Special Guest Interview: Dr. David Grunwald of DIA Health
Today, we’re excited to share an insightful interview from the Sit and Stay podcast featuring Dr. David Grunwald, a dedicated child psychiatrist and founder of DIA Health.
In our discussion, Dr. Grunwald explores the critical need for accessible mental health care, the challenges of starting a group practice, and the innovative strategies he's implementing to support underserved communities.
We hope you enjoy this enlightening conversation where Dr. Grunwald shares his journey and vision for advancing mental health care for all.
Parker Anderson: Tom, good to see you again.
Thomas Tarshis: Parker, happy Monday. Hope you had a good weekend.
Parker Anderson: Happy Monday! Welcome back to the Sit and Stay podcast by RipsyTech. If you're watching on video you can see this is a very special episode of the podcast. We have a guest here with us today! Tom, would you like to introduce everybody to our guest?
Thomas Tarshis: Yeah, we're very honored to have Dr. David Grunwald here on the [Sit and Stay] podcast, and I've known David for many years. Beyond his impressive academic credentials, the main thing to know about David is he's just one of those super kind nice people that you hope, in the field of Child Psychiatry, [that] this is the demeanor of all of your colleagues, but it actually happens to be somewhat rare.
I met David at teaching at Stanford, but David is a fellow Berkeley alumni like myself– go Bears! Then, he went to medical school at UC San Francisco, a prestigious institution, and went to do his training in General Psychiatric residency at Yale and then came out to Stanford for his Child Psychiatry fellowship, which is where I got to know [him], and David and two others in his group tended to be close, and we had lots of conversations and worked on some stuff together, and then David and I have another mutual friend and connection. It's just been great to get to know David over the years.
Since graduating fellowship in 2018, he's worked for San Francisco county, and I think it's fair to say that, like myself, David's very invested in those least fortunate in the world and especially helping youth from impoverished backgrounds with mental health issues.
But then, I was super excited when David got the little entrepreneurial bug. I think maybe after seeing how things are done incorrectly in so many places, David has taken the reins to start a business, and that's what we're gonna talk to him mainly about.
David, it’s great to have you onboard, and what did I leave out in your background? Or maybe I’ll ask you to add a couple of things.
David Grunwald: Well, thanks Tom and Parker. Thanks Tom for that generous introduction and thank you for inviting me to be here. It's an honor to be with you guys.
You covered a lot, and I have started this group with a couple of other colleagues and friends: Ish Bhalla, Aparna Atluru, and also Karsten Heil. We've all known each other in different stages of training and have different areas of expertise and skills. We're all psychiatrists though, and we wanted to figure out how to get more access to quality mental health care for more people.
We had a little more time during the middle of the pandemic... I had started a private practice a few years earlier and had always wanted to figure out a way to be able to offer care to people with commercial insurance: your Blue Shield, Blue Cross, Aetna, Cigna, and so forth. And as an early career psychiatrist, just getting started and trying to do a good job of just delivering good care. It seemed like too much to take that piece on when I started my private practice, but I always had the intent to offer care to a broader swath of the population, namely the middle class people who really get stuck without a lot of good care options in our current environment.
Thomas Tarshis: Yeah, that's a great point. Sometimes, if you can pay cash, you can get good care, and if you're actually on MediCal or other situations, sometimes, one thing you can get is get connected with behavioral health, but it's the people with their insurance cards that actually struggle the most to find anyone who can see them. We'll jump into a little bit more on that also.
I wonder, though, David. Something I don't know about you is how did you wind up choosing Psychiatry and then more specifically Child Psychiatry? What was your journey through medical school or when in your life did you figure out you wanted to work with kids?
David Grunwald: Well, that is a question I could answer a lot of different ways because there's a lot of reasons that I went into the field. But, I was a Psychology major at UC Berkeley. I always found learning about the brain, learning about personalities, learning about how people interact with each other, and how people relate to each other… It's always been fascinating for me. And in undergrad, I didn't think I was necessarily going to go into the mental health field, but I just felt like it applied to whatever career I went into.
Then, I chose to go to medical school, and first I thought I was gonna go into primary care. I was always interested in prevention. And I did some youth violence prevention research through UCSF, and actually the med school program I was in was the joint program between UC Berkeley and UCSF. And as part of that program, we all did a Master's thesis and mine was on youth violence, and through my work in that program, which involved a few different areas I went into, one was the cost analysis and one was actually getting a grant to fund a supported employment program for kids.
We actually teamed up with Friends of the Urban Forest in San Francisco, which is a gardening and street tree and sidewalk group. They do the majority of the street trees in San Francisco, and we created a program to help violently injured youth learn and develop the skills to become arborists. So I got really interested in that work and curious about why… What are the causes of youth violence? What puts someone at risk?
And the first study I was involved with was this group, which was called the San Francisco Wraparound Project, which is still run through San Francisco General Hospital… In one of the first studies, the results showed that the two most important factors for our clients to prevent recurrent violent injury [are] being gainfully employed, and number two was mental health care.
And working with these young folks, it became apparent that there was a lot of trauma in their lives. Certainly, poverty played a role and the many associated problems with poverty in our society. But also just not having access to care and not having options to get outside of the more dangerous parts of the community that many of these young people lived in, and to have the sort of employment options that people in the middle class, upper middle class, and so forth have.
Thomas Tarshis: And did you have an interest in Psychiatry then? Did that develop because of this program, and you learned pretty early in your medical school career that you thought this would be the fit for you?
David Grunwald: Yeah, so as I continued to learn in med school and got exposure to Primary Care and got exposure to Psychiatry, my mind started to change, and I started to become more… I still really respect primary care. It's a super important role that our primary care physicians play, but it just didn't feel like the right fit for me. As I became more and more passionate about the work I was doing in violence prevention, I saw a role that I could serve my community, and some of the communities I worked with through the violence prevention group, well as a mental health clinician.
Thomas Tarshis: Gotcha.
David Grunwald: I also realized that the shorter visits with primary care just weren't really as good a fit for me. I'm more of a person who really wants to talk and get to know a person to develop that deeper connection and to work... I really value working with patients over a longer period of time. Not always necessary, but at times it is and to get to know the whole family oftentimes, it's an important part of our work in child psychiatry and something that I enjoy a lot.
Thomas Tarshis: Yeah, and Parker and I were just talking about that recently, I believe. About people going into [Psychiatry] to have more time with their patients and develop that relationship.
Parker Anderson: That’s right.
Thomas Tarshis: All right, very good. So, you mentioned you started a small private practice, maybe right after you graduated, but when did you know that you wanted to create your own business?
David Grunwald: Well, the private practice was a business, and it still is and I still have that going on but much less complicated than forming a group practice and negotiating with insurance companies and all the operations and so forth. So, it didn't really occur to me until the early-mid pandemic when I had a little more time.
I had been talking to these colleague friends that I mentioned, and we were talking about this problem of trying to provide good quality, “private practice style” care to people who have commercial insurance, and there were some other companies that were venture capital-backed that were coming online, and I actually interviewed with one of them. My experience was that they weren't really set up for what we do in Child Psychiatry. That there were some good ideas and, it seemed like, good reasons for these companies, but they didn't understand the complexity of what we do.
After learning a bit more about the other companies that were out there and talking to a few other people who had started similar companies, we wanted to form our own group to be able to offer both in-person and virtual care. This is when telehealth was becoming a lot more prevalent, and our idea shifted slightly over time, but really to offer care for people with commercial insurance that's more affordable because their insurance would be covering it, more accessible both because of the options of in-person or virtual care, and with the idea to eventually expand to cover more than just Psychiatry, but we haven't gotten there yet.
Thomas Tarshis: Gotcha, gotcha. It'd be great to hear in the process of starting the practice what that's been like for you, and we had another guest who did it all by themselves, and I like the idea that you have some colleagues and friends that have been doing it together. And I wonder if maybe you can comment both on what it's like having a group of you, which I could maybe see support but maybe there's a lot of arguments behind the scenes. Has it been exciting? Has it been painful? Both? What has it been like to get your practice, this group, started?
David Grunwald: It's been a little bit of everything. It has been a lot of excitement, and I still get excited a lot of the time about the work we're doing and the possibilities, and since we've actually started seeing patients, it's exciting to know that we're providing a service that is helping people. Going from an idea to an actual group practice that provides care for people and is working somewhat how we envisioned it. That's really cool.
Definitely there have been challenges along the way. There's been a ton of learning. I think I underestimated how much there was to learn about all these different pieces of running a business, but specifically working with insurance companies, working with people who specialize in Billing, trying to coordinate everything, and trying to balance the influx of patients and referrals with the number of clinicians that we hire and want to have on staff. All this has been complex and interesting, and we're learning as we go.
Thomas Tarshis: And all of your group, I think you all have other jobs also, which is a good strategy to keep other employment, especially while you're getting started. Do you see a point where if things really take off with DIA Health, would everyone just move over full-time to DIA Health? Do you think people will maintain other jobs as well?
David Grunwald: That's a good question. For me personally, I wouldn't want to give up my job at the city and county of San Francisco. And in case anyone's listening from my city and county work, I'm not currently paid for my work at DIA Health. It's all been a labor of love, and eventually that will be as we develop this group more. But our clinicians certainly are, but that's a disclaimer I have to put out there because I haven't filed the paperwork through the city and county yet [laughs]. So this has been on my extra time around the fringes, and that goes back to your question about working with others.
I could not have done this myself. It was essential to have some really smart and skilled and driven partners to help in all the areas of starting and running a group practice. But I do think that, certainly, as DIA grows that we're going to have some folks who are going to be full-time, particularly running the operations and the administrative pieces. We've tried to make it really accessible and appealing to clinicians as well, so we don't put a work requirement for our clinicians. And no one is working full-time for DIA at this point, but if they want to, and we have the demand, which we’re seeing the demand is continuing to grow, then they're welcome to work full time for us. But we haven't quite gotten there yet.
Thomas Tarshis: Gotcha. So keeping a flexible model like a lot of new companies do where people could come work a few hours a week for you, or if they're really happy working there, and demand keeps going up, which in this field I'm sure it will, you wouldn't be opposed to having full-time clinicians with your group.
David Grunwald: Definitely not. No, we’d encourage it.
Thomas Tarshis: Okay, and the other thing about DIA health is it is somewhat rare for a small group to already accept one major insurance carrier right from launch. In fact, I usually tell new young groups just start all cash up front and get a little experience with that before you even tackle insurance companies, but David and his group have tackled some of those headaches to get in-network with Cigna, right David?
David Grunwald: That is correct, yeah.
Tom Tarshis: Which is great for anyone in the Bay Area or California that has that insurance and needs help for their kid. I wonder, David, why did you all wait until you had… That feels like it was the plan from the start to get in-network with at least one insurance before launching. Is that right?
David Grunwald: Yeah, the basis for starting this group was to be able to find a way to provide good quality care for commercially insured people. And we knew that it would be easier to get cash patients from the get-go and a lot less complex, and we do accept fee-for-service cash patients. But we felt if we weren't able to offer commercial care for the commercially insured population, then there was no point in [starting] this group, and it’s in the works to expand our contracting with other insurers. We just want to get it right for Cigna first before we sign contracts with others, and I'd have to say that Tom was a huge help in this process.
Tom has been a mentor. Someone who started a group practice himself and built that practice and had so much experience and so much valuable information. We definitely are very appreciative of your support.
Thomas Tarshis: That's kind, and Parker certainly knows that anyone who's gonna start a practice to help youth with mental health issues and deal with the headaches of accepting commercial insurance, the least I can do is lend whatever I can from my 17 years of dealing with that. It's great that you guys are doing that for [Psychiatry] patients.
And now maybe a little more sort of general, I don't know if I call them fun, questions, maybe a little bit fun. But, you're still an early career psychiatrist for another year. I think for your first seven years out, they'll consider you that, but now that you've been out six or seven years from training, is there something you would change about the mental health field if you could or something about the state of mental health care in the US that you would change?
David Grunwald: Well, it's nice to hear that I'm still considered young in some regards [all laugh]. Not hearing that as much these days.
But yeah, there are a lot of things that I would love to see changed, and I think the main thing that I'll talk about here is just that I'd like to see more accessibility to care and less barriers to care. I think first, there aren't enough psychiatrists. There aren't enough mental health clinicians, and there certainly aren't enough child psychiatrists. This is something that's backed up by data, but on top of that there's unnecessary barriers to getting the care to people and those barriers come in many different forms. Some come financially working with insurance companies, but some come in the form of stigma or kind of cultural barriers, stereotypes. And I think we are making progress in all those areas. Maybe the managed care and insurance we're not making as much progress, but it is good to see that there's more and more legislation that's being drafted to target this issue. And that there's more and more groups that at least are trying to tackle this issue, some that provide more robust care than others.
Thomas Tarshis: Yeah, good comments. I'm active with CSAP, California State Association of Psychiatrists. I think you're active with the other legislative group in California, right?
David Grunwald: Yeah, CALACAP. I've done a lot of work with them and they are basically the political advocacy arm of California's Child Psychiatry group that’s part of the national group, which is AACAP. So, it's the state arm of our national society of child psychiatrists.
Thomas Tarshis: Yeah, California tends to be progressive on a lot of the legislation, and it's great that you're active in that as well. It's been interesting to see what you can accomplish with legislation, and what you still cannot accomplish with legislation.
David Grunwald: Yeah, yeah. It's the long game is what I've learned.
Parker Anderson: I have a question for David. When we interviewed Steve Khachi, I believe accessibility to mental healthcare was the first thing that he brought up to that question as well. So, in that vein and how involved you are, I'm wondering this hypothetical question: if you had infinite money, infinite resources, what would be the first thing that you would want to tackle with something like that?
David Grunwald: Wow, that's a good question, and I would say the first… I think universal access to care. Not to say that universally everyone needs to see a mental health clinician. Although, I do believe that most people in this world could benefit from good psychotherapy. Even if you're a generally well-functioning person, we can all serve to learn a little bit more about ourselves and learn about our strengths and challenges and how we interact with others, and we can all, myself included, build our skills in being a person and knowing about ourselves as individuals.
But back to your question, I think universal access would also include universal screening. Something that can be done in schools across the country, just a baseline screener for every kid to see if there are any areas in terms of mental health that might be potentially worrisome to at least offer care. I don't think we want to force anyone to have care. And then to have a big enough workforce to provide that care and then to be able to support the care needs from the less complicated cases to the more complicated cases, and that would require a coordinated team approach with a case manager or a role like that. So I think yeah, that would be my moonshot.
Thomas Tarshis: Yeah, well said. I think David nailed it actually. Having the care needed for everyone available, and supply ready to provide it. That would be amazing.
David Grunwald: I think if we had that we would have a healthier society in general. We would have less polarization. We'd have people in general able to get along better with each other. We would have everyone potentially having the skills to work out differences and arguments better. I think that would make for a much healthier place to live.
Parker Anderson: Well said.
Thomas Tarshis: Yeah, the best shot at really fixing the world in one generation is to get everyone who needs it a dedicated mental health professional. Working with kids you see the trauma and past experiences of the parents pass on to the kids, and if we could just, for one generation, give everyone that support, I've always sort of fantasized that's the fastest way to fix all the world's problems. Cool.
David, is there anything you're really excited about in the mental health field right now?
David Grunwald: Yeah, there's a lot of excitement going on in the field, and a lot of things that are inspiring and exciting to watch happen. A lot has changed since I did my training even, and we're seeing just a ton of innovation in terms of both psychotherapy and in terms of the medications we can offer. And in some cases, combining psychotherapy with medication, and this boom in psychedelic medications being used for treatment offers a lot of promise.
There's also a lot of room for these medications to be studied more before we go and make them more widely available, particularly to children and adolescents, and there's a lot of growth in other areas. For example, dyadic care: care between a parent figure and a child. I've been watching that modality grow, and I've had some training in it myself.
Family-based care, we're seeing innovation there. We're seeing better understanding of what's needed in terms of wraparound care, which wraparound care is the type of care needed for individuals and families with greater needs than your average family, and it involves, as I mentioned before, a case manager helping to coordinate the care across many different domains. Not just psychotherapy and someone providing medication management, but also in terms of other barriers that might be impacting a person, such as academic difficulties, providing tutor support, housing support for people who are housing insecure, and many other resources, and that's actually the type of care I provide in my work for the city and county of San Francisco. I work for a clinic that provides wraparound care, and it’s been really inspiring and exciting to be a part of a team that offers a really robust type of care that I've seen, with my own eyes many times… I don't want to use the word “miracles” because it's not a miracle. It's just delivering the right resources in a coordinated way to people who need those resources.
Thomas Tarshis: Gotcha. Very good. Well, jumping back to DIA Health, looking 5, 10, 20 years in the future, what would your dream be for your company?
David Grunwald: Well, I would love to see DIA continue to grow. I would like to be able to hire more clinicians, and right now, we provide care for all ages, but just psychiatry at this point, so we would like to be able to have case managers, as I had mentioned earlier, to have therapists and psychologists and other mental health clinicians to be able to join our team. Right now, we're only offering care in the state of California, and we'd like to eventually grow and be able to provide care in other states as well. And of course, to be able to contract with all the major insurance carriers, so that anyone who has commercial insurance and wants to get care can get care at DIA.
Thomas Tarshis: Very good.
Parker Anderson: I wanted to ask a follow-up question. What advice would you offer to somebody who is thinking of starting their own group practice?
David Grunwald: I would say make sure you have patience. I mean, patients in terms of the people needing care, but also patience in terms of being able to not think you're gonna have this group start in a snap of a finger. It's taken awhile in terms of the planning and execution along all the different stages.
Make sure you have identified good mentorship, someone such as Tom. I know you can't do it for the whole world, but again, we've been really fortunate to have your sage advice throughout this process.
I would say make sure you have… I want to kind of bow down to Steve [Khachi] doing it himself because I don't know how I could have approached this work without a team. I'm sure he doesn't do it all himself, so making sure you have team members you can trust who have skills in areas where you might not have skills that you thought strategically about in terms of what your skill set is and what skills you might lack and… What else would I tell others…?
Thomas Tarshis: The “bow down to Steve” was to Steve Khachi, and I think on reflecting that, Steve's spouse Cynthia actually has been there all the way and helped run the office, and she does an amazing newsletter and some of the admin stuff. So I think it's not purely solo. He does have someone to help with some of those other skills.
David Grunwald: Yeah, that makes sense. So yeah, it is something that we went in with a huge amount of excitement, and we still have a ton of excitement, but the ability to persevere despite some letdowns, [such as] not getting all the contacts we wanted to get, things taking longer than we thought it would, having to make some changes in terms of getting the administrative support we needed, and continuing to be flexible and to the challenges that have been thrown at us. So, those are all things that someone starting a group practice should think about.
And this is partly why we're here talking. One challenge we ran into early on was being able to keep good records and also being able to bill accurately and efficiently. We've been very fortunate to have a partnership with RipsyTech, and we're just starting to get to know the product, but we've been really impressed, and we can already tell how much it's going to simplify a lot of our processes in terms of keeping good documentation, being able to manage employees, and being able to bill efficiently, which is a huge part of being able to run a group practice.
Thomas Tarshis: Well, thanks for that shout out, David. [DIA Health] is [one of] our RipsyTech clients. Other people are not, and we certainly didn't put David up to that. But we have put a lot of time and energy into the billing piece, and we've got a commercial coming out. We're really trying to streamline that and make it as easy as possible for those clinicians… If you've decided to deal with insurance companies and [are] trying to get reimbursement, at least let's try to make it so 98% of the time, your payments and everything are just automatic, and you don't need to worry about it.
But David, your comments about having patience and being flexible and calm… I've seen a lot of people who started, and more solo people who, after a few months and a few frustrations, sort of hit a “forget it” point and just scrap their dreams of their clinic or their group, and I think [with DIA Health], everyone seems very flexible, calm, and well-suited to bear with some of these setbacks that you'll face. Those are important traits both [for] psychiatrists in general but also for persevering through the business, so we're super excited to see you guys take off and see your company grow. It's such a good resource, and I think, in David and his co-founders, when you see them talk about their company, there's an extra passion or sparkle in the eye [where] you know they're excited about it and dedicated to it, which is nice to see.
David Grunwald: Thanks Tom. Like I said, it's been a labor of love, where we're giving it the old college try, and when things get frustrating, it is really nice to have a group of colleagues that I've been collaborating with who can keep up the morale. We definitely have built a lot already. We have a lot of growth ahead of us that we hope for, but to persevere through the bumps, it's been nice to have people who are helping the whole team ride through those bumps.
Thomas Tarshis: Very good. Parker, any final comments to add?
Parker Anderson: Not in particular. Really, I enjoyed sitting back and getting to listen to this. I felt like I just had a front row seat to a great interview, so I loved to listen to the both of you chat it out, so thanks for even letting me sit here and listen.
David Grunwald: Well, you got a question in [laughs].
Parker Anderson: Yeah a couple. Yeah [laughs].
Thomas Tarshis: Usually, Parker has to be the workhorse keeping me on track, David, so I think he enjoys the couple sessions now where he's been able to just relax a little bit instead of trying to rein me in from my tangents [laughs].
Parker Anderson: Well, David, it's been great having you. We really appreciate it. Like I said, it was great listening to the both of you chat over the course of this episode, so we really appreciate having you.
David Grunwald: Thanks for having me on. It's been fun talking with you all and some interesting questions to help me think back to “Why did we start doing this in the first place?” It's easy to lose perspective. You get so focused on the task at hand, so this was a treat.
Thomas Tarshis: Very good, and it's DIA Health, and we'll get your website. Is it DIA Health dot com? Is that right, David? Dot org or..?
David Grunwald: It's actually just dia.health.
Thomas Tarshis: Oh yeah, dia.health. That's easier, good job. We'll include information for your contact on the podcast when it comes out as well.
David Grunwald: Awesome, thanks. Well, I appreciate you guys…
Parker Anderson: Yeah, have a good one. Appreciate it!
David Grunwald: Okay. Alright. Take care.
Thomas Tarshis: Bye.
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Stay tuned for more insight and stories in next week’s blog post!
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