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CareTrack: Patient Empowered Telecare

Andrew Mills


CareTrack Health


Brian Prokes


Interview conducted by:

Lynn Fosse, Senior Editor

CEOCFO Magazine

Published – March 1, 2021

CEOCFO: Mr. Mills, what is the overall vision behind CareTrack Health?

Mr. Mills: The overall vision of CareTrack is to assist primary care physicians and physicians' practices at large to continuously monitor their chronically ill patients when they are away from the office.


CEOCFO: What have been the challenges in doing so?

Mr. Mills: The challenges with doing so are the physicians utilizing the service. Before CareTrack, historically, the utilization of Medicare services created to enable physicians to monitor their patients continuously has gone underutilized by physicians.

The solution that CareTrack offers is the ability for physicians to utilize those codes to keep their chronically ill patients on track and make sure that they are taking their medications and following the physicians' care plan. That is the goal and the mission of CareTrack.


CEOCFO: Why have doctors not been using the codes? Why is so hard for them to follow up the way they should?

Mr. Mills: There are a couple of underlying reasons, macro reasons. One is that we have a primary care physician shortage in the United States. There are not enough of them. Secondly, the United States is aging, so it is getting older, much like the world. There was a statistic that came out in 2019 that showed the world hit a historic moment when the number of people that are sixty-five years and older outnumber the people that were five years and younger for the first time in human history. That is endemic in the United States.


With the number of aging people, and as people age, they tend to become sicker with more chronic diseases, and we do not have enough primary care physicians. This means the workload for the primary care physician is increasing based on this aging, sicker population. Physicians do not have the staff, the systems, and tools to support that additional workload effectively. That is where CareTrack comes in, to allow them to take advantage of the programs that Medicare has set up because Medicare understands this is a systemic problem. That is where CareTrack steps in to enable physicians to monitor better those chronically ill patients or those patients that we describe as chronic but stable. They have a chronic condition that is reasonably under control but is at risk of an acute episode. That is the vast majority of Medicare patients.


CEOCFO: Would you tell us about CareTrack's Telecare platform? How does it work?

Mr. Mills: Our Telecare platform is integrated with the electronic health records system of the physician. Therefore, where the patients charting information resides, their medical history is being consumed by the CareTrack platform. That enables us to create a care plan that is understandable for the patient and builds a workflow for the physician and the care coordination team that CareTrack employs.


That structured care plan enables us to efficiently deliver continuous care with such things as remote monitoring devices. This is a kit that is shipped to the patient and is a cellular communication hub and vitals devices that connect wirelessly. Then, the device sends vitals information back to the CareTrack team to be relayed to the physician as needed.


CEOCFO: How much input does a physician have as to what might be appropriate for any specific patient or is it pretty easy when you have access to the records for CareTrack to come up with a plan?

Mr. Mills: The first point is that the physician is in complete control. The physician makes the medical decisions and decides what is appropriate for the patient's care plan. However, physicians generally follow best practices and medical guidelines.

Our system is set up to consume those medical guidelines and provide treatment plans that are in accordance with those medical guidelines, but the physician signs off on that prior to the patient ever receiving any services from CareTrack. Therefore, the physician is in complete control of how the patient receives care and what care the patient receives.

CEOCFO: Would you give us an example of a patient with a chronic condition and what might be setup to interact with CareTrack?

Mr. Mills: Yes. We describe it in a story about Bob and Mary. They are a couple. Bob is a cancer patient and has a lot of extenuating medical needs, and his caregiver is Mary. They are both elderly Medicare patients. Mary has some chronic conditions also. She has hypertension and diabetes. Mary is somewhat stable, but she is the primary caregiver for her husband Bob. What typically happens is that Bob gets all of the medical attention, and physicians are familiar with Bob's case since it is top of mind. Mary, while chronic but stable, is at risk of deteriorating into having an episode. CareTrack provides Mary support between her doctor appointments every four months.   


CareTrack provides a care team that both Bob and Mary can contact if they have any issues, twenty-four hours a day, seven days a week. As the physician defines the care plan, we will contact the patients to make sure that they understand their medication regiment, have gone to their other specialist appointments or other members of their care team. We can also provide remote monitoring devices so Mary's hypertension and diabetes vitals can be collected and brought to the attention of the physician, and they can see that trended history from object vitals data versus Mary having to keep a spiral-bound notebook with a log of her blood pressure and glucometer readings. Therefore, we reinforce Mary and Bob to ensure that they are adhering to the physician's care plan and they get a care plan that they understand. There is objective information that the physician can react to as a way to better care.   


CEOCFO: Your site shows, "Forty reasons to use CareTrack" and a couple of things jumped out at me. One is that patient adaptation of chronic management is over 70% compared to the national average of under 10% Then there is over seventy percent increase on scheduling, 56% on medication adherence.  How are you engaging with patients to produce these results?

Mr. Mills: The patients find it valuable. We are viewed, generally by the patient, as a concierge service to support the patient if they ever need anything. Patients can call us anytime. We can help schedule their appointments; we are always available day or night.


In addition to that, we have the ability to build the care plan with the patient's relevant medical information, which means we already know the patient's baseline information. It is asking value-added information that helps them move or adhere to their care plan that their physician provides for them. Therefore, we bring an extremely helpful tool for both the physician and the patient to provide additional care, resources or availability for that patient's needs than they would otherwise have.

CEOCFO: What has been the response from the medical community?

Mr. Mills: The feedback from the medical community and our customers at CareTrack has been overwhelmingly positive. In general, the utilization of these services by practices outside of CareTrack has been woefully lacking. I think it speaks to the value we bring the medical community, the physician, the patient and the insurer, to help those patients is evident by the increased utilization of the services that we provide.  


CEOCFO: How are you reaching out to doctors, to medical practices? Has it been easier to get a foot in the door during COVID as people are busier or does this make it harder? What are you finding?

Mr. Mills: Yes, it is harder at the current moment, because we are going through another spike. We found tremendous market receptivity prior to COVID. One of the interesting things about COVID is that it actually reduced the number of office visits that primary care physicians had. Therefore, they were not seeing patients as often, which is one of the principal ways that they care for patients, especially patients with chronic conditions. They were scrambling to put in telehealth solutions to augment the reduction in patients coming into practice. However, that disturbance created more noise in the system for us.


After the first spike diminished over the summer, we got more receptivity during the fall. All of a sudden, it spiked up again right after Thanksgiving. We see physicians delay decisions while trying to cope with COVID, but we see that spike coming down, especially with the vaccine getting put into play. There will be a new paradigm in medicine where these technologies will be adopted at an increasing rate, in my opinion. That is because COVID forced us into realizing that there are alternatives beyond just face-to-face, in-person appointments, that can help augment physicians to help them better treat patients.   


CEOCFO: How are you able to coordinate with the medical records systems that a physician already has in place, especially given the flaws inherent in so many of these systems?

Mr. Mills: That is a great question. That is one of the areas of our expertise. The history of CareTrack is that the founders of the company came from the electronic health record industry, and we understand the healthcare IT world. Because of this, one of the things that we do really well is connecting those electronic health record systems and mapping that data accordingly into the CareTrack platform, so that it becomes standardized. That allows our care coordination team to be extremely efficient but also drives much better quality.


An interaction with us eliminates much of the frustrations around providing the same information repeatedly. It builds continuity because we have a standardized system based on medical best practice and medical terminology. That allows us to interact with patients on an extremely qualitative level. That makes the user experience on that patient's side much better. That is one reason why we are seeing such large adoption by patients of the services we offer.  


CEOCFO: Monetarily, how does this help physicians? Clearly, theoretically, they all want their patients to do better and feel better, but how does this affect doctors' income?   

Mr. Mills: With doctors, we have seen most physicians concerned about financial risk, not losing money. There have been many programs rolled out that made a lot of promises and failed to deliver. One of the interesting things about how Telecare provides service for physicians is that we are at risk with the physician for services reimbursed by Medicare. That means physicians only pay for services that Medicare reimburses.


The net result of that is that we align with the physician's mission. It is a true partnership because the work that we do ultimately gets billed to Medicare or Medicare Advantage. The physician gets reimbursed, and CareTrack gets paid. However, the physician's financial benefit has been compelling in the amount of additional revenue from these underutilized services. For example, physicians who have fully adopted our Telecare model have increased their Medicare billing by about $349,000 per year on average, which is a substantial increase over the revenue they would be billing prior. We have seen some of our top-performing physicians go well above that!

CEOCFO: What have you learned as more and more people are using CareTrack? What might you have tweaked or changed from doctors' input and patients' input?

Mr. Mills: We would have introduced the care plan much sooner, meaning the integrated care plan that processes that patient's electronic health history. There is a tremendous amount of information that the physician already has on their patients. The ability to process that information and put it into a comprehensive care plan that the patient understands was a subsequent development as we learned more as a company.


I would have done that much sooner because that is the linchpin that drives physicians to adopt our service. For example, when we were in meetings with physicians and we first introduced the care plan, we noticed they put their phones down and started engaging with us. They leaned forward in their seats because they could see the tangible benefits of the clinical quality that we provide. Therefore, introducing the care plan much sooner in the company's history is a no-brainer.

CEOCFO: What is ahead for CareTrack? What does 2021 look like for you?

Mr. Mills: In 2021, we have a bright future! We currently provide services to independent physician practices, which means that they are not owned or employed by a larger organization like hospitals or health systems. We have opportunities to deliver service to hospital health system markets around patient readmission. Therefore, if a patient gets discharged from a hospital, we have a program that we are launching to help the patient stay out of the hospital and not be readmitted. In that market, along with the accountable care organization market (the ACO market), we see a lot of opportunities to deliver our Telecare coordination model to those markets, and we are excited about that! That is because hospitals employ approximately 50% of the country's physicians, and we see an opportunity to build a community care coordination ecosystem.

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“The solution that CareTrack offers is the ability for physicians to utilize those codes to keep their chronically ill patients on track and make sure that they are taking their medications and following the physicians' care plan. That is the goal and the mission of CareTrack.”
Andrew Mills