Friends, The focus of this interview is on recognizing and addressing one of the most ubiquitous barriers to healthcare. I’ve heard it labeled as “the last mile of care”.  What we’re talking about is where the rubber really meets the road in delivering on the triple aim of healthcare outcomes, costs & experience. Medical encounters, diagnoses, referrals, clinical interventions, care plans and prescriptions – this is where they all make a difference, or not. If you’re wondering where that is or how that happens, then listen to this interview.  Our guests today, Dr. Renee Dua & Nick Desai, are serial entrepreneurs and co-founders of two game-changing companies, Heal, and more recently, Hey Renee. They have focused their efforts on seniors, those with complex chronic conditions and the under-served, providing convenient & accessible care in the home and leveraging digital technology to customize and humanize healthcare. And, of note, they are married and have three adorable children.  Dr. Renee Dua is a nephrologist who created & co-founded HeyRenee in June 2021. Prior to HeyRenee, she co-founded Heal, where she served as Chief Medical Officer for 7 years – leading the successful delivery of over 300,000 doctor house calls, driving clinical strategy & product development. Nick Desai is the co-Founder and CEO of HeyRenee. He’s an electrical & computer engineer, and a highly accomplished entrepreneur who has created and led four successful start-ups over the past 2 decades. Prior to co-founding HeyRenee, Nick was CEO and co-founder of Heal. In this interview, we’ll hear: Why Dr. Renee Dua & Nick Desai believe that care based in the home is superior to facility-based healthcare delivery. The very personal healthcare-related stories that led this couple to co-found both Heal & HeyRenee The four levels of “knowing” a person that Nick outlines as their Whole Person approach. Why Nick believes that the numerous point digital solutions are leading to further fragmentation of care and how the HeyRenee platform is being designed to coordinate and integrate care across the continuum of care. I have to admit that it took me a couple of listens to this interview before I began to really appreciate the reframed principles and point-of-view that Renee & Nick were sharing.  I’ll try to distill them down into a few bullet points and a couple of key quotes that stood out for me.  The role of the family and caregiver is critical, and needs to be supported.  Healthcare delivered in the home is far more convenient, safer, more inclusive and engaging of family and caregivers, and more personalized.  Understanding the ‘patient’ as a whole person is central to developing a customized care plan that actually works.  Providers take a radical leap of faith each time they prescribe a medication or dictate a care plan. Patients and their caregivers need more customized care, personalized direction and contextual support in overcoming the barriers to deploying and executing on care plans.    We need to redefine value-based care in terms of improved care & outcomes leading to lower costs, rather than the current approach which is largely about checking boxes and raising risk scores.  Patients need to be enabled, caregivers need to be empowered, and we need to do this without placing extra burdens on physicians and other providers of care.   The family is the basic unit of care; helping families navigate and coordinate care is a fundamental barrier to health that healthcare leaders have not adequately understood or addressed. Renee & Nick do not pull their punches.  They believe the current healthcare system is deeply misguided – placing undue stress and burden on providers – and providing sub-optimal, depersonalized care to patients and their caregivers.  One stat Nick cites to support this statement is that nearly 75% of seniors lack a coordinated care plan. Their goal, as Renee puts it, is to create a “personalized care concierge platform that delivers whole person care.”  She goes on to say, “a platform that supports and enables all of the caretaker functions… is the most critical thing missing in healthcare.  The facts substantiate her statement and support her goal. Over 50 million Americans struggle to care for older loved ones in the face of a predicted shortage of 1.2 million home health aides in the next decade. Renee – who has over 15 years of experience as a practicing nephrologist – believes that “there is a disconnect between those in charge and those who are sick”.  When I asked what one message she would deliver to healthcare leaders, her recommendation was that healthcare administrators and executives should spend time in a doctor’s exam room, and observe the real-life challenges and barriers imposed upon providers and patients.  I’ll leave you with one final quote by Dr. Renee Dua, which I have heard echoed by other visionary entrepreneurs who are transposing and transforming care from the legacy brick and mortar ecosystem into the home-based care ecosystem. “To this day,” Renee states, “I fundamentally believe there is no magic that happens inside a building… The best doctors want to spend time with their patients, and where better to do that than in the home… Until Next Time, Wishing you Whole Person Health Zeev Neuwirth, MD

Friends, We open up this podcast talking about a yearning on the part of people for a different type of dialogue, interaction & relationship in the delivery of healthcare. In all of the interviews I’ve conducted over the past 5 years – underneath all of the discussions about value-based payment, reframed clinical and business models, advanced analytics and digital enablement, patient/customer experience, health equity and social determinants of health – underneath all of it is a deep yearning to be understood as a whole person. To have our healthcare be guided by the meaning and context of our lives. To be respected, enabled and empowered as autonomous beings.  To be healthy – physically, emotionally and relationally – so we can live our best life. Our guest in this podcast dialogue, Dr. Ben Kligler, provides a framing of the fundamental problem that is preventing providers from delivering this type of healthcare, and a reframe that will enable us to experience a more humanistic approach to healthcare delivery. What you’re going to hear in this interview may be the most significant humanistic shift occurring in the American healthcare system. Benjamin Kligler, MD, MPH, is a board-certified family physician who has been working as a clinician, educator, researcher and administrative leader in the field of complementary and integrative medicine for the past 25 years. In May 2016 he was named National Director of the Integrative Health Coordinating Center (IHCC) in the Office of Patient Centered Care and Cultural Transformation (OPCC&CT) as well as Director of Education and Research for Whole Health. In May 2020 Dr. Kligler was named Executive Director of the Office of Patient Centered Care & Cultural Transformation (PCC&CT.) He is a Professor of Family and Community Medicine at Icahn Mount Sinai School of Medicine, and was Vice Chair & Research Director of the Mount Sinai Beth Israel Department of Integrative Medicine. He is currently a core faculty member of the Leadership Program in Integrative Healthcare at Duke University. In this interview, we’ll hear about: The Whole Health System that the Veteran Health Affairs is in the midst of deploying on a national scale. The 1 fundamental reframe and the 2 key questions that are at the core of how the Whole Health movement is changing the conversation in healthcare delivery. How this approach is being digitized and integrated into the electronic medical record. How the Whole Health System is not only improving the health and well-being of patients, but is also creating a ‘best place to work’ for providers and staff in the Veterans Health Affairs (VHA). In this interview with Dr. Ben Kligler, we are witnessing a profound inflection point. Whole person and whole health care has shifted from being a theme or movement to an actual system of care that is being heavily resourced, organized, deployed and integrated into one of the largest healthcare systems in the country: the national Veterans Health Affairs (VHA). For those who are not familiar, the ~350,000 VHA employees provide care to over 6 million actively engaged veterans, across ~140 large medical centers, and over a thousand outpatient clinics. Far from being a strategy in name only, Dr. Kligler and his colleagues have already trained 32,000 people in the Whole Health System and have touched nearly 8% of all Veterans in the country.  That’s over half a million Veterans who have experienced the Whole Health System during their care journey. I am impressed not only with the progress being made, but also with the flexible approach that the VHA has taken in deploying and scaling this new approach. For example, they’re not just training providers and staff, they’re having them participate through a portion of the program itself.  When I asked Dr. Kligler, if providers and staff might feel like this is just another item on their ‘to-do’ list or another box to check, he shared that the goal is not to add more to the clinical workload, but instead to change the orientation to clinical encounters.  He also shared that it was the entire care team being trained to deliver this, not just the primary provider. The whole person/whole health approach reminds us that human beings thrive when they have meaning and purpose in their lives. It reminds us that if we don’t reframe healthcare within the context of what enables people to thrive, we will be treating the superficial symptom rather than the disease itself. There has been a lot of verbiage over the past two or three years around the notion of ‘connected care’. This generally refers to 24/7 omni-channel access to care. The whole health/whole person approach reminds us that truly meaningful access to care will require not only a digitally-enabled, omni-channel platform; but also an intentional, systematic, resourced and integrated platform for relational connectivity. The VHA is on an accelerated path to deploying the Whole Health System in every one of its medical centers and clinics. It’s incredibly inspiring. What’s also inspiring is the thought of adapting and scaling the whole health/whole person approach to other healthcare systems across the country. I, for one, plan to share this podcast and the VHA’s Whole Health System initiative with the leadership at my own institution. What’s your next step? Until Next Time, Wishing you Whole Health Zeev Neuwirth, MD

Friends, Our guest today, Dr. Roy Schoenberg, is one of the most significant contributors and accomplished entrepreneurs in the domain of telehealth & virtual healthcare. In this episode, he’ll share some unique perspectives he’s gleaned from over 25 years as a trailblazer in telehealth. He’ll also discuss a transformational initiative that he and his colleagues at Amwell are introducing, as well as what he considers to be the next revolution in healthcare delivery. Dr. Roy Schoenberg is President and CEO of Amwell.  Since co-founding the company in 2006 with his brother Ido, Amwell has grown to become one of the largest telehealth ecosystems in the world.  Among numerous accomplishments and recognitions, Roy was appointed in 2013 to the Federation of State Medical Boards Taskforce that issued the landmark guidelines for the “Appropriate Use of Telemedicine in the Practice of Medicine.”  He is the 2014 recipient of the American Telemedicine Association Industry Award for leadership in the field, and in 2020 he was named one of Modern Healthcare’s 100 Most Influential People in Healthcare. Roy holds over 50 issued U.S. Patents in the area of healthcare technology. He speaks frequently in industry and policy forums, and serves on the healthcare advisory board of MIT School of Business. He holds an MD from the Hebrew University in Israel, and a MPH from the Harvard School of Public Health. In this interview Roy shares a number of critically important inflections that reframe our understanding of the virtual and telehealth era. I’ll list the five most significant ones that I gleaned from our dialogue. First – contrary to what most people believe, telehealth encompasses much more than video visits. It is fundamentally a new and emerging multi-channel ecosystem for the distribution of healthcare that engages a broad spectrum of telecom, digital & data analytic capabilities. Second – we are just at the dawn of the telehealth era and its major transformational impact has yet to occur. Listening to Roy, it’s clear that there is no turning back, and we’re not going to return to some pre-pandemic ‘normal’ when it comes to virtual & digital health. Third – telehealth and the digital health movement will transform the way healthcare engages with its consumers. It will shift the provider/patient relationship from being reactive and episodic to being proactive, continuous, contextual and longitudinal. In Roy’s own words, “We are interacting in healthcare within the construct of the ‘visit’ – which is short, hard to get and expensive. That whole notion is going to be thrown out the window because there are so many other ways for us to interact with patients, inside their reality. It will not only change the experience and expectations of consumers, but will also dramatically move the needle on costs because we can much more appropriately use healthcare resources where they’re needed.” Roy goes on to remind us that most of healthcare actually occurs outside of ‘visits’, in what has been referred to as the ‘between-visit’ space. Yet, we have little access to understanding patients in that space, or intervening effectively and efficiently. The emerging telehealth technology will enable us to cost-effectively connect with our patients in this continuous and longitudinal fashion. It is probable that the ‘between-visit’ space can and will become the dominant place of healthcare delivery.  As I reflect on our dialogue, it seems to me that we are applying a 20th century mindset to 21st century technology. Fourth – Roy outlines three domains of care delivery in the future. 1) The physical care cluster of services – in hospitals, operating rooms, clinics…. 2) The digital care cluster of services – telehealth, asynchronous communication, messaging, assessments…. 3) A whole new generation of automated interactions – literally a vigilant presence next to the patient – tracking and following patients during the course of their healthcare journeys and lives. As Roy puts it, once we get into the continuous and longitudinal space and apply automated care, there will be so many more dimensions of patients’ lives that we can begin to understand and respond to, offering much more proactive, personalized and contextual care. Fifth – Perhaps the most transformative impact of telehealth and digital health will not be as a communication channel, but instead as a supply-demand management system. As Roy states, “The part that has changed is that we are beginning to look at telehealth and related technologies as more of a logistical infrastructure rather than just as a video conferencing capability.” Similar to the ways that Amazon transformed the retail industry, the platforms being created now, including the Amwell Converge platform, will create an unprecedented ability to connect providers and care to patients and consumers – literally revolutionizing how healthcare is distributed. Roy continues, “If you think of telehealth, not as a way for a patient to see a doctor through video, but rather as an infrastructure for the digital distribution of healthcare, it begins to sound much more like a logistical infrastructure than a way to carry out a visit.” Roy was also insistent on informing me that this is not an Amwell-only endeavor; but a major market movement. And he’s right. I’ve heard others refer to this as the ‘platform war’ and even the ‘era of the platform’. There are over 100 “platform” companies in the S&P, and within healthcare there are dozens of companies working on a platform infrastructure. What’s important to understand is that while technology is the enabler for these infrastructures, the power of platforms is in their network effect, the ability to automatically connect the right provider to the right consumer, the transformation in consumer convenience and choice, and most critically, the new strategies and business models that platforms unleash. While many are concerned about the future of healthcare, the picture that Roy paints is incredibly positive, hopeful and attainable. From the patient side, virtual & digital technologies have the ability to democratize healthcare – allowing people to access care from whom they want, when they want it, and how they want it. The telehealth era will enable care that is more accessible, convenient, personalized, affordable and equitable, and it will provide greater consumer choice. From the provider side, virtual and digital health will liberate the tremendous value proposition locked up in the hearts and minds of clinicians. Imagine a healthcare world where clinicians can offer their services not only to the patients within their immediate geography, health system, or network, but to all patients across the country and around the globe. From the public health and industry perspective, virtual and digital health will lead to greater efficiencies, effectiveness, and equity – at far lower costs – and will allow us to leverage providers’ time much more efficiently and effectively, creating unimaginable advances in capacity and population health management. I have to admit that I share Roy’s realistic optimism for the future of American healthcare delivery. Until Next Time, Be Well. Zeev Neuwirth, MD

Friends, Just about every major industry, with the exception of healthcare, has moved into the digital era. This is not my opinion alone. It is the collective perspective of the numerous guests that I’ve had on this podcast. And far from being a nice-to-have, these experts argue that in order for us to achieve the quality, cost effectiveness and experience that consumers expect, healthcare systems & providers will need to shift from being so-called digital laggards to being firmly engaged in the digital era of healthcare delivery. What is at stake, they argue, is nothing less than relevance in the market. In this episode, we have the privilege of hearing from Ries Robinson, a physician healthcare executive and serial entrepreneur who, along with his colleagues & partners at Graphite Health, is tackling the significant roadblocks in the digital transformation of healthcare, and doing it in a uniquely collaborative way.   Ries Robinson MD, is the CEO at Graphite Health. He is also the Chief Innovation Advisor at Presbyterian Healthcare Services, the largest integrated healthcare delivery system in New Mexico. Prior to joining Presbyterian, Ries founded a number of companies, including: Rodin Scientific LLC, dedicated to creating a heart failure management solution; InLight Solutions Inc. focused on creating non-invasive glucose measurement techniques; VeraLight, which established a non-invasive screening test for type II diabetes; Luminous Medical, an ICU-based continuous glucose monitor; and TruTouch Technologies, which developed a noninvasive alcohol monitor. Ries serves on the American Hospital Association ‘Center for Health Innovation Leadership’ Council.  Previously, he served on Presbyterian Healthcare Services’ Board of Directors. Ries graduated from Stanford University, where he received a bachelors and masters degree in mechanical engineering, and he also graduated from the University of New Mexico School of Medicine.   In this episode, we’ll discover: The challenges that even large healthcare systems face as they attempt to evaluate and deploy digital solutions. The reasons that becoming digitally-enabled is critical for providers and healthcare systems.  The advantages & benefits Graphite Health is bringing to healthcare systems through the creation of a “democratized public utility infrastructure” and “digital health marketplace”. Some of the challenges that Graphite Health will need to overcome in order to achieve its mission. The names of a few of the healthcare systems that have already signed on to be part of the Graphite Health consortium.  Many other experts and entrepreneurs have recognized the importance of the digital revolution in healthcare and the transformative transition we are about to make into the digital era.  But, there are a number of unique reframes that differentiate the approach Ries and his colleagues are taking.  First is the fundamental thesis that the challenge of digital transformation is not one that healthcare systems can solve individually.  As he states, “We believe that the challenge of digitally transforming our industry is bigger than any single system can solve alone.”  Ries not only states his thesis, but he takes us through the painful journey and the significant challenges that individual provider groups and healthcare systems face in attempting to work with vendors and suppliers in adopting digital solutions.   Second, Graphite Health is adopting a “public utilities infrastructure” approach. They are convening and coordinating a healthcare system-led collaborative that will create tremendous economies of scale and achieve efficiencies through standardization and aggregating the tremendous costs of digital transformation across multiple organizations. This consortium will perform numerous tasks such as vetting digital health solutions, contracting, assuring HIPAA standards, creating standards for interoperability and consumer use, and more.  When I asked Ries how he would construct an ROI or value proposition argument for healthcare CFO’s, he mentioned lowered costs, fewer resources and people, and accelerated speed to market in digitally-enabled care. He also added “market relevance”, citing the demise of Sears Roebuck as a classic case study of a large, hugely successful company that could not cross-over into the digital era. The third differentiating feature of Graphite Health is its non-stock, non-profit status and approach. Graphite is not venture capital or private equity backed. It is not attempting to enhance its market valuation with a plan to exit in five to seven years. It is member-driven and uniquely mission driven in this respect. Along these lines, Ries is very keen to point out that Graphite Health will not use its patients as products. What he means by this is that Graphite Health – unlike many digital companies – will not sell its customers data, nor will it profit in other ways from its primary customers. Taking a lesson from CivicaRx – another non-profit, member-driven, healthcare-system led consortium – Ries is creating a sustainable business model for the long run. Graphite Health has a clear sense of its purpose – which is to make healthcare better for patients and providers, assist healthcare systems and providers enter the digital era, and create far greater effectiveness and efficiencies in the healthcare system. There is also a very human side to this mission. Toward the end of our interview, Ries shared a story of speaking with a Chief Informatics Officer, who literally began to laugh as he was describing the mission and outcomes that Graphite Health would deliver.  He asked her why she was laughing. Her response, “I was just imagining how much more fun healthcare would be if we could do what you just described”. Far from being frivolous, I find this story to be hugely relevant to our times. We are witnessing an epidemic of burnout and resignation in the American healthcare system. By my reckoning, most healthcare leaders would agree that we could use a bit more fun to relieve the frustrations, strains, and burdens that providers and patients experience daily.   Until Next Time, Be Well. Zeev Neuwirth, MD

Friends, I’ve heard back from a few of you recently about some of the episodes we’ve had around employer health insurance & benefits. In fact, I was just speaking this past week with a physician colleague who listened to episode #125 with David Contorno, and he literally said that it blew his mind.  Well, I think you’ll find this episode illuminating and mind-blowing. The system of employee health benefits is one of the most opaque and confusing legacy constructs we have in healthcare. Payment, financial incentives and business models are not aligned with the best interests of healthcare consumers. This is an incredibly timely and relevant topic.  In fact, I just read a piece on ACO’s in Health Affairs (Jan 24, 2022) by Michael Chernew discussing ‘why payment reform remains necessary’. We’ve had numerous expert guests who have commented on the problem in employee-based healthcare and the need for major reform, including episode #121 with Glen Tullman, CEO of Transcarent; episode #119 with Steven Nelson, CEO of Contigo; episode #114 with Zack Cooper, a Yale economist; episode #113 with Harris Rosen, CEO of RosenCare; and episode #111 with Dave Chase, just to name a few. In this episode, we have the privilege of hearing from Francois de Brantes. Francois has spent two decades working to transform the U.S. healthcare system by improving incentives for providers and consumers, in order to encourage value-based decisions. He brings the perspective of an economist, but also has hands-on experience deploying numerous real-life programs. François de Brantes serves as Senior Vice President of ‘Episodes of Care’ at Signify Health. He leads customer development of the Medicare Advantage, Self-Insured Employer, and Commercial Payer markets.  From 2006 to 2016, he was Executive Director of the Health Care Incentives Improvement Institute (HCI3), a not-for-profit company that designed programs to motivate physicians and hospitals to improve the quality and affordability of healthcare delivery. This organization was responsible for the Bridges to Excellence® (BTE) and PROMETHEUS Payment® programs, which compensate and reward clinicians that focus on ‘episodes of care’ and ‘performance measures’. François holds a master’s degree in Economics & Finance from the University of Paris IX-Dauphine and a MBA from the Tuck School of Business Administration at Dartmouth College. In this episode, we’ll discover: The amazing journey that Francois has been on for the past couple of decades, starting with his being in corporate benefits at GE. The perverse financial incentives and disincentives built into the fee-for-service, employee health benefits contracts that drive payers, providers and patients away from healthful decisions & behaviors. The principles and tactics required for a shift to value-based employee health benefits. Specific examples of programs demonstrating the benefits of shifting to business and clinical models that focus on profits generated through value rather than volume. How ‘episodes of care’ and ‘bundled payments’ make sense from an individual consumer perspective as well as from a clinical and risk perspective. Every once in a while, a leader comes along stating the piercing truths that capture the core challenges of an era. Francois de Brantes makes such a statement, “There is no real competition for value [in the American healthcare system]. There’s competition for revenue, competition for market share, and competition for billboards, but not for value.” He further distills the fatal flaw in our healthcare system, “Fundamentally fee-for-service does not distinguish between high value care, low value care, or even harmful care for that matter”. Pushing the point even more, he shares that physicians and provider groups, for years, have shared with him the appalling reality that they are not paid to improve or optimize chronic conditions, better manage patient care, or reduce harm.  In fee-for-service, providers are simply paid for each incremental service offered, regardless of its intrinsic value to patients. Just pause for a moment and let all that sink in. Payment in American healthcare does not incent providers to do the right thing on behalf of patient care, and in many ways, disincents them. And far from blaming clinicians, Francois understands the challenges and hurdles from an economic perspective, “Clinicians are really hit with an onslaught of incentives [throughout their daily practice]… that drives them away from their professional mission…” Given that reality, Francois shares, “…the ingredients for creating competition for value are known, tested and validated: (1) transparent information on price and quality; (2) risk contracts to reduce volume incentives; and (3) benefits design that encourages steerage to value providers and reduces demand for low-value care.” Francois and his colleagues have manifested these three principles, combining them with alternative value-based payment models around episodes of care and conditions. This is a major lesson I gleaned from this interview.  Focusing on “packaged” episodes of care or conditions vs. total costs of care makes sense from a consumer-centric perspective since consumers deal with specific episodes and conditions.  It also enables providers to construct viable clinical and business models, and to take more defined risks that they have more control over. I came away from this dialogue, as I have from many of these other interviews, with the reaffirmed belief that the fundamental problem and key solution are bound to a shift toward value-based payment, and toward value-based business and care delivery redesign. The real challenge is the transition – creating the catalytic energy to overcome the entrenched incentives within which legacy stakeholders are mired. There are many other critically important improvements we can make in healthcare delivery.  But, in my opinion, without that value-based payment keystone, employee health and American public health will not improve. And, as Francois points out, this is not a threat to the free market.  Quite the opposite. The private sector is actually protected and the free market is expanded by enhancing competition for value. And most importantly, there is the human suffering and economic toll that continues to be created by legacy stakeholders clinging to FFS payment and non-value-based competition. Francois eloquently captures the call to action, “I never stop thinking about the individual consumers of care – the tens and tens of millions of people in this country… who struggle every single day with making decisions around paying for care and medicines vs. paying for food and housing. By reforming payment and benefits design, we can give those consumers what they need in order to have access to care that is good and doesn’t cost them a fortune. The moment you stop thinking about the average person and the choices they have to make that they shouldn’t have to make, you lose your sense of purpose.” Until Next Time, Be Well. Zeev Neuwirth, MD

Friends, The focus of this interview is an approach to primary care that is divergent from the mainstream approach. It’s different in a number of ways and it’s creating outstanding outcomes for patients, payers, and providers. Our guest today, Dr. Chris Crow, has a compelling story to tell. He is an inspiring leader and a bold reframer of healthcare. I’ve had the privilege of speaking with him a number of times, and am impressed by his personal story, as well as what he and his colleagues have accomplished. Christopher Crow M.D. is the CEO and Founder of the Catalyst Health Network.  He is a nationally recognized healthcare innovator with numerous recognitions & awards; but more importantly he has spent the past 20 plus years focused on helping communities thrive through improving the delivery of healthcare. In this episode, we’ll discover: Some of the underlying problems that greatly sub-optimize the performance of our healthcare system. The three major stakeholders in healthcare, which Chris and his colleagues have built their approach around. The “extended care team” approach that Chris and his colleagues have taken to create an ‘Advanced Primary Care’. The critical distinction between ‘Direct Primary Care’ and ‘Advanced Primary Care’. How Chris is organizing a sustainable financial model that can support this enhanced model of primary care. Early on in our discussion Chris points out that although American consumers demand outstanding customer service, convenience and quality in every other facet of their lives; when it comes to healthcare they have been gripped by what he terms “the tyranny of low expectations”. He goes on to state that the underlying problem is the status quo and inertia of legacy stakeholders, whom he describes as having turned the American health system into a ‘wealth system’ – that is, a system that creates wealth for the few at the expense of the majority of Americans who can not easily access or afford healthcare. One of the major root cause problems is the strong pull to maintain Fee-For-Service payment, which incentivizes volume (visits, procedures, tests, imaging & hospitalizations) over preventive care. Another is the preferential payment afforded to subspecialty and acute-based care over primary care. Chris has been, admittedly, frustrated with the American healthcare system because, as he bluntly states, we know the solution. The “prescription for America” as Chris puts it, is “advanced primary care” – primary care that is accessible, affordable, effective, equitable, and sustainable for both patients and providers. The mechanism behind advanced primary care is through a tech-enabled, virtual, “extended care team” of pharmacists, care managers, social workers and care coordinators. This extended care team is particularly focused on more complex conditions and situations. Some of the services they offer include: (1) medication management and adherence programs; (2) managing formulary-specific medication changes; (3) a referral management and tracking system that maintains network integrity and helps patients and providers navigate to higher value specialists and surgeons; and (4) addressing social determinants of health. In this advanced primary care model, patients derive tremendous benefit in terms of greater connectivity and continuity of care, as well as more preventive care and improved outcomes.  Providers derive benefit through the additional support and the reduced administrative burden, as well as the support they receive in improving clinical quality. Payers derive benefit through more cost effective care and the reduction in total costs of care. There are numerous metrics and stats that demonstrate the outcomes Chris and his colleagues have achieved. One example that Chris shared is around access. The Healthcare Catalyst Network has reduced average waiting times to see a specialist from approximately 28 days down to 4 days. Chris also shares some of the massive cost reductions his network has achieved. The approach that Chris and his colleagues are taking is incredibly mission driven. They consider healthcare to be critical for communities to thrive; and they believe that a value-based, prospective-payment model of primary care is critical in delivering the health outcomes that patients, providers and payers all want. As Chris states, “We’re trying to leave the world a better place and we believe that ‘advanced primary care for all’ in America is the prescription.” Until Next Time, Be Well. Zeev Neuwirth, MD

Friends, Our topic this week is employer-based healthcare, which accounts for nearly 50% of all the healthcare spend in the US. We’ll kick off the episode dispelling some surprising misconceptions about how healthcare insurance actually works; which explains, in large part, how the costs of care continue to rise way beyond other costs of living.  Our guest today, David Contorno is a nationally recognized expert in employee benefits. After nearly 20 years consulting to large national employers, David created E Powered Benefits: a benefits consulting firm whose mission is to deliver fully transparent, value-based benefit services. David has won numerous recognitions & awards, and has been a major contributor to the work and publications that Dave Chase has produced out of Health Rosetta, and the nationally recognized publications of Dr. Marty Makary. He mentors other benefits managers from across the country to transform their business models as well. In this episode, we’ll discover: Some surprising insights into how healthcare insurance companies, insurance brokers and benefits managers are incentivized and bonused – and the conflict-of-interest that is built into the system. The radically different and transparent approach David Contorno takes in creating healthcare benefits programs for employers and employees. How his business model has produced average one-year savings of over 50%, along with substantially reduced out-of-pocket costs for employees – all while improving quality and experience of care. The specific approaches and tactics that David uses, targeted to decrease unnecessary healthcare costs. A real-life example of how David and his colleagues have reduced the costs of a 500 person company by $35 million over the past 5 years. The complexity and lack of transparency in our employer-based healthcare payment and insurance system make it incredibly challenging to understand or do much about – even for the expert employer-based HR benefits managers, whose job is to manage the costs and quality of care for their employees. In an attempt to provide some clarity, I’ll summarize three significant take-home messages I gleaned during this interview: (I) the healthcare stakeholders that employers and employees rely on to manage quality & costs are not, for the most part, financially incentivized to lower costs, raise quality or improve outcomes of care. (II) The majority of healthcare insurance costs are actually medical costs; so the way to fix rising healthcare insurance costs is to address the detailed medical costs.. (III) The specific tactics that David focuses on include: (1) finding surgeons and surgical centers with higher quality outcomes and lower costs – centers that offer fixed-price bundled payments. (2) finding imaging centers that deliver state-of-the-art service at a fraction of the cost of high-priced centers. (3) purchasing medications outside of the traditional pharmacy benefits management (PBM) system – thus avoiding huge mark-ups. (4) providing value-based ‘direct primary care’ for chronic diseases and preventive services. These models allow a physician to spend more time with their patients rather than be driven by Fee-For-Service, RVU-based, high-volume care. (5) Employers passing the savings onto their employees rather than the more typical employer approach of pass-through cost-shifting. What I truly admire about David Contorno is that he’s adopted a radically different approach to the way that he and his company get paid. His compensation and bonus structure are based on lowering costs while assuring high quality care. And, his revenue is completely aligned with employers’ and employees’ best interests, not with those of corporate shareholders. Healthcare insurance and medical costs are a crippling problem for a significant and growing percentage of American employees and their families. The goal here is not to lay blame on legacy stakeholders in healthcare. Rather, it’s to lay out for all to see that the fundamental payment structure and incentives in the system are misaligned and grossly maladapted for the purported purpose of healthcare – that is, of keeping employees and their families healthy. David sums it up in this way, “Every entity that an employer trusts to manage healthcare costs benefits [financially] from healthcare costs going up.”  And so, as many have stated, our healthcare system isn’t broken, it’s perfectly designed to deliver the results it delivers. Until Next Time, Be Well. Zeev Neuwirth, MD

Friends, This episode is about a domain of healthcare delivery that will undergo a fundamental transformation over the next 3 – 5 years. It is the most precarious and fragmented stage of care – post-hospital discharge and post-acute care transitions. It is a side of healthcare that is ripe for disruption, with the potential to greatly reduce readmissions, reduce total costs of care, and dramatically reduce preventable pain and suffering for patients and their families. Our guest today, Yoni Shtein, is a serial entrepreneur who started his journey as a software engineer at Microsoft. Having completed his MBA at Harvard, Yoni joined RPX Corp as a founding member of the insurance business. After RPX went public, Yoni left to co-found and merge a tech fund into Fortress Investment Group, where he spent six years as an investor. Yoni then moved to Israel and launched Laguna Health, a ‘digital recovery assurance company’, with his longtime friend and colleague from Microsoft, Yael Peled Adam. They also have recently brought Dr. Alan Spiro on as their President and Chief Medical Officer. In this episode, we’ll discover: Why Yoni states that “recovery is everyone’s problem and no one’s job”, and how Laguna is making it their job! Why and how Laguna is focused on the behavioral and contextual aspects of care, even more than the clinical signs and symptoms. The three platforms that Laguna has created to engage patients and guide providers in optimizing transitions of care: their patient-facing app, the Harmony Case/Care Management Platform, and their Clinical Care Engine How Laguna is customizing care through a “choose your own adventure” approach. The tremendous outcomes Laguna is achieving in readmission reduction. During the interview Yoni states his fundamental thesis: “Laguna is reframing healthcare in changing the dialogue from readmissions and provider penalties to member ‘recovery journeys’ and payer cost drivers.” He points out that the most fundamental problem in transitions of care is the misalignment of incentives. Let’s unpack his statement. The reality is that healthcare systems and provider groups are not financially incentivized to optimize patients’ health after discharge. While there has been an increased focus over the past few years on reducing readmission rates (driven in large part by CMS readmission penalties); the fact is that hospitals’ financials are not aligned to post-hospital care. And, just to be clear, this is not to blame hospital systems. Instead, it’s a commentary on how care is paid for in our country. Given that reality, Yoni and his colleagues are targeting their efforts at entities whose business models are aligned with improving post-discharge care: (1) self-insured employers; (2) Medicare Advantage Health Plans; and (3) payers or healthcare systems that are taking financial risk for their populations’ total cost of care. A second reframe that Laguna is introducing is instead of focusing on a metric (i.e. 30-day readmission rate); they are focused on the patient’s “recovery journey”. They’re using decades of published research to identify “recovery barriers”, and are designing their products and services to mitigate and eliminate those barriers. A third reframe that Laguna has introduced is that they have designed their care model to address the behavioral and contextual aspects of care.  They’re identifying and solving for the daily barriers that people face in engaging with healthcare and optimizing their health. According to Yoni, over 50% of all readmissions are preventable. That means that the American healthcare system is failing patients and their families one out of every two readmissions. It’s been said that our healthcare system is perfectly designed to deliver the results it delivers. But if we understand how wrong those results are, why aren’t we changing the system more intentionally and more immediately? Why aren’t more healthcare leaders not pushing to create a new healthcare? Far from being discouraged, these questions only strengthen my resolve to seek avenues to create a new and more humanistic healthcare system. And, it also strengthens my belief that we need more leaders like those in Laguna, who are reframing healthcare to be what patients, their families, as well as providers need it to be, and not what ‘the system’ dictates it be. Until Next Time, Be Well. Zeev Neuwirth, MD

Friends, There are numerous critical healthcare reframes in this week’s episode. First, what Dr. Silverstein makes abundantly clear is that the senior leadership team at ChristianaCare is fully comitted to accelerating the shift to value based payment. Second, they are committed to greatly expanding the use of virtual care as a  primary mode of care. Third, they are focused on health outcomes vs healthcare delivery. Underlying these three patient-centered goals is another profound reframe, the notion that in order to achieve the quadruple aim, provider organizations must form vertical integrations and create complementary collaborations with other types of stakeholders in healthcare – such as payers and retailers. Our guest today, Ken Silverstein, is the Chief Physician Executive at ChristianaCare. He previously served as chair of ChristianaCare’s Department of Anesthesiology, Medical Director of Perioperative Services and as Chief Medical Officer. He received his undergraduate degree from Brown University, his medical degree from New York University School of Medicine and his MBA from the University of Delaware. Dr. Silverstein was a resident and a fellow in anesthesiology at the Brigham and Women’s Hospital in Boston. He completed his clinical fellowship in anesthesiology at Harvard Medical School. In this episode, we’ll learn about: The 10 year value-based collaborative agreement that ChristianaCare and Highmark have launched together. The 5 major “vehicles” that ChristianaCare & Highmark are planning to deploy within their collaboration. The guiding “partnership principles” that are being used to create a relationship-centered approach to this synergistic collaboration. The fascinating independent spin-off virtual primary care practice that ChristianaCare is building out with Highmark, that greatly improves the efficiency and effectiveness of care. At the beginning of our conversation, Ken states, “we created a new company and the intent is to completely transform healthcare.”  That bold remark speaks volumes about the visionary leadership at ChristianaCare. Another statement which gripped me was the fact that the ChristianaCare leadership team is discussing Clayton Christenen’s ‘dilemma zone’’, which the folks at ChristianaCare have relabelled as the “commitment zone”. The point of the concept is that in order to transition to a value paradigm and realize a long-term gain, leadership must accept a short-term loss. It’s amazing to see hospital leadership thinking and acting in this way. But even more amazing is the fact that their Chief Financial Officer was the one who introduced this concept to the leadership team. In our correspondence prior to the interview, Ken wrote that American healthcare is “facing an apocalyptic forecast…”.  It’s a disconcerting pronouncement from a seasoned physician executive.  But, what was concerning for me was that I had heard this very same comment from two other physician executives in the prior week. During our interview, I asked Ken what he meant by this statement. He went on to discuss issues such as the worsening unaffordability of healthcare, fragmentation of care, and inappropriate overutilization. He also passionately talked about the unacceptable inequities and disparities in healthcare, using Delaware as an example.  In Wilmington, the difference in life expectancy – what Ken referred to as the “death gap” – between white communities and black communities only 2 miles apart is 16 years! He punctuated this statistic by asking how that is acceptable to anyone. The situation may seem dire but I have to say that I have never been more hopeful, more inspired and more encouraged about the future of healthcare than I am today. The reason stems from listening to leaders like those at ChristianaCare who are not just speaking the rhetoric of reframing, but are taking the very concrete steps necessary to create a new and better healthcare. They are making the painful trade-offs required, and are investing in a better future. They are, as Simon Sinek would put it, playing the generative “long game”. ChristianaCare is making a demonstrable commitment to creating a value-based future. They are aligning their resources with their rhetoric. They are doing this not because it’s easy or safe. They are doing it, as Ken states, “because it’s the right thing to do, period.” Until Next Time, Be Well. Zeev Neuwirth, MD

Friends, With the onslaught of the Covid-19 pandemic, numerous hospital systems across the country rapidly adopted the hospital at home model in an effort to deal with overcapacity.  Many systems are planning to continue this service – even after the pandemic. The reasoning is simple. It’s a much lower-cost alternative. It’s much more personal and customized care. It’s a lot more convenient and comfortable for patients and their families. And, it’s going to be a major clinical delivery approach in the future; a major source of revenue, as well as a source for patient growth and retention. Our guest today, Raphael Rakowski, is one of the most significant entrepreneurial leaders in this rapidly advancing and transformative trend in healthcare delivery.  In 2010, years before most of us even heard of it, Raphael Rakowski led a team of engineers and clinicians in the creation of Clinically Home, the first commercially scalable model to enable safe hospitalization at home. In 2017, Raphael and his team created a next-gen version called Medically Home and joined forces with Atrius Health (a large multi-specialty medical group in eastern MA) to bring the program to market.  In 2020, after his role as CEO & Founder, Raphael was named Executive Chairman of Medically Home Group, Inc.  Medically Home operates in over 15 states at the time of this interview with a large number of strategic partners, and has most recently partnered with the Mayo Clinic & Kaiser Permanente. In this episode, we’ll learn about: Why – according to Raphael – the financial and business model for facility-based hospital care is misguided, misaligned and maladapted to the needs and safety of patients and their families. Why the shift to decentralized healthcare is necessary if we are to have a sustainable system, and how it’s consistent with the path that other industries, such as banking and retail have taken. The four operational pillars that allow Medically Home to deliver a much higher acuity level of care in the home than other ‘hospital at home’ models. The superior outcomes that Medically Home is achieving compared to traditional facility-based hospital care. How Medically Home is addressing some of the challenges in delivering high acuity care in the home setting. According to Raphael, the reason facility-based hospital care is suboptimal is that it has been fashioned like an industrial factory. He backs up his statements with powerful observations, compelling data and intelligent reasoning. For example – according to Raphael, 65% of hospital costs are due to the fixed costs of their bricks and mortar infrastructure. This overhead creates a “tax on care”, leaving only 35% for medical care. On the other hand, the cost savings Medically Home is achieving are about 25%.  Patient satisfaction is at or above hospital levels. Mortality and morbidity reductions are 10%, and fall rates and infection rates are dramatically better than facility-based hospitals. Raphael also reframes our notion of acute care and post acute care.  As he puts it, “The point of the Medically Home model is that you’re reliably integrating three things that should never have been siloed – acute care, post-acute care,and population health… There is no such thing as post-acute care. It was invented as an artifact of reimbursement. You should be cared for by the same care team until you’re not sick anymore.  This is one of the reasons for the high readmission rates we see in hospitals across the country…  We combine these together in a single episode called “stay with the patient until they’re well and you understand what it will take for them to stay well…”   At the present moment, the home-based care market in the US is approximately $140B in revenue, and predicted to grow to over $200B within the next 4 to 5 years. One can view this rapidly emerging home-based care market as a threat to hospital systems – or, as an opportunity.  For those hospital systems willing and capable enough to be early entrants – it is a huge opportunity to diversify their business models and revenue stream, and to de-risk the unprecedented market disruption that is almost certain to occur this decade. From a mission-based perspective, it is an opportunity for our healthcare systems to do what we need them to do: improve care and care outcomes, lower costs, and provide a more compassionate and convenient care experience. Until Next Time, Be Well. Zeev Neuwirth, MD