors and venture firms, What's the exit strategy? I think that's a silly question to ask. I think you don't worry about the money, you figure out what the market fit is, and know what's going to be the hardest thing that you ever do because it typically is.

John Shufeldt:
Yeah, that's very true. It's actually, I'm going to steal that one from you, too. It actually, it is. It's probably the hardest things I've done are staying present on the journey, even when everybody's telling you you're an idiot, and you're going down the wrong path.

John Criswell:
And that happens.

John Shufeldt:
Happens every day, just for other reasons. Well, John, this has been great. Thanks, I really appreciate it. I'm looking forward to supporting you and Porter and seeing how this all flushes out.

John Criswell:
Thanks, John. It's been great. I love what you're doing. The podcasts are fantastic. Your posts are fantastic.

John Shufeldt:
Thank you.

John Criswell:
I wish I was a prolific writer as you are, and how you articulate things, I think it's helpful for all the entrepreneurs that are out there listening to you.

John Shufeldt:
Thank you, John, pleasure. Well, folks, it's another really interesting episode of Entrepreneur Rx. We'll have everything in the show notes, including the transcript of this, and we'll be back to you soon. Thank you all.

John Shufeldt:
Thanks for listening to another great edition of Entrepreneur Rx. To find out how to start a business and help secure your future, go to JohnShufeldtMD.com. Thanks for listening.

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John Criswell Episode.mp3: Audio automatically transcribed by Sonix

John Criswell Episode.mp3: this mp3 audio file was automatically transcribed by Sonix with the best speech-to-text algorithms. This transcript may contain errors.

John Shufeldt:
Hello, everybody, and welcome to another edition of Entrepreneur, where we help health care professionals own their future. Hey, everybody, and welcome back to the show today. I'm excited to have John Criswell back with us, to catch us up on all the new and cool things he's been doing. John's newest transformative healthcare solution is called Porter, and Porter transforms the care at home journey for payers in the most vulnerable members. It is powered by AI derived insights and a dedicated clinical team and a really cool, sleek member facing platform. Porter delivers a smarter, faster, more personalized way to navigate the complex at home health care journey. Before Porter, John was a founder, CEO and chairman of Pulsate, which is a healthcare analytics technology company that delivered complete visibility into the efficacy of risk adjustment and quality management programs. Pulsate revolutionized AI, machine learning and analytics covering Medicare Advantage and Medicaid patients, and was the leader in creating analytics for the Affordable Care Act, thus reducing unnecessary and wasteful interventions. Pulsate was acquired in 2019 by a publicly traded company. John, good to have you back on the show. It's good to see you again.

John Criswell:
John, A pleasure. Great to see you. Summer is.

John Shufeldt:
Over. Summer Well, not in Arizona, it's not. It's still like 100 and a zillion here, which is getting a little bit old, but there's a light at the end of the tunnel, knock on wood. So catch us up. What's going on with Porter? As you know, we participated in some of the financing and it's been pretty exciting to watch the growth.

John Criswell:
It's exciting to have you and your team on board. You guys are fantastic and given your track record, we're delighted. So thank you. Just having celebrated Labor Day, we had a moment to think about our care guides and the work that we're doing in the home, and it's fantastic work. So many calls motivated, purposeful stories of helping patients, whether it's transition of care from a setting into the home, supporting their home. And we're getting fantastic results both from the member patient side, individuals that have really provided wonderful testimonials to the work that we're doing and as you know, we're primarily focused on supporting the payer community. And in that area we're hitting on the four things that we do best, starting with one is driving outcomes, supporting the reduction of trend by helping patients with the services, resources and products they need on their care journeys. That's number one. Number two, stars quality. So we support the testing that supports number one, which is reduces outcomes and costs, which adds a lot of value to the member patient journey. The third part is somewhat nebulous, if you will, but what is called risk adjustment to the larger market. So that's the financial mechanism that mouse or payers are compensated in part on. And then the fourth is retention, and our retention numbers for their members are in the high 90s. So we feel really great about how we're supporting our payers, we feel great about how we're fighting for our patients, for our members, and we think we're doing really great work. And I'm delighted to lead an organization that has taken from analytics in my past life to actually delivering the services and the technology to support a more simpler, what I call speed to recovery to achieve your best self.

John Shufeldt:
Yeah. For patient outcomes. I think anybody listening to this who is either navigating the health care system or help family members navigate the health care system, it's a morass and it's a morass to people who are in the health care system. So I can't imagine if you are a patient in the middle of nowhere, so to speak, in like, Hey, I'm not used to this. It has to be nearly impossible to navigate the health care system these days.

John Criswell:
I couldn't agree more. And I have felt for a long time prior to founding Porter that I knew enough about health care to navigate the system. And what I've come to learn is that is not true and it's overly complicated. How do we simplify it? And that's really our goal. And whether you're caring for a child, a parent or yourself, it is hard to do. It is just very difficult.

John Shufeldt:
Yeah, it's crazy. I'm glad you guys are finding some success because God knows it's needed. As I recall, you started Porter right before Covid really hit. Do I have that correct?

John Criswell:
Right. Kind of in the middle of Covid, Right in the middle.

John Shufeldt:
Okay. So good time to start a company.

John Criswell:
Yeah.

John Criswell:
That's right.

John Criswell:
Yep, Yep.

John Shufeldt:
So what's the transition like? So you manage through Covid and a startup which had to be gray hair producing, although don't see much on your head. And now you transition to kind of post-COVID leadership. What's been the transition? What's been the Aha moments?

John Criswell:
The last organization that I founded and worked for was largely, if not 98% virtual. We ultimately became 100% virtual. We still had an office. The environment, pre-COVID was very different. We had a system, we had a routine, we had rules and. And we embrace those rules because we had the privilege of working from home, which was a much more intimate, sophisticated system where I would know kids names, pets, names. I would welcome people into my kitchen, they'd welcome me into theirs. And now pre and now post Covid. It's one that I've had to really learn and adjust the new dynamic not only for my team but for myself constantly being interrupted. There's no more uninterrupted time. Whether that time is being interrupted by a delivery to your front door by a family member. It is constant interruption and that interruption creates challenges around focus. The second part, and I don't agree with this move wholly to working within four walls and office space, but I see some of the benefits that I didn't initially understand. So for your younger the new entrance into the workforce, when they're working from home, they are lacking the mentorship and the connection that one gets from an office environment. And you now couple that with even if they are required to go to an office, there's no senior level executives in the office because they're working from home. And so there's a real deficit that I think is unknown for the new entrance into the workforce in terms of how they will develop, how they're learning and how they're growing and didn't arrive at that on my own, having talked to a number of our younger, newer work entrants, it's a real challenge.

John Shufeldt:
I can only imagine starting out, you graduate from college and you think you're going to be in this workforce and be interacting with your peers and learning from them as you go, and all of a sudden you're sitting in your kitchen on a laptop going, okay, this is what I signed up for. That has to be unnerving for them.

John Criswell:
It is. And I think the other component of that is, is this really life? Because they have watched now their parents for many years work from home, family members, friends, and as they are trying to integrate and learn and grow, I can imagine the challenges that they have. We haven't solved for that yet. At Porter. We are doing some things that we think will support it, such as more frequent on sites, trying to get together for more face to face interactions involving our team in conferences and other venues where they can learn to have more face to face interaction. But I think it's still very new and unknown.

John Shufeldt:
What advice can you give to new founders who are trying to balance this? Because you saw where Facebook kind of mandated people to go back to the office and just got a tremendous amount of pushback on it because now I think people are comfortable working from home. We've already gone through over that hump. What advice do you have for founders who are trying to balance this at home, virtual versus in office continuum?

John Criswell:
I think for many entrepreneurs and doing a startup, you crave command and control, and I think that exists for leaders and publicly traded company and midsized type companies as well. I think having a decision tree within yourself and some self-awareness in terms of why I'm mandating individuals to come back. And then if you can separate that decision tree into needs versus wants, then you can develop systems that support the need for people to work remote from home and balance perhaps your need to have face time with individuals. I do believe the balance can be struck, but really having a degree of self-awareness around the reasons why. I think from a talent perspective, we have seen an influx of resumes as a result of businesses that are requiring individuals to return back to work. And it's not just a state by state. We're also seeing this as a shift from those that have moved from their primary place of business that are now being required to return or terminate employment.

John Shufeldt:
I haven't noticed that yet, but that's kind of sweeping where companies are mandating return to work and people are saying, I'm tapping out for this. I want to stay working from home.

John Criswell:
I'm tapping out. And those that have required them to return back to their primary state or place of business face some sort of termination. They're staying put. They're staying put.

John Shufeldt:
Interesting. You know, I read an article recently, I think it was in The Wall Street Journal. It said the great resignation is over. Have you seen the more applicants come back into the workforce?

John Criswell:
We're seeing a lot more applicants and especially in the stressed area of health care, Right. We lack enough nurses and nurse practitioners. So we are seeing a great deal of candidates. Our candidate flow is very strong for those that are interested in working for us. Essentially, I think that's a big part of our benefits package. I have been surprised that it has not been more significant as a market standpoint, but I do not see the Great Recession. I still see a lot of tightening across other industries and trying to hire talented individuals that lack or that have certain talents.

John Shufeldt:
For my frame of reference of being in the hospital, often it seems like there been nearly a sea change of hospital dynamics, and I don't think for the better. You know, you would think that sometimes crisis builds resilience and improves processes and everything, and I haven't seen that yet. How has it been for your business, you know, now post-apocalyptic Covid crisis? What's changed and how have you seen the relation to government agencies and just doing business?

John Criswell:
Gosh, you've actually brought up something that I don't think is discussed enough. So we know in the hospital and acute settings that they are spending more money to bring in traveling nurses, if you will, and staff. What that creates is a lack of community in the hospital system. When I would go pre-COVID into a hospital, it felt busy. There were a lot of resources around you, whether they were administrative or clinical. And now when you go to a hospital, they feel lonely, They feel empty. The nurses, the support staff, the techs, they lack the community knowledge that exists. That creates a challenge around discharge processes. When you're given all the discharge instructions in the nurses from out of town and another state, he or she has no knowledge of where the best provider or provider is or the pharmacy that will be open at 10:00 at night to provide this. I think it's a real loss. I think it's a real challenge. And I'm not sure that the the system is quite prepared to handle that given the financials that occur in hospital systems. How that has affected Porter is it's making us more valuable in transition of care because we do know we have the technology that supports what patients and members need. We are contacting them as soon as they arrive a hospital, what we call the head in the bed, we're contacting them and then we're supporting them all the way through to their home and then sending clinicians in and then spending minimally 30 days with that member to support all of their transition of care needs, social needs, food, etcetera.

John Shufeldt:
Yeah, that transition of care time is incredibly difficult because we're discharging patients far earlier than we ever have because of bed shortages in the statistics. Somebody comes back into the emergency department after just being released 80% of time. I'm going to admit them because I don't know everything that's been done to you. I have some of your records, hopefully, but you're at risk and I'm not the one taking the fall. So I'm just going to admit you back in the hospital. And that's a huge hit to the.

John Criswell:
Hospital, 100% on the quality metrics, the readmission rates, It's a real challenge for sure.

John Shufeldt:
It was funny, I was back in Saint Joe's where I've worked for 23 years and I don't work there much anymore, But I was back seeing a friend of mine who I thought I needed to do a paracentesis tap his belly, and one of the charge nurses came up to me and said, Hey, everybody's wondering who you are. And I laughed because as I looked around, I didn't recognize I'd been there forever. I wasn't quite a fixture, but I was close and I'm like, Gosh, I don't recognize any of these nurses. And it's exactly what you said. Now I have a health care staffing company, so I get it and I kind of like it. However, if you're a patient or if you're a provider who's been there like me forever, it's like, I don't know these nurses anymore because, you know, the emergency department is you have this banter and camaraderie and it's a super team effort and it still feels that way. But you're right, people are coming in. They don't have the institutional knowledge that you'd hope they do. And next week somebody else is there. It's a much different environment.

John Criswell:
It really is. And probably from your time in medicine, think it's a joke in health care, but you never want to get admitted to the E.R. during Thanksgiving or. Christmas, right? Because it's all the low level, the newbies, if you will, from a hierarchy standpoint. And at that stage of their career, they lack the institutional knowledge. But now that seems much more pervasive, right? Because of the lack of community, local support and talent that can help you navigate.

John Shufeldt:
Yeah. How was post Covid now impacted The CMS and the OIG and governmental bodies that impact health care?

John Criswell:
There's a lot of changes going on within CMS and I think all for the good focusing on ACO reach models, changing the risk adjustment model with a primary emphasis on the member, and so focus on the member for quality or what a Medicare Advantage would be referred to as stars or star ratings, a much heavier emphasis. And so the two sides, if you will, of the health care system, you have insurance and you have health care delivery. The two roads shall not meet. Well, what is happening as a result of CMS, emphasis is putting more intensity and focus on the member for insurers. And so insurers are far more engaged today in doing way more for members, whether it's transportation, whether it's food insecurity, housing, all different sorts of benefit structures and engagement mechanisms to support the member and what they need to have a better outcome. And I think that's fantastic. On the other side, OIG has taken this broader lens around payment mechanisms for payers, and recently in March of this year, Inspector Grimm from OIG said, Hey, 90% of what is happening is occurring in the home, has no evidence of treatment. That's a shocking number, 90%. And she further went to share, if you will, not by name, but by size. You could figure it out. Companies that are performing these services that have no evidence of care. Now, one could argue that the model doesn't suggest that you need evidence of care, evidence of treatment, that you need documentation to support the existence of the condition. Having said that, you're getting paid a rate to provide treatment.

John Criswell:
And so with that backdrop in March, April, I think, and we are seeing some of this more investigations and audits from OIG and CMS on how we can address these payment models to deliver care. They made a number of other comments around network, and you're probably seeing some things in the news around elimination by large payers around prior authorization. So I suppose if I was to project into the future, risk adjustment will contain sdoh social determinants of health mechanisms for payment, I would project more emphasis on the member and that will continue to inspire payers to offer more. And they're offering all different types of valuable benefits to members and I think that will continue because at the same time we're seeing more senior members switching payers than we have in their history and I think they're becoming more savvy around the benefits that are being offered. So ultimately, I think we're going to have more scrutiny, I think at least under this administration, I think that's going to continue to push more value, drive the continuity of care, the care coordination aspects, much of which is what Porter does, right? So we set up at the beginning of the end of any intervention, a care guy that spends a minimum of 30 days to help you activate your treatment plan. Because after that visit, once you've completed that, you have a laundry list of things. And many of us, including myself, don't have the time to activate those things to make the scheduling policy. And we do that for you. That then solves for Zweig's evidence of treatment concern.

John Shufeldt:
I would think that's a great answer. I've been involved in kind of the male sphere as an expert and a little bit as an attorney for three decades. And a lot of bad stuff happens when people leave the hospital. And oftentimes it leads to complaints of medical malpractice, lack of communication. The patients are upset. The providers don't call them back. They don't know where to go. They get worse. They stay at home too long. They finally go back in and they're even sicker and all hell breaks loose. If I was a provider like a hospitalist, I would insist that the hospital uses Porter or a porter like company to help with this transition of care for a number of reasons. But one of those is to reduce my medical malpractice risk, because if you're there interacting with patients and you see something or hear something, the porter ears only get perked up and say, No, no, no, this isn't right. Let's get someone on the phone that can address this or we'll help you get back to the hospital because something ain't right here.

John Criswell:
Yeah, it's actually.

John Criswell:
A very astute comment. It's something that we do not discuss during the sales process with our health systems or our payers. But I think you're spot on. When I worked in urgent care, every visit received a phone call the next day. And we forget if you're a parent and you have your child in and it's 10:00 at night and you receive your treatment plan instructions the next morning, you've probably forgotten what they said, right? And so it's there to to help support them. So there is an intrinsic value in doing that, but there's also a legal liability component as well.

John Shufeldt:
Totally mean. We do the same thing. We call people up the next day and in 36 hours and I always call it the shot over the bowel call. So if there is an issue, you'd get a shot over the bow and you'd say, Oh, we better fix this because we don't fix it. We're going to get patient complaints, we're going to get malpractice events, all sorts of things. And I can't tell you, but I know that we dodged a lot of bullets by calling people up and saying, Hey, anything else we can help you with? Did you get your prescriptions? Did you follow up with your orthopedic surgeon, what have you? And there was a lot of things we pulled out of the fire just by doing that alone. But I wondered if you went back to the hospital and say, look, if you contact your insurers, I will bet you the Porter patients are less likely to engage in medical malpractice. Probably don't have a long enough history yet, but I bet you're coming up close.

John Criswell:
I bet. And I will say that the value that we provide to those members, I think it's an unequivocal result of reduction in medical malpractice. But you're right, we're still early in that journey.

John Shufeldt:
Yeah. So we have a lot of folks who are listening and will hear this and say, wow, that is very cool. And I've got an idea that probably like Porter started out of a need you saw on the system these physicians or non physicians want to be involved in a health care startup because they have a problem worth solving. What advice would you give them because you've been there, done that a few times now.

John Criswell:
It's interesting, John, and you've done this several times as well. Your first time is different than your second time, and I feel like there should be a book written on the second and third and fourth time because it's just different. But for first time entrepreneurs, I think you need to have a discussion with yourself on just grit, persistence, and then that quickly is followed by a healthy dose of self-awareness, because at some point you will pivot, you will change as you're trying to figure and explore intellectually. And then in real life your market fit and product. And so number one is grit. That to me is the number one trait of any entrepreneur. As an investor myself, I look for and have been fortunate enough to have a couple of investments in entrepreneurs I'm just so impressed with and learn from. So grit is number one. Two is a healthy dose of self-awareness that you will change. Your idea will morph, It will grow even the best ideas. And by the way, you don't need to necessarily abandon your original thought, but you might have to put it on the shelf for a bit until you get your product fit and market, right?

John Shufeldt:
Yeah, just kind of laughing when you said this about the first, second and third. And I'm thinking intuitively, you would think the second and third are much easier than the first and it just should get better, easier every time. And I can say that it does because maybe I just now know more than I used to, because before I was fat, dumb and happy, and now I'm not quite as dumb. But now there's more. I realize I still don't know. And I can say it's been easier any time.

John Criswell:
I can attest the second time is not easier than the first for sure. And I will say that one of the challenges when you have had a successful company, many more people will pick up the phone and talk to you and as a result, you lack the real gritty thoughts and intelligence on your idea concept business. When you're new and nobody knows you and you have an idea, everybody will tell you that your idea is terrible. 99 out of 100 people will tell you it's terrible. And that is the best thing the second or third time around. Every. Listen and is afraid to tell you your idea is terrible.

John Criswell:
Yeah, that's really funny.

John Shufeldt:
That's absolutely true. The first time everybody has no problem telling you you're an idiot if they talk to you at all. By the third time they're going, huh? You know, maybe. Maybe he or she has something here when you actually don't have anything. But you think that's right?

John Criswell:
That's right.

John Criswell:
That's right.

John Criswell:
That is so.

John Shufeldt:
True. Well, John, it's been great catching up with you. I'm glad things are going so well. I expect great things from you and Porter.

John Criswell:
Well, great catching up with you. And look forward to catching up with you in Arizona soon.

John Criswell:
Thanks.

John Shufeldt:
I hope so. Well, everybody, thanks for another episode of Entrepreneurs. Thanks for listening, John. Always good. We'll have everything. The show notes for people who want to reach out and contact you. So thanks again.

John Criswell:
Thank you.

John Shufeldt:
Thanks for listening to another great edition of Entrepreneur to find out how to start a business and help secure your future. Go to John Shufelt Webmd.com. Thanks for listening.

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