Creating a New Healthcare

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

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