Creating a New Healthcare

Friends, What most of us are unaware of is that the health of the American public is worsening in relation to other developed nations – despite having, by far, the costliest and arguably most sophisticated healthcare system in the world. Our life span is decreasing. Inequities in care and disparities in health outcomes are worsening. The Washington Post, in a recent expose on American healthcare wrote that income is no longer the hallmark of inequity in the US – it’s now longevity – life itself. According to our guest today, this all sadly makes sense as we actively refuse to challenge and change the status quo in American healthcare at the necessary pace – to adopt a more practical, evidence-based, consumer-oriented approach – one that gets us beyond what she refers to as our traditional and myopic “clinical tendencies”. Our guest is an incredibly accomplished physician, lawyer and healthcare policy expert – Kameron Leigh Matthews MD, JD, FAAFP. Dr. Matthews is a board-certified Family Medicine physician who has focused her career on marginalized communities. She is an elected member of the National Academy of Medicine where she chairs the Health Policy Fellowship & Leadership Programs Advisory Committee; and is currently a participant in the 6th cohort of the Aspen Institute’s Health Innovators Fellowship. Dr. Matthews received her bachelor’s degree at Duke University, her medical degree at Johns Hopkins University, and her law degree at the University of Chicago.  What our guest and her colleagues at Cityblock Health are doing to change the status quo is straightforward yet quite remarkable. They are delivering integrated and advanced primary care to marginalized communities – and demonstrating improved outcomes.  During the course of our interview, Dr. Matthews repeatedly referenced the well-worn definition of insanity – doing more of the same but expecting a different and better result.  When I asked her what Cityblock Health was doing differently, she cited numerous specifics that include:  (1) providing care for a specific segment of the population – and deploying and customizing the healthcare resources that are needed by that segment;  (2) utilizing value-based payment in order to sustainably deliver comprehensive services and to invest in innovative care models;  (3) adopting a “partnership” model of care which includes assigning a “community health partner” (not worker) to each patient;  (4) “multi-modal” care – delivering care where, when and how patients want it to be delivered – whether in their health “hubs”, in patients’ homes, or virtually;  (5) a “one-stop-shop” of comprehensive clinical and non-clinical (SDOH) care – which includes a care team of doctors, nurses, and behavioral health experts, as well as partnerships with local healthcare systems and community-based organizations.  The foundational thesis for Cityblock Health is evidence-based medicine – and the evidence is overwhelmingly clear. The vast majority of our health outcomes are dependent upon non-clinical factors – the so-called ‘social determinants of health’. Cityblock Health has built their model based on this evidence and is deploying a “whole-person”, community-based approach. Another foundational thesis is the principle of segmentation. By focusing on a specific segment of the population, they can more readily create a highly customized, appropriately resourced, and sustainable care model.  One of the things I admire and respect about Dr. Matthews is that she not only has a prescription in hand, but she is actively delivering on it – with her work at Cityblock, her non-profit ‘Tour for Diversity in Medicine’ (which I recommend you look into), in her advocacy and policy work at the National Academy of Medicine, and more broadly in her national presentations.   Dr. Kameron’s humanistic leadership and her courageous, intelligent voice is one that I hope we’ll continue to hear more from on the national healthcare scene.  And I hope, for our sake, we have the good sense to listen to it. Zeev Neuwirth, MD

Watch out folks! A new day in Creating a New Healthcare is coming…   Creating a New Healthcare has an updated look and an updated focus. Over the past six months, I’ve been speaking with healthcare audiences across the country about my recently published book, ‘Beyond the Walls’, which is about getting beyond our limiting legacy thinking. There are 3 notable gaps that have arisen out of these conversations with providers, administrators, executives and healthcare consumers.   The first gap is a need to refocus our efforts on health – to go beyond healthcare. Our mission is not just to deliver healthcare – it’s to improve health. Somewhere along the way, it seems like we’ve lost that primary focus. We’re spending a lot of time, energy and resources on the healthcare industry rather than on the health care of the American public. In the podcast, we’re going to address that gap and expand the focus to achieving better health.    The second gap is the inequities in healthcare. And by inequities, I’m referring to the systemic and structural racism, sexism, ageism, ableism, classism and reductionism – the inequitable ‘isms’ in healthcare. What’s clear is that if we’re going to solve the challenges in healthcare, we will need to explicitly address these issues. As such, we will be discussing health equity with a focus on solutions.     The third gap that we’ll be explicitly addressing is that of leadership. What’s become abundantly clear to me is that if we are going to transform healthcare, we’re going to have to be willing to transform our leadership mindset. In the podcast, we will be focusing on a more generative, inclusive, collaborative and humanistic mindset – what I’m calling a “rebel mindset”.    Finally, the number one question I’ve been asked as I’ve spoken across the country is, ‘What can I do?’ People are desperate for tangible, do-able, next steps. So, we’re going to add a ‘do-ability’ focus to the podcast and attempt to respond to that question of ”What Can I Do?” in each episode.    This is a new day in Creating a New Healthcare. To hear more about this new, expanded version of the podcast and my personal journey that has led us here, tune in to today’s podcast, episode 168.

Friends, This interview should be required listening for every chief experience officer, every marketing officer, every chief medical officer and every chief executive officer in American healthcare.  Why? Because – when benchmarked against other public and private healthcare systems the VA outperforms on patient experience and consumer trust metrics.  And, if you want to understand ‘how’ – listen to this interview. I would suggest listening to it more than once – to capture the principles, strategies and tactics that John and his colleagues are deploying to achieve a world-class healthcare experience.  Keep in mind that the VA provides care to over 9 million Veterans annually, at over 150 hospital-based medical centers and over 1400 ambulatory centers. We cover so many profound topics, but here are a few: In 2016, the VA instituted a ‘Trust Index’ comprising 3 major domains.  They are one of the few healthcare systems across the country that have focused on restoring trust in American healthcare – and have seen remarkable improvements as a result of this focus. In addition to the Trust Index, they have also constructed a ‘Social-Drivers-of-Health’ framework which identifies these issues at every patient visit; and is also used to construct collaborative solutions with non-VA community-based organizations across the country. The VA Experience Office has collaborated with the VA Whole Health Initiative to define ‘well-being’ from patients’ and employees’ perspective, and to create wellness programs. The VA has engaged in journey mapping, service blueprints, and numerous other qualitative and quantitative research – across dozens of service lines. They use this information to train their employees in delivering a world-class healthcare experience. The emphasis on provider and employee experience is profound. In addition to their quarterly ‘V-signals’ (Veteran) patient experience surveys; they also have quarterly ‘E-signals’ – employee experience surveys.   This is one of many interviews I’ve conducted that demonstrates how far ahead the VA system is in so many respects. The VA is a hidden gem in the American healthcare system.  There are so many pearls of wisdom and sophisticated approaches that are shared in this interview.  My hope is that it reaches the audience that needs to hear them. Zeev Neuwirth, MD

Friends, This is a remarkable journey – of a physician who has gone from burnout to creating positive ‘ripples of change’ in our healthcare system. He went from being a casualty of our healthcare system to being a courageous leader. In listening to Dr. Otten’s story, I was moved from anger to elation, and I suspect you will be as well.  What’s profoundly disturbing is that this physician’s experience of anguish and burnout reflects that of the majority of clinicians and healthcare staff. What’s inspiring is that this physician made a decision to turn the dismal dilemma of American healthcare into a positive movement to humanize it. What I also admire is his collaborative approach and the inclusion of patients – coupling his initial effort, Ripple of Change, with Medicine Forward and other advocacy/activism groups.   One takeaway is that we need to change the narrative and the fundamental construct of our healthcare delivery system. We need a renewed sense of purpose & mission, and actually live it – in our policies and procedures – in our organizations – in our payment – in our daily delivery of healthcare.  What Todd and others are doing is critical and urgent. Over half of US doctors experience burnout. One quarter of the current nursing workforce are planning to leave the system in the next three years. We aren’t at a tipping point. We’ve already tipped over.  On a very personal human level, Dr. Otten had to first save himself before he could save others. There’s a profound lesson in there for all of us. Zeev Neuwirth, MD

Friends,   This dialogue is a Master Class in Care Transformation – likely owing to our guest’s unique background, which includes preventive medicine, public health, and clinical informatics. It should be required listening for all healthcare executives and managers – both clinical and administrative – as well process/quality improvement professionals. Our guest, Dr. Cole Zanetti is an insightful and brilliant process improvement and care transformation expert. He has a broadly empathetic perspective and a practical humanistic vision that is the foundation for his work and his leadership.  Dr. Zanetti currently serves as a Senior Advisor for the Veteran Affairs National Center for Care and Payment Innovation – focusing on value-based care delivery and payment innovation pilots as well as emerging technology innovation pilots. He also serves as the Chief Health Informatics Officer for the Ralph H. Johnson VA Medical Center in Charleston South Carolina, and as the Director for Digital Health at Rocky Vista University College of Osteopathic Medicine. Dr. Zanetti was trained in Family Medicine and Leadership Preventive Medicine at Dartmouth Hitchcock Medical Center. He is triple board certified in family medicine, preventive medicine, and clinical informatics – and has a Masters in Public Health from the Dartmouth Institute for Health Policy. He has also served on the National Quality Forum’s Physician Advisory Committee and as a technical expert for the Centers for Medicare & Medicaid Services.   A few months prior to this interview I heard Dr. Zanetti speak about the cutting-edge, digital-tech innovations being deployed within the VA. My intention going into the interview was to do a deep dive on those care delivery innovations. But, this conversation went in an unexpected direction, which I’m truly grateful for. We ended up exploring the philosophical underpinnings of transformation and the approaches Dr. Zanetti has had to adopt in order to do this work. In short, we discussed the ‘why’ and the ‘how’ of care transformation.   Some of the areas we covered include:   Why Dr. Zanetti firmly believes that a serious commitment to and more significant resourcing of care transformation and digital transformation is critical – for patients, for providers and their staff, and for the survival of the mission of Medicine.  How the VA is uniquely positioned to be a transformation center – a “test kitchen” for care delivery – not only for Vets but for the entire American healthcare system.  The approaches that Dr. Zanetti has learned and adopted as a leader in care transformation – with a particular focus on inquiry and positive deviance. This interview uncovers another example of how the VA is one of the most innovative and transformational healthcare systems in the country. I continue to be astounded by the “hidden gems” – the forward-thinking, nationally leading expertise and initiatives within the VA, and the unique factors that make the VA ideal for ideating, piloting, deploying and studying care transformation. Towards the end of our dialogue, I promised that I would follow up with a part 2, which I will – in which we’ll dive into the specific digital tech innovations being deployed in the VA. In the meantime, I hope you have a chance to glean the wisdom and humanity of Dr. Cole Zanetti. Until Next Time, Be Well Zeev Neuwirth, MD

Friends, This is Part 2 of an interview that is one of the most startling I’ve posted over the past 8 years. The revelation here is that the pulse oximeters we’ve been using for decades, to measure oxygen in the blood, are not always accurate in people of color. They may overestimate the amount of oxygen in the blood and miss low oxygen levels – potentially leading to delayed treatment and adverse outcomes. What’s shocking to me is that this has been documented in the medical literature for nearly two decades and little to no action has been taken. The implications are profound, especially given the disparity in deaths we witnessed along racial lines during the Covid pandemic, and the on-going widespread utilization of pulse oximetry in the post pandemic era. Our guest, the esteemed Dr. Kryger, provides us with his expert perspective on this still emerging situation. In this episode we’ll discover: Why Dr. Kryger believes it’s taken so long – decades – for some action to be taken to address the inaccuracies in pulse oximetry. Dr. Kryger’s perspective on the impact that inaccurate pulse oximetry measurements had during the Covid pandemic and its impact in the post-pandemic period. What Dr. Kryger believes that professionals, as well as the American public, should be aware of – in regard to pulse oximetry measurement – and what actions can be taken right now. This is one of those critically important and urgent issues that we need to learn more about and do more about. As our guest points out, the magnitude of this problem is enormous in that nearly 40% of the people who pulse oximeters are used on are people of color.  My purpose here is to create awareness and motivate positive action. Along those lines, I would urge you to read and respond to the FDA’s recently released discussion paper (the public is invited to respond up until Jan 16, 2024); as well as attend the FDA’s upcoming virtual public advisory meeting on Feb 2 2024.  I would also urge you to forward this podcast to your clinical colleagues as well as hospital and healthcare executives.  Zeev Neuwirth, MD

Friends, Primary care for seniors is different from care for younger patients. Yet, very few providers across the country have a different and distinct strategy to care for their aging senior patients. In this interview, we’ll be introduced to an organization that has made taking care of seniors a priority. The fundamental problems with attempting to apply generic primary care to senior care. The significant investments and thoughtful approaches that Humana has taken to create comprehensive and customized care for seniors, while also addressing inequities in care. The specific value-based care model design and data enablement that Humana has developed to support clinicians in meeting the care needs of senior patients. It’s remarkable to hear Dr. Vivek Garg discuss the multi-year strategy and tremendous commitment that has gone into the CenterWell Brand at Humana. One of the things I appreciate about Dr. Garg is his humility and transparency – about what Humana has achieved as well as what more we ALL need to achieve in order to provide the type of care that the aging senior population requires. As I mention in the closing comments of this interview, we need the type of leadership that Dr. Garg manifests – a leadership focused on outcomes that truly matter to people and communities. Wishing you all the best of health and wellness in the New Year! Zeev Neuwirth, MD

Friends, This interview is one of the most startling I’ve posted to date. In this episode, we discover that pulse oximeters – which measure blood oxygen levels – are not always accurate in people of color. Mounting evidence suggests that they’re far less accurate in people of color than in white people. They can overestimate the amount of oxygen saturation in the blood and miss low oxygen levels. As a result, people of color may be underdiagnosed and undertreated for low blood oxygen – in conditions ranging from pneumonia and flu, to numerous chronic lung conditions, to asthma, and heart failure. The clinical implications are profound. If low oxygen levels are not detected, people may not be provided appropriate monitoring and medical treatment – in their homes, in doctor’s offices, and in emergency departments, hospitals and intensive care units.  As long-time listeners of this podcast know, my approach is not to focus on what’s wrong in American healthcare; but instead, to identify what’s right – so we can adopt, scale and spread positive change. What’s right here is that one solution to this disparity already exists. Our guest, Neil Friedman and his colleagues have developed a pulse oximeter, Circul Pro, that is more accurate in people of color, as well as in white people. It’s been scientifically validated and approved by the FDA. You can learn more about it at www.circul.health.   Another positive development – two days after I recorded this interview, the Center for Devices & Radiological Health (CDRH) within the FDA released a discussion paper for public feedback entitled, “Approach for Improving the Performance Evaluation of Pulse Oximeter Devices Taking Into Consideration Skin Pigmentation, Race and Ethnicity”. They also scheduled a virtual public meeting on Feb 2, 2024 to discuss this issue.  Both announcements can be accessed here.   This interview raises more questions than answers.  For example:   Exactly how inaccurate is pulse oximetry in people of color, and to what extent is it clinically significant? Are clinicians and healthcare executives aware of the pulse oximetry issue?  And if they are, what are they doing about it? Why hasn’t the American public been made more aware of this issue, which has been documented in the medical literature for years? If pulse oximetry is racially biased, what other medical technologies, sensors, algorithms and protocols have racial biases built into them? This is one of those critically important issues that we need to learn more about and do more about. As our guest points out, the magnitude of this problem is enormous in that nearly 40% of the people who pulse oximeters are used on are people of color.  My purpose here is to create awareness and motivate positive action, not to lay blame. Along those lines, I would urge you to read and respond to the FDA’s recently released discussion paper (the public is invited to respond up until Jan 16, 2024); as well as attend the FDA’s upcoming virtual public advisory meeting on Feb 2 2024. The paper is well researched and it’s a call-to-action to advance the research – with very specific questions.  I would also urge you to forward this podcast and write up to your clinical colleagues – especially those with expertise in pulmonary, critical care, and sleep medicine.  As always, wishing you the best of health, Zeev Neuwirth, MD

Dr. Neil Wagle, Chief Medical Officer at Devoted Health, discusses the problems with primary care today and how Devoted Health offers an all-in-one solution. They focus on patients' perspectives, achieve incredible outcomes, and have constructed comprehensive clinical service lines. The podcast also explores virtual healthcare services, the importance of technology, working with provider groups and hospital systems, and the need for hope and realignment in the healthcare system.

Friends, In this episode we’re going to discuss the opportunity we have, collectively, to live longer and healthier lives – and the underlying transition that’s required in the healthcare industry to make that a reality over the next few years. The specific topics at hand include: (1) The economic imperative for why the American healthcare industry must move toward wellness; (2) the profound life-saving and cost-saving benefits of such an industry shift; (3) the central role that employers can play in wellness and longevity; and (4) some of the challenges and headwinds in this shift. Our expert guest today is Neal Batra, who is a principal in Deloitte’s Life Sciences and HealthCare practice which is focused on the redesign of business models and commercial operations. He also heads Deloitte’s Life Sciences Strategy & Analytics practice, leading the way on next-gen enterprise strategy, analytics and technology. Neal has more than 15 years of experience advising health care organizations and businesses in biotech, medtech, health insurance, and retail health care. He is the coauthor of Deloitte’s provocative ‘Future of health point-of-view’ – forecasting on the healthcare ecosystem in 2040, and the business models and capabilities that will matter most. He holds an MBA from London Business School and a BBA from the College of William and Mary. In this interview, we’ll discover: The difference between ‘life-span’ and ‘health-span’, and why ‘healthy longevity’ may be more important to us than longevity. How many additional years of life-span and health-span Neal and his colleagues believe Americans can experience by 2040. Why and how employers could be a major channel for enhancing healthy longevity. The amount of annual national healthcare spend we could save if we added well-care to our sick-care system. How this transition must include all Americans – an imperative from the disparities & inequities perspective, as well as the economic perspective. The foundational issue that Neal and his colleagues start off with is that our healthcare system, as amazing as it is – is focused on the ‘break it and fix it’ model.  It is a system that largely waits for disease and illness, and then dedicates tremendous resources and expertise toward dealing with that disease and illness burden. This is what he and many others refer to as a ‘sick-care’ system. This is in stark contrast to a system that is focused on proactive prevention of disease and illness. And Neals points out that this is not an either-or decision. What he recommends is a widening of the aperture – a diversion of some of the current healthcare spend to proactive and preventive well-care.  Neal opens up our discussion with a sobering revelation. For most Americans, the time of life when their health begins to erode corresponds to the time that they’re getting ready to retire. As he puts it, “Your healthiest years went to your employer, and in a time that was meant to be the ‘golden years’, or the years in which you had a financial foundation that allowed you to do different things with your life, your healthspan declines to a point where your quality of life declines.” A second revelation – that Neal and his colleagues have published on – is that if we transitioned to a wellness industry, Americans could add an additional 12 years to their lifespan and nearly 20 years to their healthspan, by 2040. His team has also projected that the American healthcare system could save $3.5 Trillion per year – what he refers to as a whopping ‘well-being dividend’. Neal’s point, not to be missed, is that the cost dilemma in American healthcare will not be solved through cost reduction in a sick-care system, but rather through cost prevention through a well-care system. In his own words, “I’d like to shift to a ‘cost-of-avoidance’ narrative versus a ‘cost-of-care’ narrative. The cost-of-care narrative is a trailing economic measure, and there is no amount of innovation that will ever make it cost-effective to address the population in this break-fix modality. The only way out of the economic death spiral we are in when it comes to healthcare is to jump in front of illness, and invest ferociously on disease avoidance, and early as well as real-time diagnosis.”  A critical finding – that Neal and his colleagues have also published – is that approximately $1Trillion of the $3.5 Trillion in savings will come from the elimination of the disparities and inequities in healthcare. One statistic he mentioned is that white Americans live on average, 78 years, while for black and native Americans, the ages are respectively, 72 years and 68 years. And while these and other disparities are unconscionable in and of themselves, the calculations add an economic imperative to the ethical arguments for eliminating the structural racism in our healthcare system. A third revelation and shocking forecast that Neal shared – which again, his analytics & actuarial team have published – is that, by 2040, 60% of healthcare spend in the US will go to well-care, not the treatment of disease and illness. He and his colleague predict that, by 2040, we are going to witness a “new health economy” with “new business models” which will drive 85% of all healthcare revenue. This new health economy will also be driven by a shift from a ‘rule-of-thumb’ to a ‘rule-of-one’ medicine – that is, the hyper-personalization of care – enabled by the digital and AI revolution in healthcare.  To balance out the dialogue, we did discuss the very real obstacles and headwinds to this sort of healthcare transformation. For starters, wellness care does not align with the current, predominant, industry business models. Neal’s counter-argument is that no industry has ever been transformed by incumbent stakeholders. It’s only through external pressure that the incumbents either respond and change, or they go by the wayside. His point of view is that hospital systems have two options: (1) continue to solely pursue the acute care/sick-care business model, and contract into an acute care focused factory; or (2) engage and expand into wellness care and the corresponding business models.   I don’t want to lose sight of Neal’s ‘both-and’ perspective, which is that it’s not that we have to choose between sick-care and well-care. Instead, we need to create a more balanced healthcare system that includes a significant well-care component. But, as Neal points out, we’ve got a long way to go to reach that balance. “If you held our sick care capabilities constant over the next decade and flowed everything into wellness and wellbeing, I think the yield on the American health system would be enormous economically, as well as from a health outcomes perspective”.  I’ll end with this personal observation. In my career, I’ve seen us accomplish miraculous things – creating space-age interventional cardiac labs, life-saving hemodialysis centers, and tele-stroke units. But here’s the rub. Wouldn’t you rather have the healthcare system focus a significant amount of resources and expertise on you NOT having that heart attack, kidney failure, or stroke in the first place?  I know I would.  Wishing you all the best of health and wellness! Zeev Neuwirth, MD