Rebuilding Pediatric Care From the Ground Up w/ Danish Qureshi, Founder & CEO, Zarminali Pediatrics

Welcome to Health Care Rounds. I'm your host, John Marchica, founder and CEO of Darwin Research Group. Today we're exploring a topic that doesn't get nearly enough attention in health system strategy conversations, and that is how pediatric care is organized and delivered. My guest today is Donish Kureshi, founder and CEO of Zarmanali Pediatrics. And today we're going to talk about the inspiration behind Zarmanali, the structural problems in pediatric care delivery, and what it takes to build a new model designed around children and families. So, Donish, welcome to Healthcare Rounds. Thanks, John. Great to be here. Let's start with your story. Just a little bit of research I did before our conversation today. Yeah, absolutely. So, you know, Zerminali is the third healthcare startup that I've been a part of, and really the one that is most personally informed by the situation that my wife and I went through about two years ago when our daughter was diagnosed with an autoimmune disorder. And the difficulty we had navigating the healthcare system around pediatrics to get her the type of care that she needed and ultimately get her healthier. However, despite having those great health systems and despite eventually being able to navigate to the right kind of specialists for her care, what we found was that many of those specialists worked in their own silos. They didn't coordinate with each other. There was no coordination back with our primary care pediatrician. And really the burden of care coordination fell on us as parents. And though I have 15 plus years of healthcare experience, I still found it extremely difficult and stressful to navigate. And so we as parents were left in this scenario of not just being under immense stress, but also being left with this immense feeling of guilt as our daughter's symptoms didn't improve as quickly as they should have, of saying, gosh, we were just failing her. And we should be able to do a better job than we were doing. And that's where it was really the light bulb moment for me of saying this just shouldn't be how pediatrics works in the country. That again, if someone like myself with many years of healthcare experience is finding it this difficult to navigate, I can only imagine what the average family has to deal with when their child has any form of complex issue. And so that's what informed the foundation of Zermina Lee Pediatrics is saying we can do better when it comes to pediatrics. There is an opportunity to bring together all of these different pediatric specialists under one umbrella and ultimately deliver really great care for families that doesn't have to be as stressful as it was for us in our own personal situation. You know, you said you said light bulb, and I'm always curious, was there like a single point in time where you were just said I'd had it? Like, was there one thing that really pushed you over the edge and said we need to find a better way? I think it was this a particular moment where we got referred to another specialist uh after going in circles for months and picking up the phone and calling that specialist's office only to find the first available appointment was another six months away. When we were struggling in that particular moment. And the reality is that had we known, we should have ended up with that specialist in the first place. And so our daughter could have gotten better much faster had we just gone to the right person at the right time, had there been more of a care team approach versus the way we were just sort of bouncing around. So that was really the moment where I said, This is this just can't be how it is. It shouldn't be like this. And I kept thinking about all the things that we had done at our my previous companies, particularly the last one, which was a company called LifeSance Health in the behavioral health space, where by just bringing together all of the all of the different specialties under one umbrella, creating a seamless approach for the consumer to be able to book, but also creating a care team environment for the providers to be able to truly collaborate with each other on an individual's patient uh case. Um, that's the the formula here to make an impact across the country. So I'm just wondering what is it that makes uh pediatrics different? You know, I mean your story, uh we could say a similar story with my frustration with trying to get care for my mom, for example, or for for other people. But for me, it just pediatrics just feels different. So, from your perspective, especially with your experience in healthcare, what made this different? And I guess maybe a follow-up question to that is early on, did you have some vision about what pediatric care could look like or should look like? Yeah. So I think there are a lot of similarities in uh with pediatrics to many other specialties in the country of just the stuff we hear about on a regular basis, that the healthcare system is broken, it's difficult to navigate, etc. So there are many things that are not unique to pediatrics. I think what really stands out with pediatrics specifically is that the actual patient, in this case, the ch the child, is not the one seeking out the care, is not the one booking the care, is not the one navigating the system. It's actually the caregiver, or typically the parent or someone else. And um, that process where the the patient can't always advocate for themselves, I think is something really unique to pediatrics. The other part that's unique is it's something because children in a good way tend to be much healthier than what you see with the senior population, where a lot of our focus in the healthcare system today goes, uh they tend to get ignored, or because it doesn't show up as much of as much of a cost item, maybe on a payer's PL, it tends to be an afterthought uh than something that is driving a big portion of spend in the country. But the reality is that the behaviors that are learned at a young age and the care that a child receives or doesn't receive, it carries through the entirety of their life. And I really believe that a lot of the ballooning costs that we see across all of healthcare can be traced back to the source and addressed when the child, uh when the individual is still a child, and can, if you get it right then, you can have a generational impact over the next decades on controlling costs and improving outcomes for people's lives. So, you know, again, I think there's a few things that are really unique to pediatrics. Um ultimately one of the things that is really frustrating, and again, in my last company, we saw this in the behavioral health space too, was because uh most of the outpatient or the independent practice groups that exist today in pediatrics are very, very small and uh don't have an ability to really orchestrate much of this sort of more complex care. They also are the uh because of that, they end up being the lowest reimbursed specialty or one of the lowest reimbursed specialties across all of healthcare. That creates a problem of uh individuals going through medical school and residency, they don't want to opt into pediatrics because it's not compensated well, it's not as attractive. That then perpetuates itself in a shortage of providers, a shortage of people focused on pediatrics. So, again, a lot of different things that are building on itself to say that um what we see in in pediatrics is is unique, even if there are similarities to other specialties. Why do you think maybe maybe this is the answer is self-evident, but the parents are often in that care coordinator role, which is what you were describing, the frustration. Why do you think that is the case? Like in other words, why hasn't pediatrics in general done done better with this um with care coordination? Why is it so much on the on the shoulders of the parents? You really uh our sort of diagnosis of it and the reason going back to kind of the second part of your last question, why we're trying to build this differently is what you've ended up seeing is a high degree of fragmentation across all the pediatrics. And that's not just primary care pediatrics, where you do see very small, independent practice groups out in the community that are delivering phenomenal care, just phenomenal pediatricians that love what they're doing. They got into it for the right reason, but ultimately they're working in these sort of small groups and you know, thousands of them across the country. But you also see the specialists that are pediatric focused also are broken up and fragmented pretty significantly. Um, they either are employed by the hospital systems, and you have this barrier now between the hospital system and the community-based providers, uh, which the majority of pediatric care is delivered out in the community. Or you see specialists, they may be in a community-based or independent practice group, but they're employed by the other half of their specialty. And what I mean by that is they may be a pediatric, um uh pediatric cardiologist as an example, but they're employed by the cardiology group, not by the group, or an allergist employed by an allergy group, not by a pediatric group. Ultimately, what it creates is a need for this constant referring back and forth between different groups. Every time you have a handoff like that, something gets lost. Either a family doesn't follow through, certain information on that child's case is not passed through, but something gets lost in the in the process. And that friction really makes it difficult for families and ultimately uh leads to worse outcomes for their children. So, our approach and what we're trying to build is the first true national multi-specialty group, just focused on pediatrics, where anything and everything that can be delivered outside of the hospital system is done under one umbrella, one brand name, one place that a family can go to where they know they can get any need handled, as well as layering in urgent care services as well as 24-7 telemedicine, so that when a f a child wakes up and they're sick and they can't wait for that booked appointment a week out, they can get into an urgent care, they can get access to their group uh in the middle of the night when they wake up with a cold. Um, those things are really important to reducing stress and reducing friction across the system. Really, what you're trying to do, I just want to understand this. There's in my mind, there's kind of like the first model that you described that health system, you know fill-in-the-blank children's hospital, right? And there are a lot of those across the country. And then you have these smaller pediatric groups, like it'll take me when my kids were younger, where we used to take them. What you're saying is you're trying to create something that really has everything under one roof from the basics, vaccinations, taking care of your, you know, colds and basic things, all the way to more complicated issues. And then where you would come in is being able to coordinate, especially if that care needed to happen, outside of your walls. Is that right? You're trying to try to get all that. That's correct. Yeah. So as much of it that we can deliver within our care setting, obviously being outpatient, we want to deliver that ourselves because it makes sure that the providers are working on the same team, sometimes in the same office, they're coordinating on the case together, and the family is feeling a very seamless experience. But there are absolutely more complex or acute situations that do require uh bringing in uh or sending that patient out to a hospital system for things that can only be done inpatient, or requires a specialty that is so unique or so um specialized that housing it in the community doesn't make sense. And so those that collaborative arrangement with uh children's health systems or health systems generally in any community is going to be important for us to ensure that our families are getting the best possible care. But again, where possible, we will deliver those services ourselves in an outpatient and community-based setting. And again, we believe that that not just improves outcomes, but significantly reduces the stress on families in that process. So hopefully you understand the business model a little bit to get under the hood, because this is truly something different from from my understanding, at least what you're aspiring to become. Um are are you focused on payer partnerships? Have you gone out to employers to do any kind of direct contracting? Like what is the what is the the business model? Because you got to get paid, right? Yeah. So what is what is how do you how are you going about doing this and able to uh achieve your goals? Yeah, so we're taking this in a very phased approach. And in the first phase, we're keeping it very simple. This is commercial fee for service. This is classic, covered by your health insurance on an in-network basis. There's nothing sort of complicated or sophisticated about it. But we we really view that as being the uh the foundation of what we're building, and purposely so, because we want to have margins that are sustainable and that are not reliant on um unique partnerships with a payer or a health system or whatever reimbursement vehicle uh is needed. Um there, though, what we hope to do is be able to expand into value-based care agreements with uh payers in whatever given state around managed Medicaid programs, where we're already demonstrating exactly what they're hoping for, which is by being able to deliver all of these different specialties under one umbrella and be able to more comprehensively take care of that patient, we are ultimately controlling costs for that uh pair and that specific member and also delivering better healthcare outcomes in the process. And that's sort of the holy grail of what any value-based care agreement is is structured on. And so uh we are not rushing to value-based care because, again, I believe that you have to build a sustainable margin and foundation on commercial fee for service. But from there, we will we will start to selectively contract on the value-based care side. The third phase of it for us is we do believe on a direct-to-consumer basis, there is an opportunity for additional premium services that are not typically covered by a payer in any arrangement where we can start to have a special arrangement with our um our families that are part of Zermina Lee. And that does not mean a membership-based or concierge model that creates a lot of um restrictions or narrows the number of people that can actually afford the service. But we want to be as open to as many people as possible while also offering a premium level for individuals that are looking for a different uh sort of um uh level of care that they can receive from the practice group. So that's that's the third phase that's farther out, but we will start to build towards that, regardless, even from day one on a commercial feed-for-service classic basis, having a sustainable margin profile is really critical to us. So back to the number two on the value-based care side, because that was actually my next question that I was gonna ask you. And and you had mentioned like state Medicaid potentially, that feels like kind of a capitated sort of arrangement, right, where you're gonna sort of per member per month. Do you see the um the opportunity to to do like ACO-like um arrangements in pediatrics? And the reason why I ask that is you know, we're talking about like the older population and focusing on them, and those have been when I think about CMS, it's like you're either going into an ACO or you're or you're going into you know um some kind of Medicare Advantage program, right? That's how they they're trying to capture that value, but then also control costs with those two different models. Do you see there being a possibility? Because I before you answer that, I I seem to remember here in Phoenix that there was a pediatric ACO. I didn't learn all that much about it, but what are your thoughts on that kind of you know, that that budgetary model? Yeah, pediatrics. I think that there's an opportunity there. That's not something that we're spending a lot of time on. I think for us, you know, more classic value-based care one-off arrangements with managed Medicaid programs is essentially what we're building towards. And we'll only really be doing that in selective states where the reimbursement makes sense. We're not going to be rushing to do that in every single state because not every state has payers that are excited or willing to do that. Uh, nor is the is the state Medicaid, uh, are the state Medicaid plans funded to an appropriate level to sort of justify it. But there are many states that have put pediatrics at the forefront of what they're thinking about, and they're both funding the programs appropriately around Medicaid as well as um uh more on the cutting edge of what it means to explore value-based care. So, you know, again, we're gonna do it as a much more of a one-off state-by-state, pair-by-pair sort of approach rather than um what you're describing as the kind of comprehensive ACO model across multiple practice groups in a single geography. So, what is it about, you know, I'm the theme that I'm thinking about with what you're trying to do is integration. And so are there things, are there elements about pediatric care that that makes or a different way of saying that or or what are the key elements that actually can make integrated pediatric care work? Yeah, I think it's it's first figuring out what are the things that are most impactful on that uh uh pediatric population and what are the specialties that you absolutely need to have if you want to ensure that you're providing great care to as many families as possible. And so the way that we've done this is obviously the the starting point was primary care pediatrics, urgent care is a very obvious add-on for being able to create extended hours and eventually that we'll launch the 24-7 telemedicine piece. But from the the specialty perspective, it's what's what is the um what are the pieces that are being referred out to the most today where that friction is being created and closing that gap by pulling those providers in-house. So the first things for us are launching speech, occupational, and behavioral therapy under uh kind of our umbrella, co-located in the exact same clinics as our primary care uh providers are working out of. On the medical specialty side, we're looking at allergy and derm as the top two that we're gonna revert out to on the most frequent basis. And then from there, we'll keep going down the list as our patient population grows enough to justify pulling in other specialists. Uh, so we have a pretty large presence in Michigan as an example. And because of that, it allowed us to employ a neurologist as part of the practice group. And so you start to see as your groups and your patient base grow larger and larger, you can start to pull in more of these um uh specialties that you can't do when you're small or you don't have the density that you're hoping for. And again, if you go back to the fragmentation problem, if you're a um a small independent group of maybe two to five pediatricians, you'll never Be able to employ a neurologist because it's it's not something where there's enough demand from your patients to be able to fill their caseload. Um, but you know, when you build larger groups, you can start to do things that are a lot more unique. Or the majority of the physicians are are they employed, or are they are you more in a contract model or is it both? 100% employed. So we we really believe that it's important for everyone to be underneath the same umbrella and working together on the same the same problems, and um being employed is is one way that you can accomplish that. So for me, as you expand, I would think one of the most difficult things um to accomplish is consistency, right? With any, and I think about like large health systems that start expanding their footprint. How are you gonna address that? Or how are you already addressing that? And how do you um what built-in mechanisms do you have uh to maintain that consistency for the future as you expand? Yeah, so the the consistency and quality of care that we're delivering across the country, that is um something that we talk about on a daily basis. So the the two very practical ways that we've done this is first think about the operational side, and then secondly, think about the clinical side. So on the operational side, the entire team is built around a limited set of 10 KPIs that ultimately we believe drive consistency in operations and quality of care that our patients and families experience, regardless of what city, state, or clinic they're walking into. So being really um unapologetic about we're focus on these, these are important. Um and these are your these are your KPIs. These are own KPIs, that's exactly right. Now we have other KPIs that are more well, if you hit those 10 and you do it consistently, what should you see on the the output side on the output is you have really high patient MPS or kind of review um uh review ratings. And so for us, uh year to date, uh we're obviously a couple months into the year, we have a patient MPS of 100. Last year, we ended up uh for the full year um above 80. I can't remember the exact number, but our patient MPS scores was phenomenal. And it was really attributed to the fact that um we're just unapologetic about here are the 10 things, this is what we care about, and we're gonna talk about this on a daily basis to ensure consistency across the country on the operation side, which when you walk into a clinic, the look and feel, the experience you have, a lot of that is kind of the non-clinical part. On the clinical side, which is obviously the more important part, our chief medical officer is leading the charge there to ensure that there are very specific quality measures that we are talking about and measuring across the country. Um, not just to be able to deliver great care today, but also to be able to get us to that next phase that we talked about of value-based care and being able to show that we're doing this on a regular basis. But she's and her team are in the process of building out their entire clinical analytics suite and uh ensuring that we're measuring uh the quality and the outcomes that um our families and their children are experiencing. Anas, is there a is there a role for partnerships? Uh we do a lot of work with health systems. That's kind of like our sweet spot here at Darwin. How do you look at your relationship to some of the larger IDNs out there? Yeah, so we view um health systems as uh a really key partner in what we're trying to build around the country. Um pediatrics, even in a children's hospital example, where many of the things that I'm describing may already be delivered within uh that children's health system, the reality is that 80% of pediatric care is uh delivered out in the community. And so though these children's health systems may have everything kind of within one house, similar to what we're trying to do out in the community, the reality is they're only able to meet the patient demand of a limited amount of the country. And so for us, we really view ourselves as important extenders out into that 80% of care that's delivered in the community to be able to deliver the same kind of rigor and consistency and quality that you're getting in these health systems, but deliver it in a community-based setting. So that's really important to us. But by doing that, it is still important that we maintain and have these collaborative relationships with health systems in our communities because we need to send them many referrals for patients that were unable to deliver the more complex or acute care in the outpatient or community-based setting. And so having that collaboration is really critical for any patient and their family. And so we look to, in any community that we enter, start to build those relationships with the local health systems, either on a formal basis in a contractual way, or on an informal basis. And so we always welcome any and all conversations, both inbound and outbound, as it relates to partnering with health systems in our communities. Sounds rosy, sounds the future is bright. So now I have to ask, what's keeping you up at night? Where are where are the struggles that you see as you're scaling and growing your business? What are the biggest challenges? I think the biggest challenges are the same thing that anyone trying to run healthcare at scale experiences, which is, you know, to some of your questions earlier, the consistency of care delivery when you're not doing it in a single location, but you're doing it across multiple locations in multiple states. That is one of the biggest challenges. And it always keeps you up on night at night to make sure that that consistency is delivered and your um the quality is there. I think on the growth perspective, I wouldn't call that a stressor, but it is probably the thing that keeps me up at night the most because I'm constantly thinking about how we can go faster, how can we grow larger, and how can we meet the needs of more and more families around the country. I mean, though we're in 10 states today, that's not the limit of our ambition. We really want to be delivering care across all 50 states, whether that's in-person or virtual. And we want to be able to say that we're meaningfully touching the lives of millions of people, both the direct patients as well as their caregivers, parents, the family members. Um, and so that sort of goal of being able to reach these millions of individuals is probably the thing that keeps me up the most at night, but more of a kind of positive, motivating reason than a stressor. Sure, sure. So let's go look three, five years down into the future. What does success look like? How would you describe that? So in three to five years, what I would describe as success is that we are delivering care in all 50 states, 30 of those states in person as well as virtual, 20 of those states virtual only. And it's just based on the population density. So the top 30 states account for about 85 to 90% of the US population. So those are the ones that we want to have physical presence in as well as virtual. And for the remainder, we want to be able to have virtual presence. From there, saying that we're offering a comprehensive suite of specialty services across every one of those geographies. So again, the on the therapy side, speech, occupational, behavioral, on the medical side, uh, allergy and derm to start. But hopefully that list grows much longer and we're able to go a lot deeper. And then we'll have started by that point uh signing some of our value-based care contracts, and we'll start to be able to meaningfully demonstrate that we're impacting the cost curve and the quality of care in any one of the communities that we're participating in. And I hope by that point we've also nailed the premium service offering as well. Um, so you know, that that's really the three to five year vision. Where it goes from there, I think you know, the sky's the limit. Every week there's a new interesting conversation that comes up from some partner who's reaching out about a new idea and really wants to tap into how they can better um deliver care for the pediatric population. So, you know, the reality is that vision three to five years from now could be much bigger uh than what I just outlined, but that's sort of our current ambition. I meant to ask you this as an initial question, but tell me about your name. How did you come up with the name? Yeah, so Zerminali Pediatrics is um is uh well, the name of it is derived from uh a young girl's name from the Pashto language, which is from the Afghanistan region. Uh, and what it means is uh something that's more precious to you than gold. And it's a very beautiful name that uh clearly represents the relationship between a parent and child, which is any parent would say that their child is more precious to them than gold. And for us, we want to extend that feeling into the care that we provide for uh our families and for that child, is we want to treat them like they are more precious than gold to us as well. So that was kind of the meaning behind it that really resonated with everyone when we were starting the company. The other piece is uh my daughter's name is Armina, and um because she was really the experience we went through uh with her was really the inspiration behind the company, it just made perfect sense. All right. Well, before we wrap up, I'd love to do a little lightning round. So just some quick pops into the head. Um say either a a word or a phrase. Um first one, one misconception people have about pediatric healthcare delivery. That it's um an afterthought of the overall healthcare system, that it is not a big enough place for anyone to spend time focusing on uh improving, that there's bigger problems in the senior population or other specialty areas, and so um you know don't put attention to pediatrics. Um a leadership lesson that you learned along the way. I think probably the biggest lesson that I've I'll call it relearned with Zerminali is the importance of building out a really uh high-quality talent team from the very beginning, and also being very uh unapologetic about maintaining the bar at a very high level. I think as you scale and you move quickly, there is a tendency to say, I just need people, and so I start to lower the bar on expectations of the talent that you're recruiting in. And this has been something I've learned across my entire career and has been a great reminder here at Zerminali, is you have to be unapologetic and very um unwavering about holding the bar for talent uh as high as possible. I think you just answered my next one, but I'm gonna ask anyway, because I know you've done a few of these. Most important trait for building a healthcare startup. That that's that's absolutely, I'd say, the the number one, but I guess the the nuance there in response to that question is uh you also have to recruit people in that are are not just great talents, but that they really are inspired by and believe in the mission. Uh that this is something that is as meaningful to them as it was to me at the start, that they they feel the pain that families go through and they want to solve that. That is really critical. And I think um something beyond just having a high caliber of talent is is uh really important. Uh one healthcare innovation outside pediatrics that you're watching closely? I think the obvious answer that probably anyone and everyone will give is all the innovation around AI, whether it's directly in the delivery of care, whether it's supporting um uh providers in making their lives easier, whether it's in the back office, whether it's in interfacing with consumers and how they get access to care. I think that that is moving so quickly. You know, we're we're a young company, we're like just barely over a year old. And already the things that we were thinking about AI at the foundation of our company and the decisions we're making around where and where not to introduce AI, that has already evolved in the last year because the the things that um are available now just are moving at a breakneck pace. It's quite honestly hard to even keep up with all of the different um pieces of innovation that are happening and building a tech stack that is cutting edge when the edge continues to move so rapidly out. Um that that's a real challenge, but it's also you know very exciting. Well, Dannish, thank you um so much for today. How do people get a hold of you or to learn more about your organization? Well, they can go to Zerminali.com and uh look us up, and I'm always happy to take any inbounds from interested folks that want to talk pediatrics. Well, thanks again. Thanks so much for joining us today and for sharing your story and your vision for improving pediatric care. It's very inspirational. I really appreciate it. Thanks, John. It was great being here. And thanks to all of you for listening. If you enjoyed this episode, please subscribe to Healthcare Arounds wherever you get your podcast. And I'm John Marchikca. Until next time, we'll see you next round.