Creating a New Healthcare

For anyone who doesn’t appreciate the critical importance of healthcare economics in the U.S., consider this: The average price for health insurance in the U.S. for a family of four is $18,500 per year. This is the equivalent of each American family purchasing a car every year.  Healthcare currently makes up nearly 20% of the U.S. GDP; and numerous studies have suggested that nearly one-third of that spend is unnecessary, wasteful and even harmful.  Given the unfettered rise in healthcare spending, it’s been estimated that Millennials will conservatively spend somewhere between 50 to 75% of their total lifetime earnings paying for healthcare.   These staggering statistics give you a sense of the important role that healthcare economists can play in determining the future of our healthcare system, and the future of our economy. Healthcare economists take an objective, data-driven approach to analyzing the issues of healthcare spending and utilization.  We’ll discover, in this fascinating interview with a leading healthcare economist, that many beliefs we hold about healthcare spending are based on incomplete data, and therefore erroneous conclusions. Dr. Zack Cooper – our guest on this episode of Creating a New Healthcare, trained at the London School of Economics and is an Associate Professor of Health and of Economics at Yale University. He is one of the rising stars on the healthcare economics scene; and represents the nextgen – trained in the most advanced science, analytics & machine learning that can be applied to healthcare spending, utilization & costs. His publications are regularly featured in the New York Times which wrote of Dr. Cooper’s work that it’s “likely to force a rethinking of some conventional wisdom about healthcare”.   In this interview, we’ll cover a broad range of topics including: What healthcare economists actually do & how they influence policies around healthcare delivery & payment. How Dr. Cooper’s ground-breaking research on commercial health insurance completely changes our understanding about regional healthcare utilization & costs.   Dr. Cooper’s recent research that challenges our belief that patients can act as informed consumers capable of making price-based decisions, even when they’re provided with straightforward, transparent, comparative pricing. Evidence-based recommendations for redesigning employee health plans. I came away from this from this interview with a newfound and enhanced respect for the role that healthcare economists play in creating a new healthcare. We need their powerful problem-solving methods & advanced analytics to help us decide which problems to solve and how to go about solving them.  It’s hard to argue against the notion that healthcare needs a new ‘True North’.  Perhaps we should take a closer look at the compass that Professor Cooper and his colleagues are constructing.

Social determinants of health (SDOH) represent the largest set of factors in determining healthcare outcomes & utilization. Despite understanding this, a fundamental problem remains: How to motivate & sustain healthful behavior, especially within communities experiencing profound social and economic obstacles such as unemployment, poverty, food insecurity, isolation, unsafe housing, etc. There is a tremendous amount of effective, innovative effort directed at this challenge.  But the current “screen & refer” approaches have limitations.  As we’ll discover in this podcast, Community Health Worker programs can overcome these limitations and serve as a keystone program in this domain. Community Health Worker (CHW) programs connect professional and social-service resources with the individuals & communities they are attempting to benefit. It is a unique approach that takes lay individuals from the community and trains them to be a combination of life coach, social worker, and healthcare system liaison. The basic premise relies on the idea that health is social, contextual & communal; and the closer you are to the situation, the more likely you will be to catalyze & sustain behavior change. Like many other good ideas, this one is as much about execution as it is about intention. Unfortunately, despite good intentions, many CHW programs have floundered and failed. To help us understand what is needed to create an effective and sustainable CHW model, we are fortunate to have with us Dr. Shreya Kangovi. Dr. Kangovi and her colleagues have pioneered a rigorous, evidence-based approach to building, deploying and measuring the impact of a CHW program.  Dr. Kangovi is the founder & executive director of the Penn Center for Community Health Workers – a national center of excellence dedicated to advancing health in low-income populations through CHW programs. The Penn Center spent seven years creating and refining an exemplary CHW model called IMPaCT (Individualized Management towards Patient-Centered Targets). It’s based on the application of human-centered design principles, implementation science, and robust qualitative & quantitative research methodology. In this episode, we’ll discuss: The scope of services a Community Health Worker (CHW) performs, and what makes them effective. The most critical question each Penn Center CHW client is asked. The evidence-based clinical, economic and humanistic benefits of an effective CHW program. The 5 major pitfalls that have undermined the success of CHW programs in the past, and how to turn them into opportunities for success. The services the Penn Center offers to assist other medical centers in standing up their own CHW program. From my perspective, CHW programs are a critical – but often absent – piece of the healthcare delivery ecosystem. Because they are treated as ‘soft’ programs, they often lack appropriate operational planning, resource allocation, and rigorous management and measurement. The Penn CHW program has set the standard for efficiency and sustainability. It is a masterpiece of fiscal responsibility, operational excellence, evidence-based consumer-oriented design, and system integration. If the rest of healthcare operated this way, we would be in a far better place than we are now! Zeev Neuwirth, MD

Despite the fact that nearly one in five hospitalized patients is discharged to a skilled nursing facility, inpatient rehabilitation service or into a home health care program – the so-called ‘post-acute’ care space remains a largely opaque and overlooked sector of healthcare for most hospital administrators and providers of care. It’s also extremely confusing to patients and their families. Adding to this complexity and confusion is the tremendous unwarranted variation in post-acute care. There is little standardization in how decisions are made as to where patients might be optimally discharged; and there is a staggering amount of harmful and costly variation in how patients are cared for in post-acute care facilities/programs. But, market forces and CMS-driven payments and penalties have recently brought post-acute care front and center for providers and hospital systems; and have also caught the attention of Wall Street investors, and corporations who are making significant R&D investments in this space. These forces are moving things favorably toward a triple-aim vision for post-acute care – great care & outcomes, outstanding experience & cost effectiveness. We are fortunate to have an expert on this episode who can clear some of the mist and misunderstanding shrouding this domain of care. Mr. Andy Edeburn is a Principal with Premier, Inc., with nearly 20 years of healthcare consulting experience specializing in acute, post-acute, and senior care services.  Mr. Edeburn is a nationally recognized expert who guides organizations through strategic deployment around acute and post-acute partnerships, new programs, and facility and redevelopment efforts – establishing value-based, outcome-oriented relationships as organizations transition from the fee-for-service environment. In this episode, what you’ll discover includes: The major levers that hospital systems and integrated delivery networks rely upon to positively impact post-acute care. Which set of interventions have proven to be the most powerful in managing post-acute care spending and outcomes. Some insights into the profound disruption that is about to occur in the post-acute care industry due to the impending site-neutral, unified payment that CMS is planning to implement. Which specific area of the post-acute care space has become the darling of Wall Street, as well as the focus of huge investments on the part of vendors such as Phillips and Samsung. The so-called post-acute care space is likely the next frontier of standardization and systematization in healthcare delivery.  It seems that few healthcare systems have ventured into this arena with a deliberate, well-resourced, comprehensive program to optimize care. To my mind, post-acute care, or perhaps what might be termed ‘sub-acute’ care, represents one of the most significant opportunities we have to improve care and the care experience for one of the most vulnerable and costly moments in the continuum of healthcare delivery.  It is also an opportunity to provide direction to providers, so they can bring both health and dignity to patients and their families who require this level of care. In addition to his broad experience and depth of knowledge, Andy Edeburn – our expert guest and guide in this podcast episode – has the gift of making this highly complex area seem a bit more straightforward and understandable. Andy not only provides us with a better understanding of the problem; he informs us on potential high leverage solutions. As always, I hope you get as much out of this interview as I have! Zeev Neuwirth, MD

The rapidly escalating impact of chronic disease is devastating populations, employers, payers & economies – both in the U.S. and across the globe.  The World Health Organization (WHO) projects that, by 2025, chronic disease will make up over 70% of all illness.  At the present time, preventable chronic disease is responsible for over 40 million of the 56 million annual deaths worldwide. The WHO has also projected that the global costs of healthcare will more than double between 2015 and 2030 – from $8.4 trillion to $18.3 trillion – with an estimated global productivity loss due to chronic disease, in that time frame, of $47 trillion.  This is clearly an unsustainable situation. Our guest this week, Dr. Samir Damani, is trying to solve this problem – of the escalating impact of chronic disease – by using blockchain technology. Dr. Damani brings a depth and breadth to this work by combining his skills as a clinician, researcher, technologist & entrepreneur.  He is a board-certified practicing cardiologist with a Masters in Clinical Investigation from the Scripps Research Institute, who also obtained a PharmD from the University of Georgia.  In 2011, he founded and served as CEO of ‘MD Revolution’, a technology-enabled service platform for Medicare’s Chronic Care Management program. Dr. Damani’s most recent endeavor is MintHealth, a decentralized healthcare platform designed to engage patients in committing to healthful behaviors – somewhat similar to current loyalty programs.  An individual signs up on the MintHealth platform and accumulates tokens (aka ‘purchasing power’) by demonstrating healthful behaviors – anything from listening to educational material, to demonstrating improvements in diabetes, or high blood pressure, or weight.  The tokens (called ‘Vidamints’) can be redeemed for healthful products. The blockchain platform facilitates the loyalty campaign, which is typically sponsored by an individual’s employer or insurance company. Dr. Damani and his collaborators envision that Vidamints will become a defacto healthcare campaign currency and program for organizations or government agencies interested in incenting healthful member behaviors.  In addition to the incentive program, the MintHealth platform could serve as a secure and portable, cloud-based personal health record, allowing participants to control and direct their own health data.  They also intend for the MintHealth platform to serve as a Health Information Exchange (HIE), allowing for the protected and seamless transfer of personal health information amongst numerous healthcare stakeholders. In this episode, we discuss how MintHealth is addressing the following issues: Interoperability – the ability to safely and securely move health data between closed electronic medical record systems. Sustained behavior change – creation of a behavioral economic approach to engage and empower people in their pursuit of healthful behaviors and optimal health outcomes. Self-sovereignty – Providing patients with the ability to control and direct their own health data and records. Economics – Driving down the increasing and unsustainable costs of chronic disease. Dr. Damani and his colleagues are attempting to create a healthcare marketplace that increases healthcare consumers purchasing power through rewarding healthful behaviors and healthy outcomes.  They are attempting to solve one of the most significant and challenging healthcare related problems of our era.  To listeners of this podcast it will be clear that Dr. Damani is a passionate, persistent and purpose-driven leader who has his eyes set on winning the long game. As always, I hope you get as much out of this interview as I have! Zeev

It’s been said that our zip codes impact our health more than our genetic codes.  How do the social determinants of health — education, employment, public transportation, safe housing and neighborhoods, access to healthy food… — so profoundly affect healthcare utilization and health outcomes? In this interview, you’ll hear an emerging story of how the leadership of a healthcare system in New Jersey is addressing this issue head-on and going right to the root cause.  My remarkable guest, Michellene Davis – a lawyer and policy expert – is the Executive Vice President & Chief Corporate Affairs Officer for RWJBarnabas Health – the largest healthcare system and largest non-profit employer in the state of New Jersey.  Ms. Davis has been named as New Jersey’s top healthcare lobbyist and Modern Healthcare recently recognized her with their 2018 Top 25 Most Influential Minorities in Healthcare Award. Key topics and stories we’ll explore in this interview include: RWJBarnabas Health’s rollout of a novel and compelling “anchor” strategy, synergistic with larger economic and cultural revitalization efforts like the ‘Newark 2020 Initiative’ launched by Newark Mayor Ras J. Baraka. The overall approach and major interventions of the ‘Social Impact & Community Investment Practice’ that focus on education, economic stability, neighborhood and built environments, global health and employee engagement & volunteerism. Inspiring stories of local entrepreneurs who are growing successful businesses and enriching the local community as part of the “Hire, Buy, Invest” strategy that Ms. Davis is leading on behalf of RWJBarnabas Health. Ms. Davis emphasizes how her organization’s community-focused initiatives make sense, not only from a healthcare perspective, but also from a business and economic perspective.  The approach taken in New Jersey is focused on implementing long-term, expanded and self-sustaining solutions; and is being accomplished through the intentional inclusion of multiple stakeholders who might otherwise be competitors. Ms. Davis’ initiatives strive to not only be enabling, but also empowering and self-generating.  They include providing local communities with access to healthy foods, transportation and safe housing – critically and immediately important efforts!   But, they go beyond that – to actually providing employment to local citizens.  And even beyond that – to actively supporting local entrepreneurs and small businesses – teaching them how to grow their businesses and become even more entrepreneurial. Hang onto your seats (or earbuds) folks.  Ms. Davis is a powerhouse!  All of her talent and energy is highly purpose-driven and laser-focused on “eliminating” the adverse negative impacts of the social determinants of health. There are numerous lessons to be learned from this interview – lessons that can translate into action.  My hope is that you’ll share this interview with your local healthcare systems and local government, and begin to organize similar efforts.  And, if you’re engaged in similar ‘anchor’ strategy efforts, I would love to hear about it.  From my perspective, this interview is one of the most inspiring and potentially catalyzing dialogues posted on this podcast series to date. As always, I hope you get as much out of this interview as I have! Zeev Neuwirth, MD

Friends & colleagues, The care of patients with chronic medical conditions represents a significant dilemma in healthcare today. How do we optimize cost effectiveness while achieving good health outcomes? In today’s interview, we learn how ChenMed empowers primary care physicians to deploy a VIP concierge experience that delivers affordability and outstanding health outcomes for seniors. My esteemed guest is the CEO of ChenMed, Dr. Chris Chen, a cardiologist & physician executive who has devoted his career to building this premier practice focused on the care of low to moderate income patients with complex, chronic medical & social issues. In this interview, we’ll explore how ChenMed manifests its vision to: (1) be America’s leading primary care provider; and (2) transform care for those who need it the most – the elderly, the sick and the poor. Key topics covered include:      · Specific tactics ChenMed uses to deliver outstanding outcomes that mutually and simultaneously benefit patient well-being, provider satisfaction, and payor success.      · How ChenMed’s focus on preventive primary care demonstrably improves health outcomes & reduces the need for downstream “catastrophic” care such as ED visits & hospitalizations.      · The training and development of ChenMed’s incoming physicians – building their readiness for accountability as well as advanced training in service orientation, finance and leadership.        · The holistic approach ChenMed takes in the ‘care’ of people – focusing on lifestyle issues, social supports & behaviors – rather than solely on clinical ‘healthcare’.   Throughout the interview, Chris shares the underlying mission-driven philosophy that differentiates his practice from others. He reveals numerous pearls in the second half of the interview you’ll not want to miss.  Of note, in addition to the intense focus on person-centered care, Chris also describes how ChenMed creates a supportive, respectful & meaningful environment for physicians and other providers. If you’d like to understand what outstanding ‘triple-aim’ primary care looks like, this is the ticket. Chris informs us that the three values upon which ChenMed’s strategy & tactics are built are love, accountability & passion.  Many organizations use these words.  ChenMed clearly makes them part of their daily operation. I always leave my conversations with Chris with a renewed sense of conviction, courage and hope.  I suspect you will as well. As always, I hope you get as much out of this interview as I have! Zeev Neuwirth, MD

Human behavior is, by far, the single biggest lever we have to impact our health outcomes. Yet, despite the profound impact our behaviors have on health outcomes, as well as on our national & global economic health; we continue to see adherence rates to appropriate treatment and medication taking hover between 40 to 50%!  These incredibly low adherence rates exist in chronic issues such as diabetes treatment and blood pressure control; and they also occur even after life-threatening events such as heart attacks. This is, without question, a major health care challenge for patients, providers, payers & employers.  In fact, it’s one of the most significant challenges for just about every stakeholder in healthcare, including pharmaceutical companies and pharmacies. Clearly, behavior change is a tough nut to crack.  We all want to do the right things – but behavior change is challenging to initiate, and even more challenging to sustain.  Gratefully, there is a discipline called ‘behavioral economics’ – a combination of microeconomics, psychology & neuroscience – that is demonstrating marked success in making it easier for patients, as well as doctors, to repeatedly and more easily perform & sustain desired healthful behaviors. In this interview, Dr. Kevin Volpp, one of the most highly published and productive physician-scientists in this discipline, shares numerous applications & techniques of behavioral economics – as applied directly to patients’ & providers’ behaviors. What you’ll hear in this interview includes: How a large employer-based incentive program tripled the rate of sustained smoking cessation – from 5% to 15%.  And,in a smaller subset of employees (~14%) the intervention achieved rates of 50% long term smoking cessation! How a default electronic medical record intervention increased physicians’ prescribing of generic medications from less than 60% to 99% – leading to savings of approximately $32M in a couple of years time. How behavioral economics is being deployed to create a new primary care payment system in the Hawaii Medical Services Agency – incenting doctors to deliver high value care. Toward the end of our dialogue, Dr. Volpp sketches an enlightened picture of the future of healthcare – a tremendous emancipation of value that could occur, if we can begin combining virtual digital technologies with the powerful techniques of behavioral economics Clayton Christensen, the preeminent Harvard Business School Professor & one of the leading management scholars of our time, wrote in The Innovator’s Prescription: A Disruptive Solution for Health Care, “There are more than 9,000 billing codes for individual procedures and units of care.  But there is not a single billing code for patient adherence or improvement, or for helping patients stay well.”  In my opinion, Dr. Kevin Volpp’s groundbreaking work in Behavioral Economics addresses Dr. Christensen’s keen observation by focusing on creating the procedures & interventions for helping patients stay well, as well as helping physicians and other providers help patients stay well.   I came away from this interview with one lingering question: Given the clear potential for behavioral economics to achieve sustained healthful behaviors, improve our health and the health of our nation, and lower the crippling costs of healthcare – how come we’re not doing more of it?  My hope – and intention – is that this interview advances the greater awareness of one of the most significant opportunities we have available to us to improve healthcare. As always, I do hope you get as much out of this interview as I have! Zeev Neuwirth, MD  

Have you ever wondered what it takes to be a model healthcare system?  In this interview, Dr. Mark Briesacher provides us with profound insight into how Intermountain Healthcare consistently maintains its position at the forefront of clinical outcomes, improvement & innovation.  Mark informs us that the organization’s original charge was to create “a Model Healthcare System.” What you’ll discover in this interview is how he and his colleagues have taken that charge to heart. One manifestation of that charge is the “Clinical Reorganization” being deployed to create a consumer-oriented, community-based model of healthcare.  Dr. Briesacher describes a two-part construct – a highly innovative community division focused on long-term health, prevention & wellness; and an acute, episodic-care division composed of specialty surgical/medical centers-of-excellence.  Mark discusses the unique contributions of each, and also emphasizes the synergistic intersection between them – which leads to optimal decisions about appropriateness of care as well as world class health outcomes. Another example of creating ‘a Model Healthcare System’ is the innovative insurance product called ‘SelectHealth Share’ – an offering of Intermountain’s embedded SelectHealth Plan. This product creates explicit shared accountability between the Employers/Employees (customer), the SelectHealth Plan & Intermountain Healthcare providers.  All of this contributes to what Mark refers to as a “community” of health.   A third illustration of creating ‘a Model Healthcare System” is the consumer-oriented, digitally-powered, transformational patient experience that Intermountain Healthcare is building – which, as Mark points out,  “… all starts with the digital front door that removes as much friction as possible.” Toward the end of our interview, Mark shares a number of heartwarming and inspiring stories from his upbringing.  Please don’t miss this! These snapshots provide us with an understanding of how and why his personal values are so highly aligned with Intermountain’s long-standing culture of excellence, integrity and community service. Mark is, without question, a highly capable and humble servant leader; and Intermountain Healthcare is the quintessential ‘learning organization’.  Dr. Briesacher and his colleagues are brilliantly carrying out their charge to create ‘a Model Healthcare System’.  There are numerous lessons and learnings to be gleaned & emulated from their example! As always I hope you get as much out of this interview as I have! Zeev Neuwirth, MD

Al Lewis may be one of the most controversial, and respected, figures in the employee health & wellness industry.  His insight and candor have earned him various labels and epithets including, “the founding father” of disease management and alternatively, the “troublemaker-in-chief” of the wellness industry. Whether you like him or not, I doubt that anyone can challenge his integrity, or the rigorous intellectual approach he takes in analyzing the efficacy of employer-based wellness and care management programs. By way of introduction – Al Lewis attended Harvard College, where he studied and then taught Economics.  He graduated from Harvard Law School, and eventually became a partner at Bain & Company; prior to becoming a nationally recognized expert and consultant in the fields of employee health & care management. Al has authored a number of critically acclaimed books on employee health & care management, including ‘Why Nobody Believes The Numbers’, which was named ‘2012 healthcare book of the year’ in Forbes. In this interview Al Lewis – true to form – dispels numerous myths and radically reorients our thinking on the critically important issue of employee health & wellness. According to Mr. Lewis, the most significant healthcare cost & health outcomes opportunity for employers is NOT getting employees to “take more steps or eat more broccoli;” but instead to prevent them from having unnecessary screenings, tests and treatments – what he terms “hyper-diagnosis.” He has, over many years, repeatedly documented and demonstrated that healthcare over-utilization wastes tremendous money and adversely impacts employee health. He also argues that current Health Risk Assessments (HRA’s) are misguided, wasteful and potentially harmful. What you’ll discover in this interview includes: 1. Why, according to Al Lewis, employee health wellness programs are a waste of money and, more importantly, are potentially harmful to employee’s health & wellness. If you’re interested in his online documented expose on the “mis-statements” of the wellness industry, you can learn more on www.theysaidwhat.net. 2. Mr. Lewis’ online program ‘Quizzify’ (available to employers at www.quizzify.com) – which uses games, quizzes and assessments to educate employees on how to better manage their health, healthcare, and healthcare expenditures – and whose basic purpose is to create a culture of healthcare literacy. 3. How employers can provide services that enhance employee health & wellness – what Mr. Lewis terms “wellness done for employees” instead of “wellness done to employees”. 4. Al’s forecast for the future of the wellness industry – an industry which he predicts is going to change dramatically in nine months, as a result of major court rulings. Mr. Lewis certainly puts his money where his mouth is. If you don’t agree with him, he’s offering a $3 million reward to anyone who can demonstrate that wellness programs actually save money, or if he can’t prove that they don’t save money! It is refreshing, enlightening and encouraging to have a conscientious industry watchdog with the intellectual rigor, acumen and experience that Al Lewis possesses.  For the purpose of this podcast series, it’s not his critique that is most important.  What’s important is what Al Lewis is creating, and how he is contributing to Creating a New (and better) Healthcare.  Again, I did warn you all that he is a controversial and respected authority.  If you have any difference in opinion, Al is ready to listen and respond. As always I hope you get as much out of this interview as I have! Zeev Neuwirth, MD

Given the rapid, tumultuous, and unprecedented changes in healthcare these days, there are very few things that are as important to a hospital system or integrated delivery network as developing and deploying a sound and forward-thinking strategy. In this interview we have the amazing good fortune and unusual opportunity of picking the brain of the senior strategy executive for one of the most successful, visionary and pioneering healthcare systems in the world – Geisinger.   Dominic Moffa is a seasoned healthcare executive with a long standing track record of success.  He’s also an incredibly humble, generous, practical and fun guy. In this interview he generously shares some of the life lessons and rules of thumb that have contributed to his amazing success, and the success of the organizations he’s been a leader in.  It’s clear from his straightforward responses that he not only talks the talk, he walks the walk. What you’ll learn in this interview includes: The primary market forces that Dominic perceives to be strategic challenges for healthcare systems The three fundamental building blocks of the Geisinger Strategy Dominic’s 3D’s of Strategy Deployment How Geisinger is transforming itself – and healthcare – not from the inside out, but from the outside in How the ‘hospital of the future’ may actually be much more than a hospital The transformative social and community commitments Geisinger is making in its ‘Fresh Food Farmacy’, it’s Genomics initiative, and its Springboard Healthy Scranton Initiative Toward the end of the interview Dominic shares the best piece of advice he was ever given.  Folks – this is not to be missed, as it is certainly one of the best we have heard on this podcast series to date! As always, I hope you get as much out of this interview as I have! One final note – I would feel remiss if I didn’t extend a personal message of sincere appreciation to the entire Geisinger organization – for their many years of being leaders in healthcare, but also being generous in sharing the lessons they’ve learned.  While it’s apparent, as Mr. Moffa points out in this interview, that their primary focus is to provide outstanding medical care to their patients and the populations they serve; it’s also abundantly clear that they understand, and take seriously, their innovative and pioneering role in helping to advance the American Healthcare System.   Zeev Neuwirth, MD