Q&A: Brad Smith, CareBridge co-founder

Nashville's CareBridge is now on the nation's radar.

According to Inc. magazine, which ranked CareBridge America's fastest growing company this year, revenue expanded 157,144 percent in 2022 to nearly $873 million. In addition, Inc. notes that hospitalizations for CareBridge's patients are down 23 percent and nursing home days have decreased by 16 percent compared to outcomes from a patient's previous provider.

Health insurance companies hire CareBridge to provide care for patients with physical, intellectual and developmental disabilities who receive home- and community-based services. It offers in-home assistance and caregiver support, as well as virtual care though tablets in an effort to prevent hospitalizations.

Brad Smith and Bill Frist co-founded the company in 2019, but it was not the first time the pair worked together. They founded palliative care provider Aspire Health in 2012 and sold it to insurance company Anthem in 2018. The two also connected on an education nonprofit, The State Collaborative on Reforming Education (SCORE) in 2009, which Frist funded and Smith ran.

Smith took a short hiatus from the company to work as director of the federal Center for Medicare & Medicaid Innovation (CMMI), which focuses on implementing new payment models, during the Trump administration. At CMMI, he succeeded another local health care entrepreneur, Adam Boehler. Returning to Nashville, Smith launched Russell Street Ventures in March 2021 and started its first company, Main Street Health, aimed at Medicare patients in rural communities, later that year.

Smith rejoined CareBridge as executive chairman in 2022. He sat down with the Post to discuss the company's growth, TennCare and labor issues in home health care.

Why is now the time for the company to expand so significantly?

In the '80s, there started to be this movement to help folks [with physical and intellectual disabilities] be at home and not necessarily in facilities, unless they needed to be.

What you've seen over the past 30 years really is a movement, where probably 70 or 80 percent of the expense for these kinds of services were in facilities. Now that's grown to about 60 or 70 percent of that being in the home. The real focus was on keeping folks out of facilities and helping them in the home, but I think there hasn't been as much focus on how to optimize a patient's experience in that home, and really keep them fully as safe as they can be and as healthy as they can be at home. I think CareBridge is positioned at the right time to be really helpful with that issue.

Having worked during the Trump Administration for CMS, what are some things that you've learned from that experience that you brought back to CareBridge?

When I was at CMS, almost all of the innovation was around Medicare and around older adults, and there was very little innovation in Medicaid. One of the things I left really excited about doing was trying to find groups of patients who are being underserved, and honestly under focused on and under invested in. I think the [home- and community-based services] population is one of those. I hope that one of the things that folks see from how fast CareBridge is growing is that you can build really good value-based care companies that serve Medicaid patients, and I think that's a group and an opportunity that's been way overlooked in our society.

Having worked on things from a government perspective, and now an entrepreneurial perspective, how do you see your role in helping this population? Which sector can make more of a difference?

CareBridge is a good example of how both those things work together. What creates the opportunity for us is the fact that many states are in managed care for Medicaid. They've capitated out the cost of their patients to the health plan. If the states weren't doing that, a model like ours couldn't work as well. We have to go out and build a very specific model that can be successful within that payment arrangement.

I think it really requires both the government and the private sector — the government to set the right macro environment, and then the private sector to build creative entrepreneurial solutions, and you can't really have one be successful without the other. I think what we saw in government is that where the federal government fails is when it tries to micromanage the details of how the solutions get built.

A lot of the innovation models you tried at CMS didn't work, right?

We did 54 [payment models], and only four of them saved the money and very few of them, arguably, none of them improved quality in a material way. We changed a lot of the payment models, but it turned out in the end, the results that people at least on print thought they wanted — lower costs and higher quality — were not the things that were getting achieved.

How is working with TennCare different from other state Medicaid programs?

TennCare is one of the most forward-thinking Medicaid agencies in the country. They've been a national leader in the long-term support services, LTSS, and home- and community-based services (HCBS) space for a long time.

They've also been a leader in allowing different kinds of technologies and things like that in the home for HCBS members. I think Tennessee is one of the best examples in the country of how a Medicaid program can be run well, both generally, but also specifically for the HCBS population.

Has CareBridge been able to contribute to cutting down waitlists for home- and community-based services?

What we really focus on is helping figure out how to maximize and leverage the caregiver as much as possible. A really good example would be, let's say a patient has been able to take a shower before but they're getting a little less able to do that on their own. One option could be to have a caregiver come start giving them a bath every other day or something like that. What we found over time, is that as folks start having other folks do things for them, they tend to get weaker and their muscles atrophy and are able to do less. An alternative would be to add a shower chair, a grab bar in the shower, a long-handled sponge and then have an occupational therapist or physical therapist come help train somebody for a couple of weeks for how to give themselves a shower safely in their home with those additional [durable medical equipment] and other items, and that allows you to then better leverage the caregiver hours.

And so our hope is that by trying to maximize patient independence in the home, we can maximize the use of the available caregivers. And we think if we as a country do that well, it'll allow us to get more people off the waitlist over time.