Friends, The day after we recorded this interview, I picked up the May 2nd 2023 issue of JAMA and discovered that one of the leading research studies was about the rising trend in mental health-related ED visits among youth. https://jamanetwork.com/journals/jama/article-abstract/2804326 The stats were shocking and of serious concern. Between 2011 and 2020, the percentage of pediatric ED visits attributed to mental health issues had risen from 7.7% to 13.1% – and the annual absolute numbers had risen from 4.8M to 7.5M – an average annual increase of 8%!  Even more startling was the 5-fold increase in suicide-related pediatric ED visits, which had leapt from 0.9% to 4.2% of all pediatric ED visits. Think about it. One out of every 25 pediatric ED visits are due to suicidality, and one out of every 7 pediatric ED visits are related to mental health!  The study authors stated that “these findings underscore an urgent need to improve crisis and emergency mental health service capacity for young people…”   This study was timely – but more to the point, this episode of Creating a New Healthcare’ was timely – in that we’re going to discover and hear about a company that has created an evidence-based, highly effective and accessible solution to the “urgent need” and “crisis” of acute mental health issues amongst youth in the U.S.   Our guest today is Carter Barnhart. Carter is the co-founder and CEO of Charlie Health, the largest virtual provider of high acuity mental health treatment for youth in crisis. You’ll hear much more about Carter’s background and the reason she founded Charlie Health during the interview. Prior to Charlie Health, Carter was in the C-suite at Newport Academy, a teen residential treatment program. In this interview, we’ll hear about: Some other startling statistics on the dramatic rise of life-threatening mental health challenges amongst teens in our country. The overcrowding of ED’s and the profound lack of access to effective care for teens who are experiencing acute mental health crises. A highly effective, evidence-based solution for acute mental health crisis called Intensive Outpatient Programming (IOP), which has existed for some time. How Charlie Health has virtualized this highly effective Intensive Outpatient Programming (IOP), and made it more personalized and more accessible to youth across the country. The “uphill” battle Charlie Health has been fighting to ensure Intensive Outpatient Programming (IOP) continues to be available and accessible to young people in need. Some important points to note about Charlie Health: First – When Carter and others refer to IOP as “Intensive” Outpatient Programming, they mean it. The Charlie Health treatment experience is customized to the needs of the individual client, and it’s comprehensive. Charlie Health’s virtual IOP includes 9-11 hours of evidence-based care weekly, via support group sessions, individual therapy, and family therapy. In addition, they have 24/7 emergency crisis care available to their clients and families.  Second – Carter and her colleagues have been incredibly diligent in implementing measurement-based care practices and outcomes transparency – both of which the behavioral health industry has been slow to adopt. They frequently partner with academic medical centers to study and publish peer-reviewed articles that demonstrate the efficacy of their program and track patient outcomes. What we know is that we now have an evidence-based program that is highly effective. Third – Not only is the program effective, but it’s accessible in an unprecedented way to youth across the country, due to its being a virtual-first program rather than a place-based IOP. As Carter states during the interview, over 95% of the people in this country do not have access to mental health treatment. Charlie Health has solved that problem of accessibility for those struggling most acutely – not discounting the fact that internet connectivity is still a problem for many Americans. Fourth – One of the profound advantages – and secret sauces – is that the virtual access enables Charlie Health to match the client with a therapist and a group of peers that are more like them – which Carter shares is a well known and critical success factor for sustaining engagement and achieving positive outcomes. Place-based brick and mortar programs have a far more limited selection of therapists and clients to match from.  FIfth – Another profound advantage of Charlie Health is that they partner with hospitals and emergency departments. This sort of integrated care is absolutely critical if we are going to solve the mental health crisis. Patients do have the ability and opportunity to access Charlie Health directly if they are experiencing a mental health crisis, but they can also be transitioned to Charlie Health in a timely way from an ED or from an inpatient hospital-based unit.   Finally – Charlie Health is a multi-faceted organization. In addition to its robust multi-modal IOP, they have a significant research arm, and they offer a “Charlie University” – on-going CEU training to their own therapists as well as for therapists outside of Charlie Health. One final significant activity is that they are constantly advocating for payment codes for IOP – what Carter refers to as an “uphill battle”, but one they seem to be winning as they are now live in 23 states! The problem of acute mental health crises amongst youth in our country is alarming, and continuing to worsen. As I said multiple times during the interview, it’s nothing less than heartbreaking. The problem is compounded by the lack of access to care, and even more than that, by the lack of access to care that actually works and helps these young people. Charlie Health has taken a proven highly effective treatment approach – Intensive Outpatient Programming (IOP) – and made it much more accessible, more customized, and I would suggest, more effective. The work Carter and her colleagues are doing to obtain payment codes for IOP is also life saving.  I’m overwhelmed by the magnitude of this heart-breaking problem, but even more overwhelmed by the empathy and effectiveness of the solution that Charlie Health has developed at scale. We need Charlie Health, and other virtually-enabled programs like it, deployed at many more hospital systems and ED’s across the country – as soon as possible. Until Next Time, Be Well Zeev Neuwirth, MD

Friends, This was the most challenging interview I’ve conducted and posted, in the nearly 6 years that I’ve been hosting the ‘Creating a New Healthcare’ podcast. I spent weeks listening to the audio file – trying to figure out how to understand it, what to do with it, and how to present it to you. In the end, I believe it’s important to share it and to broaden this specific dialogue. The conversation you’ll be listening to this episode is a conversation about an article that Dr. Don Berwick published earlier this year, in JAMA – the Journal of the American Medical Association. Its title: Salve Lucrum: The Existential Threat of Greed in US Health Care. I’ll save you the bother of looking up what ‘Salve Lucrum’ means. Here’s what chatgpt says: “Salve Lucrum” is a Latin phrase that translates to “Hail Profit” or “Greetings Profit” in English. The phrase has its origins in ancient Rome, where it was commonly used as a greeting among merchants and traders. It expressed the hope for a successful and profitable transaction, as well as the desire for financial gain. In addition to its use in ancient Rome, “Salve Lucrum” has also been used in various other contexts throughout history, including in medieval Europe and in modern times. It remains a popular phrase among businesspeople and investors who are focused on maximizing their profits. Per chatgpt, “It remains a popular phrase among businesspeople and investors who are focused on maximizing their profits.” Dr. Berwick’s thesis in the JAMA article, and in our conversation, is that “the immoderate pursuit of profit” has superseded the mission of patient care and public health. In the interview he states that it “has shifted the focus from people to money”, and that, “no sector of US healthcare is immune… neither drug companies, nor insurers, nor hospitals, nor investors, nor physician practices.”  I suspect that, for many of you who are employed in one of those sectors, this topic will be incredibly uncomfortable. I know it is for me. But, I also believe it’s a serious issue that deserves broader dialogue and attention. One might argue with some of the specifics and even the underlying premise that greed is the core problem. But, there is no question that the issues Dr. Berwick points out are real and are negatively impacting the health of Americans. One example of that reality comes from President Biden’s recent state of the union address in which he chides the pharmaceutical industry for the exorbitant, unethical and unnecessary pricing of medications. President Biden shared the example of pharmaceutical companies charging over $250 for a vial of insulin that costs $10 – $15 to produce. What makes this a public health agenda is that a significant percentage of the over 30 million Americans with diabetes can’t afford their insulin. Another recent and timely example is the actions that Congress and the President are taking to curtail some of the profiteering in the insurance industry sector in regard to Medicare Advantage risk adjustments and payments.  In this dialogue, Dr. Berwick walks us through each sector of the U.S. health industry, pointing out the perverse behaviors and implications of this “immoderate pursuit of profit”.  One important point to keep in mind. Dr. Berwick makes it abundantly clear that he is not speaking about individuals, but about the system. As he puts it, “I’m not pointing a finger at individuals at all. I’m saying you are trapped in a system which is making you act in ways you don’t want to…” Having said that, he’s also unabashedly stating that “profiteering, storing money away, getting the most you can, has become… the dominant behavior, the dominant agenda of too many organizations in the country.”   Toward the end of the interview, we shifted the conversation from critique to action. Dr. Berwick outlines three or four actions we can take to address this issue – whether from the perspective of patient, provider, caregiver, policy maker or administrator. None of them are easy, but all are necessary. After a few weeks of thinking about our conversation, I’m not sure that greed is the issue at all. I think a more fundamental problem is the one that Dr. Berwick has raised before and points out in this conversation. That issue being the commoditization of healthcare – having healthcare as a consumer good instead of a public good. As he states, “I have come to believe… we got this thing set up really wrong, that health and healthcare are important social goods. We all depend on it. We all need it. It’s like clean air, not like automobiles… A market for automobiles makes sense to me. A market for consumer goods makes sense to me. But not a market for clean air, and not a market for health. We’ve used market theory, profit theory, capitalist theory where it shouldn’t apply.” There is no doubt in my mind that Dr Berwick is identifying and articulating a problem of titanic proportion – a problem that is eroding the health and financial welfare for the majority of Americans. It is, as he suggests, an existential issue that is contributing greatly to the unsustainability of our current system of healthcare. Having said that, I’m still uncertain of what we can actually do about it. What I am certain about is that there are few other individuals in the healthcare industry with greater intelligence, integrity, courage and a track record of commitment to patient care and public health than Dr. Berwick. His message comes from a set of principles that are unadulterated and unfiltered. His authority is not one of power or position, but one of profound patient-centered and public health purpose. Dr. Berwick – his career and his leadership – is an exemplar of what we need more leaders to strive toward. I’ll wrap up this commentary with a goal that Dr. Berwick stated, and which also expresses my overarching goal in this interview and on this podcast. “My hope is that by speaking out and having others speak out, we can begin to create a sense of agency where we say, ‘we can change this and we will’…” Until Next Time, Wishing you Purpose and Agency Zeev Neuwirth, MD   Brief Bio on Dr. Donald M. Berwick: Donald M. Berwick, MD, MPP, FRCP is President Emeritus and Senior Fellow at the Institute for Healthcare Improvement (IHI), an organization that he co-founded and led as President and CEO for 18 years. An elected member of the Institute of Medicine (IOM), Dr. Berwick served two terms on the IOM’s governing Council, and was a member of the IOM’s Global Health Board. He also served on President Clinton’s Advisory Commission on Consumer Protection and Quality in the Healthcare Industry. Dr. Berwick contributed greatly to the landmark 2001 IOM report – Crossing the Quality Chasm; as well as the landmark, To Err is Human report. Dr. Berwick served as vice chair of the U.S. Preventive Services Task Force and chair of the National Advisory Council of the Agency for Healthcare Research and Quality. In July, 2010, President Obama appointed Dr. Berwick to the position of Administrator of the Centers for Medicare and Medicaid Services (CMS), which he held until December 2011. A pediatrician by background, Dr. Berwick has served as Clinical Professor of Pediatrics and Health Care Policy at the Harvard Medical School, Professor of Health Policy and Management at the Harvard School of Public Health, and as a member of the staffs of Boston’s Children’s Hospital Medical Center, Massachusetts General Hospital, and the Brigham and Women’s Hospital. He has co-authored over 160 scientific articles & six books. In 2005, Dr. Berwick was appointed “Honorary Knight Commander of the British Empire” by Queen Elizabeth II, the highest honor awarded by the UK to non-British citizens, in recognition of his work with the British National Health Service. 

Friends, The topic of this episode is about an emerging healthcare marketplace transformation, which is the introduction of platforms into healthcare. What surprised me about this movement is how many years it’s been developing. For example, last July I attended the 2022 MIT Platform Strategy Summit. Turns out it was their 10th annual symposium on this topic. The first day was dedicated to healthcare and entitled, ‘The Platform Revolution Comes to Healthcare’. The opening presentation was entitled, Healthcare Platform Megatrends: Discovering the Power of Network Effects. Our two podcast guests delivered that presentation. It was the most lucid and engaging explanation I’ve ever heard on the topic. Not surprising, given that they’ve been studying platforms for over a decade, have written blogs, spoken at prestigious institutions, launched their own podcast, and are writing a book.  Dr. Randy Williams is an experienced physician, healthcare executive, digital health pioneer and serial entrepreneur. He is the managing director of Digital Care Advisors, a healthcare strategic consulting and advisory firm. Following his medical training as a heart failure & transplant cardiologist at Johns Hopkins, he was recruited to Northwestern University where he built one of the first nationally recognized chronic care programs in heart failure and care management. Dr. Williams has testified in the US Senate and advised the Congressional Budget Office in both the George W. Bush and Barack Obama administrations on issues related to healthcare reform.  Vince Kuraitis is Principal and Founder of Better Health Technologies, LLC – developing strategy, partnerships and business models with a unique focus on platform strategy. His experience includes: President, Health Choice (medical call center), VP of Corporate Development & Specialty Operations at Saint Alphonsus Regional Medical Center; Regional Director of Marketing of National Medical Enterprises (hospital chain with 100 facilities). Vince holds both an MBA and a JD from UCLA. He is on the editorial advisory boards of Accountable Care News and Population Health News.  In this interview, we’ll discover: A platform does not only refer to a digital technology infrastructure, but is also a function of a novel business model. Examples of mega platforms in other industries – some of which have already entered the healthcare market. The opportunities platforms provide, as well as the strategic threat, especially if legacy stakeholders ignore them. What the ‘network effect’ means, as well as other characteristics that define a platform. The underlying market forces that are propelling platforms as a dominant component of healthcare delivery. Some important takeaways from this interview.  First, platforms will be a foundational component of healthcare delivery in the near future. They already are in many other industries. Think Amazon in retail, Uber in travel, AirBnB in the hotel industry, and Netflix in streaming entertainment. Second, platforms will revolutionize healthcare delivery, similar to the ways they’ve improved other industries such as banking, retail, travel and communications – making it more convenient, more consumer-oriented, more more accessible, more cost effective, and replete with more choices. Third, platforms are not a ‘nice to have’, and they’re not a futuristic phenomena. In fact, I first heard about platforms from the CEO of the Mayo Clinic, Dr. Enrico Ferrugia, during a talk he gave at the 2021 HLTH conference. He described the emphasis Mayo was going to place on platforms and some of the strategic advantages. As Dr. Randy Williams put it during the interview, “Every executive in healthcare needs to become familiar with what platform thinking is all about because they don’t want to fall asleep at the switch. This is coming to a neighborhood near you.” Until Next Time, Be Well Zeev Neuwirth, MD

Folks, We recorded this interview in February – the dead of winter – and I have to admit that I needed some sunshine and positivity. Steve Sell supplied it with his enthusiasm, his can-do spirit and the fantastic advancements that agilon is making in allowing providers to practice primary care medicine with more time, more resources and more support while improving the care, care experience and outcomes for patients, and more specifically for Seniors. How important is this?  Well, we all know that primary care is a withering specialty in American healthcare with dire consequences for the American public  in terms of health outcomes and costs of care. But don’t take my word for it. The National Academy of Science, Engineering & Medicine – in an extensive report published in May 2021 wrote, “…primary care in the US is fragile and  weakening…  it’s not configured to provide… comprehensive, preventive & chronic care needs…”.  The Centers for Medicare & Medicaid – also responding to this reality – literally has had two major refreshes of its strategy in the past year. Folks, the topic you’re going to be listening about in this episode is an existential issue for American healthcare.  So, when you hear the enthusiasm and excitement in my own voice during this dialogue, you’ll understand why.  Our guest this episode, Steve Sell, has served as the Chief Executive Officer and President of agilon health since June 2020. Prior to his current role, Steve served as President, CEO and Chairman of Health Net, Centene’s largest subsidiary, and has held a number of executive roles prior to that.  Steve received his B.A. from Swarthmore College and holds an MBA from the Stanford Graduate School of Business. In this episode, we’ll hear about: The challenges that primary care providers endure on a daily basis, and how agilon is solving these daily frustrations and impediments. How agilon is literally converting traditional fee-for-service ecosystems into value-based Medicare Advantage ecosystems. The incredible and much needed resources and supports that agilon is providing to primary care physicians and their practices. The multi-disciplinary, team-based approach that agilon is taking which directly and intentionally addresses the social determinants of health and health disparities – with demonstrable improvements in patient experience, care quality outcomes and cost reductions. The business model that mitigates the risk for primary care providers while enhancing their income as they transition from a perverse fee-for-service model to value-based payment. Friends – here’s the rub – the bottom line, so to speak. In the US, we spend way less than 10% of all healthcare expenditures on primary care – far less than most other developed nations. Despite the fact that decades of research demonstrate that the more primary care you have in a region, the better health outcomes you have and the lower costs you have. So, what we have is a perverse inversion of what we need from our healthcare system and in clinical care. The other perverse situation is that we’ve put primary care on a volume-driven, transactional payment and incentive model. The point of primary care is to prevent, and prevention takes time. It takes getting to know the individual and their family, the context of their life and their health habits, and then orchestrate care around their needs. It is a completely different value proposition than procedural care or even specialty care, and yet, we have ignored that and subjected both patients and providers to what many are now calling a ‘moral injury’.   What I don’t understand is how healthcare leaders across the country, who must know this, are choosing to ignore it. What I also don’t understand is how CMS is not studying models like this, emulating them and spreading them. This is not a hypothetical model of care. This is a model of care that has been replicated in numerous regions with numerous stakeholders. It is a model that has been applied to lower income populations.  And most importantly, it is a model that has demonstrated improvements in patient experience and outcomes of care, as well as reductions in avoidable care and costs.  What are the leaders and experts waiting for?? And again, this is why I truly appreciate and applaud what agilon – and other similar companies – are doing. They are taking the high road by infusing primary care with the resources and support to make it what it should be for patients, and providers and their teams. They are making the transition to value-based payment rapidly – not a ten year, fifteen-year or never-year plan – but now.   I won’t get into the specifics of how they’re doing all of this, but it’s all incredibly practical and all about the daily practice of medicine.  It’s all about where the rubber hits the road – removing the hundreds of daily roadblocks and incredibly frustrating, time-wasting hurdles that primary care providers are subjected to just to deliver good care. I would encourage you to listen to the podcast episode. It’s a truly elegant business model that removes the risk of transitioning from the primary care providers and allows them to practice medicine the way they know they should and the way they want to – the right way for their patients. It also allows primary care providers to do this while not suffering any loss in income. In fact, what surprised me is how much primary care providers can increase their income – which is frankly important if we are to have physicians, PA’s, and nurses go into primary care versus the much higher paying specialties.  I’m truly interested in hearing your thoughts and questions about what agilon is doing.  Please post on LinkedIn or Twitter. This is a dialogue we must have in order to drive the much needed changes in American healthcare. Until Next Time, Be Well. Zeev Neuwirth, MD

Friends, Let’s start with a statistic. I suspect that many of you consider rural healthcare a somewhat esoteric or niche market. Let’s correct that misconception right up front. There are over 60 million Americans who live in rural settings and they tend to be older and have more medical conditions than the general population. Just for comparison’s sake, there are 30 million Americans with diabetes – that’s half the number who live in rural America. Point being, the topic we’re talking about in this episode addresses about one fifth of all Americans and according to this week’s guest, “there’s definitely a misperception around the size and the crisis that’s happening in rural America.” And if you’re wondering what makes this a crisis, hit ‘play’ and listen to this enlightening dialogue with a healthcare leader who, along with her colleagues, is attempting to make a positive difference in the lives of nearly one out of every 5 Americans. Our guest this week, Dr. Jennifer Schneider, is the co-founder & CEO of Homeward Health. Prior to this, she served as Chief Medical Officer of Livongo and then as its President, where she led the company’s strategic clinical product vision, data science & clinical trials. As many of you are aware, Livongo was acquired by Teladoc in the largest digital health acquisition to date. Prior to Livongo, Dr. Schneider held several key leadership roles at Castlight Health, including as its Chief Medical Officer.  Earlier in her career, she was a health outcomes researcher and Chief Resident at Stanford University, and has practiced as an attending physician at Stanford University and Kaiser Permanente. She is the author of Decoding Health Signals: Silicon Valley’s Consumer-First Approach to a New Era of Health, which explores how companies are using big data analytics and artificial intelligence to reinvent care delivery for people with chronic conditions.  In this episode, we’ll hear about: The unique challenges of providing and receiving healthcare in rural America Some startling statistics about the lack of providers and access to care in rural America. The 3 differentiating ways in which Homeward Health is tackling the problem of rural healthcare. A unique partnership that Homeward Health has formed with Rite Aid. Some of the amazing state-of-the-art, tech-enabled approaches that Homeward Health is bringing to an antiquated system of care for the elderly in rural America. This mission is very personal for Dr. Jenny Schneider, as was her last venture at Livongo. Jenny was diagnosed with type 1 diabetes as a child, and her treatment was delayed for weeks because she was living in rural America and did not have access to the healthcare she needed. So, in a very real sense, she has come home. With Livongo and now with Homeward, Jenny – one of the leading physician healthcare entrepreneurs in our country – is addressing medical conditions and healthcare challenges that she and her family have great personal familiarity with. It’s a profoundly purposeful story.  While the technologic and digital sophistication that Homeward Health uses is amazing, the real differentiation is that they are tackling the very practical challenges in a 3 part fashion.  First, the shift to a viable economic model: value-based payment. They’re focused on the senior segment and are leveraging Medicare Advantage payments. Let’s be clear, there is no way that Fee-For-Service (FFS) aligns with the care of the elderly. Older people require a relational approach to healthcare, not a transactional approach, and the FFS payment model incentivizes transactional volume, not relational preventive care.  Second, Homeward is able to replicate and scale its services because of the state-of-the-art tech-enabling platform. Folks – there is no way around this. The brick & mortar, centralized care delivery model is not financially viable. What is needed now – for so many reasons – is the ability to utilize remote patient monitoring, virtualized care, and home-based care delivery.  Third, the key differentiator is building credibility, trust and synergistic impact through partnering with local healthcare systems.  I love the fact that Homeward is partnering with hospital systems in a way that benefits the healthcare system, the local communities and most importantly, patients and their families. We’ve heard this theme of partnership from other forward thinking healthcare entrepreneurs. It may be the key to unlocking the future of healthcare delivery.   The partnership with Rite aid is particularly interesting. As I understand it, Homeward is using mobile health units and literally parking itself in Rite Aid parking lots. This does at least two things.  First, it brings medical care closer to people’s homes in rural America; and second, it provides tremendous convenience by enabling folks to obtain their prescriptions and other medical equipment simply by walking right into the adjacent Rite Aid store.  Keep in mind that we’re talking about older patients in which medications are not only critical but a major challenge – in terms of appropriate dosing and polypharmacy. Being next to Rite Aid, with immediate access to pharmacists and pharmacy tech’s is the right way to deliver healthcare for the senior population.   The specifics of the care model that Jenny and her colleagues have created is incredibly elegant and supremely patient-focused, with much of it actually being accomplished within patients’ homes – both virtually and in person. I hope you appreciate learning about it as much as I did; and please let me know what you think. Until Next Time, Be Well. Zeev Neuwirth, MD

Friends, I have to tell you that each time I have the opportunity to speak with Dr. Patrick Conway, it’s a treat. He is an erudite and accomplished healthcare executive – having served as the CEO of Blue Cross Blue Shield of North Carolina and previous to that as the deputy administrator for innovation and quality at the Center for Medicare and Medicaid Services, as well as the agency’s Chief Medical Officer. He also brings an incredibly grounded perspective from his many years of clinical practice as a pediatric hospitalist (which he continues to do), and in his previous role overseeing clinical operations and quality improvement at Cincinnati Children’s Hospital. Of note, at one point he also practiced in a federally qualified healthcare center, serving the most undeserved families in our healthcare system. I’m not at all surprised at the accolades he’s received – being elected to the National Academy of Medicine in 2014 and receiving the President’s Senior Executive Distinguished Service Award. But, what impresses me the most about Dr. Conway is his never ending pursuit to create better healthcare – better healthcare for children, for the elderly, for individuals on Medicaid and dual eligible patients with disabilities and complex chronic conditions, and for those suffering with mental illness. I could have easily titled our conversation, ‘Caring for the underserved in American healthcare’. Patrick is a highly experienced and practical executive who can quote stats, facts, policies and payment models with the best of them; but what he can also do is share with you the real life stories of patients he’s seen and continues to see – stories that reveal the critical need to transform American healthcare.  In this episode, we’ll hear about: The vast portfolio of care solutions that Dr. Conway oversees which includes home and community care, post-acute care, mental and behavioral health, specialty care, complex chronic care, senior care, and federal health services. A dive into the behavioral health “crisis” and what Optum Healthcare is doing to address it. A discussion on the challenges of rural health and senior care, with examples of the solutions and partnerships that Optum is assembling, including a recent partnership with Walmart.  A couple of recommendations Dr. Conway has for hospital system leaders. Some reflections regarding the impact CMS and CMMI has and are continuing to have on American healthcare. The scope and scale of what Dr. Conway and his colleagues are building is remarkable, and yet, he will be the first to admit that his organization is not flawless and they are still figuring it out. He’ll also be the first to point out the awesome potential for good and the possibilities at scale they are striving for. What inspires me the most about Patrick are the underlying values he brings to this work.  In this interview he notes that competition is a fact of life; but, we can and should be more collaborative. He is an ardent, long-time champion for the accelerated transition to value-based care. And finally, he talks about the selfless risks that leaders must be willing to take in order to manifest their mission – financial risks, cultural risks and leadership risks.   I expect that there will be some listeners and readers who will be critical of my lauding Optum. Look, while there are valid criticisms that can be directed at UnitedHealth Group and its insurer arm, UnitedHealthcare, I don’t know many stakeholder groups in American healthcare that are immune from serious critique and in need of significant reformation. Folks, my purpose in this podcast is not to critique, but to discover positive transformative change and to share that with others – to learn from, to emulate and to collaborate with positive deviance, so that we can humanize our healthcare system.   The reality is that we can’t continue on the path and trajectory we’ve been on for the past few decades. We are at numerous existential crossroads in healthcare, and in the health and welfare of our public. We need to figure out how to reframe, redesign and reorganize our healthcare system so that it delivers what we all want and need for our families, our communities and our country. And that means we’ll have to figure out how to relate to one another differently.  So, I hope you perceive this dialogue in the way it was intended: as an inspiring message about possibilities. The message I hope you hear is one that transcends what you think of payers or retailers or big tech or any other stakeholder in the healthcare industry. The message I hope you hear is a shared collective mission.  And, my friends, we must rally around that mission, if not for our sake, then for the sake of the generations that follow us.  Until Next Time, Be Well. Zeev Neuwirth, MD

Friends, It’s always enlightening and inspiring to hear from Dr. Robert Pearl, our guest this episode. He tackles critical issues in healthcare head on and with unabashed honesty and unfiltered integrity. The topics you’ll be hearing about this episode include what Dr. Pearl refers to as “the middleman mentality”, which he argues is “killing American medicine” and limiting the potential of healthcare leadership, leading to an incrementalist approach. We’ll also hear his insightful perspective on how large disruptors like Amazon, CVS & Walmart are playing what he calls “healthcare’s long game”, and the impact that could have on legacy healthcare systems and providers. Dr. Robert Pearl was the CEO of The Permanente Medical Group (Kaiser Permanente) from 1999-2017. In this role he led 12,000 physicians, 42,000 staff and was responsible for the nationally recognized medical care of over 5 million Kaiser Permanente members on both the west and east coasts. Named one of Modern Healthcare’s 50 most influential physician leaders, Dr. Pearl serves as a clinical professor of plastic surgery at Stanford University School of Medicine and is on the faculty of the Stanford Graduate School of Business.  He is the author of two books, Mistreated: Why we think we’re getting good healthcare – and why we’re usually wrong, and Uncaring: How the culture of medicine kills doctors and patients.  He is also a podcast host and a regular contributor to Forbes. In this episode, we’ll hear about: The incrementalist “middleman” mindset and the type of transformative leadership that will be required for healthcare systems to thrive. The short, middle and long game that large retailers are playing, and the impact this will have on hospital systems & provider groups. A strong argument for why healthcare must move to capitation, and why it has to be embedded at the healthcare delivery level. Dr. Pearl is not speaking from an idealistic or ivory tower perspective. He is speaking from decades of delivering some of the highest quality, most accessible, and most cost effective care we’ve witnessed in our country – at scale!  He does not sugarcoat the challenge that healthcare systems face in transitioning from an out-moded fee-for-service (FFS) business model to value-based payment. But, at the same time, he holds no punches in articulating how damaging the FFS based healthcare system is for patients, for providers, and for our communities. He also makes the point that the current system is actively being disrupted. Given those realities, the argument for incrementalism seems indefensible; and yet, that is where we find ourselves today. The solution, according to Dr. Pearl, is leadership. The type of forward-thinking leadership that is willing to make the tough decisions and willing to take the courageous steps to transform healthcare delivery. Until Next Time, Be Well. Zeev Neuwirth, MD

Friends, In this episode, we have the unique opportunity of being introduced to two critical components in the future of healthcare delivery: platforms and flywheels.  We also have the great fortune of being introduced to one of the national leaders in digital healthcare, Sara Vaezy. Our guest will share why and how platforms and flywheels are necessary for healthcare systems to remain competitive in the digital era, and why they’re important now. Sara Vaezy is the recently appointed Chief Digital Officer for Providence where she is responsible for digital strategy, product innovation, marketing, digital experience, and commercialization for the integrated delivery network which includes 52 hospitals and over 1000 clinics serving over 5 million unique patients. In addition to her work at Providence, Sara serves as the NCQA Board Director, as a member of inaugural class of the Frist Cressey Ventures Collective, a Health Evolution Forum Fellow, a World 50 Digital 50 member, and a Forbes Business Council Member. She has won numerous awards and recognitions that include a Becker’s Rising Star in Health IT (2020) and a Becker’s Women to Watch in Health IT (2020 & 2022). Sara holds an MHA and an MPH in Health Policy from the University of Washington School of Public Health and BA’s in Physics and Philosophy from the University of California, Berkeley.  In this episode, we’ll discuss: Why platforms and flywheels are vital for the mission and viability of healthcare systems.  Examples of platforms and flywheels outside of healthcare and how they enhance consumer acquisition, engagement and retention.  Why platforms are a prerequisite for healthcare systems to compete effectively in the digital era.   How flywheels can also support the transition to value-based care  The ‘know me, care for me, and ease my way’ promise that Providence Health makes to its patients, and how that directs their digital health strategy and deployment.  There are numerous lessons to be learned from Sara Vaezy in this dialogue – lessons about healthcare consumerism, digital healthcare, the competitive landscape and value-based care.  Speaking with Sara is always a privilege, a pleasure and a deeply inspiring experience.  Until Next Time, Be Well. Zeev Neuwirth, MD

Friends, The problem of inequity in women’s health is a hugely disturbing one, particularly in American healthcare. For example – the disparity in maternal-fetal mortality & outcomes among Black women compared to White women in our country is an egregious example of a long-standing unsolved inequity. To put it plainly, it’s a shocking disparity and one that has to be addressed and eliminated.   In this dialogue we are introduced to another shocking inequity in women’s health. The issue is menopause, and I have to admit that I was unaware of the enormity of this unaddressed issue, and its debilitating impact on literally tens of millions of women each year. As always, our main focus here will not be on the problem, but more so on a solution that a courageous group of leaders have deployed to create a new and more humanistic approach to healthcare in our country.   Joanna Strober is the CEO of Midi Health.  Prior to Midi, Joanna founded Kurbo Health, a digital therapeutic for childhood obesity that she grew to serve tens of thousands of adolescents worldwide and sold to Weight Watchers in 2018. Prior to following her passion for digital health, Joanna spent fifteen years making investments in venture capital and private equity. Joanna is also the co-author of Getting to 50/50, a best selling book written to help parents thrive in the workforce after having children. Joanna received her BA in Political Science from University of Pennsylvania and holds a JD from University of California, Los Angeles where she was UCLA Law Review editor. In this episode, we’ll discover: How Joanna Strober personally discovered one of the great hidden inequities in American healthcare – an issue that is impacting nearly 60 million women. How painful and debilitating menopausal symptoms can be, and how these symptoms can be mis-disagnosed and mis-treated by well-intentioned providers. The impact menopause has on the professional lives of tens of millions of women in our country, and its negative impact on corporate America. The evidence-based, expert-supported, consumer-oriented & hyper-focused model of care that Joanna & her colleagues have created to address the problem of menopause in America. How Midi Health can be a synergistic and collaborative partner with providers and healthcare systems. A number of summary learnings are well worth reviewing:   Nearly 60 million women in the USA are in the menopausal age range. The symptoms are incredibly debilitating and are often missed and misdiagnosed by providers, leading to costly testing as well as inappropriate treatments. It’s not hard to see how these symptoms could be confused for other issues, as they include: migrainous headaches, sleep disturbances, anxiety and depression, heart palpitations, brain fog, memory problems, and a lack of energy.  As Joanna states, when these symptoms arise in a women between the ages of 40 to 65, menopause should be on the top of the list of possible causes rather than at the bottom. Women struggle to find appropriate care because the bottom line is that primary care physicians, neurologists, cardiologists, sleep medicine doctors and even gynecologists don’t get significant, if any, formal training in menopause. In addition to the personally debilitating symptoms, menopause also impacts women’s professional lives. Here are some stats Joanna shared with us:  Nearly 60% of women have to take time off from work due to menopause. Nearly 20% have to take off more than 4 weeks. In one survey, 60% of women said they did not apply for a promotion or raise because of their menopause symptoms. 25% said they had considered quitting their jobs, and 10% actually quit their jobs as a result of their menopausal symptoms What struck me during this interview was the truly exceptional clinical program that Joanna and her colleagues have built at Midi Health. It is one of the most elegant and sophisticated clinical/operational models of care that I have come across. It’s also supremely consumer oriented. The model is virtual which makes it accessible and convenient. Below is a high-level overview. The major interface women have is with a nurse practitioner who is certified by NAMS – the National Association of Menopause Specialists. In addition to being highly trained and vetted, these nurse practitioners are also following continuously updated, evidence-based protocols that the renowned experts at Midi Health have painstakingly created. If you take a look at their website, you’ll get a sense of the depth of the experts and expertise that Midi has brought to bear.   In addition to the NAMS certification and updated protocols, these nurse practitioners receive on-going training by the core team of experts. During the actual patients visits, the nurse practitioners also have real-time, on-demand access to the panel of experts. So they can literally obtain an expert consultation during the virtual visit.  And, this is not just general menopausal experts; but it’s specific sub-specialized expertise such as for breast cancer or osteoporosis or mental health or for naturopathic treatment alternatives.   Prior to the initial virtual visit, women complete a comprehensive pre-visit assessment which allows the Midi providers to be highly focused and to customize the visit.  The NP’s, working in conjunction with the women’s providers, can order tests. Once a treatment plan is decided upon they can prescribe the appropriate hormonal or naturopathic treatment.  Joanna shares that it usually takes a few follow-up virtual visits to adjust and correctly titrate the right dosing, and then these women are followed up as needed or annually.   What’s important to point out is that the Midi model is one that is complementary to provider groups and health systems. Midi NP’s will refer back to the women’s PCP or ObGyn for testing and for more clinically complex situations such as bone fragility or bleeding. I was pleasantly surprised to discover that it is a collaborative and not a competitive model of care. As Joanna states during the interview, “Our women are getting mammograms and they’re finding out that they have breast cancer.  We are diagnosing a lot of osteoporosis.  We want to partner with hospital systems because we’ll be sending a lot of patients to them.  We don’t view it as competitive.  Instead, we think our goal is to be this initial screen, to do this initial care and then refer into the hospital’s systems for what they do best, which is the more specialized care and more specialized procedures.” Menopause has been a hidden giant of a problem that women have suffered with, and it’s breathtaking to see how Midi Health is solving for it. One of the core underlying reframes here is the segmental focus that Midi has taken. The team at Midi has developed a highly focused, highly customized solution that addresses a very specific – but large – gap in American healthcare.  I think there’s a lesson here that can and should be transposed onto other conditions. I believe that Midi, and others in this genre are creating a whole new category and categorization of healthcare.   As you may have noted, Midi Health provides care for women with commercial health insurance. While we did not explore this topic, one would hope and expect that the solution will be made available to women who are uninsured, under-insured, as well as those on Medicaid. Midi is charting a bold new direction in healthcare and they are differentiating themselves in numerous ways.  First, they are differentiating themselves as a highly credible and reputable healthcare company, not as a product company.  Second, they are creating a virtual platform with the ability to scale, as opposed to the more typical brick and mortar clinics that are much more costly and geographically limited. This model will be able to treat women across the country and across the globe.  Third, due to the virtual visits and their digital tech platform, they will be able to collect significant amounts of data that can be analyzed and used to improve and further personalize care.  And finally, they are creating a collaborative model of care that can be integrated with providers and healthcare systems.  I truly admire and respect what these folks have done. It’s awe inspiring.  I believe that we will be seeing and hearing a lot more from the tremendous leaders and team at Midi Health.   Until Next Time, Be Well. Zeev Neuwirth, MD

Friends, Our dialogue this episode centers on one of the most transformative and divergent clinical care models that I have come across. People throw around phrases like relationship-centered, patient-centered, preventive, personalized, and social determinants of health. In the model we’re discussing in this episode, you’ll see all of that actually being integrated into a coordinated ecosystem of care that delivers continuous, comprehensive, cost-effective and dignified VIP care to older, poorer and sicker Americans. People refer to ChenMed as one of the iconic, value-based senior care models or Medicare Advantage care models. It is also one of the best examples of a mission-driven healthcare organization. If you’ve ever wondered how a small group of people can transform the American healthcare system, I would suggest you listen very carefully to this interview. I would also recommend that you read the book that Dr. Chris Chen & Dr. Gordon Chen recently co-authored, The Calling – a Memoir of Family, Faith and the Future of Healthcare. Dr. Chris Chen is CEO & Co-Founder of ChenMed. Since becoming ChenMed’s CEO in 2009, Dr. Chen and his colleagues have built the decades-old, highly successful ChenMed model into a scalable organization with over 100 sites now spanning dozens of cities across numerous states.  ChenMed has been named to Newsweek’s “Most Loved Workplaces” list, Fortune Magazine’s “Change the World” list, as well as earning recognition by the White House, the Department of Health and Human Services, and the U.K. National Health Service. ChenMed was recently named by Newsweek as the #1 workplace in healthcare. ChenMed has also been featured in numerous publications including Medical Economics which named ChenMed, “Best Primary Care System in the U.S.”  Dr. Chen graduated from the University of Miami’s Honors Program in Medicine. He went on to complete his medical training at Beth Israel Deaconess, a Harvard University teaching hospital, after which he completed a fellowship in cardiology at Cornell University Medical College in New York City. In this episode, we’ll discover: The foundational healthcare vision and mission that this organization adheres to and delivers upon.  The pivotal capitation payment model ChenMed has adopted, and how that enables the shift from transactional, volume-driven and reactive care to one that is highly relational, personalized and preventive.   The numerous clinical, operational and technologic initiatives and infrastructure ChenMed has launched, which differentiate it from the primary care being deployed in the vast majority of healthcare systems across the country. How ChenMed treats its providers with the same respect, dignity and humanity that it applies to the patients and families it serves. The analytic and technologic sophistication that ChenMed has invested in, which greatly enable providers and their teams. The remarkable business acumen that Chris and his colleagues bring to bear – allowing for a model that is viable, replicable and scalable. I first met Chris Chen over seven years ago, and I’ve been observing the phenomenal maturation and advancement of the ChenMed model ever since.  Below are 3 reflections.  First, ChenMed is solving a serious and unresolved problem in our country – affordable, effective and dignified healthcare for older, sicker and poorer Americans. Poverty, overall, in the US is decreasing; but it appears to be rebounding for older Americans. A recent NYT article by Lydia DePillis (An Uptick in Elder Poverty: A Blip, or a Sign of Things to Come, Oct 17, 2022) cites that nearly one in ten Americans over the age of 65 live below the poverty line. One in five Hispanic or Black American Women over 65 live below the poverty line. One in four Americans over 65 years of age make less than 150% of the federal poverty line which is, on average, $19,494 for an individual living alone.  I was surprised, actually shocked, to learn of the high and rising prevalence of poverty amongst our senior population. At this level of poverty, preventive primary care is unaffordable. The ethical imperative is clear. But, what we also know is that the vast majority of the costs of healthcare are attributed to the older, sicker and poorer population. So, there is an economic imperative as well.   Second, what I have come to learn is how poorly understood ChenMed is amongst healthcare leaders. I’ve listened to knowledgeable experts speak without any coherent awareness of the integrated ecosystem ChenMed has built. I’m under no illusion that I fully understand the ChenMed model, but I continue to be an avid student; and continue to be an outspoken champion. Third, one thing I’ve observed over and over again with ChenMed is their divergent thinking and approach to primary care, and healthcare in general. They have reframed the practice of medicine to align with the core principles of our profession. There are literally dozens, if not hundreds, of ways that this manifests in their clinical, operational and technological infrastructures; in their processes and protocols; and most importantly, in their outcomes. Chris highlights a few of these differentiating elements in our dialogue.  I’ll share an example below. Most primary care across the country is based on a volume-driven, RVU-based, transactional framework that does not recognize that some patients require a very different approach. The wisdom, humanity and integrity of the senior Dr. James Chen and his sons is their firm belief that primary care is about establishing a healing and healthful relationship, not about being a visit vendor. They have understood that in order to create healthful relationships in older and sicker patients, visits must be more frequent, longer, supported by a team, and intensely focused on contextual factors, non-clinical determinants of health and lifestyle modifications. They have understood that this requires much greater investment in primary care, sophisticated protocols and technology that is built specifically for this purpose, and ultimately an approach that they characterize as love. They have also understood that top-down, centralized and generic approaches to population health are blunt instruments. So instead, they’ve empowered, deputized and resourced their physicians to essentially be the population health managers of their patients. Another related example is that they’ve reduced the number of patients each provider cares for to 400.  Contrast that to the typical primary care doctor in the US who carries a panel size between 1500 – 2000 patients. This profound decrease in panel size enables ChenMed physicians and their teams to provide the holistic, comprehensive, continuous and personalized care that is required for this segment of the population. It allows them to spend the attention and time that is required to keep these patients healthy, and out of the ED and hospital. ChenMed is a humanistic inversion of the American healthcare system. It’s approach is an anomaly that, in my opinion, should be studied and applied more broadly across our country. The Chens and their colleagues are missionaries bringing care to the underserved populations in our country: to seniors, to those who have less means and less money, and to those who have more complex and challenging clinical and psychosocial situations. What’s incredible is that the care, experience and outcomes they’re bringing are far superior to the primary care that the vast majority of older Americans receive, and it is far more cost effective. The ChenMed approach and others that are similarly rehumanizing healthcare are incredibly inspiring and compelling. Over the past few years I’ve been pondering the question of why healthcare systems around the country aren’t adopting or emulating these models of primary care, at least for the underserved populations and communities they serve?  I am sincerely interested in how those of us in leadership roles in healthcare can see models like this and not become immediate advocates and champions. I’m sincerely interested in your thoughts and questions. Until Next Time, Be Well. Zeev Neuwirth, MD