Welcome And Guest Snapshot

SPEAKER_00 0:02

Thanks for tuning in to the Chalk Talk Gym podcast. For resources, show notes, and ways to get in touch, visit us at ChalkTalkGym.com. Cooper Selnik runs Group Recovery Together. This is an outpatient addiction treatment provider rebuilding how Americans access care for substance use disorder. Cooper got sober at 22, started his career in Venture Capital, and brings both live experience and a sharp business mind to one of healthcare's most stigmatized fields. Groups combine small group community with evidence-based medicine and billpayers only when patients actually get well. We talk about the pivot from cash pay to insurance, the measurements that matter, which is engagement and abstinence and retention, and why local presence still beats pure telehealth in rural America, and how alignment with incentives lets groups invest in its workforce while reducing total cost of care. So tell me and the audience a little bit more about this very unique journey.

SPEAKER_01 1:09

So my name is Cooper Zelnick. I run an organization called Groups Recover Together. We are an outpatient addiction treatment provider. And I got sober when I was 22. So I struggled with addiction. Recovery ran in my family too, thankfully. And I found myself in recovery. And after a couple of years of working not in this space at all, I decided that I wanted to give back and be of service in that way. And that's how I found my way to this work. That is right. I was lucky enough to start my career in venture.

Where Outpatient Treatment Fits

SPEAKER_00 1:39

So where does your organization fit in the continuum of healthcare in general for people? Maybe explain for people that don't know whether it's opioid addiction. I mean, you cover all of them, right? Alcohol. Yeah.

SPEAKER_01 1:52

So we're an outpatient addiction treatment provider, right? If you think about how folks might receive addiction treatment, there is a whole universe of inpatient or residential treatment that should be for folks who are very sick. We have a belief, and I think the data shows this, that where someone gets treatment is unfortunately not always a result of what they need. It's often a result of community biases or stigma or happenstance. But in the continuum, there's residential or inpatient treatment, there's partial hospitalization, there's IOP or intensive outpatient, there's outpatient, which is what we do, and then there's primary care, right? Where you could get ongoing treatment, but isn't really where someone would start. So that's where we fit. We serve everyone, right? And we're like we serve folks who otherwise would be going to inpatient, who otherwise would be getting residential care, who otherwise might be going to methadone clinics. And folks find us either through word of mouth, you know, they know someone who's in our treatment model already, or through a community partner. And some of our biggest community partners are criminal justice, jails and prisons, also hospitals, emergency rooms, primary care, other treatment providers. So that's how folks typically find us. Yeah, that's how we think about our work. We want to bring the best of community support together with the best of evidence-based medicine. People can access one or the other. It's very hard to access both at once in an integrated and holistic way. And that's what we're trying to do for the folks we serve. And I think that's why we're able to achieve the outcomes we are. So, how did you discover this and what were you picking for outcomes when you started

The VA Origin Of Group Care

SPEAKER_01 3:24

this? We discovered this in 2014 at the White River Junction VA Hospital in Vermont. And there are a couple of things that are special about the VA. The way the VA is funded using block grants means that when you're providing services inside a VA, you are not shackled to like a traditional fee schedule. You don't have to do the things that are reimbursable. And the other issue at that time was the substance use disorder epidemic, the opioid use disorder epidemic was raging and there was not a lot of access to care. So our founding physicians had this pretty simple idea, which is what if you bring patients together in small groups and you do that to one, build community and two, stretch limited physician bandwidth further. If physicians could see patients in small groups, they could integrate into that community and provide medical care that was much more efficient. And we were uniquely empowered to do that because of the care setting, which was the VA. So that's how we found it. And what we saw was just trying to solve that problem, right? Like bring folks with common problems together to find common solutions and do it in a way that was efficient. We were able to actually solve this, the most pressing and challenging problem in outpatient care, which is dropout. Most people who go to addiction treatment don't stay long enough for it to work. And we weren't trying to solve that problem, but by building these little communities of providers and patients together, people stayed. It was engaging, like it felt good. And what we realized was, oh my lord, we've actually solved the thing that's plagued to this industry by creating community. So that was how we stumbled upon it all those years ago. So I think it starts with where we provide treatment, right? Like most inpatient or residential addiction treatment happens in a couple of states. It happens in Florida, it happens in Minnesota, it happens in California. So people have to leave their communities to go to treatment, which is disrupt, lose access to your family, your job, your responsibilities. And then you come back and you don't necessarily have the support. And our fundamental belief is like if you believe that addiction is a chronic disease, you have to treat it that way. So we open our offices in the communities that need us. We staff those offices with local care teams and we fit treatment into people's lives. So these are all like the structural things we do. We have appointments available for people working first, second, and third shift. We are really thoughtful about in-person and virtual options so that folks can access treatment. Secondarily, I think that it is very specifically our belief that you need to find, achieve, and then maintain a life worth being sober for. This is not just about sitting on the couch, not drinking or not using. And a life worth being sober for is different for different people, but often involves family, friends, work, hobbies, like the things that make life rich. And it's our job to help people rediscover those, find new things that fit into those categories, reconnect with old things. It's not our job to provide an alternative to that. It's a bridge

Treating Addiction In Real Life

SPEAKER_01 6:39

back to that.

SPEAKER_00 6:39

So what are your biggest challenges your organization is facing as you start to expand?

SPEAKER_01 6:45

So look, we face the challenges everyone faces, right? So one, finding amazing staff is really hard, really hard. That's not unique to us. That's the industry, right? There is a supply and demand imbalance. There's a shortage of amazing providers. That's always been a challenge. The second challenge, obviously, is there are structural barriers to expanding access to care, right? Like federal and state policy stuff can be really challenging. Reimbursement and regulatory stuff can be really challenging. This is just hard work. You know, this is a regulated industry. This is not a particularly lucrative field. This is not, you know, you do this because you really care and we do really care. But it's it is just hard. You know, it's add to that, like wanting to provide care to the most underserved, most rural, smallest communities in our country, that adds another dimension that's really challenging.

SPEAKER_00 7:35

So, how do you fund market rate compensation in the in that model? Because, you know, for the folks that I know that run nursing homes and some of the ancillary centers, the insurance reimbursement tends to be basically minimum wage level, which is hard to attract someone, right?

SPEAKER_01 7:51

To yeah, it's very challenging. So the way that we've thought about this is we operate an aligned incentives

Paying For Outcomes Not Visits

SPEAKER_01 7:56

model. We have a unique clinical model for treating folks with addiction. That clinical model delivers very powerful and industry-leading clinical outcomes. Specifically, if an individual seeks treatment at one of our facilities in our model, that individual is more likely to engage in care, more likely to become abstinent from illicit drugs, and more likely to be retained in treatment for an appropriate amount of time to get stable and get healthy. Those clinical outcomes directly reduce total cost of care. So they yield a reduction in health care expense that is experienced by states, health plans, insurance companies, and the federal government. Our organization contracts with those entities, health plans, states, the federal government, in a different way than all other providers. Rather than saying, hey, we did X visit, pay us $30, or we did Y appointment, pay us $40. We say we only want to get paid if the folks we are serving get well, we want to be paid enough to sustainably invest in care and hire an amazing team. So that is how we've structured our organization and it's created this virtuous cycle, right? Where when we get great outcomes for the folks we serve, we're able to invest more in the folks delivering that care and so on and so forth. Yeah. And what I'm really describing is the difference between fee for service, which is how most healthcare is delivered in the United States still, and value-based care, which has been this real buzzword in healthcare or in venture. But, you know, I we really start by taking like a totally meat and potatoes definition of value-based care. We want to be on the hook for the outcomes. If we don't deliver, we don't want to get paid. If we deliver, we want to get compensated. And that's how we define value-based care and how we've implemented it at groups. But thank you. Yeah, for folks who want to get involved and want to learn more about us and want to work in the field, please reach out.

SPEAKER_00 9:46

On your several year journey that you've had, tell me about a time you've had to adapt or shift or pivot quickly to change your business model to make it successful.

The Pivot From Cash To Insurance

SPEAKER_01 9:56

Yeah. So the first one that comes to mind, and this was a real existential threat and challenge, is when we were founded all those years back in Vermont and New Hampshire, we built a model for folks without insurance. This was before the Affordable Care Act. This was before Medicaid expansion, and we were very focused on serving an uninsured population because at that time, if you were uninsured, an appointment could cost as much as $1,500, which was crazy. So we built this model that was really cheap and really simple and really efficient so that people could afford to pay out of pocket. And people paid $50 a week out of pocket. And that propelled our growth for several years. And then the world changed. Providers like us started taking insurance. And $50 was cheap, but it wasn't free. Suddenly, the folks we were serving had this option. They could spend $50 they didn't necessarily have with us, or they could go across the street and get care that was worse, but was free because they were able to use their Medicaid benefit. We realized that in order to continue fulfilling our mission of helping people access care in order to survive as an organization, we had to learn to take insurance. And we hadn't wanted to and we didn't know anything about it. And it was enormously challenging. So here's what we did. We went to insurance companies and said, we have this special model, it delivers these great outcomes. We need to get paid in this special way. And they said, well, here's our fee schedule. And we said, What's a fee schedule? They said, it's how we pay everyone else. And we looked at the fee schedule and realized that what we did wasn't on there. So we faced this existential threat, right? We had to make this choice between changing what we did, moving away from the thing that worked for our members to meet the requirements of the healthcare system, or demanding that the healthcare system be different to meet the unique elements of our model. And we, maybe out of naivete, maybe out of arrogance, maybe just out of a deep commitment to our beliefs and our philosophy, probably all of the above, chose to demand that the healthcare system meet us where we were at. And it was really hard and it slowed us down and everyone thought we were crazy. And but what it's enabled us to do all these years later is to live, continue to deliver outcomes that no one else can deliver and drive great results is the only reason we exist and the only reason we should continue to exist. So it was a huge challenge. But all these years later, the vast majority, 95% of our members, use some form of insurance to pay for their care at groups. We are able to accept all those forms of care. We get compensated in a unique way that empowers us and incentivizes us to keep investing in this care. And we're able to get even better results than we could back then. So I think it all worked out. That is right. We knew we had served at that point hundreds of people and we had seen the results for them. So what we knew was that what we were doing was working. And we had read the literature about industry standard results and saw that those results were 10%, 20% of what we were able to achieve. So we were blind from a data perspective in the way that healthcare companies would think about data. But we did, I think we had a really clear perspective on what matters to the folks we serve, what matters from a population health perspective. And that empowered us to kind of stay true to our North Star on.

SPEAKER_00 12:59

Yeah. So let's talk about that

Measuring Engagement Abstinence Retention

SPEAKER_00 13:01

a little bit. So what from a payer perspective, yeah, their definition of outcomes is what? How do they define outcomes to you?

SPEAKER_01 13:09

So there are a couple of things, right? There are internal clinical outcomes that we all agree on, clinical proxies for cost or things that are just widely understood to be valuable. So if you're in the addiction treatment industry, people come to us because they can't stop using drugs or alcohol. We measure that. And it's our job to help them stop. So that's an outcome that matters to us. It matters to the folks we serve, and it matters to insurance companies, right? Now, why does it matter to them? Because it's predictive of an overall stabilization of that patient that leads to other health and cost benefits that matter, right? So is that as simple as a drug test, or is that sort of a clinical interview kind of thing? How do you decide that? We do both. So we do drug testing critically. We do something called presumptive drug testing. So it's very cheap, simple point of care testing. You can do very expensive fancy testing, but that creates misalignment, right? Because it provides information, but at an enormous cost to the health insurance company. So we're trying, everything we do is trying to sit at the intersection of matters to the patient, makes sense for us, and matters to the health plan, rather than something that doesn't matter to the patient, doesn't matter to the health plan and might drive value to an organization, right? Like that's why something known as definitive drug testing is a historical source of fraud, waste, and abuse in our industry. Yes. Drug testing, also clinical interviews, also engagement at counseling, also treatment plan updates, self-report PROs, like patient reported outcomes, things like that. All those come together. And there are a couple of internal clinical outcomes that matter to us. Engagement, like are you showing up? Are you doing the thing? Abstinence, are you ceasing your use of substances or reducing your use of substances in a harm reduction model? And retention and treatment. And retention and treatment is this really interesting one because it is a proxy for health care cost reductions and it is predictive. So if you can retain a patient as an outpatient treatment provider in care for six months, 180 days, that individual is much less likely to suffer a relapse or fatal overdose in the future, and healthcare costs go down. So the north star for us is that because it matters to folks we serve. They come to us because they don't want to relapse or overdose. And it matters to health plans. They pay us to reduce cost. Now, from a health plan perspective, there are a whole bunch of other ones that matter. Arguably the final, most important, most fundamental metric is total cost of care. If we render an intervention or render services, does healthcare expense go down? Because if it doesn't go down, we don't really deserve to get paid. Doesn't mean that what we do isn't valuable, but we shouldn't be getting paid in a premium way if we're not driving a result for the health plan too. Reductions in readmission rate. If someone comes to our treatment, are they less likely to need or go to treatment again, go to treatment elsewhere? Reductions in hospitalization. Like is someone less likely to go to an emergency room because they're stable? Increases in primary care visits. Is someone, you know, beginning to engage with high value, low-cost preventative health care? And then that those are metrics that you can measure in a whole bunch of ways. The federal government also has metrics they really care about in our space. And those matter to health plans because they get compensated on them. They matter to us because it's a really nice balanced scorecard where you can compare us to others. Things like if someone does find themselves in the hospital, how quickly do you follow up? If someone needs treatment, how quickly do you initiate it? If someone's getting medication, are they actually filling it at the pharmacy? All of these metrics that really matter. So those are in no particular order. That's kind of the universe of how we think about outcomes.

Building Dignity Versus Old Models

SPEAKER_01 16:40

So I'll compare us to a couple of different things. In a methadone clinic, you line up at 545 every morning. You get called by a number, not your name, you reach your hand through bars to grab a cup of medication, and you provide often a urine screen where someone watches you provide it. That's an experience that is highly rigid, that often gets in the way of life, and that can be to dehumanizing. By contrast, at groups, everyone knows your name. There are no bars. We don't wear uniforms. You can show up at a time that's convenient for you. If you have something come up, we have makeup groups and flexibility. So you can go change the time you're showing up. And you do that not alone, but with peers. So you get to build community as you have flexibility and get treated in a way that has dignity and hope. That really matters. If you compare us to an inpatient program, 30 days in a different state, you might make really great connections, but then you have to go back to your life and those folks don't come with you. By contrast, we are a longer-term, lighter weight treatment program in the community you live in, right? So you can build connections that last. But I think fundamentally, what we're doing is bringing people with common problems together to find common solutions. And that sounds obvious, but most addiction treatment is individual, not group-based. And I would argue that contributes to isolation, shame, and stigma, whereas bringing people together creates community and connectedness and the ability to understand that you're not alone, which really helps.

Expansion Risks And Virtual Care

SPEAKER_01 18:23

Well, the opportunity is we were a large provider, but most folks who need care still don't get it in the United States. We are in a dozen states, but we're not in 50. We are in many communities, but not all. My mission is not to be the only addiction treatment provider at all. I don't believe that what I do works for everyone. I don't want to be the only person who's doing this work, but I do want anyone who needs our help to be able to access it. And we're also investing in building more services for the folks who we're serving today because they need more than what we're doing today. We're investing in serving ancillary populations. We're expanding to new geographies, but fundamentally, our mission is to change lives, and I want to change as many lives as I can. That's the opportunity. The threat is there are a lot of them. The drug supply continues to be contaminated with synthetic drugs that are increasingly scary and dangerous. That's hard. It creates overdoses, and providers have to adapt to serve a more acute and sick population. There is going to be a reduction in Medicaid funding associated with federal legislation that was passed last year. That will limit access to care for certain vulnerable people. And providers like us will have to get really creative to make sure we can support that population, are always shifting regulatory landscapes that are challenging. There are any number of challenges associated, as we talked about, with staffing and bringing great folks into the field and helping those folks not burn out and stay in the field. So those are some of the threats that we're actively monitoring and working on. Virtual care expands access for sure. It allows people who couldn't previously get into care to access care. And that's a really good thing. We do virtual care a little different from how most providers do it. So I think what you said is the very optimistic early COVID thesis, which is okay, thank God we have these digital tools. Now you can reach any rural area, the farthest flung places easily from your phone. And that's true. But the problem with that is if you are in a tiny town in eastern Kentucky and you are talking to a therapist from northern New Jersey, that person might not know what you're going through. That person might not know, definitely won't know, you know, where to send you if you need different help. But the way we do virtual care is we still continue to open offices in rural small towns. We then staff those offices with local care teams. And even if you're only coming to group on your phone and you never step foot in an office for whatever reason, you're still in a community of people who live around you being served by a care team member who lives around you out of an office that is near you. And the reason we do that is because it creates the bonds in the community and the cultural competency that drives great outcomes. So I very much believe in virtual care. I very much believe in digital, but I don't think you can do it in a way that ignores the importance and the impact of local presence.

Asking For Help And Next Steps

SPEAKER_01 21:19

What else would you like to share with the audience? Well, I think, you know, as when you're talking about addiction and recovery, the thing I always like to say is if you are listening to this because you think you might need some help, please talk to someone about it. Doesn't have to be us. You can call us if you want. You can go on our website if you want. But this is one of those things where everyone who's going through it for whatever reason feels like they're the first and only person to ever experience this. That was my experience, right? I was going through it and I thought no one could possibly understand this. Like no one could know what I'm going through. No one could ever have gone through this before. And it isn't true, but it feels true. So I think the big thing I'd want to share with the audience is to the extent that you think you might have an issue. You think you might need some help, just share it with somebody you trust and ask for some help.

SPEAKER_00 22:05

Providers and nurses that listen to this podcast, where's your website? Where can they go for this information?

SPEAKER_01 22:10

So our website is join. You can submit a form there and refer someone into treatment, or you can ask for help yourself. You can also call us if that's easier and ask for help that way. Our number is 888-858-1723. And as a provider, you can reach out to us if you want to refer a patient of yours into treatment as well. Perfect.

SPEAKER_00 22:33

I'll put also put that in the show notes.

SPEAKER_01 22:35

Well, thank you very much. My pleasure. It was so lovely to talk to you. Take care.

SPEAKER_00 22:41

Thanks for tuning into the Chalk Talk Gym podcast. For resources, show notes, and ways to get in touch, visit us at chalk talkgym.com.