Q&A: Call9 CEO Tim Peck

By Darius Tahir 

SAN FRANCISCO — As an emergency room physician, Tim Peck saw too many nursing room patients, often with insufficient clinical records. So he co-founded Call9, which uses telemedicine to triage and care for patients in nursing homes, in the process reducing referrals to the emergency department. He's been advocating for the bipartisan RUSH Act, H.R. 6502 (115), which would pay for telemedicine to be used in skilled nursing facilities.

POLITICO interviewed Peck at last week's J.P. Morgan Healthcare Conference. 

This transcript has been edited for length and clarity.

Why'd you start Call9? 

I'm an emergency physician, by training. Went to NYU, Harvard residency. Stayed on as faculty at the medical school there, worked at the Beth Israel Deaconess emergency department. Left in early 2015 to live in Silicon Valley, trying to solve a problem. The problem was my own: In the emergency department, about 19 percent of the ambulances that come to the emergency department originate from nursing homes.

[W]e never gave very good care to those patients. ... 43 percent of them came with dementia ... Most of them become delirious, confused upon the transfer. You don't get great information. They rarely come with their advocates. We never had time to call their family members. 

Then you wind up ordering every test under the rainbow, racking up the fee for service costs, putting them in the hallway. They get dry, they get bedsores, infections. The big thing here is we inevitably admit them to the hospital. We don't send them back to the nursing home. Because it's easier to do that. 

So that's why I left, trying to figure out that problem. I didn't know much about nursing homes. So I went and lived in one for three months, trying to understand everything I could.

Petty eye-opening. Tried to get down to why all these transfers were happening, on a macro level, it's 1.3 million transfers a year. CMS studies showed two-thirds of them were avoidable, as per their DRG codes. ... It represents — not just CMS, but MA, private insurance — about $40 billion in unnecessary spending, when you put all that together.

[In these facilities, the] nursing-to-patient ratios were 1:36, across the country, on average. So you have a single patient who gets a fever, even, that nurse has 35 other chronic care patients to take care of, they call 911, get that patient out of there.

How'd you decide to solve this problem?

After a number of iterations we decided to place a paramedic in the nursing home, 24/7. Or an EMT. This person understands emergencies. They go to the bedside when there's a need.

Tap an app on the iPhone, connect to an emergency physician who's home remote, 24/7 on their laptops. The telemedicine system that connects the paramedic and the patient to the physician at home is all our proprietary technology.

Then we have a platform, our own electronic medical system, along with integrations with all the EMRs in nursing homes, the three biggest EMRs in nursing homes.

So how does your tech work, and what results do you have? 

We're able to do predictive analytics on the patients to see who we should be seeing very early in the course of illness. We watch for trends as their vital signs change, as their diets change, and they're taking in less food, whatever it may be. It's much easier to treat these patients when they have a fever of 100.4 than when they have a fever of 104.

All in all, of the patients we see, about 80 percent of them stay in their beds. Which leads to an absolute reduction in 50-60 percent of hospitalizations. That's pretty good, to do that.

So what's your business model?

At first there was no real way of being paid for doing this. It was outside of the box. It was outside anything CMS saw was possible.

So we treated a few thousand Medicare Advantage patients, brought that data back to the MA plans, were able to get into shared savings, value-based arrangements with pretty much all the local major national payers.

But CMS is really the big issue. About 60 percent of nursing home patients are, across the country, on original Medicare. So we can get paid fee-for-service from Medicare, but we're saving Medicare a ton of money. The way for this to actually work is to do value-based care and shared savings. 

We went to CMS. Personally we went to CMS, Call9, and said, Hey, we have this Medicare Advantage data. Can we do a demo? What do you want to do with this? This is working. They said, we need original Medicare data. We said OK, we treated 10,000 Medicare patients, original Medicare patients, at a loss. 

What happened with the data? 

Got that data, went to CMS. At the same time, the Ways and Means Committee got a hold of that data. They were looking for ways to bring telemedicine into nursing homes. It kind of meshed. It was good timing. They started building legislation around this idea. That became the RUSH Act. Lots of people put their comments in. It was introduced last year, bipartisanly, with people from both the Ways and Means and E&C, on both sides of the aisle.

Urban, rural. It's pretty disparate political views. So it was pretty great. 

What's next in the new Congress? 

Anna Eshoo, who's the chairwoman of the E&C health subcommittee is on the bill ... It'll be a priority. It's good. Hopefully by the end of January if not the beginning of February. 

It creates a value-based arrangement. If there's savings at the end of the day, 50 percent goes to Medicare, 37.5 goes to the physician group like call9 or Kaiser, and 12.5 goes to the nursing home itself. To align all incentives.

We've been sticking to New York and larger cities at this point. We're all throughout lower New York — Hudson Valley, Long Island, and now we're in Syracuse and Albany too. We can't really expand outside of Medicare Advantage markets until the Medicare piece is figured out. There are people in need of this service, and Medicare's losing a lot of money. We need to figure out a way to partner and make it happen.

What's your overall take on policy?

The movement towards value-based care is impressive. The enabling of telemedicine is pretty amazing. There wasn't a bill for the last twenty years, since 2001. Now there's been five telemedicine bills in the past year. I think that says a lot about the willingness — the dam is breaking. 

On the nursing home side, the regulatory is evolving towards value as well. Getting away from fee for service is the reason I started this company.

Ashley Langan