Creating a New Healthcare

Friends, Whether you’re 25 years old or 75 years old, when you walk into primary care providers’ offices in most places across the country, the care you’ll receive is pretty much the same. The people in the office are the same; the services are the same; the protocols are the same; the time slots you get are the same. Does that make sense to you? To state the obvious – a 65-year old, 75-year old and 85-year old have much different needs, concerns and issues to deal with than patients in a younger demographic. And yet, the healthcare seniors receive is largely undifferentiated. In this episode, we’ll hear about a segmented, customized, personalized and holistic approach to senior care that is being delivered by a highly innovative pay-vider. Humana has, for years, been a national leader in senior care, home-based care, and the social determinants of health. In this episode, we’ll explore these topics with the incredibly accomplished Dr. William Shrank. Now, I do want to add that there are other organizations who have been segmenting and customizing care for seniors. My three favorite examples are ChenMed, CareMore and Iora Health. ChenMed is, in my opinion, the paragon for VIP care of seniors.  A few other examples include Archwell, Oak Street, Patina, Landmark, Lena Health, and Landmark which is now part of Optum. Large hospital/healthcare systems across the country are also beginning to develop similar models of care that are focused on seniors. Dr. William Shrank serves as a Senior Advisor at Humana, after recently stepping down as Chief Medical Officer. His current responsibilities include implementing Humana’s integrated care delivery strategy. He leads Humana’s Care Delivery Organization, clinical operations, and the Bold Goal population health strategy. Dr. Shrank held the position of Chief Medical and Corporate Affairs Officer from July 2019 to July 2021, during which time he also oversaw government affairs. Dr. Shrank joined Humana as Chief Medical Officer in April 2019, having previously been employed by the University of Pittsburgh Medical Center (UPMC) where he served as Chief Medical Officer of their Insurance Services Division from 2016 to 2019. Prior to UPMC, Dr. Shrank served as Senior Vice President, Chief Scientific Officer, and Chief Medical Officer of Provider Innovation at CVS Health. Before joining CVS Health, Dr. Shrank served as Director of the Research and Rapid-Cycle Evaluation Group for the Center for Medicare and Medicaid Innovation, part of the Centers for Medicaid and Medicare Services (CMS). Dr. Shrank began his career as a practicing physician with Brigham and Women’s Hospital in Boston and as an Assistant Professor at Harvard Medical School. He has authored over 250 peer-reviewed publications. Dr. Shrank received his M.D. from Cornell University Medical College. He completed his residency in Internal Medicine at Georgetown University and his fellowship in Health Policy Research at UCLA. He also earned a Master of Science degree in health services from UCLA and a bachelor’s degree from Brown University. In this interview, we’ll hear about: The impressive investments that Humana has made into senior care, home-based care & the social determinants of health. Humana’s national deployment of senior care clinics as well as the larger integrated Centerwell brand that includes home-based care & pharmacy. The incredibly thoughtful divisions they’ve created focusing on digital health, social equity, and clinical solutions.  How Dr. Shrank views the relationship between healthcare systems and payers. The significant emphasis that Humana places on being a “rapid learning organization” and their focus on data-driven decisions & evidence-based deployment. I admire so many things about Dr. Shrank. He is a physician, health services researcher, healthcare administrator and visionary leader. He’s also incredibly humble and as much a learner as he is a doer. His background and the years he spent at CMS and CVS have provided him with incredible experience in how to deploy and evaluate large-scale, value-based programs.  Along these lines, the emphasis that Humana has placed on scientifically evaluating their initiatives and making data-informed decisions is exemplary. In this episode, Dr. Shrank articulates some of the challenges in systematically and scientifically evaluating whether or not initiatives create patient engagement and deliver on outcomes; as well as their scale-ability.  One also has to respect Humana’s forward-thinking focus on social equity and the social determinants of health, which is largely credited to their CEO, Bruce Broussard, who initiated “The Bold Goal” project in 2015. Along these lines, Dr. Shrank discusses the CDC’s self-reported “healthy days” metric that Humana has been pursuing; as well as their perspective, which is to make social determinants of health an integral part of every day care delivery.  We go into some depth on why Humana has created a segmented and customized care model focused on seniors, and what differentiates this value-based model from the generic primary care medical home. Dr. Shrank is very firm in his belief that in order to deliver seamless, personalized care and optimal outcomes for the senior segment of our population, we need to create a very different primary care model. He also makes the point that data and analytics is the key to understanding patients’ needs, and that these understandings will contribute more to personalized care than genomics.  In the final moments of the interview, I asked Dr. Shrank what message he had for healthcare system C-suites.  His response was one word, “partner”.  He makes the point that healthcare is too complex for any one system or stakeholder to get it right; and in the best interest of our patients and our communities, we need to become better partners with one another.  When I asked him what message he had for the leaders at HHS & CMS, his response was to put outcomes over ideology; which is no small task given the current polarized political climate.  Dr. Shrank didn’t use this term, but it was apparent to me that throughout our dialogue he was painting a picture of a ‘whole health’ model of care. His point of view is laser focused on what matters most to patients, especially those that are part of more vulnerable populations. One saving grace of our healthcare system is that we have humanitarian leaders like Dr. Shrank and his colleagues at Humana who not only talk the talk but also walk the walk – leaders who are committed to a value-based system of care that places personalized health outcomes as their KPI. Until next time, be well. Zeev Neuwirth, MD

This is a singularly unusual and unprecedented episode. Aug 17th 2022, which is the day of the posting of this episode, is the 5th anniversary of the ‘Creating a New Healthcare’ podcast. I’m taking this opportunity to spend a few minutes reflecting on the journey – and to share those reflections with you. As always, I am interested in your thoughts as well, so please respond on LinkedIn and Twitter. Initially, I was planning to host this by myself, but then I thought how much more interesting and fun it would be to have someone else to speak with, especially someone who is adept with hosting their own podcast. The first person who came to mind was the amazing Scott Becker, who graciously agreed to interview me for this episode. Scott Becker needs no introduction, but for those who don’t know his history… Scott Becker is the founder & publisher of The Becker’s Healthcare and Becker’s Hospital Review. He is an attorney, a partner at McGuireWoods and a former board member of McGuireWoods.   Scott also served as chair of the national health care practice at McGuireWoods for more than 12 years.  He is a graduate of Harvard Law School and a CPA.  And, as I mentioned before, an amazing podcast host! In this interview, I’ll share: The very real tension that is driving this podcast, as well as its fundamental purpose, which is a bit different from other podcasts. A few critical lessons I’ve learned from our guests over the past 5 years. Some examples of the courageous journeys that we’ve been privy to hearing on this podcast. A couple of favorite quotes from the amazing leaders I’ve interviewed. What continues to energize and inspire me about the podcast journey and some thoughts about what’s next. Without giving away too much, here are a few brief thoughts on this discussion with Scott Becker.   First – it was an incredible honor to have Scott Becker interview me. He is one of the most generous individuals I have come across in the healthcare world and I have tremendous respect for what he has built, including the incredible relationships he has fostered.   Second – when I reviewed the list of the brilliant leaders who have been on the ‘Creating a New Healthcare’ podcast – over 250 interviews, 137 of which I’ve posted – I was surprised at how many were situated within legacy healthcare organizations: hospital systems, payers… I would have thought that the majority were entrepreneurs in start-ups, but it seemed to be split pretty evenly. The takeaway is that transformational change can and does occur within legacy healthcare systems – hugely hopeful and inspiring! Third – although I’ve conducted hundreds of interviews, there are actually a relatively small number of critical lessons or themes that these leaders all resonate around. I share 3 major lessons in response to a question Scott asks; but there are a few others that are woven throughout the dialogue. And I love that Scott inserts some important takeaways in there as well.     Fourth – despite a lot of rhetoric about the demise of our healthcare system, I share an informed and grounded perspective that I have never been more encouraged, hopeful and inspired than I am today. This doesn’t come from an armchair perspective. I work in our healthcare system each and every day, as I have for the past 30 plus years. And, my overall sense is that there has never been a better time for the humanistic transformation of American healthcare.    Fifth – My overarching perspective is one of respect and gratitude. There is no question that our healthcare system is in need of some serious fundamental change.  But, there is also no question in my mind that the vast majority of the people working within our healthcare system are truly amazing. The doctors, nurses, PA’s and other providers, as well as the administrative leaders and staff who work tirelessly each and every day – week after week, month after month, year after year.  No matter what swirls around them, no matter what politics or payments or pandemics, they perform professionally – with compassion and empathy. They hold our system together. My respect, gratitude and hope arise from working with, watching and learning from these truly incredible individuals. Two final thoughts here –  I’d like to take a moment to thank all of you out there who have been listening to, commenting on and sharing this podcast with your professional networks. I can’t begin to tell you how important and meaningful your feedback is to me.   I hope you enjoy and benefit from listening to this particular podcast episode as much as I did in recording it. Until Next Time, Be Well Zeev Neuwirth, MD

Friends, There is a quiet, maybe not so quiet, revolution happening in healthcare delivery. The transposition of healthcare out of the legacy bricks & mortar sites and into the home. Payers such as Humana and Optum, as well as retailers such as Amazon, Best Buy Health and Walgreens are spending tens of billions of dollars acquiring companies and capabilities to bring medical care into the home. There are hundreds of vendors that are already years into creating a home-based care ecosystem. With the increasingly sophisticated remote monitoring, digital diagnostic equipment, predictive analytics, telemedicine & logistics software capabilities, we are seeing these companies provide more personalized and contextualized care that, in many ways, is not only more convenient, but actually superior to care in the hospitals, ED’s & clinics. We’ll be asking our guest today, Dr. Mark Prather, to share his industry-leading experience and wisdom on all of this. Dr. Prather has an impressive track record in both the clinical and entrepreneurial domains. He practiced as a board-certified emergency medicine physician for more than two decades. He was a founder and served as President of US Acute Care Solutions, an integrated acute care physician staffing organization serving approximately six million patients annually. He has partnered in multiple medical industry startups, including iTriage, an early digital patient navigation tool. Dr. Prather obtained his undergraduate degree in Molecular Biology at Vanderbilt University. He attended medical school at UCLA, where he graduated with honors, and completed residency training in Emergency Medicine at Denver Health where he also served as Chief Resident. He also obtained a Master of Business Administration from the University of Colorado School of Business. In this interview, we’ll hear about: The profound & documented clinical, interpersonal & economic advantages of home-based care compared to traditional brick & mortar hospital based care. How home-based care is much more effective in assessing & addressing social determinants of health. The evolution of Dispatch Health from urgent/emergent care at home to a full service home-based healthcare ecosystem, and why Mark decided to start with urgent/emergent care visits. How Dispatch Health is evolving their payment into the value-based realm & the incredible cost savings they’ve already demonstrated. Some critical comments from Mark regarding how home-based care is actually much safer, far less fragmented, and much more personal than the traditional brick & mortar care being delivered in hospitals, ED’s & doctors’ offices. Why Mark firmly believes that home-based care will disintermediate the brick & mortar landscape of healthcare delivery. There are a few take-aways that I believe are incredibly important for all of us to understand about the home-based care ecosystem. First – Healthcare in the home is not a hypothetical and not some future state. It is happening and in significant numbers. Dispatch Health has already seen hundreds of thousands of patients, over 700,000 in the home, and is seeing hundreds of thousands of patients annually. Second – The acuity or severity of patients being cared for in the ‘Hospital at Home’ are not the mildly sick patients. Mark’s data reveals that the patients cared for in the home are in the top 10% of acuity according to the Charleston Comorbidity Index. Third – the cost savings are real and significant! Dispatch Health is documenting savings of $5000 – $7000 per admission compared to traditional hospital admissions. Mark goes into some detail as to how these cost savings are occurring. What’s remarkable to note is that these savings accrue not because there is less care, but actually because there is more and better care. Fourth – In addition to the concrete clinical & safety benefits, Dispatch Health has an average Net Promoter Score of 95%, with over 700,000 patient home visits & home hospitalizations. Along the lines of patient experience & satisfaction, it seems almost too obvious to mention but this sort of care delivered in the home is infinitely more convenient and comfortable for patients and their families than hospital-based care or traditional ED or even urgent care. Fifth – Care delivered in the home is much more personal, customized and contextual than care delivered in hospitals, ED’s, nursing homes, urgent care centers & doctor’s offices. Mark points out that being in the home really shifts the focus of the clinicians from a limited triage & treat function to a treat & recovery function. Clinicians & staff in the home have purview into the patient’s life – into non-clinical determinants of health like social supports, medications, food security and home safety – that have as much, if not more, of an impact on health outcomes. One great example Mark provides of how home-based is more humanistic is around end-of-life conversations. These sorts of conversations are challenging in the ED & hospital setting. But, in the home care setting, they become much more personalized and comfortable for patients and their families. Sixth – The clinical benefits are myriad including:(1) far lower risk of hospital acquired infections and other dangerous conditions; (2) lower risk of delirium and falls; (3) lower risk of malnutrition; (4) lower risk of readmission and/or the need for post acute care nursing facilities; and (5) lower risk of mortality – Mark quotes a 20% reduction in mortality. Seventh – the advantage of the patient being initially evaluated at home. Once a patient enters a brick & mortar Emergency Department, their chance of being referred to ‘hospital at home’ is about 35%. Mark attributes this largely to the pressure ED docs face in getting people out of the ED and into a hospital bed. But, if the patient is initially evaluated in the home, their chance of staying in the home (aka – being referred into the ‘hospital at home’ service) is 97%. Two final lessons – one of the key reframes I’ve learned from Dr. Prather as well as other leaders in the home-based care space is that the notions of Urgent Care, Emergency Care, Hospital Care, Post Acute Care – are all arbitrary legacy concepts that have little bearing in the home-based care ecosystem. As Mark and other leaders put it, ‘care is care’. If a patient needs medical/clinical care in the home, it’s simply that – whether it’s urgent, emergency, hospital level, post-acute hospital care and so on. The difference is just a matter of how much and how intense that care is. But the point is that it doesn’t make sense to label it based on legacy brick & mortar concepts. The other related lesson is how much more seamless and safe home-based care is, as compared to traditional brick & mortar hospital-based care. For example – when a patient is discharged from a 5 – 7 day hospital stay, they typically get transitioned to a nursing or rehab facility, or they get transferred back home. What most people don’t understand is that this requires numerous hand-offs which introduce tremendous opportunities for safety errors, and typically leads to a readmission back into the hospital about 20% of the time. If the patient is discharged home, there is also a bit of a leap of faith, because as much as case managers and care managers can inquire about, they don’t have an in-person understanding of what the home environment looks like. What I found fascinating about the Dispatch health ‘hospital at home’ model is that the patient is actually not discharged. The intensity of their care may be reduced after 5 – 7 days, but they are actually followed for up to 30 days. And because there are no artificial hand-offs and because the clinicians and staff are in the home, there is far less risk involved in the transitions of care. I suspect that the vast majority of clinicians and healthcare leaders are unaware of this particularly important point. Dr. Prather is, as he modestly puts it, “an old hospital systems guy”. But he has spent the past decade intensely studying, innovating and now building an incredibly robust home-based ecosystem of care. Mark is not an academic physician or researcher. He is a seasoned clinician and clinical leader, and a highly experienced and successful healthcare entrepreneur, who had to be convinced that the clinical model and business model for home based care worked better than the traditional hospital and ED based model. He’s convinced. How about you? Until Next Time, Be Well Zeev Neuwirth, MD

Friends, The first interview we conducted with Ben Kligler (see episode #130) was an introduction to a game-changing humanistic inflection in healthcare delivery called ‘Whole Health’.  If you haven’t listened to it yet, you must. What the VA is deploying on a national scale may be the largest and most significant positive transformation occurring in the American healthcare system. This interview builds on what we discovered in episode 130, but we get a chance to really discover the essence of this life-saving movement.  In the beginning of this interview, Dr. Kligler lays it out plainly, “…we are creating an actual delivery system built on whole health”.  His response to the ‘why’ question is also straightforward and rings true. “… we’ve gotten to the limit of what disease-oriented care can do in terms of improving our health and well-being…” He goes on to support this statement with statistics and well reasoned arguments. One stat he cites is that the US continues to rank the lowest on multiple domains of healthcare, including health outcomes, when compared to other high-income countries. In fact, the US ranks 37th in the world when it comes to healthcare outcomes, despite grossly outspending every other country.   I think most of us understand the problem at hand, but we may not really understand the ‘whole health’ solution. Ben does a fantastic job of distilling it down for us, “Our theory is that our legacy healthcare approach is not tapping into one of the most powerful sources of health, which is a person’s ability to make changes in their life and move forward, toward what’s important to them; and to address what’s in their way – what’s keeping them from having a healthy life.  [Whole health] is also a vehicle for addressing the social and structural determinants of health… It’s really the solution to what’s holding our healthcare system back… because managing disease is simply not enough…” 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 two questions that form the foundation for the ‘whole health’ program.  I’ll give you a teaser. The first question is, ‘what in your life most matters to you?’ Can you guess what the second question might be?  See below.  The specific domains within the “circle of health” which assist providers and patients in identifying what’s most important and most relevant to the context of patients’ lives. How this program is intent on not only identifying the issues, but also providing the tools and support in attaining and maintaining those personal goals.   The ‘whole health’ outcomes that the VA is measuring and tracking, and those they’re already beginning to see improvements in.   Some of the challenges in studying these outcomes and deploying the program on a national scale, as well as next steps  There are a few notable comments from this dialogue with Dr. Kligler that stand out for me.   First – a surprising benefit of the VA’s Whole Health approach is that the providers and staff are also benefiting. The VA is observing an improvement in provider & staff work satisfaction as well as a reduction in turnover. Given the significant burnout (~50% amongst doctors and nurses) and the ‘great resignation’ in healthcare, leaders should take note and consider this Whole Health approach. It should come as no surprise that one of the core defining elements of burnout is depersonalization.  Second – One of the most surprising and telling stats that Dr. Kligler cites is that people who have a low sense of purpose are two and a half times more likely to die than people who have a high sense of purpose.  Based on that research, he goes on to ask the question ‘why isn’t ‘purpose’ a core vital sign?’.  Well, in the whole health approach it is one of the main domains on the ‘circle of health’. His point is that ‘sense of purpose’ and other non-clinical factors are, in fact, ‘vital’ signs – determinants of our vitality. We’ve known this for years, with mounds of scientific evidence to support it, and yet, we continue to propagate a system that excludes these ‘vital’ signs. Why is that?  Third – Dr. Kligler points out the critical reason why the VA can pursue a Whole Health contextualized/personalized approach to healthcare, while most other healthcare systems can not. It has to do with payment & compensation. The VA is essentially a value-based, capitated-payment provider – a so-called payvider. What this means is that if the VA prevents a bad outcome, it gets to keep the savings, which it uses to re-invest in its healthcare delivery system. So, in the VA system, prevention has a positive return-on-investment and is consistent with the business model. On the other hand, the overwhelming majority of payment in this country (outside of the VA) is fee-for-service (FFS). You get paid for what you do rather than what you prevent, which makes it financially more difficult to invest in proactive, personalized, preventive care. As he puts it, the VA is not ‘conflicted’ or ‘confused’ by a FFS payment model in which contextual factors of care have little to no return on investment.  For those of you who listen to this podcast regularly, this is a recurrent theme.    Fourth – Despite the challenges and conflicting incentives of our FFS-based healthcare system, I was very encouraged to hear that others across the country are also developing a ‘whole health’ or ‘whole person’ approach.  Dr. Kligler shares that the National Academy of Medicine (NAM) is planning to publish a report some time next year, providing an inventory and summary of the whole health movement.  On a final note – I’m writing this on a hot and humid afternoon of July 4, 2022.  I share this with you because Independence Day reminds all of us of the soldiers and veterans who established our independence and continue to defend it. The fact that the Veterans Administration is spearheading the ‘whole health’ approach – rehumanizing healthcare for our veterans – is particularly poignant and special on this day.  Another connection of Whole Health with this day has to do with the concept of liberty. “We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness.”   We cherish our liberties in this country because they enable us to express ourselves, to pursue our dreams and goals, to achieve and manifest what matters most to us, to be the best we can be, and to live the best life we can.  I view Whole Health as a public health movement that is based on the principle of liberty – enabling and empowering us to attain what matters most to us. I salute Dr. Ben Kligler and his colleagues, and the brilliantly humanistic leadership of the Veterans Administration for creating and supporting the whole health revolution.   Wishing you Whole Health Until Next Time, Be Well Zeev Neuwirth, MD

Friends, I’ve listened to this podcast multiple times, in preparation for this write-up.  Each time I listen, I learn something new and continue to be blown away by what the visionary folks at Laguna Health are doing and building. The bottom line here is that our healthcare system is not designed to identify and address the contextual [life] barriers of care. As a result, patients and their families suffer, health outcomes are worse, and the jobs of providers and their teams are made much more difficult. Laguna Health is reversing that by creating a much more contextualized and personalized healthcare approach.  In this interview we distill decades of patient-centered research that Dr. Saul Weiner and Dr. Alan Schwartz have conducted and are now embedding within the Laguna Health approach. It is the most significant and impactful applied research I have ever encountered in terms of understanding how the context of people’s lives impact their healthcare and their health outcomes. And, importantly, how clinicians, clinical teams and healthcare systems can identify barriers to care and address them as an integral part of the healthcare experience.  The magic, however, doesn’t stop here.  Laguna Health has taken this extraordinarily empathetic approach and combined it with the most advanced digital technologies to create an ecosystem of care that supports the provider-patient relationship and promotes a humanistic form of healthcare. This is in stark contrast to what most patients and providers have to endure – which is an underlying technologic platform and system of care that makes it difficult for providers to really listen to and understand their patients, and makes it very difficult for patients and their families to navigate healthcare within the larger context of their daily lives.  The majority of the interview was conducted with Dr. Weiner and Dr. Schwartz, who literally wrote the book on ‘Contextualizing Care’. We were also fortunate to have Dr. Spiro (Chief Medical Officer) as well as Yoni Shtein (co-founder and CEO) on the line to provide some brilliant commentary in what was one of the most engaging and awe-inspiring conversations I’ve had on this podcast.  Dr. Weiner is co-founder of the Institute for Practice and Provider Performance Improvement. Dr. Weiner is a professor of medicine, pediatrics and medical education at the University of Illinois at Chicago, and deputy director of the research Center of Innovation for Complex Chronic Health Care at the Veterans Health Administration. He graduated from the Geisel School of Medicine at Dartmouth, completed his residency in Internal Medicine at the University of Chicago and is a former Robert Wood Johnson Foundation Generalist Physician Faculty Scholar. Dr. Schwartz is also a co-founder of the Institute for Practice and Provider Performance Improvement. He is the Michael Reese endowed professor of medical education, and research professor of pediatrics at the University of Illinois at Chicago. Dr. Schwartz received his PhD in cognitive psychology and Masters in business at the University of California, Berkeley. He is currently enrolled in the JD program at the University of Illinois at Chicago School of Law. Dr. Alan Schwartz & Dr. Saul Weiner co-authored the book on contextualized care – Listening for What Matters: Avoiding Contextual Errors in Health Care.    In this interview, we’ll hear: What contextualizing care actually means – from the physician and medical researcher who have been studying this topic for over 20 years, and who have taught it to thousands of doctors and healthcare teams. How critically important contextualizing care is in delivering optimal healthcare outcomes, and how frequently it is ignored in clinical practice. The difference between empathetic care and contextualized care. Contextualized care is not the same thing as good bedside manner! The twelve domains of contextualizing care that Dr. Weiner and Dr. Schwartz have discerned from intensely & rigorously studying over 5000 patient-provider encounters. Which one of the twelve barrier domains these experts emphasized as being grossly missed in healthcare delivery.   What I love about the Laguna Health story is that these visionary leaders are operationalizing and technologizing – automating – a humanistic form of healthcare delivery that is almost the inverse of mainstream healthcare. They are literally contextualizing care for each and every patient and their families by embedding it in the process and embedding it in the tech platforms.  Most providers would agree that the current legacy electronic health records as well as workflows make it more difficult to understand the context of patients’ lives and its impacts on healthcare. What Laguna is building is quite the opposite – creating a tech platform and a system of care that literally has personalized care built into it, at every step of the way – from assisting the provider teams in identifying barriers to healthcare, to supporting their inquiry of those barriers, to eliciting actionable responses from patients, to identifying and implementing a plan of action to overcome these contextual barriers.   The team at Laguna Health is taking Dr. Weiner and Dr. Schwart’s profound work and putting it on steroids, enabling it with state-of-the-art data analytics and machine learning, natural language processing and voice analytic technologies, as well as embedding it within their team structure, their training and their workflows.  I could literally feel the energy and enthusiasm in speaking with Dr. Weiner and Dr. Schwartz – the realization that their decades of research and teaching were being taken to a whole different level.  As I listened to these leaders from Laguna Health, I could not help but realize that they are, in fact, creating a new, better and more humanistic healthcare system. I also could not help but think that they are doing nothing less than creating a new standard of care. It is breathtaking and inspiring – and I encourage you to listen to this episode more than once. You will be better for it.  Until Next Time, Be Well Zeev Neuwirth, MD

Friends, Our topic today is nothing less than a new standard of care for a vulnerable segment of the population that has been subjected to highly fragmented, uncoordinated and grossly inadequate medical care. For those of us who have experience with older parents as well as for physicians and other providers of care – you understand how challenging, frustrating and heartbreaking this situation can be. Dr. Michael Le, and his colleagues at Landmark Health and Optum’s Home & Community division, have spent decades developing and deploying a remarkably humanistic alternative approach to care for this vulnerable population.  He outlines for us a comprehensive, concierge-like, premier home-based care ecosystem for frail seniors and those with complex chronic conditions. Dr. Michael Le is the Chief Medical Officer of Optum Home & Community, as well as the Co-founder & Chief Medical Officer of Landmark Health. He has spent the majority of his career serving high-acuity, frail patients through the development and implementation of innovative care models.  Prior to Landmark, Dr. Le served as the Chief Medical Officer of Fidelis SeniorCare, a Medicare Advantage Special Needs Plan.  Before that, he was the Senior Medical Officer at CareMore, a Medicare Advantage plan where he ran high-risk clinical programs. Prior to CareMore, Dr. Le was a Regional Lead Hospitalist at HealthCare Partners, a risk-bearing medical group, where he was the physician lead for the company’s high-risk Ambulatory Case Management program. Dr. Le received his MD at UCLA and completed his residency in internal medicine at Cedars-Sinai.  In this interview, we’ll hear: The profound problem and tremendous gap in the American healthcare delivery system that Landmark is solving. The various types of home-based care that Landmark offers to frail elderly individuals and seniors with complex chronic conditions. The remarkable outcomes that Landmark has achieved for patients, providers and payers. Where Landmark is going next and some insights into Optum’s Home & Community division. There are some many wonderful aspects to the healthcare approach Dr. Le and his colleagues have created at Landmark Health and are now incorporating as part of Optum’s Home & Community division. The core team is a pod composed of a physician, a NP or PA, a nurse care manager, and a health ambassador/health coach.  Surrounding this core team is another team of a pharmacist, a psychiatrist and a social worker.  And even beyond that, there is another team of specialists in urgent and emergent care that can be deployed for more complex testing and procedures in the home.  It’s nothing less than an entire ecosystem of high quality, comprehensive clinical care that can be delivered in patients’ home – 24/7!   Another key differentiator of this new standard of care is that it’s equally focused on the social and behavioral aspects of medical care.  In fact, Michael shares with us that over 50% of the calls they receive from patients and family members have to do with psychosocial factors, the social determinants of health and palliative care needs.  What I found remarkable is that Landmark trains every one of its providers and team members in a specially designed program around how to discuss and deliver excellent Palliative Care. It’s clear from listening to Michael that they not only talk the talk around Palliative Care and outstandingly respectful and dignified end of life care – they walk the walk.  It’s heartwarming to hear how intentionally caring Landmark is in this domain. The proof, of course, is in the pudding and Landmark’s outcomes are remarkable. A 20 plus percentage reduction in hospital admissions; a 20 – 30% improvement in the Medical Loss Ratio; a 43% reduction in emergent dialysis starts. The statistic or outcome that really gripped me was the 26% reduction in mortality.  This is astounding – and it really speaks to the holistic care that the Landmark team provides, and their approach to dealing with the real barriers to care in real time.   When you listen to Dr. Michael Le speak, you hear a physician who grew up watching his father practice medicine in a small town, carrying a black bag and doing home visits.  Michael and his Landmark colleagues have brought the best of the past into the present, and propelled that care into the future with a high tech, high touch holistic approach to care that delivers hospital and ED quality care in the comfort, convenience and safety of the patients home.  This type of care would be welcome by all of us, but it’s especially needed and appreciated by those elder patients who are suffering with complex and chronic conditions – issues such as dementia, frailty, and end stage chronic diseases.  Landmark Health was acquired by Optum Health and Dr. Le could have easily retired.  But instead he has joined Optum Home & Community and launched a whole new chapter in his career and a whole new chapter in the field of home-based care.  As he puts it, “The vision at Optum Home & Community is to break down silos and improve collaboration – to give patients a seamless care experience across their entire continuum of needs”.  He and his colleagues at Optum have united numerous companies under the umbrella of home-based care, and their goal is to scale it across the country.  It’s a breath-takingly bold and brilliant vision – and one that will contribute to improving the care for some of the most needy and vulnerable seniors.  I have so much respect and admiration for Dr. Michael Le and his colleagues.  We need more leaders like this in healthcare: focused on what truly matters and what truly makes a difference in patients’ lives – in all of our lives! Until Next Time, Be Well Zeev Neuwirth, MD

Friends, Our topic today is an overview of some of the most serious and consequential challenges facing our healthcare system and our public health, as shared with us by one of the most erudite, accomplished and ethically driven leaders of our era, Dr. Don Berwick. As always, our focus will not be on what’s wrong with American healthcare, but rather on solutions – on what is actually being done to reframe and recreate healthcare. We’ll also get a preview into some of Don’s recent thoughts and a recommendation that he is planning to publish. 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.  In this interview, we’ll hear: The core issue that Dr. Berwick believes is corrupting American healthcare – imminently threatening public health, public trust in healthcare and the Medicare Trust Fund. A brief on some of the critical threats to public & global health, such as global warming and worsening health disparities. The global and governmental agencies, and governments that are solving issues such as early childhood development and elder care. A recommendation for an interdependent “all government” approach at the Federal level, as well a specific action plan for healthcare system leaders. One of the most revealing exposes on the Medicare Advantage payment model. The fundamental ethical perspective Dr. Berwick holds is that healthcare should be considered a human right and a public good – not an industry controlled and driven by private sector profit. Another fundamental belief is that healthcare should be patient-centered – that all decisions and actions should be in the best interest of the patient and their family, as understood and articulated from their perspective.  Another point that Don Berwick elaborates on is that public health, our health, is greatly impacted by broader socio-political and ecological issues. Issues such as climate change, racism, early childhood development, voter rights, and the marginalization of vulnerable segments of the population. In order to tackle these issues, he advocates for an integrated, multi-sector, all of government approach.    And while Dr. Berwick opens up this interview with the statement that he’s deeply concerned about the future of healthcare in America, he does not dwell on the problem. Instead, he shares the abundance of potential as well as concrete solutions and efforts that are already in place. In this interview, and throughout his career, Don exhibits the attributes of a master community organizer – moving swiftly from problem to solution to action.  Over the last few years, in his published articles and public talks, Dr. Berwick has begun to lay bare some of the ethical and moral hazards within our healthcare system; and to call for the specific, critical actions that must be taken to address them. He writes, speaks and acts with intellectual integrity, originality and rigor; with a powerful sense of collaborative, empathic leadership; and with a practical down-to-earth sensibility – no ego, no ulterior motive and no self-serving agenda. Dr. Berwick has become the truth-bearer of American healthcare as well as, perhaps, its ethical lightning rod. He has transcended to a meta-position of value-based leadership that I can not adequately label or describe. As with all transcendent leaders, it’s a bit unsettling but also compelling. I’ve been told that integrity of character is a magnetic force. If so, Dr. Berwick’s values, vision and mission are the true north we should all set our professional healthcare compasses to.   Until Next Time, Wishing you Integrity Zeev Neuwirth, MD

Friends, The topic today is one that is near and dear to my heart, and what I spend a fair share of my time working on. We’ll be focusing on the challenges that seniors face in navigating our complex healthcare system. This is a critically relevant issue for all of us in healthcare – now and for the next few decades. The population of Americans over the age of 65 is growing at a much faster rate than the general population. By 2034, there will be more Americans over 65 than under 18 years old. It’s a segment of the population that carries a tremendous amount of chronic disease and is in need of medical attention across the entire continuum of care – from preventive primary care, to specialty care, to surgeries and hospital care, and onto long-term care and more intensive palliative care.  Over 75% of seniors have 2 or more chronic diseases, and over 50% have 3 or more chronic diseases. The annual medical expenditures of seniors has surpassed $750B and is expected to double by 2030. Layered on top of this is the epidemic of social isolation & loneliness that seniors experience, and the marked issue of health disparities. In this interview we’re going to hear what our guest, Alex Harb, has discovered about the challenges that seniors face in navigating the healthcare system, and what he has created to address and mitigate those challenges.   Alex was born in São Paulo, Brazil and raised in Santa Cruz, Bolivia before immigrating at the age of 9 with his mother. He received degrees in Biochemistry and Economics from the University of Texas at Austin and pursued post-baccalaureate training in software development from UT-Austin; followed by a Digital Health Biodesign Fellowship at Texas Medical Center’s (TMC) Innovation Institute. During his tenure at TMC, he observed, first-hand, some of the challenges that seniors encounter in their healthcare journey. It was from this experience that he launched Lena Health, whose mission is to simplify and improve the patient experience and outcomes for seniors, utilizing a tech-enabled, concierge-like, personal health assistant solution for navigating their health needs. In this interview, we’ll hear: How and why Alex pivoted Lena Health’s focus from social isolation to healthcare navigation. Some really interesting and important understandings Alex and his team have gleaned about what seniors actually need in regard to their healthcare journey, and the communication channels they prefer. The very consumer-oriented, effective and efficient approach that Alex has taken in organizing this concierge-like healthcare navigator solution.  The outstanding value-based outcomes Lena Health has produced to date in terms of reducing ED visits, hospitalizations and readmissions, as well as off-loading nearly 20% of nurse navigator time. How Lena Health achieves a Net Promoter Score of 94 and a monthly usage of nearly 90% A dominant theme has been emerging as we continue to explore the home-based healthcare journey.  I would characterize the theme in four ways.  First, it’s a profoundly consumer-oriented approach. Second, it’s a profoundly contextual approach – actually exploring & uncovering the context of the individual & their family’s health journey – not an industry-centric health journey. Third, it’s an approach that could be labeled ‘whole person’ or ‘whole health’ – pulling in the entire context of a patient’s life as part of the healthcare experience and intervention. Fourth, it builds the technology around the consumers’ needs rather than forcing the consumer (both patient and provider) to bend themselves around onerous technology.  In this interview, we’ve discovered another visionary healthcare entrepreneur – Alex Harb – who is reframing and recreating healthcare from this contextual, whole-person perspective. And, as in every interview, Alex Harb shares with us a few really key learnings that he’s gleaned. Over 90% of the requests made by seniors were not clinical and not related to social isolation; but instead were logistical, task-oriented needs around navigating the healthcare system. These care tasks included: (1) care coordination – such as scheduling appointments, referrals, medication prescriptions & refills, insurance & payment issues, and (2) social navigation – such as housing, food insecurity, transportation, access to medical equipment… 80 – 90% of these logistical task-oriented needs could be conducted either through an automated chatbot or through SMS texting with the majority being readily addressed via an AI-enabled automated chatbot channel.  Seniors were incredibly comfortable with the ease and convenience of SMS texting. (As a related aside, Alex shared a stat with me – over 80% of seniors do not log onto electronic medical record websites.) When I did some back of the napkin calculations, it appeared that 60 – 70% of the Lena Health interactions are occurring via chatbot, 20 – 30% via text messaging, and 10 – 20% via phone call with a human personal health assistant. The implications of this are astounding for a number of reasons.  First, it begins to really break down the myth that seniors can’t or don’t respond to automated chatbot communications. This point is validated by the incredible utilization Lena Health is achieving (nearly 90% monthly usage) and a NPS (Net Promoter Score) of 94.  Second, it begins to demonstrate how automated channels such as chatbot and asynchronous channels such as texting can really leverage and preserve synchronous in-person communications for the moments and needs that really matter.   Third, Lena Health is a spectacular example of what Roy Schoenberg, the co-founder & CEO of Amwell refers to as the third domain of healthcare.  As you might recall from that interview, Roy painted a picture of healthcare occurring in three domains or clusters: in-person, virtual & automated.  He was particularly excited about the transformation that automated healthcare will bring. In his opinion, this will be a significant part of our healthcare experience in the near future.  When I queried Alex about his notion of a concierge-like experience, his response was that the personal health assistants would not so much be out-sourced as “near sourced”. His approach is to hire a team of personal health assistants that are local to the healthcare system client, and therefore local to patients and their families. An individual patient would be assigned to a specific health assistant; but the entire team would also become familiar with the patient, and would get to “know” that individual, providing that relationship-based, concierge experience.   Adding to the seamless care experience, the Lena Health team also connects directly to patients’ providers and clinical care team, acting as a care team extender. Healthcare systems have the option to allow the Lena Health personal health assistants access to their EHR, so that the team can actually communicate directly with the patients’ providers.   The advantages to healthcare systems are obvious. First, they don’t have to stand up and maintain an entire health navigator program. Second, they do not have to hire, train and manage these navigators. Third, they don’t have to attempt to develop, purchase and maintain the chatbot technology and platform that Lena Health has created and is continuously improving upon.   I am super impressed with Alex Harb and the empathy-driven approach that Lena Health is taking in understanding and supporting seniors. While the focus is on the logistical care navigation & coordination needs of older patients, and while the under-the-hood product is highly tech-enabled, it’s clear that the fundamental purpose is to humanize healthcare. As Alex so eloquently states, “For me, it’s about how do we improve the aging experience of our seniors; and how do we build solutions that are based on human touch and connection that can be maintained throughout their experience”. Until Next Time, Wishing you Whole Person Health Zeev Neuwirth, MD

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