Lessons from Samir Malik, CEO and Co-Founder of firsthand, on Changing the Paradigm of Care for Individuals with Serious Mental Illness (SMI)
Samir Malik, CEO and Cofounder of firsthand, an organization built on supporting and improving care for those with SMI (serious mental illness)
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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 excited to get to know Samir Malik. In addition to being a cofounder of firsthand, Samir also served as Co-founder of AssuranceSD, a board director of Ride Health, Co-Founder of Zipcare Transportation, and Cofounder/CEO of Genoa Telepsychiatry, which was acquired by UnitedHealth Group.
Samir is on a mission with his team at firsthand to change the way that individuals who struggle with serious mental illness (SMI) access care and support. Serious mental illness (SMI) is defined as mental/behavioral health issues that cause functional impairment by limiting one or more major life activities (schizophrenia, borderline personality disorder, bipolar disorder, etc.) firsthand helps SMI patients engage with the healthcare ecosystem by focusing on delivering real outcomes for a population that has historically been underserved, stigmatized, and deprioritized. In fact, only 65.4% of adults living with SMI received treatment last year.
firsthand was founded in 2021 and recently raised 30 million in series B funding led by Google Ventures.
In this episode, Samir talks about his path to entrepreneurship, being a serial entrepreneur, how he started firsthand, and his advice for founders in healthcare.
If you prefer listening, here’s the link to the podcast!
Entrepreneurship that Started with a Passion for Problem Solving
After college, Samir worked as a consultant for McKinsey. He thrived in this role, relishing the challenge of working alongside other brilliant minds to deliver innovative solutions for clients.
Samir's passion for problem-solving truly flourished when he transitioned to operations for CenterPointe Behavioral Health System, an organization committed to offering high quality behavioral services in St. Louis. Here, he was able to take his ideation skills and follow them through to completion, using his expertise to make a real difference in people's lives.
Samir's entrepreneurial journey consists of being a Co-Founder of firsthand, Assurance SD, Zipcare, and Genoa Telepsychiatry. It was his unwavering commitment to solving important problems that drove him to start these companies.
In particular, Genoa Telepsychiatry was founded as a solution to the issue of limited access to psychiatric care in smaller communities.
“I started Genoa Telepsychiatry to solve an important problem. Psychiatric recovery is difficult and requires an intensive, team effort. The hospital I worked with in St. Louis noticed that many of the folks we were helping didn’t live in St. Louis. They lived in smaller towns where they didn't have good access to follow-up care and would decompensate, landing right back in the hospital.”
The central question for Samir was: how can we help improve access and the provision of care for folks in smaller communities? The answer was creating Genoa Telepsychiatry, a telemedicine solution that could connect individuals in safety net communities with high-quality care.
“At the core, my experience with entrepreneurship comes from a love of problem solving. It starts with the problem and figuring out what you can do to make a difference.”
The Origin of firsthand
Samir and his team successfully sold Genoa Telepsychiatry to UnitedHealth Group, but his passion for improving mental healthcare persisted. He engaged with various individuals, including investors, seeking opportunities to make a meaningful impact in the space.
Eventually, his path intersected with that of his current co-founder, Ananth, who shared his zeal for helping individuals affected by serious mental illness (SMI).
The prevalence of SMI has surged in recent years, with the age group between 18 and 25 being the most affected. Driven by their shared commitment to make a positive difference in this space, Samir and Ananth have devoted themselves to this critical cause.
Samir and his team had a few compelling insights.
They observed that safety net providers at community mental health centers were performing life-changing work. Despite their modest pay, these staff members were going above and beyond for their patients, which resulted in significant improvements in their lives.
They noted that the number of people engaging with mental health centers was significantly lower than the number of people who could benefit from such engagement. They saw too many individuals living on the streets or in shelters who were not accessing the care they needed, despite it being available to them.
Medicaid enrollees struggling with serious mental illness (SMI) required frequent utilization of medical services, resulting in a high expense profile. For instance, Medicaid enrollees diagnosed with SMI often had healthcare utilization of $20,000 or more annually, with around 70% of this group not engaging regularly in outpatient services.
After controlling for various demographic and medical factors, they discovered a significant cost difference between individuals engaged in outpatient behavioral services and those who are not.
These insights helped Samir and his team identify where to build their business. They noticed a critical 70% gap in engagement for Medicaid enrollees with SMI who needed care. By focusing on building trust and connecting with this cohort, they knew they could create significant savings by helping individuals access the right care program, medication, or patient-doctor relationship. This realization became the driving force behind firsthand.
The name "firsthand" reflects the organization's peer-led model, harnessing the power of shared lived experience in building trust and relationships. firsthand uses a combination of peers, care navigators, clinicians and technology to engage Medicaid enrollees living with SMI and help them navigate their care journeys.
They work closely with Managed Medicaid plans, who pay firsthand to engage their members and share the savings generated by their efforts.
The Power of the “Lived Experience”
firsthand began with an idea that was constantly refined and improved upon by each member of the team, giving them ownership and agency over the project. This sense of ownership and commitment towards the idea allowed for a much more sophisticated and refined approach.
“We pollinated and cross-pollinated the concepts and iterations on the idea that got it to a much more refined and sophisticated place. And in doing so we could all collectively say, we are building firsthand together.”
One of his teammates suggested the idea of rubber wristbands promoting firsthand’s nurse triage line, ensuring that individuals with SMI could easily contact them in times of need and avoid the emergency room. This was one of the many ideas that came from the frontlines of the organization, which follows the ethos of ensuring everyone has a stake in the mission - to help individuals living with SMI recover.
What sets firsthand apart from other organizations is the trust they build with the individuals they serve. Over two-thirds of the employees have lived experience with serious mental illness and are called firsthand guides.
“Our workforce has spent time in the same shelters, under the same bridges, and in the same churches, as the folks we are trying to help.”
That “lived experience” provides two very meaningful benefits to individuals living with SMI.
firsthand guides know where to go.
They know exactly what corner to be on on Tuesday afternoons, and what bridges to go under when the weather's not great. And that's where they can find folks.
firsthand guides are a representation that recovery is possible
firsthand guides are not telling folks, “this is what you need to do better and this is what you've done wrong”. Instead, they're presenting themselves as a lived example of what better can be.
This creates a narrative that makes a world of difference in building trust with individuals who battle with SMI. In fact, firsthand reports a 70% enrollment rate of individuals they meet in person, compared to other programs that only have about 20% engagement.
How firsthand helps those with SMI
firsthand is not trying to directly address all of the needs of the individuals they serve. Many great resources already exist to serve individuals living with SMI, including social service agencies, community mental health programs, primary care, medical homes, and various other offerings.
The main role of firsthand is to fill the gaps in support that these organizations may not be able to cover on their own.
It starts with outreach and trust building through the lived experience. firsthand then becomes a partner for folks living with SMI in their recovery journey. This could mean joining individuals at their appointments, assisting individuals in building and following self-management routines including exercise and nutrition, and even helping folks apply for various benefits that they are entitled to
“There's a whole host of benefits out there provided by state, federal and local governments, that the individuals we're trying to help are eligible for. However, it's hard to apply for these benefits especially when you don't have an address or if you don't have a stable form of communication.”
To address this challenge, firsthand social workers sit down with individuals and help them complete applications for transit vouchers, supplemental nutrition programs, job training programs, housing support, and other benefits.
Another critical component of firsthand's services is clinical support provided by nurse practitioners and nurses.
“At firsthand there is a team of nurses that are available to assist, assess and triage folks as they have needs”
People living with SMI often over-utilize emergency and acute care settings, but by engaging with clinical staff in a familiar setting, they are more likely to trust and share personal information. The care team assesses and triages individuals' needs, uncovering crucial information that can guide them to the right kind of care.
Selling What you Built vs. Building What You Can Sell
Samir’s endeavor with firsthand was different from his previous business ventures.
With Genoa telepsychiatry, he and his team built a solution and was trying to convince the market to buy what he and his team built.
“In 2011, we had to go pull the market to us. This was the early days of telemedicine, before telemedicine was a thing. And so we found ourselves spending a lot of calories convincing the market that this was a solution that filled their need. We were selling what we had built.
However, with firsthand, Samir and his team took a more deliberate approach. Rather than jumping straight into building a product, they first did extensive market research. They talked to customers, health plan leaders, and executives who had experience dealing with the problem they were trying to solve - low engagement rates for SMI patients leading to poor outcomes. By doing so, they were able to iterate on their ideas and get feedback from various stakeholders.
This approach allowed the firsthand team to build a product that met the market's needs, rather than trying to convince the market to adopt what they had already built.
"Eventually it got to a place where every time we got on the phone with a health plan leader, they'd say, Oh, wow, if you had that product, that'd be great. And that's when we knew what we had to build."
By building a product that the market was already clamoring for, firsthand was able to quickly develop credibility and gain traction. In healthcare, where change and innovation can be difficult to instigate, this approach made all the difference.
Finding the Right Partners and Investors
The firsthand team de-risked the idea considerably before taking in any capital. They would approach investors who they believed were aligned on a values perspective.
“We were doing these discovery calls together, our potential investors were coming on the ride with us, learning about the opportunity, and finding out what customers are interested in. When we were ready to actually bring on capital, the investors had already seen everything they needed to see.”
Bringing in capital is a relatively straightforward process from the financial perspective. But finding the right partners who are deeply aligned with you from a values perspective and see the problem the same way you do takes time.
There were certain values that Samir and his team were looking for in their partners/investors.
They wanted individuals who shared the value of treating others with respect and staying committed to a mission.
They also looked for partners that didn’t have an ego. They wanted investors and collaborators of the company to have a desire to keep learning, explore alternative options, and accept that they could be wrong.
Investors and partners also needed to create deals in a fair manner instead of doing deals in a one-sided maximization format.
“That’s not to say there isn't negotiation and you don’t wrangle and wrestle with the terms, but you approach the negotiation with the intent of making it as fair as possible for all parties involved.”
Challenges Along the Way for firsthand
firsthand has locations in Florida, Ohio, and Tennessee. These locations were chosen thoughtfully as a market design to prove the business model can be successful in heterogeneous markets.
“Tennessee is a state where its Medicaid program is only awarded to three plans, meaning there aren't too many plans to reach out to. You work with one plan in the state of Tennessee and you get a third of Medicaid. On the other hand, Ohio has anywhere from eight to fourteen Medicaid plans in a given market county based on the way they segment it. Tennessee also has not expanded Medicaid, while Ohio has expanded Medicaid.”
These differences result in a distinct operational environment for firsthand. If they can succeed in these three states, then expansion to any state becomes feasible.
Innovating in the Medicaid space is also more challenging than Medicare and commercial. On a per enrollee basis, Medicaid is the least funded and the product/offering in Medicaid is usually less scalable given the different approvals and regulations of each state Medicaid plan.
“While there are many challenges in Medicaid that make it a harder place to build a good business, at the same time, the free market is the free market, and it's working exactly how it should. There is a reason that there are tens, or hundreds of billions of dollars of innovation being poured into Medicare Advantage, because it was initially seen as a lower hanging opportunity. But at the same time, you have a very competitive landscape.
“Medicaid is kind of the other way around. So you pick your battle with what challenges you are excited to take on. If you want to try to climb a mountain that few have climbed before, then maybe Medicaid is the right place to innovate. There aren't going to be many other people on that trail. But it's not an easy trail either”
Future of firsthand
firsthand recently raised a series B. With the new funding the team is hoping to expand their footprint in their existing markets.
“We have about 50,000 lives under attribution today. We've only knocked on about 5000 doors. We have a lot more new doors to knock on. And so part of the funding is going to help us build up our teams and our staff”
firsthand also hopes to demonstrate that their practices are not only scalable but also replicable. The experience of people in one market is not different from the experience of those they serve in a completely different market.
“We've done enough work in these markets across thousands of individuals. We can start to apply the power of technology to understand what are the best practices in one area and how do we share those practices into another region. These are things that require investments in application building and data science to show that we can replicate our results.”
Finally, with the new resources and funding, firsthand is making sure they are investing in a culture that allows them to maintain the “lived experience” as the centerpiece of what they are doing.
“It requires building a special organization, to say, you're coming to us while still in recovery. We're going to build the support and the accommodation and the structure to allow folks to continue on the recovery journey while working here. We have now proven through our engagement rates, that this is the right thing to do. And to invest in that to make sure we can do it while at scale is critically important.”
Advice for Founders
Start with the right people
No matter what problem you aim to solve, surrounding yourself with talented and enjoyable colleagues who are smarter than you is key. Disagreements can and will arise, but the underlying relationship should remain intact.
Build what you can sell
In healthcare, risk-taking is not widely embraced. To find product-market fit, it's crucial to dedicate ample time to market research, talking to customers, and building early MVPs.
Look for investors and partners that fit with your values
Every company and team should operate by a specific set of values. Your investors and partners must share those values and fit well within your ecosystem.
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Interested in firsthand or joining their team? Learn more on their website and LinkedIn
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