Creating a New Healthcare

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

Glen Tullman, Founder & CEO of Transcarent, discusses the need for a better healthcare system, a consumer-centric approach to digital health, Transcarent's offerings to hospital systems, progress and updates at Transcarent, and the importance of encouraging change and innovation in healthcare.

Friends, The central role that Medicare, and CMS, play in our healthcare system can not be overstated. There are approximately 64 million Americans in the Medicare program, with annual payments of $1 Trillion, comprising over 20% of the healthcare spend in our country.  In addition to its size and scope, CMS, through the Medicare program, is leading the nation in advancing value-based care, and has been deploying landmark historic initiatives at an accelerated pace. This is a unique interview in that we will be hearing directly from the impressive and highly accomplished leader at CMS who is leading Medicare. And, as I promised during the interview, I’ve attached a few links to cms.gov at the end of these notes. Our guest this episode is Dr. Meena Seshamani who currently serves as Deputy Administrator and Director of the Center for Medicare, at the Centers for Medicare & Medicaid Services. Since joining CMS, Dr. Seshamani has led her team of nearly 1,000 through a critical agenda of initiatives to advance health equity; expand access to coverage and care; drive innovation for high-quality, whole-person care; and promote affordability and sustainability of the Medicare program for generations to come. She is the senior official responsible for CMS’s implementation activities under the Inflation Reduction Act, which is the largest change to the Medicare program since the enactment of Part D in 2003. Dr. Seshamani is a Hopkins trained surgeon and an economist, having obtained a doctorate in economics at Oxford. Prior to joining CMS, she served as Vice President of Clinical Care Transformation at MedStar Health – a multi-hospital system – where she developed & implemented population health and value-based care initiatives. She also cared for patients as a head & neck surgeon at MedStar Georgetown University Hospital and at Kaiser Permanente in San Francisco. Dr. Seshamani served on the leadership of the Biden-Harris Transition HHS Agency Review Team. Prior to MedStar Health, she was Director of the Office of Health Reform at the US Department of Health and Human Services, where she drove strategy and led implementation of the Affordable Care Act across the Department, including coverage policy, delivery system reform, and public health policy.   In this interview, we’ll discover: How providers can be aware of the activities at CMS, and how to engage more with CMS.  Some of the most significant recent changes in Medicare that are coming out of the Inflation Reduction Act, as well as other landmark programs.  How CMS is encouraging and supporting providers in joining and advancing their participation in alternative payment models like the Medicare Shared Savings Program – the largest accountable care organization in the country.  How CMS is directly supporting providers in rural America – providers who are caring for tens of millions of Americans. One of the most landmark initiatives we discussed in this interview was the historic ‘Medicare Drug Price Negotiation Program’. This is the first time ever that Medicare will be negotiating directly with pharmaceutical manufacturers for the prices of some of the highest cost drugs in the Medicare program. It’s fascinating to hear Dr. Seshamani describe the thoughtful and thorough preparation, as well as the ongoing research and assessment that is going into architecting the negotiation process. It’s also compelling to hear that CMS is focused not only on optimizing costs but also on evaluating the real-world effectiveness of these medications. In its first year, the program will focus on ten of the highest cost medications, but those numbers will increase rapidly to cover many more high-cost medications. The law will also cap medication costs for any individual Medicare beneficiary to no more than $2,000 per year. Another landmark initiative we discussed is the ‘intensive outpatient program’. As Meena eloquently puts it, “We have made some of the most significant changes in behavioral health in the history of the Medicare program – creating entirely new benefits…”  For example, these new benefits allow licensed marriage & family therapists, mental health counselors, addiction counselors, and care navigators to become billable Medicare providers – so that beneficiaries receive more whole-person, team-based care, radically improving the way that mental healthcare can be delivered. I came away from this interview awed by the sheer number of historic, value-based initiatives that CMS is launching – enhancing affordability and equity of care and advancing care in critical areas such as behavioral health. I was also impressed by the transparency and level of engagement that CMS is enabling with providers and the public at large. Another facet that I have to call out is the focus CMS is placing on studying the effectiveness of their efforts, with an emphasis on actual health outcomes in the real-world setting.  There is so much more happening at CMS that we did not have the time to cover. What CMS is doing, and importantly, how they’re doing it, is a manifestation of their courageous, humanistic, conscious leadership. It’s also a reflection of the capability, commitment and integrity of their teams, and their overall palpable dedication to public service.  I came away from this interview hugely inspired and hopeful about the future of American healthcare. We have extraordinary leaders and sophisticated, dedicated teams at CMS – public servants who are advancing and transforming healthcare delivery in unprecedented ways. Their pace, productivity, and impact is remarkable. Their purpose is exemplary. I hope you come away from this interview as catalyzed to engage with CMS as I am. To that end, please take a moment to click on the cms.gov links below – and join in enhancing CMS’s mission. Until Next Time, Zeev Neuwirth, MD   Proposed CY 2024 Physician Fee Schedule Rule: Press Release: https://www.cms.gov/newsroom/press-releases/cms-physician-payment-rule-advances-health-equity Behavioral Health Blog: https://www.cms.gov/blog/important-new-changes-improve-access-behavioral-health-medicare General Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2024-medicare-physician-fee-schedule-proposed-rule Medicare Shared Savings Program Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2024-medicare-physician-fee-schedule-proposed-rule  Quality Payment Program Fact Sheet (PDF): https://gcc02.safelinks.protection.outlook.com/?url=https%3A%2F%2Fqpp-cm-prod-content.s3.amazonaws.com%2Fuploads%2F2483%2F2024%2520QPP%2520Proposed%2520Rule%2520Fact%2520Sheet%2520and%2520Policy%2520Comparison%2520Table.pdf&data=05%7C01%7CDiana.Perez-Rivera%40cms.hhs.gov%7Cc22ffc1b576744bc8a6808db83ec982d%7Cfbdcedc170a9414bbfa5c3063fc3395e%7C0%7C0%7C638248824408723905%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C3000%7C%7C%7C&sdata=XIEAjHwFCgW8KZskBift7lQrbZ7HUTJdlvQNKztH7Sw%3D&reserved=0 Proposed Rule: https://www.federalregister.gov/documents/2023/08/07/2023-14624/medicare-and-medicaid-programs-cy-2024-payment-policies-under-the-physician-fee-schedule-and-other Comments due by September 11, 2023   Proposed CY 2024 Outpatient Prospective Payment System Rule: Press Release: https://www.cms.gov/newsroom/press-releases/cms-proposes-policies-expand-behavioral-health-access-and-further-efforts-increase-hospital-price General Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/cy-2024-medicare-hospital-outpatient-prospective-payment-system-and-ambulatory-surgical-center Hospital Price Transparency Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/cy-2024-hospital-outpatient-prospective-payment-system-opps-policy-changes-hospital-price Proposed Rule: https://www.federalregister.gov/documents/2023/07/31/2023-14768/medicare-program-hospital-outpatient-prospective-payment-and-ambulatory-surgical-center-payment Comments due by September 11, 2023   Proposed CY 2024 Home Health Prospective Payment System Rule: Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2024-home-health-prospective-payment-system-proposed-rule-cms-1780-p Rule: https://www.federalregister.gov/documents/2023/07/10/2023-14044/medicare-program-calendar-year-cy-2024-home-health-hh-prospective-payment-system-rate-update-hh Comments due by August 29, 2023   Proposed CY 2024 End Stage Renal Disease (ESRD) Prospective Payment System Rule: Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/calendar-year-2024-end-stage-renal-disease-esrd-prospective-payment-system-pps-proposed-rule-cms Rule: https://www.federalregister.gov/documents/2023/06/30/2023-13748/medicare-program-end-stage-renal-disease-prospective-payment-system-payment-for-renal-dialysis Comments due by August 25, 2023   Final FY 2024 Inpatient Prospective Payment System Rule: Press Release: https://www.cms.gov/newsroom/press-releases/new-cms-rule-promotes-high-quality-care-and-rewards-hospitals-deliver-high-quality-care-underserved Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/fy-2024-hospital-inpatient-prospective-payment-system-ipps-and-long-term-care-hospital-prospective-0 Rule: https://www.federalregister.gov/public-inspection/2023-16252/medicare-program-hospital-inpatient-prospective-payment-systems-for-acute-care-hospitals-and-the   Final FY 2024 Inpatient Psychiatric Facility Prospective Payment System Rule: Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/fiscal-year-2024-medicare-inpatient-psychiatric-facility-prospective-payment-system-and-quality Rule: https://www.federalregister.gov/documents/2023/08/02/2023-16083/medicare-program-fy-2024-inpatient-psychiatric-facilities-prospective-payment-system-rate-update   Final FY 2024 Inpatient Rehabilitation Facility Prospective Payment System Rule: Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/fiscal-year-2024-inpatient-rehabilitation-facility-prospective-payment-system-final-rule-cms-1781-f Rule: https://www.federalregister.gov/documents/2023/08/02/2023-16050/medicare-program-inpatient-rehabilitation-facility-prospective-payment-system-for-federal-fiscal   Final FY 2024 Skilled Nursing Facility Prospective Payment System Rule: Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/fiscal-year-fy-2024-skilled-nursing-facility-perspective-payment-system-final-rule-cms-1779-f Rule:  https://www.federalregister.gov/documents/2023/08/07/2023-16249/medicare-program-prospective-payment-system-and-consolidated-billing-for-skilled-nursing-facilities   Final FY 2024 Hospice Payment Rate Update Rule: Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/fiscal-year-2024-hospice-payment-rate-update-final-rule-cms-1787-f Rule: https://www.federalregister.gov/documents/2023/08/02/2023-16116/medicare-program-fy-2024-hospice-wage-index-and-payment-rate-update-hospice-conditions-of

Friends, There is no question that digital health is a critical part of the future of healthcare delivery. It is what I term ‘the great enabler’.  And in this interview we have the opportunity to speak with a physician leader who is at the tip of that spear: Dr. Eve Cunningham, a physician executive in virtual care & digital health at Providence, one of the largest and most progressive healthcare systems in the country. Dr. Cunningham currently serves as Group Vice President and Chief of Virtual Care and Digital Health for Providence Health. She joined Providence St. Joseph Health in 2017 as the Chief Medical Officer of Providence Medical Group Southwest. Eve is board certified in Obstetrics and Gynecology and has practiced for over 12 years. She earned her medical degree at Saint Louis University School of Medicine and did her postgraduate residency training at Kaiser Los Angeles Medical Center. Eve also obtained a Master’s in Business Administration from the University of Massachusetts Amherst. In this interview, we’ll discover: Why Digital Health is an absolutely critical part of the current and immediate future of healthcare – a must-do can’t-fail for any healthcare system or provider organization. The three major ways that Dr. Cunningham and her teams serve within Providence Health: to promote, develop and support digital health efforts. Some of the amazing virtual services and digital products she and her team have developed and are spreading at a large scale. A few of the critical success factors Dr. Cunningham believes to be essential for the viability of any digital health division and program. I’ve had the privilege of interviewing and speaking with a number of leaders at Providence. Each time I do, I walk away with even more respect for this organization – its mission, its forward-thinking culture, and the level of professionalism, competence and collaboration.  I also walk away with awe at the innovative and transformative services and products they are constantly incubating, scaling and commercializing. This conversation with Dr. Eve Cunningham was no different.   I had heard Dr. Cunningham speak at a symposium a few months prior and I was impressed with her attitude and her approach. She has a unique set of skills – bringing the traditional chief medical officer acumen and experience to bear – the clinical and operational chops. But she also possesses a bold and practical irreverence for traditional approaches that are not future facing. Her ability to meld these two together is quite remarkable and striking. She has no problem in telling it straight, something I deeply admire. In regard to telling it straight, Eve shared some very practical tips in regard to digital health initiatives; chief amongst them were three things. First – being crystal clear about the value proposition, the key performance indicators, and being to demonstrate the value proposition through these metrics.  Second – working very closely with financial colleagues to be able to demonstrate a hard return on investment.  Third – piloting programs that were not only clinically and operationally feasible as well as financially viable, but also programs that are scalable.  She talked about scale on the level of tens of thousands, if not hundreds of thousands of patients.  In regard to some of the exciting programs and innovative products? Well, you’ll have to listen to the interview.  But, I’ll give you a sneak preview. One product we discussed at length is called MedPearl – a digitally-enabled specialty referral system/algorithm that every integrated healthcare provider system or group has been desperately seeking for decades. If you’re a healthcare leader, you will not want to miss this discussion. Another is a set of digitally-enabled surgery support tools which will radically change surgical care forever.  I’ve understood that all healthcare is going to be digitally-enabled in the near future. But it’s leaders like Dr. Eve Cunningham and her colleagues at Providence that are making it a reality. A reality that is going to improve patient access, outcomes, experience, equity and affordability – as well as improve the effectiveness, efficiency and job doability for providers of care. There is no question in my mind that digital is the enabler for humanizing healthcare delivery for all. I’ll leave you with a brief quote from Dr. Cunningham which really captures the essence of the imperative: “I would say that virtual and digital is our way forward into the future, and we have to 10x it!  My goal is 10x what we’re doing in the next five years because that’s what’s going to keep us afloat as an organization.  We have to change. Traditional healthcare delivery is not sustainable in its current state…” Until Next Time, Zeev Neuwirth, MD

Friends, In my upcoming book, Beyond The Walls, I spend an entire chapter discussing how platforms have revolutionized other industries and how they’re about to do the same in healthcare.  Over the past couple of years, I’ve had the privilege of interviewing and learning from the experts who have been working with platforms for years. Geoffrey Parker, who wrote the now classic text The Platform Revolution, Vince Kuraitis, and Dr. Randy Williams have been working over the past decade to introduce the platform revolution into healthcare. If you’re interested in really understanding what platforms in healthcare look like and what differentiates them from our more typical business models, I recommend you listen to my podcast interview with Vince and Randy (episode # 149, April 19th 2023) and read chapter 7 in my about to be published book, Beyond The Walls.  During that interview, Vince & Randy mentioned an exciting example of a platform business model in healthcare. The company is called KeyCare. It was founded and is being led by physician entrepreneur Dr. Lyle Berkowitz. In this interview we’re going to discover how this novel platform is attempting to solve the issues of access to care, capacity, cost-effectiveness, and burnout amongst providers and their teams. Lyle Berkowitz, MD, is the Founder and CEO of KeyCare, the nation’s only virtual care company built on the Epic platform. He has more than twenty years of experience as a primary care physician, health system executive and informatics expert, and serial entrepreneur. Previous roles include Founder & Chairman of Healthfinch, Chief Medical Officer at MDLIVE and Director of Innovation for Northwestern Medicine in Chicago. Dr. Berkowitz is also Editor-in-Chief for Telehealth and Medicine Today.  He’s served on numerous industry boards in the past and is currently a board member for Oneview Healthcare. Lyle has been listed as one of HealthLeader’s Twenty People Who Make Healthcare Better, Healthspottr’s Future Health Top 100, and Modern Healthcare’s Top 25 Clinical Informaticists. He has been elected to Fellowships in both the American College of Physicians (ACP) and the Healthcare Information Management Systems Society (HIMSS). He graduated with a Biomedical Engineering degree from the University of Pennsylvania and is an Associate Professor of Clinical Medicine at the Feinberg School of Medicine at Northwestern University.   In this interview, we’ll discover: How KeyCare can address the shortage of primary care physicians in American healthcare. The major differentiating benefits of KeyCare and the variety of use cases for healthcare systems. The three “R’s” and the three “C’s” that are critical for the adoption of KeyCare as well as other virtual services. Throughout the interview Dr. Berkowitz illustrates the numerous ways that healthcare systems as well as other provider groups can utilize and leverage KeyCare. The initial use case, and probably the most challenging to manage, is ‘on-demand’ and ‘urgent care’ – or what might be considered part of the so-called ‘digital front door’. Instead of staffing and managing their own virtual on-demand urgent care services, healthcare systems can rely on KeyCare. Lyle points out that on-demand care is not a differentiating value proposition for healthcare systems. By outsourcing it, systems can focus their efforts and resources on the aspects of care that are differentiating and of higher margin. One sub-category of on-demand urgent care is patient populations in value-based contracts. Lyle suggests that KeyCare could assist healthcare systems in reducing avoidable ED visits and other costly alternatives, thereby lowering the costs of care in these risk-based populations.  Another significant use case is primary care. Lyle proposes that KeyCare could become an extension of a PCP’s team, performing a number of functions that enhance efficiency of care, allowing a provider and their on-site teams to perform to the top of their license, and increasing access and capacity, enabling a provider to manage much larger panel sizes. The way this might work would be for KeyCare to manage patients with chronic disease who are relatively stable, to perform routine visits including annual wellness visits, and to do follow up care. This would allow PCP’s to see more complex patients as well as new patients. In risk-based contracts, KeyCare could assist by closing care gaps and updating data points for risk score adjustments, thereby helping to appropriately increase the per member per month (PMPM) payments.  In addition to on-demand and primary care, KeyCare can also offer specialty services such as behavioral health.  There are a few key benefits to KeyCare (sorry, I couldn’t resist).  First, one differentiating benefit is that KeyCare is essentially a virtual provider group that is on an Epic instance. The advantages to healthcare systems who are on the Epic electronic health system are significant in terms of interoperability through: (1) the Epic ‘Care Everywhere’ function which would allow for robust data sharing; (2) cross-instance scheduling via new functionality called ‘Book Anywhere’; (3) cross-instance on-demand telehealth requests via new functionality called ‘Telehealth Everywhere’; and (4) cross-instance messaging, orders and referrals.  This cross-instance functionality and automatic interoperability allows KeyCare to send messages, schedule appointments and referrals, perform telehealth visits, and obtain and record patient information in patients’ charts – all without the need for new interfaces. It would appear seamless to patients as well as to providers.  Another benefit to healthcare systems is that KeyCare has urgent care providers who are licensed in all 50 states. This is a major market advantage to healthcare systems or other provider groups who are interested in winning contracts from a wider swath of potential customers such as employers who have employees and beneficiaries that live beyond a local or regional geography.   A third benefit, Lyle suggests, is that it will be far more cost-effective for a healthcare system to outsource virtual, team-based extension of PCP’s teams rather than build and maintain these services in house. KeyCare is essentially a virtual care focused factory.  As such it’s likely to be far more efficient than virtual care teams functioning within healthcare systems, and it will be constantly investing in people, process and technology to upgrade and optimize its effectiveness and efficiency.   KeyCare is a two-sided platform – a “population health enablement company”. On one side, there are the customers that would utilize KeyCare’s services – healthcare systems, provider groups, payers and employers. On the other side are the virtual providers and virtual provider groups who are offering their services. KeyCare is the technologic and business platform or marketplace that brings them together.   The promise is there. But, as Dr. Berkowitz points out, there are 3 challenges to overcome in provider acceptance and adoption. He refers to these as the “3 C’s”.  The first “C” is presenting providers with a clinically-connected care team that they feel comfortable with – sharing their patients and their data. The second “C” is compensation – assuring providers that this will enhance their compensation rather than diminish it. The third “C” is culture – the change management as well as workflow configuration required to integrate this type of care.  But, the promise is there, and it’s an important one. From a patient perspective, KeyCare can increase convenient access to care through its myriad use cases, including offering virtual specialty services such as behavioral health. From a provider perspective, it can reduce provider burnout by removing the more routine functions and services – enabling providers to grow their panels and focus on more complex care needs. From a healthcare system perspective, it can increase efficiencies of care, create patient growth, improve performance in value-based contracts, and allow systems to focus their resources and capabilities into higher margin more differentiating services.  It seems to be a win-win-win. I applaud Dr. Berkowitz for his patient-centered mission and his ingenuity in creating this novel population health enablement platform. I’ll leave you with my favorite quote of this entire interview: Our goal, our purpose in life, as an organization, is to make sure everybody gets the healthcare they deserve and they get that access. The more we can do online, the more that relieves the pressure for providers in the office as well, so both sides can win.” Until Next Time, Zeev Neuwirth, MD

Friends, This week’s interview is nothing less than awesome, and it’s awesome for three reasons.  First, Dr. Rishi Sikka is a brilliant and accomplished physician executive with an incredibly diverse professional background. He brings that diversity of thought and vision into his work and into our dialogue. Second, we’re going to discuss some key new leadership competencies that both Dr. Sikka and I believe are critical for the future advancement of healthcare delivery in our country. Third, as I mention in the intro to this interview, I’m about to publish a second book entitled Beyond the Walls.  It’s a market-based, three-part strategy for the transformation of American healthcare. What was so confirming to me is that Dr. Sikka’s perspective, as well as his strategic and tactical vision, is fully aligned with what I’ve written in that book. Of note, he has not yet read the book. As you can tell, I’m incredibly excited about this interview, and once you listen, I suspect you’ll be as well.  Dr. Rishi Sikka is currently a venture partner at Lifeforce Capital, and a Professor of the Health Services, Policy and Practice at Brown University School of Public Health. His past executive roles include: President of System Enterprises at Sutter Health as well as Senior Vice President of Clinical Operations & President of the Advocate Insurance Segregated Portfolio Company. He earned his bachelor’s in economics at the Wharton School at the University of Pennsylvania and his medical degree from the Mayo Clinic Medical School.  He is co-author of the book Leading Healthcare Transformation: A Primer for Clinical Leaders, and has written for the Wall Street Journal and Harvard Business Review. In 2021, he was recognized as a Top 50 Clinical Executive by Modern Healthcare. In this interview, we’ll discuss: Why Dr. Sikka believes that diverse backgrounds and disciplines foster opportunity in healthcare delivery.  Dr. Sikka’s recommendation for how leaders can tactically embed relationship-centered care into daily clinical practice.  The importance of ‘Championing the Trust Agenda’ – both for patients as well as providers.   The issue of provider burnout and demoralization, and a tactical approach to addressing it – an approach that Dr. Sikka has some experience with.  The notion of partnering and collaborating, which is a reframe of the old ‘buy it or build it’ paradigm.    A few new and promising trends in healthcare delivery – based on Dr. Sikka’s VC experience working with a portfolio of entrepreneurial companies.   This conversation with Dr. Rishi Sikka was enlightening, inspiring, encouraging, and quite honestly, fun. He’s a bold thinker and doer, but he shares his point of view in a collaborative and humble way.  This interview touches upon a number of really important lessons for a new leadership – what I would label ‘beyond the walls’ leadership. I’ll briefly touch upon a few of these. Seeking diversity of experience and disciplines. Most of us recognize the critical importance of diversity, but do we recognize the importance of diversity of experience, disciplines and thought? Dr. Sikka brings an incredibly broad and diverse background to bear. He was initially an economics major prior to going to medical school. As a medical student, he took off a few months to work as a managed care researcher, learning how to use big data (claims data) to assess quality and outcomes of care. While in medical school he also spent time as a reporter and on-air broadcaster for a local NBC affiliate.  In addition, Dr. Sikka is a student of other industries – proactively borrowing and learning the lessons that others have had to learn the hard way. His own healthcare leadership perspective is imbued with these diversities of experience and thought, which he believes is supremely helpful in creating new ideas and opportunities in healthcare delivery.   Deploying Relationship Centered Care.   Most of us are familiar with this phrase, but Dr Sikka believes it’s essential to not just voice that sentiment, but also to operationalize it.  He provides a number of examples of how to tactically deploy relationship centered care. One that he shares is the notion that, as we leverage AI to increase productivity, we should divert some of that enhanced capacity into time that providers can spend with their patients.   Fostering ‘mastery, autonomy and purpose’. Borrowing from Daniel Pink’s book Drive – The Surprising Truth About What Motivates Us, Dr. Sikka discusses how we can and must leverage mastery, autonomy and purpose in combating provider demoralization and burnout. Once again, he takes this from the strategic level to tactical deployment – sharing his own experience as a physician executive in shared governance organizations, in which physicians are treated not as employees but as true partners.  ‘Championing the Trust Agenda’. Once again, borrowing from hard-earned lessons in other industries, Dr. Sikka shares a phrase he heard directly from the leadership team at SC Johnson. He points out that healthcare has become highly transactional, and that we must refocus on building trusting relationships with patients as well as with our providers. One key part of championing the trust agenda is to align what’s happening on the front lines of care and in daily operations, to the stated purpose and mission of our organizations and our industry. The larger the delta is between what actually happens in reality and what leaders espouse is a chasm of distrust and disillusionment. He points out that it’s all about leadership – a topic he notes I’ve discussed at length in this podcast series and in my books.  Shifting to partnership and collaboration, This is a bit of a reframe on the old ‘buy it or build it’ paradigm. Dr. Sikka borrows a lesson from the automotive industry, which was illustrated in Ram Charan’s 2021 book, Rethinking Competitive Advantage: New Rules for the Digital Age.  Professor Charan points out that as automotive companies entered the digital age, rather than attempt to build new capabilities and assets themselves, they partnered and collaborated with companies that have this experience – for example, in building batteries. They realized that attempting to build all of the new capabilities and assets was an outdated and limiting strategy. One company, Volkswagen, decided to take the legacy tack of building batteries themselves, attempting to hire thousands of engineers. The outcome? VW has fallen far behind its competitors and its CEO was ousted for deploying this non-competitive strategy of ‘building it all ourselves’.  What’s important to note is that we’re seeing a similar transformation in healthcare. In fact, in Beyond The Walls, I devote an entire chapter to the “The power of platforms” and provide numerous examples of how payers as well as hospital systems are shifting from the traditional ‘build it or buy it’ model to a partnering and collaboration one, with great success.  Building strategic ecosystems of care. At one point in our dialogue, Dr. Sikka mentions the notion of hospital systems building strategic ecosystems of care. I believe this is an integral corollary to the partnership and collaboration transformation mentioned above. This shift, from attempting to build or be an entire ecosystem, to convening and leading a broader strategic ecosystem based on collaborations and partnerships is a concept I illustrate in Beyond The Walls. We have witnessed a ‘platform revolution’ in other industries (think Amazon or Uber), and we have already entered that revolutionary transformation in healthcare delivery. I provide a number of examples of platforms in Beyond The Walls, and many more are about to enter onto the healthcare scene.  As with partnerships and collaborations, platforms represent a new leadership competency.   Approaching care from a customized and segmented perspective. In his current role, as a venture partner at Lifeforce Capital, Dr. Sikka is constantly evaluating and engaging with a portfolio of entrepreneurial companies. One of the new and promising directions he sees is a movement in value-based care to “carve outs” – organizations that are managing specialty-specific or condition specific risk-based contracts within a group of patients. One example would be an organization that manages the renal risk exclusively in a capitation or shared savings contract. Another he points might be a company that manages orthopedic risk, and yet another would be a company that manages oncology spend. This segmentation of clinical care and value-based risk is one I discuss in my first book on Reframing Healthcare, and once again, we’re witnessing its early manifestation in the healthcare market. I believe this also represents a new leadership competency: the ability to segment and customize clinical care and operations, as well as assume segmented risk within a population, based on specialty or conditions.  In this interview, Dr. Sikka and I quickly leapt into the ‘why’ – the purpose and mission of healthcare delivery, and the leadership competencies required to carry out the mission. I’ve attempted to capture some of those key leadership competencies above.  What I find most enlightening about this discussion, however, aren’t the specific concepts themselves. Instead, it’s the fact that Dr. Sikka is actually recognizing that there are new core competencies in healthcare leadership. Competencies that we need to discern and learn, especially as we enter the digital era. I’ve not heard many people articulate this understanding.  During the course of this interview, we not only attend to the ‘why’ but also discuss the ‘what’ and the ‘how’ – the tactical deployment of these leadership competencies and directions. And we connect the two – aligning stated purpose and mission with tactical operational deployment. Dr. Sikka sums this all up well toward the end of our conversation. “There’s a saying in our business, ‘No margin, no mission’… The interesting thing is that that’s actually not the original saying. The actual saying, attributed to Sister Generose Gervais, one of the co-founders of the Mayo Clinic is, ‘No margin, no mission. No mission, no need for money’. What it’s saying is that mission comes first, and mission matters the most. I think this is a very pivotal moment for healthcare organizations to put mission first, to return to mission, to connect to purpose, and to champion the trust agenda with our patients, providers and employees… It’s a fundamental belief that if we return to mission, the positive economic and financial results will follow. That’s the core of some of the pieces that need to be put into place now.”  Until next time, be well. Zeev Neuwirth, MD

[In order to provide accessible content, here is a full transcript of this interview] Friends, The topic this week is caregiving and caregivers – an issue that is so much larger, so much more devastating, and so much more in need of reform than most of us are aware. There are over 50 million family caregivers in the US, and they suffer financially, emotionally, psychologically and physically with negative consequences that persist for the rest of their lives. The solution, according to our expert guest, comes down to funding and policy: to provide the funding through Medicaid’s Long-term services and supports (LTSS) and remove the stringent requirements that grossly limit appropriate access to those funds.  During this episode, we’ll dive into the underlying systemic social biases around the elderly and the disabled – a bias that is preventing the policy and funding changes needed to alleviate the heartbreaking suffering of caregivers and their loved ones. In this interview, Professor Laura Mauldin will distill the learnings from her research, as well as from her own personal experience in caregiving.  She also provides recommendations for what needs to be done to remedy the situation. Laura Mauldin PhD is a writer and scholar based in Brooklyn, New York. She’s currently an associate professor at the University of Connecticut. Laura’s research focuses on disability care and technology. Her first book, Made to Hear: Cochlear Implants and Raising Deaf Children, documents the structure and culture of the systems we’ve designed to try to make deaf kids hear. Laura is currently writing a book – scheduled to be published in 2025 –  on spousal caregiving which weaves together research, memoir and cultural commentary.  In this interview, we’ll discover: The major reasons for why the number of family caregivers in the US is rapidly growing.  The various traumas that are inflicted upon caregivers, something that most of us who have not lived this experience are completely unaware of.  An insidious systemic bias in our society toward the disabled, which Professor Mauldin refers to as ‘ableism’.    An explanation of the institutional bias built into Medicaid policy, which greatly limits the access to paid caregiving for over 90% of Americans who want and need it.  How the formal healthcare system – insurance companies, pharmaceutical companies, device manufacturers, and hospital systems – benefits financially at the emotional, physical and financial expense of caregivers. Something I had never considered.   The very specific policies and funding that we need to change in order to remedy this situation and provide the support that family caregivers require.   Professor Mauldin is a remarkable scholar.  As a highly trained qualitative researcher, she intentionally decided not to take a neutral stance in her research on caregiving and caregivers. Instead, she infused her work with her own lived experience of being a caregiver.  She infused it with a studied understanding of the political and social biases that are root causes for why the situation isn’t being addressed and remedied. She infused it with the power of story and not just with the power of statistics. In this interview, Laura Mauldin shares her own story of caregiving and reveals what most of us have little to no understanding of – a world that is so radically different. She talks about the daily “terror” and “exhaustion”, the “isolation” and a sense of being “invisible”.  She also describes a profound “demotion” in her relationship with her partner – a shift from being a “lover” to being a “life support system”. The stories she shares, her own as well as those from the dozens of families she studied, are heartbreaking and informing.  Laura points out that the suffering of caregivers isn’t limited to their emotional, psychological and physical health.  It also has a profound 3-part impact on their financial health. First, caregivers are largely unpaid for this in this country. Only about 7% of Americans can afford private pay care-giving, which means that well over 90% of caregiving goes unpaid for in the US. Second, if family caregivers have a job, they often see a marked decrease in their earned salaries, due to the time they must spend caregiving. Third, caregivers suffer a marked loss in their retirement savings, in part, as a result of the compounded losses in their job salary over the course of years.  One of the most enlightening parts of the dialogue was Professor Mauldin’s articulation of ‘ableism’, which I had never heard of before. I found it to be inspiring and liberating – yes, liberating. This sense of liberation comes from her shining a light on a part of our lives that is hidden from view, a part of our lives that has been cloaked in shame and bias, and a part of our life in which we desperately seek to maintain some semblance of control and independent living. She explains how our culture “devalues disabled people, disabled bodies, and people who are viewed as unproductive.” And she connects this ubiquitous indoctrination of ‘able-ism’ to the ‘institutional bias’ policies embedded in Medicaid, and then directly to the suffering of caregivers and their families. She points out how these biases embedded into policy and payment prevent us from maintaining our independence as we age, or as we become infirm or disabled.   The sense of liberation stems from two things. First, just naming the indoctrinating bias that we’ve all been engulfed in removes, or at least softens, some of the stigma and fear. It opens up the possibility for new understandings and new ways of relating to ourselves, to our bodies, to one another, and especially to those whom we love dearly. Second, once we name it, we can reframe the situation, pull back the cloak of silence, and shine a light on these hidden biases, stigmas and fears. We can examine them in the light of day. We can talk about them. We can actually begin to collectively do something about them. Beliefs and biases hidden are unassailable. Fears and stigmas unspoken fester in our individual and collective consciousness. To that point, Lauren illustrates this in a story she shares about her personal experience as a caregiver – bringing a group of physicians together around a table – and hearing nothing but soul crushing silence and inaction. Revealing the truth is the first step toward healing. It is a gift – a gift that Professor Mauldin shares generously. But, as she points out, taking action is the next step. What I learned is that we need more activism around changing Medicaid policies and funding. We need to very specifically change the policies and funding of the “long term services and supports”, and the “home and community-based services”.   Professor Mauldin’s contribution to our understanding of caregiving and caregivers is revealing and moving. She connects the dots on the issue of caregiving in a way that I’ve never before experienced. I had the opportunity to listen to her present in an online forum and was absolutely mesmerized by her eloquence, her intellectual integrity, her scholarly brilliance, her honesty and her courage in discussing an issue that is so very personal to her. I believe her upcoming book, which will be published by Ecco Press in early 2025, is going to be a landmark contribution to this important issue. I believe that Professor Mauldin should be listened to and her recommendations heeded. [In order to provide accessible content, here is a full transcript of this interview] Until next time, be well. Zeev Neuwirth, MD