Lessons from Ron Vianu, Founder and CEO of Covera Health, on building start-ups and his efforts to deliver collaborative quality measures
Ron Vianu Co-Founder and CEO at Covera Health, an organization that supports providers, health plans, and employers with quality insights delivered throughout the healthcare ecosystem
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Welcome back to the Pear Healthcare Playbook! Every week, we’ll be getting to know trailblazing healthcare leaders and dive into building a digital health business from 0 to 1.
Today, we're thrilled to introduce Ron Vianu, the CEO and visionary behind Covera Health. Covera Health is a pioneering AI-enabled diagnostic technology company, specializing in radiology performance measurement and its consequential impact on healthcare. With a career spanning over three decades, Ron has been a driving force at the intersection of healthcare, technology, and insurance.
Ron's entrepreneurial journey began over 30 years ago, founding his first health tech company while a senior at NYU. His first deep exposure to the field of Radiology was with Spreemo, a company he founded with his co-founder, an orthopedic surgeon, in 2010. Spreemo was a referral management platform in the occupational medicine space. Spreemo grew to over 200 employees across offices in New York City and Dallas and received significant investment from venture and PE investors.
In this episode, we talk about Ron’s work with Spreemo, how he started Covera Health, the partnership with Walmart, his thoughts on the future of AI in radiology, and advice he has for founders.
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Ron’s Work with Spreemo:
Spreemo was founded to advance the consumerization of healthcare – a belief that medical care could be purchased like online goods, where costs and quality rankings were readily available to support informed decision making. Ron no longer believes this is a fair burden to be placed on patients, but more on that below.
Acting as a healthcare marketplace bridging employers, insurers, and healthcare providers, Spreemo initially focused on radiology services within the workers' compensation sector. The focus on radiology, Ron admits, was wholly misguided. It was his belief that radiology care does not suffer from quality issues, like all other medical specialties and, as such, ideal for such a marketplace where price and convenience are sufficient factors to consider when making care decisions.
Central to Spreemo's earliest philosophy was that a marketplace for radiological services would address a known variability in imaging fees for “similar services” where an MRI at one facility could cost $3000 but $400 in another, a difference that wasn’t easily explained by market conditions.
However, Spreemo’s efforts were met with immediate skepticism from the radiology community. Radiology physicians felt misunderstood and undervalued. Worse, they felt Spreemo would further contribute to their commoditization, the prevailing belief that imaging services were largely the same regardless of the physician or imaging center involved in the diagnostic test. This phenomenon, they explained to Ron, negatively impacted patient care, the field of radiology and contributed to poor outcomes.
This feedback fueled Ron's determination to delve deeper. Recognizing the lack of standardized metrics for assessing radiology quality, Ron and his team embarked on a quest to define and quantify quality. Spreemo’s approach to the problem of quality measurement received significant attention from payers and providers, allowing the company to scale and grow rapidly.
Ron noted that Spreemo’s Board and his investors were hesitant to fully invest in tackling such a complex problem, and the company was sold before he could address the issue. Ultimately, Spreemo's legacy lies in its relentless pursuit of solving the complexities surrounding healthcare quality and its efforts laid the groundwork for Covera Health.
Today, Ron champions a belief that patients should be able to be confident in the quality of care they receive without having to judge the performance of their physicians, a significant evolution from his prior viewpoint and a fundamental shift towards prioritizing patient trust and care quality.
Why quality matters so much in radiology
Quality in radiology holds immense significance due to its direct impact on downstream care.
Providers frequently rely on X-rays, MRIs, and CT scans to inform patient diagnoses and make critical decisions in healthcare. However, it's rare for patients and many providers to consider the variability in the quality and interpretation of these images. Yet, Ron indicates that significant variability does exist and has a profound impact on patient care.
“I was in the office of Richard Herzog MD FACR who was the head of spinal imaging at Hospital for Special Surgery (HSS) at that time. I asked him why someone should go to HSS for spinal imaging vs. somewhere else.”
During their conversation, Ron posed a thought-provoking question: If he were to send his mother (who had a bad back) to multiple imaging centers for an MRI, would the results be different? Intrigued by the query, Herzog acknowledged that while patients typically don't undergo scans at multiple centers, the idea piqued his interest.
With his mother’s consent, Ron accompanied his mom to three different imaging centers across NY city for a MRI (safe and doesn’t involve radiation).
The contrast in experiences was stark. At one center near his home, his mother breezed through the process, enjoying the convenience of a stand-up MRI and swift service that took about 18 minutes. This is the center she would have recommended to her friends based on the quick service and painless study.
The academic medical center provided a vastly different experience, with a prolonged scan time that lasted about 45 minutes and was less comfortable.
Returning to HSS with the reports from three centers, the physicians at HSS were struck by the discrepancies in the diagnoses.
Despite undergoing the same type of scan, the diagnoses varied significantly, further cementing the concern about the presumption that there’s little to no variability of radiological quality across different facilities, a belief commonly held by payers.
Following this insight, a prospective observational study was conducted by HSS in NY and Jefferson Medical Center in PA where one patient was sent to 10 imaging centers to have her low back imaged by MRI over a period of 3 weeks. Two reference MRI exams were performed at HSS at the start and end of the study.
Across all 10 study examinations, there were 49 distinct findings reported related to the presence of a distinct pathology at a specific motion segment. Zero interpretive findings were reported in all 10 study examinations and only one finding was reported in nine out of 10 study examinations (source).
The research revealed significant differences in interpretive findings and a notable occurrence of errors in radiologists' reports when examining MRI scans of the lumbar spine from the same patient across 10 different MRI centers within a brief timeframe.
Consequently, the authors suggest that both the facility where the MRI is conducted and the radiologist interpreting the results can directly influence the diagnosis, subsequent treatment decisions, and overall clinical outcomes for the patient.
These findings underscored the pressing need to address the lack of standardized quality metrics in radiology.
Ron came to understand that the interpretive nature of radiological studies, influenced by factors like equipment quality, position of patient, imaging sequences, and professional judgment (specialist in spinal imaging vs. general radiologist), could result in significantly varied diagnoses. Furthermore, the downward pricing pressure on imaging centers results in incentives to reduce scan times to increase throughput of patients though doing so could compromise the thoroughness and quality of scans.
Creating Covera Health
“When we established and funded Spreemo, our primary focus wasn't on addressing quality issues. Frankly, I didn't receive much support from our board to tackle this problem. However, as an executive team, we recognized the profound impact that solving quality concerns could have across the medical field, particularly in radiology.”
From his perspective, Ron observed that few, if any, areas of medicine possessed true quality metrics accepted by payers and providers, and thus capable of addressing critical issues. Quality, to him, entailed providing physicians with actionable information that enhanced their ability to assess and improve patient care effectively, while enabling payers to build incentives to promote care quality. In order for this to work, any quality standard would need to be trusted by all three: payers, patients, and providers, an incredibly challenging feat in today's medical landscape.
As a team, they believed that addressing quality variability and the lack of accepted measures was paramount. This conviction led to the founding of Covera Health. Covera was built on the foundation that universally accepted measures of care quality and physician performance would dramatically improve patient outcomes and reduce waste and costs related to misguided care journeys.
Radiology they felt was the right place to start, as it’s a foundational diagnostic discipline, suffers from an incorrect perception that it is a commodity, yet has an outsized impact on patient care and outcomes.
This is the opportunity the founding team of Covera identified. business centered around understanding and improving quality. By empowering payers to manage networks more effectively and enabling physicians to benchmark their performance, they aimed to enhance overall patient care.
“When we established and funded Spreemo, our primary focus wasn't on addressing quality issues. Frankly, I didn't receive much support from our board to tackle that problem. However, as an executive team, we believed that solving quality concerns in medicine, starting with radiology, was both intriguing and impactful. From my perspective, few areas of medicine have true quality metrics capable of addressing critical issues.”
Ron's journey to building Covera Health stemmed from conducting prospective randomized trials with major employers to evaluate the impact of radiological quality on patient care and costs. Through this work, he recognized that while payers overlooked radiology quality, often considering it a commodity, it suffered from variability and held the potential to significantly influence patient care outcomes.
Understanding the concerns of both payers and radiologists, Ron devised a straightforward solution. He reached out to large employers offering a service to guide patients to high-quality imaging centers in their communities. Covera would then collaborate with these centers to ensure patients were matched with the most suitable providers and provide analytics and insights to improve performance.
In order to create an environment suitable for meaningful dialogue around quality, Covera Health applied for and was certified as a Patient Safety Organization by the AHRQ. This allows Covera Health to provide a safe, secure, and aligned framework for providers to share quality insights, collaborate on quality improvement initiatives, and ultimately support improved patient care and outcomes.
How Covera Partnered with Walmart
The breakthrough moment came when Walmart became Covera's first client, a significant achievement for a startup. Launching a national partnership with such a renowned company underscored the value and potential impact of Covera's mission to enhance radiological quality and patient care outcomes.
“Persistence is key with any partnership. I must have attended 40 meetings or so with Walmart teams in order to get the first introduction to the team that could even evaluate our solution. They were difficult folks to get to but they wanted to innovate and partner with us.”
Walmart presented a unique challenge and opportunity for Covera Health.
"At that time, Walmart typically conducted few pilots. It was a philosophy of their benefits program with the rationale that they only did what was reasonable to manage their members (more than 1 million) and they did not want to experiment but deploy solutions they knew 100% worked."
However, Walmart recognized the potential impact of radiology quality on patient care and costs based on other care programs they managed. Covera, with its innovative approach, aimed to address this issue by guiding patients to high-quality imaging centers and providers, thus enhancing outcomes.
Over the course of about a year, Covera Health guided Walmart through a process of understanding its framework that enabled it to measure and improve radiological care quality. The key question that emerged was whether they could implement a national solution and, if so, how long it would take.
Initially, the focus was on facilitating patient access to high-quality imaging centers and providers. Many companies today in healthcare are looking to identify high performing physicians in every area of medicine; it's a fairly common solution.
However, under Walmart's guidance, Covera's perspective evolved. They began to consider how to bring quality healthcare directly to patients, regardless of their location.
“Walmart, given their size and given that they are pretty much in every community across the country, they often ask a little bit of a different question, which is how do we raise the quality of health care across every community in the country because they are in every community of the country.”
Walmart's emphasis on healthcare quality prompted Covera to explore ways to elevate healthcare standards in every community. They recognized the potential strain on resources if patients were directed exclusively to existing high-quality providers, especially in rural areas with limited access to advanced medical facilities or subspecialized physicians.
This led Covera to investigate the role of AI in healthcare delivery, aiming to provide actionable insights to physicians across different regions.
Today, Covera's approach revolves around three main strategies: collaborating with employers to guide patients to high-quality imaging centers, partner with health plans to support their providers with AI insights to identify and address potential errors in radiological diagnoses, and use performance data to help those providers engage in quality improvement and peer learning initiatives. This proactive approach enables them to enhance patient care within local communities by providing valuable insights to radiologists both before and after patient interactions.
When partnering with Walmart, Covera Health encountered the challenge of integrating their technology platform and program framework with major insurers like Aetna, United, and Blue Cross
It was crucial for Covera to recognize that their program relied heavily on the collaboration of these stakeholders. However, at the outset, they had limited knowledge about their internal priorities, decision-making processes, and incentives related to program implementation.
As Covera convened meetings with these stakeholders in Northwest Arkansas, they gained valuable insights into their perspectives and motivations, allowing them to better understand the intricacies of the healthcare landscape and tailor their approach accordingly. This experience underscored the importance of comprehensively understanding all stakeholders involved in supporting their program.
Covera Health Partnership with Radiologists
Securing buy-in from providers has proven to be one of the more intriguing and challenging aspects of Ron's business journey. Radiologists, in particular, tend to be quite skeptical when it comes to outside assistance, especially if it's related to payers. Over the years, they've often felt commodified and undervalued within the healthcare system. Therefore, establishing trust with them is paramount.
From the outset, Covera Health's approach has been twofold: first, to genuinely assist radiologists in improving their practice, and second, to demonstrate the value they bring to patient care. When Covera Health was founded in 2017, amidst the growing hype surrounding AI's potential to revolutionize radiology, the team was deliberate in its focus. Rather than aiming to replace radiologists or simply speed up their workflow, the goal was to help them quantify quality better.
“As we considered leveraging AI, our primary focus was on how to assist you in quantifying quality better. Not on how to help you read faster, nor on how to automate what you're doing. Rather, can we help you understand how you're performing in a secure environment, where that information is solely for your benefit.”
The emphasis was on creating tools that enabled radiologists to understand their performance in a safe and confidential environment, allowing for peer learning and self-improvement.
The team's aim has been to ensure that every patient receives a report containing accurate information tailored to their specific needs, thereby enhancing the overall quality of care provided by radiologists.
Future of Radiology and AI
Ron sees the trajectory of AI in radiology as a transformative force with profound implications for the field. He acknowledges that the precise direction of this evolution is still uncertain, given the rapid advancements in generative AI and the unexpected ways in which industries are being reshaped by artificial intelligence.
Reflecting on recent developments, Covera Health acquired CoReed, an AI quality assurance. CoRead, based in Cary, North Carolina, offers a solution that helps radiologists identify blindspots and misdiagnosis. Its solution has been validated on data from more than 2,000 hospital sites in the U.S.
This underscores the importance of leveraging AI at scale to provide performance measures across every area of radiology.
The goal for 2024 is to equip radiologists with comprehensive insights into their performance, spanning modalities, study types, and pathologies.
Ron envisions a future where radiologists can access not only patient data but also detailed analytics on their own performance and that of their practice. This holistic view enables them to identify areas for improvement and engage in data-driven peer learning programs. Moreover, Ron emphasized the potential of aggregated data to advocate for higher investment in quality from payers, based on objective evidence of its impact on patient care outcomes and costs.
AI has also initiated a significant transformation within the field of radiology, reshaping conventional workflows and enhancing the role of radiologists.
Insights for Healthcare Founders
1. Understand the Payer landscape
Ron encourages entrepreneurs to talk to other founders at later stages to gain valuable insights into the challenges and nuances of the payer landscape.
Payers and employers operate in siloed structures, with various departments focusing on different initiatives. Making connections within these organizations and understanding how they fit into the ecosystem is crucial for effective engagement.
Innovative employers who like to work with healthcare startups include Walmart, Boeing, AT&T, Microsoft, and PBGH. PBGH, purchaser business group on health, is a coalition of the nation's major private and public employers that implement innovative programs and best practices to increase health care value.
For any startup, it's crucial to begin by engaging with these innovative players, as their endorsement can validate your approach for others. Typically, other entities in the field follow suit.
Notably, health plans tend to be cautious and are often the last to adopt new programs. For instance, last year, Covera Health successfully deployed their solution with Blue Cross of Michigan, which covers a significant population of around 5 million individuals. Payers like them usually wait until a startup has proven success before adopting their solutions.
Pick the right investors
Selecting the right investors is crucial for any founder, as they should align with the company's vision and long-term goals. While it's essential to choose investors who share your vision, it's equally important to welcome alternative perspectives and conflicting views that contribute to finding the best solutions. Ultimately, mutual understanding and alignment on the company's trajectory are key.
While valuation is a factor, founders should prioritize recommendations from trusted sources within the healthcare community when choosing investors. Personal referrals can significantly mitigate risk and foster more productive partnerships.
Investors should not only provide capital but also offer guidance on when and how much to raise, as well as assist in forecasting future revenues and costs. Additionally, they can facilitate introductions to other investors, especially during the early stages of funding, which is vital for advancing the company's mission and growth.
In essence, finding the right investor is not just about securing funds—it's about building a supportive partnership. A wrong investor can crumble a company, but the right investor can propel the company on its journey towards success.
Interested in Covera Health? Learn more on their website, X, and LinkedIn
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