Lessons from Afia Asamoah and Dr. Sanjay Basu, Co-founders of Waymark, on differentiated, effective care models for Medicaid
This episode is part of Pear VC's series on Medicaid, covering the basics that founders need to know to build innovations that support communities in need.
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This series aims to demystify Medicaid, starting with insights from federal and state agencies, FQHCs, and managed care organizations, before exploring successful founders' strategies. Read our primers on the key players and innovations here, and stay tuned for upcoming posts featuring interviews with key opinion leaders, purchasers, and startup founders.
Today, we're excited to get to know Afia Asamoah and Dr. Sanjay Basu. Afia is the Head of Legal and People and Sanjay is the Head of Clinical of Waymark, a value-based primary care enabler for Medicaid.
Founded in 2021, Waymark has raised $87M in funding to date from investors such as Lux Capital, CVS Health Ventures, Andreesen Horowitz and NEA. The company is pioneering in the healthcare space by offering tech-enabled, community-based services to Medicaid beneficiaries, ensuring they receive top-notch care and support.
Afia Asamoah currently serves as Head of Legal and People at Waymark. Her background as a strategic legal leader has been instrumental in navigating companies through the complex landscapes of healthcare and technology. Before co-founding Waymark, Afia served as Head of Legal at Google Health and held pivotal positions within Verily Life Sciences, Google, and the US FDA, shaping policies and driving innovation. Afia's educational journey began at Harvard University, where she pursued a BA in Psychology/Pre-Med, followed by a JD from Harvard Law School and a Masters of Public Policy from Harvard University Kennedy School of Government.
Sanjay Basu currently serves as Head of Clinical and brings to Waymark a deep expertise in public health and epidemiology. With an illustrious career dedicated to enhancing healthcare access and quality, especially for underserved communities, Sanjay's work spans across clinical practice, research, and technology. Before Waymark, he was involved in groundbreaking research at Harvard University and Stanford University. Sanjay's academic path took him from the Massachusetts Institute of Technology (MIT) for his undergraduate degree to the University of Oxford for his MSc, and finally to Yale University, where he earned an MD-PhD.
Together, Afia and Sanjay are on a mission with Waymark to make Medicaid more accessible and impactful for millions, leveraging their unique blend of expertise in healthcare, technology, and policy.
In this episode, we learn about Waymark’s differentiated, research-backed, care model for Medicaid and a thoughtful approach to cost-effectiveness that is consistent with the interests of low-income patients.
Here is the recording if you would like to listen!
Afia’s background as a legal scholar in health policy
Afia’s interest in healthcare began early, inspired by her family. Born in and having spent time in Ghana, she saw firsthand how public health work could make a real difference.
"My dad is an anesthesiologist, both of my grandfathers were pharmacists. I just thought it was really powerful to impact people's healthcare... foundational to everything, right, from wealth to joy to connection."
Afia’s experience in health policy internship introduced her to the potential of law and regulation as tools for improving healthcare equity. With a JD and health policy degree, Afia began her career at law firms advising biotech and medical device companies. Her time at the FDA during the Obama administration deepened her understanding of how regulatory frameworks could drive change.
Legal experience can be instrumental for building startups in regulated spaces
Afia emphasizes that healthcare is built on a foundation of laws and regulations, which ensure that healthcare delivery is "safe and effective." For instance, the FDA focuses on creating a legal and regulatory bar that ensures that drug development activities align with safety and effectiveness standards. Ultimately, legal policy work is "incredibly helpful" for understanding the motivations and underpinnings of the health care regulatory framework.
After moving to industry, Afia has continued to maintain her passion for health policy by "reading regulations and getting in the weeds." This dedication helps Waymark in multiple ways:
"Medicaid is a federal-state program," meaning each state has its own regulations, making it a complex legal landscape. This understanding is crucial for building Waymark’s business model, ensuring compliance, and effectively partnering with patients and providers.
Afia's legal skills have been invaluable for navigating contracts, especially given Waymark’s payer partnerships. "There’s always some contractual arrangement... helpful to have done lots of deals and negotiations."
Her policy background helps Waymark stay "agile" as regulations and the healthcare landscape evolve.
Afia’s exposure to big tech at Google
Afia joined Google in 2013, at a time when digital health was still in its early stages. "I joined before digital health was a thing... and of course, now all tech companies are doing healthcare, but when I joined, that wasn't the case." During her time there, she was surrounded by "incredibly smart people" who were passionate about using technology to make a positive impact.
"The culture of that place is inherently innovative... it's where Waymo spun out of, it's where Verily Life Sciences, the team I joined, spun out of."
Afia started at Google X, known for its bold, innovative projects. Google X was focused on "moonshots"—ambitious, long-term projects with the potential to revolutionize healthcare. For Afia, this was a new and exciting experience, starkly different from her previous work in government and law firms.
However, Afia also saw the limitations of working in big tech. "There was always tension... you're in Silicon Valley dreaming up all these amazing ways technology can impact healthcare, but you're not sitting next to the doctor to see how it's actually going to be operationalized."
"Health is human, technology is a tool to enable that... and it forms the way we're building Waymark. The tech enables the care of our community-based teams; it’s not front and center."
Afia became increasingly focused on the importance of being "proximate to the communities and the environments" where healthcare technologies would be used. Afia’s time at Google shaped her belief that technology should serve as an enabler, not the focus, of healthcare. This philosophy is now core to Waymark’s approach, where technology supports the work of community-based teams providing care directly to underserved populations.
Sanjay’s grassroots medical experience in community-based health
“Back in 2005, I started to learn about the programs that would address patients who didn’t show up at a clinic. Often, the doctor’s office visit is the last thing on their mind because of all the other things going on in life.”
Sanjay’s journey to co-founding Waymark was driven by his interest in community-based outreach programs. He realized that the most vulnerable patients often missed their appointments, only to end up hospitalized or in the emergency room.
Through his academic work, Sanjay began studying how these outreach programs could be more effective. He developed an understanding on how these teams should be staffed, and what type of training and support helped community outreach teams be more successful.
However, he noticed a recurring issue: most of these programs were funded by grants. The reliance on grants led to instability, making it hard for people to build careers in community health work.
“The most innovative programs in this space were funded temporarily by grants—HIV grants, hepatitis C grants, and more recently, COVID grants. The majority of systems still paid for visiting a doctor and having them bill your insurance company for that 15-minute visit. All this other support that’s needed is really hard to fund.”
This experience sparked the idea for Waymark. “What about value-based agreements that pay more for population-oriented care? It could be at the level of an individual patient, a household, or even a whole community.” Sanjay envisioned Waymark as a sustainable model for providing the community support needed around primary care visits. “It’s more in the community, being proactive with population health.”
Sanjay’s learnings from decades of research on care delivery
Sanjay’s background in academia helps him recognize the need for "healthy doses of skepticism" about health improvements, noting that many rigorous studies yield "null results." He navigates the "bewildering array of claims" in health, illustrating this with examples like "blueberries are good for you" versus "blueberries will kill you."
He brings that emphasis on evidence-based practices to bear at Waymark by leveraging "really rigorous, large, randomized trials," including research from UPenn, and focusing on "what's been really reliably shown to work" rather than unproven technologies.
"At Waymark, we made a very conscious decision to base our workflows and our protocols and the technology we use increasingly on really rigorous, large, randomized trials. We want to stay the course and rely on what's been really reliably shown to work in many, many communities."
Sanjay shares insights from his academic care delivery research, noting that "subtle changes" in service delivery can greatly affect outcomes, turning potential null results into benefits. He emphasizes the importance of "being really tight on ensuring that we're delivering care reliably," highlighting consistent and cost-effective operations. He characterizes their offering as a "tech-enabled service" that is rigorously validated, rather than merely a flashy new product.
On working together
Afia enjoys working with Sanjay for his humor, lived experience, and academic expertise in their field, especially as they tackle the complex Medicaid space. Sanjay values Afia’s expertise in navigating Medicaid’s complexity, describing her as having a "nerdy and fun intensity" for solving difficult problems.
“What I appreciate so much in terms of working with Sanjay and Rajaie is that there's humor... even though the work is really, really hard.”
Scaling a business in Medicaid is like managing 50 different countries, each with its own system, which Sanjay finds overwhelming but Afia thrives on. Afia’s ability to handle both government and tech complexities complements Sanjay’s focus on patient care.
Waymark’s culture is focused on careful, sustainable infrastructure rather than "disrupting" the system.
“We joke that we're not a typical startup—sometimes it feels like we're 100 years old, not like those vibrant college students inventing something in a garage.”
Intro to Waymark
Waymark is dedicated to enhancing healthcare access and outcomes for individuals enrolled in Medicaid. Waymark connects patients with local care teams that include community health workers, therapists, pharmacists, and care coordinators. This approach ensures that care is not only accessible but also tailored to meet the unique needs of each individual.
Waymark's mission is to improve patient health by focusing on outcomes and paying for keeping people healthier and out of the hospital. Waymark hires community-based teams to build trust and relationships with patients, offering services like pharmacy, therapy, and behavioral health, including virtual options.
Waymark partners with managed Medicaid plans, which cover over 70% of Medicaid patients, to provide care and share in savings from improved patient outcomes. The model uses a capitation payment system, where Waymark receives funds per patient and scales services accordingly.
"Health is really human and so we don't want to lose sight of that, but we're also practical and realize that humans don't necessarily scale ad nauseam."
Waymark integrates technology to enhance the effectiveness of community care teams and scale interventions, guided by data science to prioritize high-risk patients.
Their product teams build tools that upskill their community based care teams and help them reach their maximum effectiveness.
Their data science team built a tool called Signal which helps identify patients at risk of avoidable hospitalizations and ED visits with >90% accuracy, ensuring targeted, efficient care.
Waymark’s differentiated care model
Traditional healthcare models intervene too late, focusing on high-cost claimants using phone-based nurse calls, which often fail to engage patients effectively. Waymark's approach is proactive and in-person, recognizing that many Medicaid patients lack reliable contact information, and need more direct support.
“So going back to the randomized trials there were these two randomized trials of those nurse telephone help lines and unfortunately they were both null with the two biggest trials.
So what's different about this model? The first aspect is in person. I know a lot of patients with Medicaid who don't even have a reliable phone number. A lot of my patients are homeless. So there's not a reliable address either meeting them in the communities. Community health workers even know, oh, when Carlos relapses, he hangs out at his cousin's couch.”
Community health workers from the same neighborhoods help locate and engage patients, guiding them through medical processes like rehab or primary care visits. Technology is used to enhance human efforts, such as using data to predict and prevent health crises (e.g., offering early refills during wildfire smoke to asthma patients).
“There's something so profoundly powerful about ironically going back to in-person [care], despite how much technology we have. So what we use the technology for is kind of directing the human aspects to be more effective.”
Data science also helps identify social-medical interactions, like helping patients manage insulin during low food availability at the end of the month (due to depleted SNAP benefits for instance), preventing health issues before they escalate. Social workers can give these patients food vouchers at the end of the month and pharmacists can help them with insulin adjustments.
Randomized Control Trials (RCTs) in Care Delivery
Sanjay shares that RCTs for social interventions can yield mixed results, just like trials for different medications. A null result in one trial doesn't imply that all social interventions will fail; effectiveness depends on tailoring the intervention to the right population.
The Camden Coalition, which aimed to reduce hospital use and costs for high-cost patients through community-based nursing, yielded disappointing results when tested via RCT, but provided key lessons. Iteration on the model led to more effective multidisciplinary approaches, incorporating community health workers, pharmacists, and behavioral health support.
Shifting care coordination to primary care rather than hospitals and introducing proactive technology helped reduce emergency room visits and improve outcomes. Later trials showed significant improvements in cost reduction, emergency department usage, and patient satisfaction with their own health outcomes.
Waymark’s approach to cost-effectiveness
Sanjay's recent paper reveals that standard cost-effectiveness analyses (CEAs) can undervalue interventions for marginalized groups due to structural inequities like higher baseline health costs and competing risks.
For Black populations in Oakland, a sugar-sweetened beverage tax could provide significant health benefits. However, higher competing risks like lung disease and violence, along with lower Medicaid-based healthcare costs, make the estimated health gains and savings seem smaller than they could be. As a result, the tax appears less cost-effective for Black communities, potentially leading to decisions that deepen health disparities.
This ties directly to Waymark’s mission of improving health outcomes for Medicaid patients, many from disadvantaged backgrounds, through proactive, community-based care. While traditional CEAs may show these interventions as less cost-effective, Waymark’s focus on preventative care and equity demonstrates the need for new approaches that better capture the long-term value of improving health for marginalized populations.
On costs for Medicaid
Waymark recognizes that reducing cost is not just about reducing utilization but about creating an efficient system for providers to provide evidence-based preventative care that can reduce downstream costs for individuals on Medicaid.
Missed opportunities, like non-emergent ER visits and preventable hospitalizations, are the most expensive parts of Medicaid. Common issues include patients missing routine medications and paperwork delays, leading to ER visits, especially on weekends.
Many problems stem from inefficiencies in the system, such as outdated technology and overly complex processes. Providers face unnecessary burdens from poorly designed electronic health records (EHRs) and workarounds, driving up costs. Healthcare technology lags behind other sectors, with many tasks still reliant on manual systems like faxes, which frustrates providers. The biggest cost isn't personnel or data systems, but maintaining outdated routines and inefficiencies.
Selling into Medicaid
"The best relationships are truly a partnership… These contracts are not just one-year contracts; they’re multi-year."
Afia emphasizes that Medicaid operates differently in each state, and each MCO relationship is unique. She advises that successful contracts rely on building strong relationships and aligning mutual goals.
She stresses the importance of collaborating closely with partners and keeping communication open to foster a sense of teamwork and commitment to shared objectives.
Afia acknowledges that securing the first contract can be challenging due to a lack of data or proof points. Her advice is to focus on de-risking strategies to make it easier for partners to commit.
She highlights that Medicaid contracting involves lengthy sales processes and advises being patient and prepared for the time it takes to build relationships and negotiate terms.
Afia cautions that personnel changes within organizations can disrupt relationships and negotiations. She suggests fostering multiple connections to navigate these challenges effectively.
Afia emphasizes that the most effective interventions are those that address the unique needs of each market and local community.
She points out that each Medicaid plan prioritizes different quality metrics and incentivizes performance in various ways. Her advice is to understand these nuances to craft a consistent and compelling value proposition.
Afia suggests tailoring your approach for each state, considering local insights and community needs to implement services effectively.
Deciding on an Initial Market
Sanjay evaluates market entry decisions both analytically and logically.
He talks about the basic spreadsheet exercise which involves a lot of data, weighted parameters, even including factors like what percent of the market would be amenable to these types of interventions.
On the other hand, a critical factor in entering a market is whether you have a trusted partner who is willing to take on a risk with an early stage startup.
“A lot of the hardest competition is existing value-based contracts that we call value veneers. They're sort of a crowd that has an existing value-based contract and it's really 99% plus fee-for-service.”
Another learning Sanjay mentions is that the biggest competition comes not from other companies but from existing, ineffective value-based contracts that maintain the status quo.
Many contracts check a box for value-based care without truly transforming care models, making it necessary to unwind these for meaningful change.
Understanding the needs of health plans with existing contracts is essential for fostering effective partnerships.
Obstacles and Opportunities for Medicaid
Afia and Sanjay share that community-based care and multi-disciplinary teams are gaining policy support, presenting significant opportunities for innovation in healthcare.
“Every health-tech startup talks about scaling, and I think the sheer volume of patients in Medicaid is intimidating. There's just so much need.”
Addressing health-related social needs, such as housing and food security, is emerging as a critical area for innovation within Medicaid and Medicare. Many current initiatives are pilot projects, but success could lead to increased funding and broader implementation.
A large percentage of children and births are supported by Medicaid, highlighting opportunities in maternal health and equity-focused improvements.
Advice for Founders
Being close to the issues you aim to address is crucial; engaging directly with communities can lead to transformative insights and solutions.
It’s important to understand the needs of the population you want to serve rather than mimicking existing solutions; ask patients what they truly need.
Experiences in clinical settings can provide valuable motivation and insights, highlighting systemic problems that need addressing.
Patience is key; recognize what's missing in the healthcare landscape and focus on filling those gaps. The Medicaid population often falls behind in healthcare services, making it essential to approach challenges as a long-term commitment rather than a quick fix.
Sponsor note: This is the Pear Healthcare Playbook podcast. This season is brought to you by Banc of California. Banc of California partners with leaders to help them identify the right products and services for their business needs.