Astrana, Awell, and the Emergence of CareOps as a VBC Differentiator

I wanted to share a recent great conversation I had with two leading organizations in healthcare and value-based care: Astrana and Awell. The two recently announced an innovative partnership which I think is flying under the radar. In general these organizations are underrated, and I wanted to draw some more attention to them.

So today kicks off an essay on Awell and Astrana, including how to form a thoughtful partnership and implement a successful pilot. Then I’ll dive into how Astrana thinks about scaling as a value-based care player (hint: flexibility is key) and how Astrana thinks about vetting partners for its enterprise. 

Thanks to both Astrana’s Brandon Sim and Awell’s Thomas Vande Casteele and Rik Renard for sitting down and having a great conversation with me!

Let’s dive in!

Key Takeaways from my Conversation with Awell and Astrana Leadership

Astrana Health and Awell is the first ever true partnership to bring CareOps to value-based care at scale.

Astrana stands out as one of the few organizations at its scale capable of moving swiftly and experimenting boldly. Their partnership with Awell further amplifies this agility and innovative capacity.

More care delivery organizations need to find a way to design and continue to improve their care processes at scale and closer to the speed of software companies. 

In healthcare, for sake of conservatism but also as a result of the slow movement of information, process improvements take months or years, but we can do better. If a new method of taking care of patients is proven unequivocally better, it needs to be rolled out as soon as possible. 

Organizations that iterate and learn what works and what doesn’t for their markets and populations will win over time. Awell enables this iteration in a no-code, flexible way and works with several care delivery organizations leading the way in CareOps.

Awell, Astrana, and the Emergence of CareOps as a VBC Differentiator

Imagine you’ve built a product so good that your customers don’t want you to list them on your website as a partner, because it would give away the source of their secret sauce.

Awell works with some of the most innovative care delivery companies in the game, and they’re far and away the leading organization in Care Operations – CareOps – defined as the process of combining agile, efficient software with clinical expertise to create the best possible clinical workflow. High quality, high efficiency. And this mantra aligns closely with the objectives of value-based care, where Astrana Health is busy building and scaling a market-leading asset.

I recently chatted with Astrana’s CEO Brandon Sim, and Awell’s Thomas Vande Casteele and Rik Renard about their recent partnership announced on August 25 along with their thoughts on what’s going on in value-based care.

So with that introduction aside, here’s how Awell is supercharging clinical workflows for Astrana, and how Astrana is staying ahead of the value-based care game by leveraging Awell’s platform at scale in the first ever partnership to bring CareOps to value-based care.

Awell will be a household name (in niche healthcare corners of the world) in short order. Astrana is one of the most underrated companies in healthcare And today I’m excited to tell Hospitalogists more about both of them.

The 18-Month Long Partnership Journey that Started with a Tweet

When he’s not too busy closing deals or working with existing partners, Rik Renard at Awell finds himself on X (formerly known as Twitter) networking, but also posting hilarious healthcare memes. Well…you never know who’s going to come across your profile on any given day. The algorithm giveth, and the algorithm taketh away (I should know). 

On this particular day, when Astrana CEO Brandon Sim started following Rik, little did he know the algorithm would give Awell an enterprise-level partner 18 months later.

So while I’m not necessarily advocating for business development through memes in healthcare, it DID open the door for a conversation between Brandon and Rik to talk about ways Astrana and Awell could work together.

How Awell and Astrana Formed a Successful Pilot around Strategic Priorities

After initially touching base on Twitter in January 2023, Rik messaged Brandon to congratulate him on Astrana’s results one quarter, and that conversation eventually led to a meeting of the minds. Astrana had early interest in Awell’s model from the beginning, but timing became right in the first part of 2024. At that point, Awell and Astrana began talking about a potential pilot between the two parties.

Something that differentiates Awell is their team’s unquenchable thirst to drive results for their partners and their desire to ‘prove, not tell’ the value they bring. Awell wants its customers to look badass – not them. To this end, Awell took inspiration from Palantir’s boot camp concept and applied it to healthcare. 

In forming the pilot, including which workflows to develop, and what KPIs to track, Awell’s team flew out to Astrana’s HQ and asked Astrana for hard problems they could solve together. Workflows that were manual they could automate. Tough value-based care functions that were headaches to deal with.

From these conversations, Awell and Astrana landed on 10+ use cases surrounding transitional care management functions – an area overgrown with manual tasks as patients leave the hospital and require follow ups / discharge to appropriate care settings. In most care delivery organizations, it’s difficult to improve these processes, which include tasks like contacting patients, following up, faxing doctors, and more. 

The pilot sought to answer two primary questions:

• Can Awell help Astrana support more patients with the same transitional care management team (i.e., make them more productive)?
• Can Awell integrate well within the Astrana stack and drive efficiency gains elsewhere?

The answer to both of these questions was a resounding yes.

The pilot rolled out to Astrana’s ACO population – 35k or so members. In most cases, Astrana trials new concepts or partners in their ACO (internally referred to as their ‘sandbox’ or an area to experiment more intimately prior to rolling out to other use cases and populations) because it’s a more controlled environment. They work closely with their PCPs to understand processes and implement solutions to what they hear together. Then they can expand to more complex phases where things are more hands-off or exert less influence.

Diving into the weeds, here are more specifics around how Awell implemented the pilot with Astrana:

• Awell first lands on a use case and from conversations with Astrana, the two then decide on transitional care management (TCM), the current needs in the area, and solutions therein
• Awell designs the v1 of the care flow and goes live with v1
• After a few days, Awell asks for feedback and – together with the care management team – Awell makes improvements to the flow. As an aside, as it sits today, Awell and Astrana are on v156 of this care flow within the pilot to prove how much they really do iterate processes with their partners!!
• Awell held weekly syncs with operating and clinical personnel on the ground to understand what’s working and what’s not – an important, underrated step. Although they are technically not the decision makers, they are an extremely important voice and Awell does everything they can to make them feel involved and heard so that they love Awell by the end of things
• Awell reported on KPIs to people on the ground + leadership every week and had a dashboard to help facilitate this reporting process and show progress

As mentioned, the pilot proved to be successful – time spent on TCM patients decreased by 75% as Awell automated several manual steps. After running for 2 months and seeing the results along with how Awell runs things in a partnership, Astrana made the buy decision and scaled the pilot quickly from there.  They’re now running workflows across multiple use cases beyond TCM including ECM, SNPs, Post ED programs, Medication Reconciliation Post-Discharge, ESRD Coordination, ESPDT (Early and Periodic Screening, Diagnostic, and Treatment), with more on the way. From this point, the partnership will expand to Astrana’s Medicare Advantage population and together, the two can innovate much faster than other operators in healthcare and lead the charge in creating agile organizations.

Other helpful tidbits for setting up a successful pilot: 

• Ideally you pilot in 2 different markets with 2 different leaders so you can compare results. Sometimes it’s the market leader who influenced the results, not the vendor.
  • In general you ALWAYS want to pilot in 2 states or more; because sometimes you can have bad software results simply due to the patient population not being receptive to it (or you are held back by certain bottlenecks like a poor point of contact at Location A, while the POC at location B is super motivated)
• Scope a pilot in time and align on outcomes from the get go (with your partner setting the targets) – More capacity, better quality, less burnout
• Define what success looks like. E.g., “if these results happen, then we will sign a contract.”

The Vetting Process: How Astrana Thinks about Potential Partnerships across its Organization

The next part of my conversation with Awell and Astrana focused a bit more on Astrana, their model, and how they view the world as a scaled – and scaling – VBC player. The VBC tech stack is a bit of a black box, and I wanted to understand how Astrana thinks about partnerships and build vs. buy decisions with potential vendors, so I asked Brandon… how does Astrana vet potential partners? And his answer held a common thread: “Know where your core competencies lie, and solve for flexibility.”

Because Astrana takes on full risk and gets most of the premium dollar (85%-90%) in working with payors, Astrana considers itself top of the funnel for all patient care. That means Astrana is the one making all of the decisions on tech stack and does its best to understand who or what is the expert in care delivery or other core competencies involved with value-based care (e.g., transitional care management), providing their doctors and clinicians with the best tooling possible.

Specifically calling out Awell, Astrana was planning on building its own clinical workflow tool prior to learning about Awell’s solution. But Brandon realized it was already built – and built well by Awell, with validation from other Awell partners both in the U.S. and at several hospitals abroad. Astrana could integrate Awell into its stack faster and accelerate its ability to perform clinical workflows – especially with non-clinical, non-technical folks – then iterate on those care plans in a more nimble fashion. The low code or no code environment was a game changer. Awell provides infrastructure. It’s not the tech that sets you apart – it’s the care flows you build on there – much better place to build engineering resources

Astrana also partners in this way with other companies. For instance, its recent partnership with Elation – and others – that hold tremendous value for Astrana but things like EHRs aren’t in their wheelhouse and they’re more than happy to admit to that fact. From a capital project perspective, building out things that have already been built and are actively doing a good job is not Astrana’s MO or in their shareholders’ best interest. Shareholders don’t want Astrana to build tech internally. They want to see Astrana scaling to new markets like Nevada and partnering with new physicians to deliver excellent risk-based care. 

As an interesting analogy, technology companies would never build their own cloud servers. Instead they work with AWS or Azure:

“As an organization whether you’re VC backed or public or whatever, if you went to your shareholders and said you’re going to install servers in your basement, they’d say you were crazy.” 

Beyond the tech stack, the same partnership strategy rings true in care delivery. Astrana knows it’s not the experts in kidney care or cardiology, and they want to work with the best, high quality physicians or practices partners to deliver that care more quickly into the hands of their patients

The Divergence in Partnership Strategy:

Over time we’ve seen 2 diverging strategies emerge – companies who want to custom build every part of their ecosystem – and then people who are very proud to stitch together vendors.

The common thread throughout our conversation was…there’s a good balance where you know what you’re good at and what you’re bad at. Someone like Awell strikes the right balance because it’s creating infrastructure that isn’t going to differentiate a care delivery services organization itself, but the actual implementation provides flexibility. They’re a SaaS provider that gives you leniency & isn’t opinionated. As a value-based care player like Astrana, you need infrastructure flexible enough to bend to the populations and local markets you’re serving. This type of infrastructure helps you scale to diverse local markets and populations. More on that in a sec.

There’s an important inflexion point in the industry in late 2024. Care is evolving and is of course multimodal – complexity of care delivery is increasing and you need to be more flexible as an enabler providing key infrastructure for care teams and physicians. E.g. – ‘this population needs more at-home care or more text messaging, etc.’

Finally, CIOs are fed up with point solutions – and you’re going to see hospitals and other enterprise players shifting from 20 point solutions to platform-based solutions over time.

Solving for Scalability in Value-Based Care

One brewing problem in VBC I wanted to ask Brandon, Thomas, and Rik was a simple question around growth: How do you scale VBC effectively? 

For instance – we’ve seen certain models work amazingly in specific markets, but as those players try and scale beyond that first market, things break or don’t work as well. So how can you create a scalable care delivery risk-bearing organization in healthcare in 2024 across multiple local markets that are not homogenous by any stretch?

In case you missed the section above, the answer lies in model flexibility. So what does flexibility look like in practice?

• Figure out parts of the process that can be codified and standardize-able across communities.
• Give physician leaders the ability to interface in the way that they want – because every physician is different.
• Understand what else needs to be modular or configurable from there.
• Recognize that local markets vary drastically. They are not homogenous

Solving the local market problem in value-based care is difficult. It’s even harder to scale a homogenous VBC model across different, diverse local markets. For instance, even Coastal California is quite different from Central California, despite being close in proximity, and different methods of care delivery or touchpoints are needed depending on the population. At its core, community level, you need to understand how care is delivered.

Many VBC players today (you can name the marquee examples) have fallen short due to the simple fact that they have been very dogmatic and rigid about how their care model needs to be implemented, and therefore over indexed on their existing care model rather than iterating. For instance – staffing ratios, type of care, site of care, size of clinic – many think a successful model looks the same everywhere. But your model needs room for fluidity and iteration.

We’ve seen successful VBC companies across the US that present great results in their core markets. It’s really only when they fill up their coffers with investor money and start to scale to other markets where they run into trouble.

If you consider a hypothetical world in which you took all of these VBC peers that have really struggled and there wasn’t some existential investor pressure to land and expand their base business beyond their existing core markets, you probably don’t get into the mess we’re in today with some of those players. 

In fact if you had just rolled up all of those disparate players in the markets they excelled in, you’d probably have a nice little holding company and would be doing quite a bit better than we see today. 

Ironically, one of the most successful value-based care companies at scale – whether by intent or accident; we’ll never know – is Optum. Optum runs its aligned practices in this way, where they haven’t really deeply integrated them into the business. The fragmentation and diversification of Optum’s provider portfolio – and the disparate care teams and care modalities therein – has in no small way allowed Optum to become the juggernaut it is today.

How Astrana Built a Collaborative Company Culture

Another underrated aspect of any organization is how culture is implemented from the top down. I was really curious to understand how Brandon and leadership at every level helps Astrana achieve success for its partner physicians and ultimately patients. How has Astrana built a company culture where there’s such a great need for collaboration, communication, and desire to learn? Brandon gave me some great responses, which I’ve summarized below:

• They’re underdogs – they’ve hired folks that appreciate this underdog, underrated chip-on-your shoulder mentality, and they’re also not afraid to think when appropriate from a first principles perspective about healthcare. Leadership holds a healthy blend between physicians as well as folks that are newer to the space that tackle problems from various viewpoints.
• They’re confident to ask why something is the way it is or why they can’t do it a different way. Brandon himself even asks ‘dumb’ or seemingly ‘simple’ questions in company-wide Slack channels. If your CEO is leading the way and setting that example, it instills a company culture of intellectual curiosity.
• They understand Founder mode means getting your hands dirty with things – understanding the details and what various parties are responsible for – and then updating your mental model of how you view the world constantly with new information.
• They want to move fast, but not break things. Healthcare is a highly regulated industry with real lives at stake. Balancing for moving fast, but not breaking anything sacrosanct (and putting in appropriate guardrails) is top of mind for Astrana.
• Finally, Astrana is a mission-driven company with the goal of providing excellent patient care, and do so in culturally competent ways (highlighted by their recent partnership with SCAN).

What’s Next for Awell and Astrana?

As CareOps and the organizations involved in the movement evolve, they’ll continue to iterate and hold a mindset of continuous improvement. Ultimately Awell wants to push the envelope forward in care delivery, answering the following question to iterate and make a better product:

How can we promote more organizations to be more nimble and think about constant evolution based on the nuances of the patient populations or communities they’re serving so that Awell’s product becomes more valuable?

From Awell’s perspective, if its version within a particular organization stays on v1 and never iterates or improves on feedback from patients and providers, Awell’s product becomes less valuable. It’s almost a network effect in a way.

At the end of the day, as quality and consumer-oriented approaches to patient care start to differentiate value-based care players, the only long-term sustainable competitive advantage is to learn faster than your peers. Right now, it takes on average 17 years between publication of medical journals and widespread adoption of that evidence. Rik and Thomas made it very clear that It’s part of Awell’s mission to drive down those 17 years to 17 months or even 17 days – and create global learnings and best practices for all clinical workflows. Eventually, as companies working on the same problem or disease states experiment on flows, the flows – independently – tend to converge as best practices emerge, which is pretty cool. At scale, Awell finds that one flow for a particular use case tends to be better than all of the others. And so as companies experiment with solutions like Awell’s, we’ll start to see innovation incrementally improve, and get a little faster…and a little faster…until deployments for new workflows take days rather than half a year, and move functionally closer to software. As this takes place and organizations collaborate further on tools like Awell’s, we’ll see patient care continue to improve.

It may sound like a bit ‘pie in the sky’ esque from someone who is an optimist and wants to move the needle in healthcare, but we are closer than ever to this future after seeing the level of innovation, excitement, and passion from founders in just getting back from the HLTH conference in Vegas. Yes, I’m drinking the Kool-aid, and why not?

Over time, Awell and others are developing proprietary datasets – libraries of care plans or workflows. In the long term, this translates into better healthcare for all of us.