Creating a New Healthcare

Friends, This is a super interesting and fast paced dialogue about a topic that is poorly understood by most, including healthcare executives and policy experts. The topic is employee health plans. Our guest today, Dave Chase is a remarkable healthcare entrepreneur with decades of experience who has been one of the most brilliant thinkers and activists in reforming employee healthcare benefits. He and his colleagues at Health Rosetta have really unearthed the core underlying problems and are doing something about them. They do, in fact, have a blueprint that is replicable, scalable and sustainable; and they have numerous examples of success. Given that nearly 50 percent of healthcare is paid by employers, this issue has broad impact and significant implications for American healthcare and for the financial welfare of working Americans and their families.  In this interview, we’ll discover: To what extent employee health plans have been eroding the wages and retirement funds of working Americans for the past 3 decades. The implications of the Consolidated Appropriations Act of 2021, which requires employers to be fiduciary stewards of their employees’ health plans. The importance of understanding the legal documents of health plans as the untapped lever that can enable us to fix American healthcare. The undisclosed revenue streams and incentives that are contributing to the outsized and unsustainable rising costs of employee health plans. The “open sourcing” in hospitals, and in healthcare in general, that is needed to improve quality, safety and costs. Examples of companies that have successfully redesigned their health benefits resulting in better health outcomes and lower costs for their employees. Of all the opaque and confusing aspects of healthcare delivery, the legal agreements of employee health plans, may top them all. This wouldn’t necessarily be an issue except for the incontrovertible fact that what they’re hiding is literally decades of misaligned incentives that reward increased pricing rather than high quality care, positive health outcomes, cost effective pricing, convenient access and consumer-oriented navigation. What’s hard to comprehend is how many hands there are in the pockets of the American workers, siphoning off decades of hard earned wages and retirement savings. The irony is that these employer health plans benefit the insurance companies, third party administrators, health benefits managers, PBM’s, and hospital systems more than they benefit the employers or employees.   And let’s be clear – this is not a minor issue affecting a small percentage of the population. This is a huge issue affecting the majority of working Americans. What we’re talking about is not being able to afford healthcare and having to forego it to pay for housing costs, food, clothing, child care and transportation. What we’re talking about are tens of millions of Americans who can’t afford preventive medical care, medications and much needed medical procedures.  Here are some stats that Dave provided – a sobering and alarming perspective on the severity and magnitude of the situation. Over 100 million Americans carry medical debt, which is one of the leading causes of individual and family financial ruin. Over 60% of Americans earn less than $60,000 per year while the cost for a family of four in an employer-sponsored PPO health plan in 2023 is over $30,000. This places healthcare insurance at literally 50% of earnings for the majority of Americans – completely untenable and almost mind boggling. Tens of millions of Americans are what Dave terms “functionally uninsured”. They have health insurance but their life savings are far less than the deductible required. To put some numbers to this, the majority of Americans have less than $1000 in total savings while the deductibles for an individual range from $1800 to $2400; and for a family of four, the deductibles range from $3600 to $4800.  What this means is that tens of millions of Americans are literally one ED visit or one hospitalization away from financial ruin.  The situation is dire but there is some good news and positive momentum. It’s taken decades but it’s heartening to learn that regulatory policies and laws are finally beginning to protect employees. As Dave informs us, the Consolidated Appropriations Act of 2020/2021 will put the onus on employers as “plan sponsors”, but will also empower them by requiring transparency and prohibiting contract terms that harm employers and employees. The Department of Labor has been charged with enforcing the law and is already demanding documentation from employers. Plan sponsors will be required to prove to the federal government that they are good financial stewards of their employees’ health benefits, and transparently demonstrate to their employees that they are contracting for cost effective, high quality healthcare. From a political perspective this Act is supported by the previous Trump Administration as well as the current Biden Administration, and has the full support from both parties in Congress. I realize it’s a bit in the weeds but I think it’s important and helpful to share a a few examples of what this law requires (as in present tense): Removal of ‘gag clauses’ from service provider contracts, including health plans, third party administrators, consultants, brokers, pharmacy benefits managers, and any other entity involved in health benefits. No more withheld claims data other than privacy protected data. Reporting requirements for pharmacy and prescription drug prices. Disclosure of direct and indirect compensation from all service providers, so hidden incentive arrangements between brokers and plans or PBMs and drug companies must be fully accounted for. Parity between mental health and substance use disorder benefits and other health benefits. The Act establishes a vastly more stringent requirement around parity than employers are accustomed to, including significantly enhanced documentation requirements. The title from a reference article by Leah Binder in Forbes.com (Feb 28, 2022) that I used in writing this copy really captures the current situation. “This Federal Law Will Completely Overhaul Company Health Benefits. Nobody Is Ready.”  Regardless of the short term compliance hassles and costs imposed on employers, this is a great oversight for employees and their families. It will not erase the decades of tremendous harm imposed on working Americans, but it will prevent harm for future generations. Another complementary positive step is the work that Health Rosetta and others have been doing to create the mechanisms for improving health plan benefits. While the Consolidated Appropriate Act law is a forcing function, the tools that Health Rosetta has been developing are actually paving the path forward. As Dave states, “Our goal [at Health Rosetta] is to transform employee health plans from being the number one driver of inflation, poverty and bankruptcy to delivering what they should be: a driver of well-being and wealth”.  Dave goes on to make a foundational reframing point toward the end of the dialogue: “… It’s weird that the way we navigate the healthcare roads from a financial standpoint is looking in the rearview mirror, aka claims. How about we look through the windshield, what are actually leading indicators of a high performance health plan? Over several years, what we found was, we could get at the best predictors. There’s about 40 questions that effectively diagnose a health plan… we have a score… and then we give a prescription for a care plan. Here’s how you fix it, here’s the proven approaches to that.” Dave Chase and his colleagues at Health Rosetta have spent years studying what works and are offering that to employers and benefits managers. Their approach is replicable, scalable and sustainable as evidenced by the numerous case studies they’ve published and posted. It’s also the right thing to do for employers and working American families. There is no question about that. The only question is – ‘why aren’t more employers, payers, third party administrators, benefits managers and consultants adopting their approach?’  If you’d like to learn more and hear about their successful case studies, check out the health rosetta website https://healthrosetta.org and their upcoming annual symposium, https://rosettafest.org which is happening this August.  Until Next Time, Zeev Neuwirth, MD

Friends, I began this interview in a fairly calm state of mind, but I was shaken by the end. Throughout our dialogue, I could not help repeating the word ‘startling’ as our two expert guests shared stats on the state of primary care in their home state of Massachusetts and across the country. For example, were you aware that only about 5% of the total healthcare spend in the U.S. is in primary care? That is startling given that the literature repeatedly demonstrates primary care to be the keystone in any effective healthcare system. It is troubling in that this is a far smaller percentage compared to other developed nations. And, it is of national concern given that the health outcomes in the U.S. continue to lag every other developed nation. In fact, a recent presentation at a NCQA forum #qualitytalks2023 (data derived from the KFF) showed a major dip in life expectancy in the U.S. whereas other developed nations continued to show improvement.  Early on in the interview, I asked Dr. Gergen Barnett how she would assess Primary Care, if it were a patient of hers. Her response, “It’s on life support”.  They say you can’t fix what you can’t measure. To that end, we’ll also learn about a critical new step the Massachusetts Health Quality Partners (MHQP) and the Center for Health Information and Analysis (CHIA) have taken in beginning to measure the health of Primary Care through an annual dashboard of ‘vital signs’.  What gives me some hope are expert champions, like our guests this episode, who are dedicating their careers and their keen skills to solving the primary care crisis in our country.  Barbra Rabson has led Massachusetts Health Quality Partners (MHQP) since 1998. Under her leadership, MHQP has become a national leader in the measurement and public reporting of healthcare information, with a particular focus on measuring and improving patients’ experiences of care. She serves on numerous state committees and boards including within the MA Dept of HHS, the Massachusetts Health Equity Data Standards Technical Advisory Committee, the Betsy Lehman Center Task Force on Measurement and Transparency. She also serves on the Board of the Massachusetts Health Data Consortium. Ms. Rabson received her Master’s degree in Public Health from Yale University and her undergraduate degree from Brandeis University. Dr. Katherine Gergen Barnett is the Vice Chair of Primary Care Innovation and Transformation in the Department of Family Medicine at Boston Medical Center (BMC).She’s a Clinical Associate Professor at Boston University School of Medicine, an Associate at Harvard’s Center for Primary Care, and a Health Innovators Fellow at the Aspen Institute. Prior to joining BMC in 2009, Dr. Gergen Barnett attended Yale University School of Medicine and worked at the National Institutes of Health. She is a practicing physician, an active researcher, a medical educator and is involved in local and state health policy. She is also a regular contributor to The Boston Globe and Boston Public Radio. In this interview, we’ll discover: Why primary care is critical to our public health and the viability of our healthcare system. The extreme lack of investment that has been crippling the field of Primary Care, and the challenges imposed by the predominant Fee-For-Service payment model. The novel ‘vital signs’ dashboard that the MHQP, in partnership with the Center for Health Information and Analysis (CHIA), has constructed to measure and monitor the health of primary care in Massachusetts. A number of startling stats in the domains of Primary Care Finances, Capacity, Performance and Equity. A few encouraging solutions that Dr. Gergen Barnett and her colleagues have been working on.   Some important points I took away from this interview. It is well known that primary care is the keystone for a viable and sustainable healthcare system. Without it, the system crumbles under its own weight. There have been numerous studies and reports verifying this, including a seminal report last year from the National Academy of Science Engineering & Medicine which stated, “Primary care is the only health care component where an increased supply is associated with better population health and more equitable outcomes.”  Another conclusion from that report, “… primary care in the United States is fragile and weakening… [it is]… not configured to provide… comprehensive, preventive and chronic care needs…” By all accounts, our primary care system is in bad shape and getting worse. It’s not a stable situation. You can get a sense of this by going onto the MHQP/CHIA website and reviewing the Primary Care Dashboard they’ve constructed.  There are also some additional links at the bottom of these show notes, provided by our two experts. Despite the failing state of Primary Care, we are continuing to see gross underinvestment and a relative lack of research. I was shocked to discover that only 0.2% of all NIH funding goes toward Primary Care research. Research is always the first step to a better future. This stat demonstrates that we’re stepping backwards, not forward when it comes to the state of primary care in the U.S. While MHQP, CHIA and others, such as the Milbank Fund, are measuring and monitoring the state of affairs, it does not appear that political leaders at the state and federal level are aware of the looming crisis and its ramifications.  We all need to do more to raise that awareness, or face the consequences.  And time is of the essence. From my perspective, we are heading into a perfect storm – an increased need and demand, a decreased supply, and rising costs and inequities of care that will leave a majority of Americans without access to care. To that end, I’ve included a number of links to further inform you and catalyze action. Final thought – there are two scenarios – two situations we might find ourselves in a few years from now.   One scenario is a crisis – and I suspect that we’ll be looking at one another and wondering why we didn’t act, especially when the facts were so apparent.  The other scenario is a crisis abated – and I suspect we’ll be looking at one another with gratitude that we did act.   Which one of those two scenarios we find ourselves in is a direct function of what our leadership – our healthcare leaders and our political leaders – do today. It’s a function of what we do today. I left this interview dumbfounded, frustrated and inspired to speak out even more. I’m curious how it leaves you. And even more curious about what you’re going to do about it.  For starters – please share this podcast with anyone and everyone you know, including your congressional representatives. It is nothing less than a matter of life and death.  Until Next Time, Zeev Neuwirth, MD

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