Creating a New Healthcare

This week we’ll be discussing some of the groundbreaking transformations being developed by the North Carolina Department of Health & Human Services (DHHS) under the leadership of Dr. Mandy Cohen.   The North Carolina DHHS is charged with the health and wellness of over 10 million people. This healthcare system, with an annual budget of $20 billion, is one of the largest state healthcare systems in the country.  The NC Medicaid program within the DHHS directly serves nearly 2.3 million people – 1 out of every 5 people in North Carolina.  It also serves approximately 1.2 million children in North Carolina. Our guest on this episode is Dr. Mandy Cohen, who was appointed to the role of Secretary of the North Carolina Department of Health & Human Services (DHHS) in January 2017 by Governor Roy Cooper.  Before coming to NC, Dr. Cohen served as the Chief Operating Officer and Chief of Staff at the Centers for Medicare & Medicaid Services (CMS). She was responsible for implementing policies for Medicare, Medicaid, the Children’s Health Insurance Program (CHIP) and the Federal Health Insurance Marketplace.  In February 2019 she was named one of the Top 25 Women Leaders in Healthcare.  In this interview, we’ll talk with Dr. Cohen about: Why North Carolina is shifting its statewide Medicaid program to Managed Care. How she is reframing and redefining healthcare within the NC DHHS – from “buying healthcare” to “buying health” services – a progressive shift that is consistent with the direction the healthcare market is heading. The highly innovative initiatives being launched in the Medicaid Managed Care program, with a particular focus on the social determinants of health, and some illustrative examples of how this is leading to markedly improved health outcomes and lower costs of health. How DHHS is integrating mental health with physical health – and the advantages of that integration. North Carolina is one of the last of the large states to transition to Medicaid Managed Care.  As a result, it’s also one of the most informed states making this transition. Dr. Cohen and her team have intentionally studied the successes of other state healthcare systems as well as the successes of healthcare systems within NC – attempting to build on those lessons.   As you’ll hear in the interview, the overarching plan is to fundamentally shift from “buying healthcare” to “buying health” – that is to purchase services that cost-effectively advance health outcomes – whether those services be clinical care, behavioral care, or social and community care.  Another facet of the plan is to deploy outcomes-based payment models instead of the current volume-based, fee-for-service payment. The systematic approach of the Medicaid Managed Care program will begin with the screening of individuals’ medical care needs as well as factors related to social determinants of health.  The approach also includes rigorous testing of the numerous pilots & initiatives in order to determine which innovations work and which do not.  It is a healthcare outcomes analyst’s dream, but more importantly, it’s what we need if we’re to advance the health and well being of North Carolina, as well as the country.   The success of this immense and critically important effort will require a multi-stakeholder approach. To that end, the DHHS has been, over the past couple of years, actively engaging the expertise of numerous physicians and administrators from across the state – drawing from the sophisticated world-class hospital systems and academic medical centers that call North Carolina home, as well as the independent providers and community-based organizations serving both urban and rural communities.   I applaud the legislature and political leaders of North Carolina for initiating this innovative transition to Medicaid Managed Care – for supporting it and funding it; as well as CMS for providing the waiver.  As Dr. Cohen points out in this interview, health and well-being is not a partisan issue – it’s an issue that is fundamental to the overall health and well-being of our commonwealth and our nation.

Is there a senior leader in your organization with the sole job of eliminating “customer friction points”?  Well, there is at Banner Health.  Valerie Monet is the Senior Director of Customer Experience Strategy at Banner Health.  This demonstrates a remarkable commitment to the consumerist mindset from one of the largest and most forward-thinking integrated healthcare systems in the country.  Banner Health is attempting to improve the patient experience by transforming the customer experience. Valerie Monet has over a decade of involvement  in healthcare customer experience. Prior to joining Banner Health, Valerie spent thirteen years at J.D. Power where her responsibilities included strategic planning, business development, customer experience management and consumer data analytics, as well as qualitative ‘voice-of-the-customer’ data collection.  In this role, she worked with dozens of top performing consumer-oriented companies in the U.S. and Canada. In this interview we’ll discuss: Why a focus on customer experience has become increasingly important to healthcare systems in differentiating themselves from their competitors. What strategies Banner Health is deploying to reduce customer friction points and differentiate it’s consumer experience, including their omnipresent patient/customer persona – “Sophia”. How Valerie and her colleagues utilize both quantitative and qualitative data to understand the customer experience and measure the improvements. How Valerie understands consumerism to be highly complementary and synergistic with the concept of “patient”. The similarities and marked differences between the customer experience in healthcare and other industries, and why healthcare experiences tend to be more polarized – either really good or really bad… At this point in time, Valerie admits that she can’t easily quantify the outcomes of many of her hypothesis, despite dogged efforts to do so.  I admire and respect her honesty regarding where she’s at and where she’s trying to get to.  Much in keeping with other experts I’ve interviewed, Valerie emphasizes that many of the insights have to be gleaned from qualitative research and field data collection – direct conversations with healthcare consumers.  As she puts it, customer experience is a data scientist’s dream; but there’s also an art to it.  The measurement of experience is impacted by numerous factors such as patient expectations and the strength of the doctor-patient relationship.  Science, as she points out, will only get you so far. One of the most telling insights Valerie shared was when I asked her to instruct us, in less than 30 seconds, how we might go about setting up an amazing customer experience division.  Her immediate answer was, “just start listening to your customers and patients – start getting feedback – find a starting place, sit there and observe and listen – and just start to understand what they feel and what they see and what it’s like to be on the other side.” In the end, what I repeatedly come back to is that customer experience is about better understanding the people we care for and treat, understanding what they want and need, making it easier for them to manage their healthcare and their health, and creating better experiences and better outcomes – call it what you will… This was one of the most interesting discussions I’ve had on one of the most important topics in healthcare.  It’s clear that Valerie is excited by the intellectual, emotional and purposeful pursuit of customer experience; and she makes it salient and purposeful for those of us who are not experts in this domain.  Her curiosity and fascination with this topic are infectious. Until next time, be well. Zeev

William Gibson, the noted science fiction author wrote, “the future is already here, it’s just not widely distributed yet.”  Our guest this week describes a future revolution in healthcare that is, in fact, already here.  Digital health therapeutics are transforming the delivery and experience of medical care and rapidly gaining traction in healthcare delivery. Anand Iyer, the Chief Strategy Officer for Welldoc, has been engaged in digital health for well over a decade.  He is a respected global digital health leader.  Anand has a doctorate in computer and electrical engineering as well as a MBA from Carnegie Mellon.  Anand and his colleagues are part of a large and growing community of cutting-edge digital entrepreneurs that are building the technologic infrastructure and capabilities to enable a completely different approach to medical care. In this interview, Anand describes the digital therapeutics that are being used to provide clinical care to patients with chronic diseases such as diabetes and hypertension.  To date, Welldoc’s FDA approved digital therapeutic, Blue Star, has been used by tens of thousands of healthcare consumers with diabetes. In addition, in this episode Anand shares the following: How digital health software and algorithms are becoming FDA-approved and regulated therapeutics, similar to medications and medical devices. The three main facets of the Blue Star digital health program – targeted at patients, providers and health systems. The requirements for the acceptance and adoption of digital health into mainstream clinical delivery. Why digital health is the only viable option in addressing numerous chronic diseases that are advancing at epidemic proportion. Why digital health presents a great solution to some of the challenges in providing optimal care to the Medicaid population – addressing some of the existing inequities in quality, accessibility, affordability and engagement. How different digital health platforms are beginning to coalesce, affording users a singular, non-fragmented, seamless experience. It is remarkable that Anand and his colleagues understood this potential well over a decade ago – the use of digital apps to treat diabetes, hypertension, depression, heart failure and numerous other chronic diseases.  Given their forethought, Anand asks us to imagine what digital technology and advanced analytics will be able to accomplish in the next 5 years. The use of: 24/7 real-time biometric recording and psychosocial/consumer information; coupled with machine learning, artificial intelligence, predictive analytics, voice technologies, natural language processing and avatars; plus new coordinating & integrating operating platforms – will enable unimagined advances in medical care.   Three closing thoughts: The take-home point is that digital health will almost certainly be a profound (and perhaps unprecedented) enabler in making high-quality healthcare accessible, affordable and sustainable – for everyone. Digital health will also be a major enabler in engaging healthcare consumers, finally breaking the quality & outcomes barrier we’ve been unable to penetrate over the past couple of decades. Although digital technology is going to be a game-changing enabler, our purpose should not be to digitize healthcare, but to humanize it. As always, I am very interested in hearing your thoughts about this exciting domain of creating a new healthcare. This will be one of a number of upcoming interviews focused on digital health. Until next time, be well! Zeev

Dear Friends & Colleagues, The phrase, “Last Mile of Healthcare,” is used to describe a number of situations in healthcare.  First, it’s been used to describe the value-laden interface between a provider and a patient.  Second, it describes patients in the context of their life – as individuals making healthful as well as unhealthful decisions.  It is in these so-called ‘last mile of healthcare’ moments that the issue of behavior is paramount – provider behavior and patient behavior.  The metaphor has significant ramifications in population health as well as in public health.  For example, chronic disease management, which now accounts for the majority of healthcare encounters, as well as costs, is all about behavior change.  It’s not so much the advice or treatment as much as the follow-up that really makes the difference.  Despite all of our advances, sustained behavior change remains a holy grail of healthcare delivery. This week’s guest has made it her career ambition to tackle this issue head on.  She and her colleagues are consumed by the issue of engagement and behavior change.  Their tool box is called ‘behavioral economics’.  Karen Horgan is the CEO and a co-founder at VAL Health, which she started with her colleagues Kevin Volpp MD and David Asch.  I’ve been a long-time fan of Dr. Volpp’s work and had the wonderful opportunity to interview him on this podcast a while back . Behavioral Economics provides an evidence-based array of methods to create healthful behavior change. There have been a plethora of recent studies demonstrating how Behavioral Economics can greatly advance how we communicate and engage with patients, as well as with providers.  As Karen points out in this interview, these market-tested techniques are used in many other industries, as well as in public health campaigns. In this interview Karen will share: The basic underlying principles of Behavioral Economics. Illustrations of the most powerful Behavioral Economics techniques used to influence healthy patient behaviors as well as value-based provider behaviors. A number of impressive examples of how Karen and her colleagues at VAL Health are deploying Behavioral Economic initiatives with provider and payer clients. Why Behavioral Economics isn’t more well known in healthcare; where she’s seeing greater adoption; and how long she believes it’ll take for general adoption to hit that exponential inflection point. Up until now, in our Fee-For-Service dominated market, patient behavior and follow-up has not really mattered.  For the most part, healthcare systems, provider groups and individual clinicians do not get paid, bonused or dis-incented based on outcomes.  But, as the market shifts to value-based payment, both provider behavior – in terms of appropriate utilization and quality care – as well as patient behavior, will actually make a huge impact on revenue. From my perspective, it’s exciting and encouraging.  Here we have a scientifically proven approach to influence positive behavior, an approach that does not manipulate behavior or force compliance, but instead makes it easier for people to do the right things to enhance health outcomes.  The vision that Karen Horgan paints is a world in which the way we communicate and engage with patients will include Behavioral Economic techniques as a matter of course. It will just be the way we deliver healthcare. I, for one, would like to see us nudge this along a bit faster.  But in the meantime, I’ll be closely following the work that these folks are doing to further validate and advance one of the toughest nuts to crack in healthcare – our own behavior! Until next time, be well! Zeev Neuwirth, MD

The topic we’re going to cover in this podcast episode may be one of the most disruptive changes in hospital care to come along in over a century.  It’s the movement of ‘hospital at home’ – literally shifting hospital-based care to people’s homes. It might sound a bit futuristic, but it’s already an established practice in other countries; and it’s rapidly gaining traction here in the US. Our guest today is a leading medical director and researcher in this area.  David Levine, MD MPH MA, is a practicing general internist and clinician-investigator at Brigham Health and Harvard Medical School.  His research is focused on digital health technology, measuring the quality & experience of outpatient care, and optimizing healthcare at home.  As assistant medical director of “alternative care pathways” for the Brigham and Women’s Physician Organization, Dr. Levine works to bring acute, hospital-level care to patients’ homes as a substitute to traditional hospitalization.   In this interview, Dr. Levine discusses: How ‘hospital at home’ actually works and the specific conditions that can be treated in the home instead of in hospitals. Some of the critical problems that ‘hospital at home’ addresses and solves. Why and how, when appropriately implemented, ‘hospital at home’ can be a superior substitute for hospital-based care. Why and how ‘hospital at home’ is more customized and personalized care. Some of the positive outcomes that have been demonstrated in research studies with the ‘hospital at home’ approach. This ‘hospital at home’ movement is one of those elegant ideas that makes you wonder, “why didn’t someone think of doing this sooner?”  And more importantly, “why aren’t we doing more of this, right now?” It addresses some major issues, including access to hospital care, and the rising and uncontrollable costs of healthcare, as well as safety and quality of care.    It was a privilege speaking with Dr. Levine. He brings a deep sense of humanity to his work.  It’s clear that his primary goal is not just the advancement of technology, but the advancement of health for patients.  He also brings a researcher’s diligence – not wanting to overstate where we are and what we’ve demonstrated to date. It is incredible to think that nearly 25% of all hospital admissions could safely – perhaps even more safely – be deployed to patient’s homes.  And that, at some point in the very near future, that number could be as high as 50%, or more, of all hospital admissions. In addition to being a safer option, ‘hospital at home’ is more personalized and customer-oriented care as well – for the patient and their family.  It’s more accessible, more convenient and more comfortable. It’s not only better medical care; it’s better patient care. This is one of those single point innovations that could potentially change the face of healthcare delivery forever.  And, it’s not a future discussion. It’s an immediately important issue for senior leaders across the country who are, right now, grappling with billion dollar, long-range decisions on how to invest in the infrastructure of healthcare delivery. As always, I hope you’ve benefited from this interview as much as I have. Until next time, be well. Zeev Neuwirth, MD

Dear Friends & Colleagues, Today’s brief podcast is not our usual bi-weekly interview episode.  Instead, I’d like to share some exciting news.  It’s regarding the publication of my book, ‘Reframing Healthcare – A Roadmap for Creating Disruptive Change’,  which is now officially available for pre-order on Amazon.com, with a publication date of April 23rd. In this brief podcast I’ll discuss: What ‘Reframing Healthcare’ is about Why I wrote this book & what I’m hoping to see happen as a result A call-to-action for you As we get closer to the publication date, I’ll share more details about the contents of the book. I think it will be of interest to many of you who listen regularly, as the themes we discuss in the podcast series are featured throughout the book. As always, I appreciate your support, and welcome you to the #reframehealthcare movement. Stay tuned for a regularly scheduled podcast interview next week. It’s another real-life example of healthcare leaders who are disrupting and reframing healthcare in profoundly positive and humanistic ways. Until next time, Be Well. Zeev Neuwirth, MD

Dear Listeners, Healthcare consumerism is on everyone’s mind these days. It’s a growing movement being taken up across the industry – from entrepreneurial start-ups, to retail and dig-tech giants, to leading hospital systems and healthcare insurance companies. This is a big shift for an industry that has been woefully behind other sectors in understanding its customers’ needs and expectations. There are numerous challenges to making this shift from patient-centered mindset to a consumer-centric mindset. Fortunately, there are experts like our guest this week Kevan Mabbutt, who joins us again to assist us in making the transition to a more consumer-oriented era. Kevan Mabbutt is the Senior Vice President and Chief Consumer Officer of Intermountain Healthcare. He was previously at The Walt Disney Company, where he served as the Global Head of Consumer Insight. We were fortunate to have Kevan first  join us back in early Fall 2018, for Episode 45. If you haven’t listened to that episode, I would strongly encourage you to do so. It was the single most downloaded episode of this podcast series, at over 10,000 downloads. During that dialogue, Mr. Mabbutt introduced us to some different ways of understanding the consumerist mindset. And now, 6 months later, we advance the dialogue and delve deeper into how Mr. Mabbutt is bringing his decades of world-class experience to healthcare. In this episode we’ll discuss: How Mr. Mabbutt and his colleagues are developing the first phases of the ‘InterMountain Health’ experience. Their comprehensive end-to-end digital platform which makes it easier to obtain “access to, navigation through, education around, and payment for” healthcare delivery. How Kevan is reframing patient loyalty in terms of “relevance” and “preference” – a shift that will require not only a different design approach, but also fundamentally different metrics for assessing patient experience. The approach Mr. Mabbutt took in building Disney theme park experiences, and how he’s applying that to discovering the “friction” or “pain points” in healthcare delivery. A reorienting focus on how healthcare occupies a ‘space’ in patients’ lives, instead of focusing solely on how patients occupy a ‘space’ in the healthcare delivery system. There are numerous pearls of wisdom that Mr. Mabbutt shares with us during the course of this interview. But, the most important message, from my perspective, is that consumerism is a sophisticated way to enhance, advance and elevate humanism in healthcare – to support and sustain those of us who are serving in the system; and to enable greater empathy, dignity and connectivity, as well as a safer, more seamless and effective care environment to those who are being served by the system. Given the current state of healthcare delivery – the frustrations faced by patients, the lack of transparency, the challenges of navigating the system, the plummeting public trust in healthcare, the obstacles providers and staff face daily, as well as the horrendous crisis of provider burnout – who can argue with the consumerist approach that Mr. Mabbutt and his colleagues at Intermountain are taking?  The only question in my mind is why isn’t this consumerist approach being deployed at more healthcare institutions? As always, I hope you get as much out of this interview as I have. Zeev Neuwirth, MD

There are numerous reasons to focus on caring for our aging population.  First, it’s the right thing to do.  Second, the utilization of care and medical costs in the older population with more complex and chronic medical conditions are tremendous.  For example, the budget for Medicare jumped $300 billion between 2007 and 2017.  In fact, Medicare costs are the 2nd largest federal expenditure, next to social security.  Third, these costs are continuing to rise. It’s predicted that per capita Medicare expenditures will rise at least 4.6% annually for the next decade.  At present there are over 60 million people enrolled in Medicare with an estimated 10,000 more enrolling each day.  It’s an unsustainable situation, from a cost perspective.  Finally, we know that there are significant opportunities for improvement – in care, outcomes, and cost. Our guest today represents an organization that is addressing this issue in new and better ways.  Sachin Jain is the CEO of CareMore. Founded in 1993, CareMore is a prepaid integrated delivery system and health plan that provides medical care to approximately 150,000 Medicare & Medicaid patients in over 40 clinics across nearly a dozen states. Dr. Jain brings a remarkable background to leading CareMore. He received an MD, an MBA, and his residency training in Internal Medicine, all within the Harvard system.  He has held a number of positions at the Centers for Medicare & Medicaid Services (CMS) and CMMI (the CMS innovation division).   He has also published over 100 peer reviewed journal articles. Some of the major points that Dr. Jain will share in this episode include: Why we need to move away from a generic primary care model to more customized models of care, such as for the older patient with complex chronic conditions. The various approaches that CareMore takes to address the Social Determinants of Health such as transportation, nutrition, physical fitness and care in patients homes. How CareMore reorganized the physical infrastructure of their clinics to address the issue of Social Isolation and Loneliness – what has been termed “an epidemic in plain sight”. Their industry leading “Togetherness Program” as well as other programs that also address social isolation and loneliness. CareMore’s method for reducing hospitalizations and readmissions, and how they markedly reduce healthcare costs through their focus on transitions of care. Throughout this interview, Dr. Jain shares CareMore’s compelling story – what makes their model profoundly different from and better than the generic primary care medical home model. One other theme I found encouraging is the attention CareMore pays to the professional development and sustainment of its providers and staff.  The thinking that providers should have an ‘owner’ vs. ‘employee’ mentality speaks to one of the major crises of healthcare today – provider and staff burnout.  As Sachin states, if we’re going to save healthcare, we’re going to have to really support the people who are actually providing care. There are numerous lessons to be gleaned from this interview – from CareMore’s focused segmented approach, to their highly coordinated care model, to their focus on social determinants of health and social connectivity, to their attention to sustaining the professionalism and engagement of their providers.  Dr. Jain and his colleagues at CareMore refer to it all as “Radical Common Sense”.  And, that’s exactly what it is! As always, I hope you get as much out of this interview as I have. Zeev Neuwirth, MD

Trust – or the lack of it – is a critically important issue in healthcare these days. This issue has tangible impact on the care of patients and the work life of providers. There is no question that trust in our medical system has declined. The Gallup poll shows a massive drop in public trust of the medical system from 76% in 1977 to 36% in 2018.. Another highly respected index, the Edelman Trust Barometer, suggests that the American public’s trust in healthcare “crashed” in 2018; dropping 25 points. The Edelman survey experts called this an “extreme trust loss”.   In response to this distrust epidemic, the American Board of Internal Medicine (ABIM) Foundation has just launched a campaign to address the issue.  It’s called the ‘Trust Practice’ Challenge. What’s unique about this particular interview is that we’ll not only be introduced to an exciting new venture in healthcare, and talk about it with a world-class expert; but, we’ll also have the chance to participate in it! In this interview Dr. Richard Baron, the CEO of the ABIM and the ABIM Foundation, shares the goals of the Trust Practice Challenge –  to elicit “inspiring and best-in-class” examples of practices that cultivate trust from and between individuals, provider groups, departments and institutions within and across healthcare.  The purpose of this campaign is to seek out a community of individuals and organizations who care deeply about rebuilding trust in healthcare, and who are interested in getting better at it. The ultimate goal is to improve healthcare relationships, and the experience and outcomes of medical care. Some of the topics Dr. Baron touches on include: The current societal factors that led the ABIM Foundation to select ‘trust’ as the major initiative to address at this point in time and what they’re hoping to accomplish through this initiative. How trust has been eroded in healthcare – between patients and providers, between the public and the healthcare system, between providers and the healthcare system… The elements of trust the ABIM Foundation is hoping to address and rebuild in the profession of medicine and in healthcare in general. “The four simple rules”  the ABIM Foundation took in launching the Choosing Wisely campaign and how they are adopting that same approach to creating a network of trust. A more detailed description of the ABIM “Trust Practice” Challenge and how you can immediately contribute to that campaign and the community of trust. I applaud the ABIM Foundation for taking on an issue that is so critically important and so ambitious. I am not aware of any other national, systematic effort explicitly focused on rebuilding trust in healthcare.   I also have to share my admiration for their co-creative approach. It’s a highly appreciative, collaborative and respectful stance – looking to the expertise and integrity that is abundant in the profession of medicine and the healthcare community at large. The ABIM Foundation’s ‘trust practice’ initiative is visionary.  It has the potential to reframe and reshape how we think about and go about the work of healthcare delivery, as well as how we redesign and reorganize healthcare delivery for the future.  I plan to share this campaign with my colleagues.. The online submission form can be accessed here/, or at www.abimfoundation.org. The last day for submissions is Thursday, February 28th 2019. Zeev Neuwirth, MD

Welcome to the first ‘Creating a New Healthcare’ podcast of 2019! This is an incredibly timely topic.  At the start of each year, most of us resolve to discard bad habits and take up new, healthier ones. We all struggle with the perennial challenge of getting motivated, avoiding frustration; and sustaining new behaviors beyond just a few days or weeks.  In this interview we discuss a new approach and health app focused on healthy eating – fresh Tri – which our guest co-developed with Walmart. Our guest this week – Kyra Bobinet – is a bestselling author and the CEO-founder of engagedIN, a neuroscience behavior design firm that uses neuroscience to make health and wellness products, and communications, more engaging. Kyra is a physician who received a masters in public health from Harvard. She was the recipient of Harvard’s 2015 Innovator Award. Kyra is the author of A Well Designed Life: 10 Lessons in Brain Science and Design Thinking for a Mindful, Healthy, and Purposeful Life.  She and her work have been featured by the Wall Street Journal, New York Times, Huffington Post and NPR. She’s created health startups, blockbuster products, health apps, and evidence-based programs in mind-body & metabolic medicine.   Some of the incredibly relevant issues covered in this episode include: “The emperor has no clothes.” – Kyra’s assessment of the employer wellness industry The fundamental differences that make her new app – fresh Tri – unique in the world of healthy habit development Why the perception of ‘failure’ is actually harmful to our health and is the neurophysiological basis for de-motivation How to apply the basic principle of design thinking to constantly improve one’s   approach to developing healthful habits – and how to side-step failure traps A rare opportunity to hear an expert describe  ‘the anatomy and physiology of behavior design’ The ‘secret sauce’ Kyra discovered and believes to be the single most important factor in sustained behavior change What’s unique about this interview and the work Dr. Bobinet is doing is that it goes beyond healthcare and physical health. This message of how we perceive failure and success is a fundamental life skill. Kyra’s research can assist us in avoiding the pitfalls of self-defeat in all aspects of our lives. Her underlying motivation – to remove the self-blame and harsh criticism we inflict upon ourselves – is a hopeful and realistic way to begin the new year.   As always, I hope you get as much out of this interview as I have. Zeev Neuwirth, MD