Friends,

In this episode we’re going to discuss the opportunity we have, collectively, to live longer and healthier lives – and the underlying transition that’s required in the healthcare industry to make that a reality over the next few years.

The specific topics at hand include: (1) The economic imperative for why the American healthcare industry must move toward wellness; (2) the profound life-saving and cost-saving benefits of such an industry shift; (3) the central role that employers can play in wellness and longevity; and (4) some of the challenges and headwinds in this shift.

Our expert guest today is Neal Batra, who is a principal in Deloitte’s Life Sciences and HealthCare practice which is focused on the redesign of business models and commercial operations. He also heads Deloitte’s Life Sciences Strategy & Analytics practice, leading the way on next-gen enterprise strategy, analytics and technology. Neal has more than 15 years of experience advising health care organizations and businesses in biotech, medtech, health insurance, and retail health care. He is the coauthor of Deloitte’s provocative ‘Future of health point-of-view’ – forecasting on the healthcare ecosystem in 2040, and the business models and capabilities that will matter most. He holds an MBA from London Business School and a BBA from the College of William and Mary.

In this interview, we’ll discover:

The foundational issue that Neal and his colleagues start off with is that our healthcare system, as amazing as it is – is focused on the ‘break it and fix it’ model.  It is a system that largely waits for disease and illness, and then dedicates tremendous resources and expertise toward dealing with that disease and illness burden. This is what he and many others refer to as a ‘sick-care’ system. This is in stark contrast to a system that is focused on proactive prevention of disease and illness. And Neals points out that this is not an either-or decision. What he recommends is a widening of the aperture – a diversion of some of the current healthcare spend to proactive and preventive well-care. 

Neal opens up our discussion with a sobering revelation. For most Americans, the time of life when their health begins to erode corresponds to the time that they’re getting ready to retire. As he puts it, “Your healthiest years went to your employer, and in a time that was meant to be the ‘golden years’, or the years in which you had a financial foundation that allowed you to do different things with your life, your healthspan declines to a point where your quality of life declines.”

A second revelation – that Neal and his colleagues have published on – is that if we transitioned to a wellness industry, Americans could add an additional 12 years to their lifespan and nearly 20 years to their healthspan, by 2040. His team has also projected that the American healthcare system could save $3.5 Trillion per year – what he refers to as a whopping ‘well-being dividend’. Neal’s point, not to be missed, is that the cost dilemma in American healthcare will not be solved through cost reduction in a sick-care system, but rather through cost prevention through a well-care system. In his own words, “I’d like to shift to a ‘cost-of-avoidance’ narrative versus a ‘cost-of-care’ narrative. The cost-of-care narrative is a trailing economic measure, and there is no amount of innovation that will ever make it cost-effective to address the population in this break-fix modality. The only way out of the economic death spiral we are in when it comes to healthcare is to jump in front of illness, and invest ferociously on disease avoidance, and early as well as real-time diagnosis.” 

A critical finding – that Neal and his colleagues have also published – is that approximately $1Trillion of the $3.5 Trillion in savings will come from the elimination of the disparities and inequities in healthcare. One statistic he mentioned is that white Americans live on average, 78 years, while for black and native Americans, the ages are respectively, 72 years and 68 years. And while these and other disparities are unconscionable in and of themselves, the calculations add an economic imperative to the ethical arguments for eliminating the structural racism in our healthcare system.

A third revelation and shocking forecast that Neal shared – which again, his analytics & actuarial team have published – is that, by 2040, 60% of healthcare spend in the US will go to well-care, not the treatment of disease and illness. He and his colleague predict that, by 2040, we are going to witness a “new health economy” with “new business models” which will drive 85% of all healthcare revenue. This new health economy will also be driven by a shift from a ‘rule-of-thumb’ to a ‘rule-of-one’ medicine – that is, the hyper-personalization of care – enabled by the digital and AI revolution in healthcare. 

To balance out the dialogue, we did discuss the very real obstacles and headwinds to this sort of healthcare transformation. For starters, wellness care does not align with the current, predominant, industry business models. Neal’s counter-argument is that no industry has ever been transformed by incumbent stakeholders. It’s only through external pressure that the incumbents either respond and change, or they go by the wayside. His point of view is that hospital systems have two options: (1) continue to solely pursue the acute care/sick-care business model, and contract into an acute care focused factory; or (2) engage and expand into wellness care and the corresponding business models.  

I don’t want to lose sight of Neal’s ‘both-and’ perspective, which is that it’s not that we have to choose between sick-care and well-care. Instead, we need to create a more balanced healthcare system that includes a significant well-care component. But, as Neal points out, we’ve got a long way to go to reach that balance. “If you held our sick care capabilities constant over the next decade and flowed everything into wellness and wellbeing, I think the yield on the American health system would be enormous economically, as well as from a health outcomes perspective”. 

I’ll end with this personal observation. In my career, I’ve seen us accomplish miraculous things – creating space-age interventional cardiac labs, life-saving hemodialysis centers, and tele-stroke units. But here’s the rub. Wouldn’t you rather have the healthcare system focus a significant amount of resources and expertise on you NOT having that heart attack, kidney failure, or stroke in the first place?  I know I would. 

Wishing you all the best of health and wellness!

Zeev Neuwirth, MD

Friends,

I’ve had the great privilege of interviewing and interacting with Glen Tullman a number of times over the past few years. The last time we spoke in a formal interview was episode #121, which was posted on Sept 22, 2021. That episode was entitled, “A master class in building a healthcare consumer experience company”. And it was exactly that – a master class. My experience is that this episode is a continuation of that master class in humanizing healthcare and in achieving markedly improved health outcomes.

Glen Tullman is the Chief Executive Officer of Transcarent and the former Executive Chairman, Chief Executive Officer, and Founder of Livongo Health. He previously ran two other public companies. During his time as

Chief Executive Officer of Allscripts, the Company was the leading provider of electronic prescribing, practice management, and electronic health records for physician practices. Prior to Allscripts, he was Chief Executive Officer of Enterprise Systems, the leading resource management systems for hospitals, which he also took public and then sold to McKesson/HBOC. Glen is also one of two Founding Partners at 7wireVentures, one of the highest- returning venture capital funds in Illinois. He is the author of On Our Terms: Empowering the New Health Consumer, in which he proposes new solutions to address the chronic condition epidemic facing our country.  A strong proponent of philanthropy, Glen was honored in 2019 with a Robert F. Kennedy Human Rights ‘Ripple of Hope’ Award for his career focused on improving the safety, empathy, and efficiency of our healthcare system. He also serves as a Life Director of the Illinois Chapter of JDRF, the leading organization advancing life-changing breakthroughs for Type 1 Diabetes. Glen has three amazing children and a new granddaughter who inspire him every day.

In this interview, we’ll discover:

Before we go any further, it’s important to briefly point out that Transcarent is inserting itself into the employer healthcare space as an alternative to the large BUCAH insurance companies that are acting as third party administrators (TPA’s) for self-insured employers – large, mid-sized and even relatively small employers. Transcarent is in what we refer to as the ‘direct-to-employer’ market. For those who are unfamiliar with the acronym, BUCAH stands for Blue Cross, United Healthcare, Cigna, Aetna (now CVS Health), and Humana. 

This episode is a master class in humanistic consumer-oriented care. In the previous podcast we recorded, Glen outlined 3 major needs people have when it comes to healthcare delivery. Briefly stated, these are: unbiased information, unbiased referrals, and support navigating the system. In this podcast he expands upon those to articulate five major value propositions that Transcarent is offering. These 5 are all embedded within the Transcarent app, and include:

Transcarent is partnering with home health companies, such as Dispatch Health, to deliver care into the home or directly to the individual via telehealth and digital options.

Transcarent is partnering with the Cleveland Clinic in offering literally world-class 2nd opinions when an individual has been recommended to have surgery. The reason being that a significant percentage of recommended surgeries are unnecessary and potentially harmful. And once the 2nd opinion is rendered, Transcarent can provide options for the best surgeons and hundreds of sites across the country to have the procedure.  One thing to note here is that Transcarent is working with employers to provide surgical care without any payment or co-payment to employees. The way this works from a financial perspective is that by reducing inappropriate surgeries and suboptimal outcomes, Transcarent plans to save employers enough money to provide the needed and appropriate surgeries for free. 

Glen quotes a stat that nearly one quarter of all cancer diagnoses and cancer care in this country is being done without the latest information or being provided at the lowest cost high quality sites. Transcarent’s platform approach utilizes state-of-the-art information and expertise to assist employees in obtaining the best care and the best value option.

Transcarent is utilizing a relatively new business/tech model, which is called a platform. Examples of well known platforms include Amazon, Uber and Airbnb. The model is different from the typical business model in that the platform doesn’t necessarily build, create or produce products and services. Instead, it hosts or convenes them in one place and provides highly consumer-oriented services to make them accessible to the consumer.  Platforms are, essentially, virtual digital marketplaces, but they provide customized and personalized information and convenient access that isn’t available in brick & mortar market places. For example, the well-known, “people like you bought” or “people who bought this also bought…”  The customers on the Transcarent platform are self-insured employers, with the ultimate consumer being employees. The vendors supplying the products and services would include healthcare systems, provider practices, and digital health companies. 

One of the lessons I’ve learned from this conversation with Glen is that Transcarent is not only a platform but it’s a platform plus, or what Glen calls a “convener plus”. Glen explains that unlike Amazon, Transcarent not only provides the product or service, but it assists the customer in navigating through the experience. As he eloquently puts it,

And, one advantage of this platform approach is that the services that any given employer is looking for can be accessed on the platform without having to purchase the entire bundle of services.  It’s a truly ‘choose your own journey’ type of business model – highly customized for any given employer customer.  Another related advantage of the platform model is that if an employer has a product or service they like, Transcarent can place that on the platform instead of forcing the employer to switch. As Glen states, most vendors require that you “rip out and replace” the current product or service you’re using. Transcarent’s platform and approach avoids that.

What I’d like to conclude with is an issue that is, in my opinion, the most root cause in healthcare today. In Glen’s own words:

I’ve written extensively about Glen and about Transcarent in my recent book – Beyond The Walls – and for good reason. Glen is one of the most accomplished healthcare leaders in the world. But, even more than that, he is a humanistically disruptive and consumer-obsessed healthcare leader. There are very few leaders I’ve met who possess his unrelenting focus on the actual experience of care from the point of view of the individual healthcare consumer. Glen is brutally straightforward on his take of the American healthcare experience. He calls it like it is. As he states so clearly – “healthcare is more confusing, more complex, and more costly than it’s ever been before… [and the situation] is getting worse, not better”. He also makes the point that a major cause is “maximizing profits over care”. It’s Glen’s objectively truthful sensibilities and his integrity which has fueled his incredibly disruptive and positively advancing achievements.

When I asked Glen what message he would want to share with healthcare leaders and employer leadership, he responded with two questions. First – what are you doing now that is really different and better – actually innovating rather than incrementally improving?  Second – why would you not at least try this new approach – given the reality that the current approaches we’ve been rehashing for decades is clearly not working and in fact, is making things worse? 

I’ll leave you all to ponder and respond to those two questions.

Zeev Neuwirth, MD

Friends,

The central role that Medicare, and CMS, play in our healthcare system can not be overstated. There are approximately 64 million Americans in the Medicare program, with annual payments of $1 Trillion, comprising over 20% of the healthcare spend in our country.  In addition to its size and scope, CMS, through the Medicare program, is leading the nation in advancing value-based care, and has been deploying landmark historic initiatives at an accelerated pace. This is a unique interview in that we will be hearing directly from the impressive and highly accomplished leader at CMS who is leading Medicare. And, as I promised during the interview, I’ve attached a few links to cms.gov at the end of these notes.

Our guest this episode is Dr. Meena Seshamani who currently serves as Deputy Administrator and Director of the Center for Medicare, at the Centers for Medicare & Medicaid Services. Since joining CMS, Dr. Seshamani has led her team of nearly 1,000 through a critical agenda of initiatives to advance health equity; expand access to coverage and care; drive innovation for high-quality, whole-person care; and promote affordability and sustainability of the Medicare program for generations to come. She is the senior official responsible for CMS’s implementation activities under the Inflation Reduction Act, which is the largest change to the Medicare program since the enactment of Part D in 2003. Dr. Seshamani is a Hopkins trained surgeon and an economist, having obtained a doctorate in economics at Oxford. Prior to joining CMS, she served as Vice President of Clinical Care Transformation at MedStar Health – a multi-hospital system – where she developed & implemented population health and value-based care initiatives. She also cared for patients as a head & neck surgeon at MedStar Georgetown University Hospital and at Kaiser Permanente in San Francisco. Dr. Seshamani served on the leadership of the Biden-Harris Transition HHS Agency Review Team. Prior to MedStar Health, she was Director of the Office of Health Reform at the US Department of Health and Human Services, where she drove strategy and led implementation of the Affordable Care Act across the Department, including coverage policy, delivery system reform, and public health policy.  

In this interview, we’ll discover:

One of the most landmark initiatives we discussed in this interview was the historic ‘Medicare Drug Price Negotiation Program’. This is the first time ever that Medicare will be negotiating directly with pharmaceutical manufacturers for the prices of some of the highest cost drugs in the Medicare program. It’s fascinating to hear Dr. Seshamani describe the thoughtful and thorough preparation, as well as the ongoing research and assessment that is going into architecting the negotiation process. It’s also compelling to hear that CMS is focused not only on optimizing costs but also on evaluating the real-world effectiveness of these medications. In its first year, the program will focus on ten of the highest cost medications, but those numbers will increase rapidly to cover many more high-cost medications. The law will also cap medication costs for any individual Medicare beneficiary to no more than $2,000 per year.

Another landmark initiative we discussed is the ‘intensive outpatient program’. As Meena eloquently puts it, “We have made some of the most significant changes in behavioral health in the history of the Medicare program – creating entirely new benefits…”  For example, these new benefits allow licensed marriage & family therapists, mental health counselors, addiction counselors, and care navigators to become billable Medicare providers – so that beneficiaries receive more whole-person, team-based care, radically improving the way that mental healthcare can be delivered.

I came away from this interview awed by the sheer number of historic, value-based initiatives that CMS is launching – enhancing affordability and equity of care and advancing care in critical areas such as behavioral health. I was also impressed by the transparency and level of engagement that CMS is enabling with providers and the public at large. Another facet that I have to call out is the focus CMS is placing on studying the effectiveness of their efforts, with an emphasis on actual health outcomes in the real-world setting. 

There is so much more happening at CMS that we did not have the time to cover. What CMS is doing, and importantly, how they’re doing it, is a manifestation of their courageous, humanistic, conscious leadership. It’s also a reflection of the capability, commitment and integrity of their teams, and their overall palpable dedication to public service. 

I came away from this interview hugely inspired and hopeful about the future of American healthcare. We have extraordinary leaders and sophisticated, dedicated teams at CMS – public servants who are advancing and transforming healthcare delivery in unprecedented ways. Their pace, productivity, and impact is remarkable. Their purpose is exemplary. I hope you come away from this interview as catalyzed to engage with CMS as I am. To that end, please take a moment to click on the cms.gov links below – and join in enhancing CMS’s mission.

Zeev Neuwirth, MD

Friends,

There is no question that digital health is a critical part of the future of healthcare delivery. It is what I term ‘the great enabler’.  And in this interview we have the opportunity to speak with a physician leader who is at the tip of that spear: Dr. Eve Cunningham, a physician executive in virtual care & digital health at Providence, one of the largest and most progressive healthcare systems in the country.

In this interview, we’ll discover:

I’ve had the privilege of interviewing and speaking with a number of leaders at Providence. Each time I do, I walk away with even more respect for this organization – its mission, its forward-thinking culture, and the level of professionalism, competence and collaboration.  I also walk away with awe at the innovative and transformative services and products they are constantly incubating, scaling and commercializing. This conversation with Dr. Eve Cunningham was no different.  

I had heard Dr. Cunningham speak at a symposium a few months prior and I was impressed with her attitude and her approach. She has a unique set of skills – bringing the traditional chief medical officer acumen and experience to bear – the clinical and operational chops. But she also possesses a bold and practical irreverence for traditional approaches that are not future facing. Her ability to meld these two together is quite remarkable and striking. She has no problem in telling it straight, something I deeply admire.

In regard to telling it straight, Eve shared some very practical tips in regard to digital health initiatives; chief amongst them were three things. First – being crystal clear about the value proposition, the key performance indicators, and being to demonstrate the value proposition through these metrics.  Second – working very closely with financial colleagues to be able to demonstrate a hard return on investment.  Third – piloting programs that were not only clinically and operationally feasible as well as financially viable, but also programs that are scalable.  She talked about scale on the level of tens of thousands, if not hundreds of thousands of patients. 

In regard to some of the exciting programs and innovative products? Well, you’ll have to listen to the interview.  But, I’ll give you a sneak preview. One product we discussed at length is called MedPearl – a digitally-enabled specialty referral system/algorithm that every integrated healthcare provider system or group has been desperately seeking for decades. If you’re a healthcare leader, you will not want to miss this discussion. Another is a set of digitally-enabled surgery support tools which will radically change surgical care forever. 

I’ve understood that all healthcare is going to be digitally-enabled in the near future. But it’s leaders like Dr. Eve Cunningham and her colleagues at Providence that are making it a reality. A reality that is going to improve patient access, outcomes, experience, equity and affordability – as well as improve the effectiveness, efficiency and job doability for providers of care. There is no question in my mind that digital is the enabler for humanizing healthcare delivery for all.

I’ll leave you with a brief quote from Dr. Cunningham which really captures the essence of the imperative:

Zeev Neuwirth, MD

Friends,

In my upcoming book, Beyond The Walls, I spend an entire chapter discussing how platforms have revolutionized other industries and how they’re about to do the same in healthcare.  Over the past couple of years, I’ve had the privilege of interviewing and learning from the experts who have been working with platforms for years. Geoffrey Parker, who wrote the now classic text The Platform Revolution, Vince Kuraitis, and Dr. Randy Williams have been working over the past decade to introduce the platform revolution into healthcare. If you’re interested in really understanding what platforms in healthcare look like and what differentiates them from our more typical business models, I recommend you listen to my podcast interview with Vince and Randy (episode # 149, April 19th 2023) and read chapter 7 in my about to be published book, Beyond The Walls.  During that interview, Vince & Randy mentioned an exciting example of a platform business model in healthcare. The company is called KeyCare. It was founded and is being led by physician entrepreneur Dr. Lyle Berkowitz. In this interview we’re going to discover how this novel platform is attempting to solve the issues of access to care, capacity, cost-effectiveness, and burnout amongst providers and their teams.

Lyle Berkowitz, MD, is the Founder and CEO of KeyCare, the nation’s only virtual care company built on the Epic platform. He has more than twenty years of experience as a primary care physician, health system executive and informatics expert, and serial entrepreneur. Previous roles include Founder & Chairman of Healthfinch, Chief Medical Officer at MDLIVE and Director of Innovation for Northwestern Medicine in Chicago. Dr. Berkowitz is also Editor-in-Chief for Telehealth and Medicine Today.  He’s served on numerous industry boards in the past and is currently a board member for Oneview Healthcare. Lyle has been listed as one of HealthLeader’s Twenty People Who Make Healthcare Better, Healthspottr’s Future Health Top 100, and Modern Healthcare’s Top 25 Clinical Informaticists. He has been elected to Fellowships in both the American College of Physicians (ACP) and the Healthcare Information Management Systems Society (HIMSS). He graduated with a Biomedical Engineering degree from the University of Pennsylvania and is an Associate Professor of Clinical Medicine at the Feinberg School of Medicine at Northwestern University.  

In this interview, we’ll discover:

Throughout the interview Dr. Berkowitz illustrates the numerous ways that healthcare systems as well as other provider groups can utilize and leverage KeyCare.

Another significant use case is primary care. Lyle proposes that KeyCare could become an extension of a PCP’s team, performing a number of functions that enhance efficiency of care, allowing a provider and their on-site teams to perform to the top of their license, and increasing access and capacity, enabling a provider to manage much larger panel sizes. The way this might work would be for KeyCare to manage patients with chronic disease who are relatively stable, to perform routine visits including annual wellness visits, and to do follow up care. This would allow PCP’s to see more complex patients as well as new patients. In risk-based contracts, KeyCare could assist by closing care gaps and updating data points for risk score adjustments, thereby helping to appropriately increase the per member per month (PMPM) payments. 

In addition to on-demand and primary care, KeyCare can also offer specialty services such as behavioral health. 

There are a few key benefits to KeyCare (sorry, I couldn’t resist). 

First, one differentiating benefit is that KeyCare is essentially a virtual provider group that is on an Epic instance. The advantages to healthcare systems who are on the Epic electronic health system are significant in terms of interoperability through: (1) the Epic ‘Care Everywhere’ function which would allow for robust data sharing; (2) cross-instance scheduling via new functionality called ‘Book Anywhere’; (3) cross-instance on-demand telehealth requests via new functionality called ‘Telehealth Everywhere’; and (4) cross-instance messaging, orders and referrals. 

This cross-instance functionality and automatic interoperability allows KeyCare to send messages, schedule appointments and referrals, perform telehealth visits, and obtain and record patient information in patients’ charts – all without the need for new interfaces. It would appear seamless to patients as well as to providers. 

Another benefit to healthcare systems is that KeyCare has urgent care providers who are licensed in all 50 states. This is a major market advantage to healthcare systems or other provider groups who are interested in winning contracts from a wider swath of potential customers such as employers who have employees and beneficiaries that live beyond a local or regional geography.  

A third benefit, Lyle suggests, is that it will be far more cost-effective for a healthcare system to outsource virtual, team-based extension of PCP’s teams rather than build and maintain these services in house. KeyCare is essentially a virtual care focused factory.  As such it’s likely to be far more efficient than virtual care teams functioning within healthcare systems, and it will be constantly investing in people, process and technology to upgrade and optimize its effectiveness and efficiency.  

KeyCare is a two-sided platform – a “population health enablement company”. On one side, there are the customers that would utilize KeyCare’s services – healthcare systems, provider groups, payers and employers. On the other side are the virtual providers and virtual provider groups who are offering their services. KeyCare is the technologic and business platform or marketplace that brings them together.  

The promise is there. But, as Dr. Berkowitz points out, there are 3 challenges to overcome in provider acceptance and adoption. He refers to these as the “3 C’s”.  The first “C” is presenting providers with a clinically-connected care team that they feel comfortable with – sharing their patients and their data. The second “C” is compensation – assuring providers that this will enhance their compensation rather than diminish it. The third “C” is culture – the change management as well as workflow configuration required to integrate this type of care. 

But, the promise is there, and it’s an important one. From a patient perspective, KeyCare can increase convenient access to care through its myriad use cases, including offering virtual specialty services such as behavioral health. From a provider perspective, it can reduce provider burnout by removing the more routine functions and services – enabling providers to grow their panels and focus on more complex care needs. From a healthcare system perspective, it can increase efficiencies of care, create patient growth, improve performance in value-based contracts, and allow systems to focus their resources and capabilities into higher margin more differentiating services. 

It seems to be a win-win-win. I applaud Dr. Berkowitz for his patient-centered mission and his ingenuity in creating this novel population health enablement platform. I’ll leave you with my favorite quote of this entire interview:

Our goal, our purpose in life, as an organization, is to make sure everybody gets the healthcare they deserve and they get that access. The more we can do online, the more that relieves the pressure for providers in the office as well, so both sides can win.”

Zeev Neuwirth, MD

Friends,

This week’s interview is nothing less than awesome, and it’s awesome for three reasons.  First, Dr. Rishi Sikka is a brilliant and accomplished physician executive with an incredibly diverse professional background. He brings that diversity of thought and vision into his work and into our dialogue. Second, we’re going to discuss some key new leadership competencies that both Dr. Sikka and I believe are critical for the future advancement of healthcare delivery in our country. Third, as I mention in the intro to this interview, I’m about to publish a second book entitled Beyond the Walls.  It’s a market-based, three-part strategy for the transformation of American healthcare. What was so confirming to me is that Dr. Sikka’s perspective, as well as his strategic and tactical vision, is fully aligned with what I’ve written in that book. Of note, he has not yet read the book. As you can tell, I’m incredibly excited about this interview, and once you listen, I suspect you’ll be as well. 

Dr. Rishi Sikka is currently a venture partner at Lifeforce Capital, and a Professor of the Health Services, Policy and Practice at Brown University School of Public Health. His past executive roles include: President of System Enterprises at Sutter Health as well as Senior Vice President of Clinical Operations & President of the Advocate Insurance Segregated Portfolio Company. He earned his bachelor’s in economics at the Wharton School at the University of Pennsylvania and his medical degree from the Mayo Clinic Medical School.  He is co-author of the book Leading Healthcare Transformation: A Primer for Clinical Leaders, and has written for the Wall Street Journal and Harvard Business Review. In 2021, he was recognized as a Top 50 Clinical Executive by Modern Healthcare.

In this interview, we’ll discuss:

This conversation with Dr. Rishi Sikka was enlightening, inspiring, encouraging, and quite honestly, fun. He’s a bold thinker and doer, but he shares his point of view in a collaborative and humble way. 

This interview touches upon a number of really important lessons for a new leadership – what I would label ‘beyond the walls’ leadership. I’ll briefly touch upon a few of these.

In this interview, Dr. Sikka and I quickly leapt into the ‘why’ – the purpose and mission of healthcare delivery, and the leadership competencies required to carry out the mission. I’ve attempted to capture some of those key leadership competencies above. 

What I find most enlightening about this discussion, however, aren’t the specific concepts themselves. Instead, it’s the fact that Dr. Sikka is actually recognizing that there are new core competencies in healthcare leadership. Competencies that we need to discern and learn, especially as we enter the digital era. I’ve not heard many people articulate this understanding. 

During the course of this interview, we not only attend to the ‘why’ but also discuss the ‘what’ and the ‘how’ – the tactical deployment of these leadership competencies and directions. And we connect the two – aligning stated purpose and mission with tactical operational deployment. Dr. Sikka sums this all up well toward the end of our conversation.

Until next time, be well.

[In order to provide accessible content, here is a full transcript of this interview]

Friends,

The topic this week is caregiving and caregivers – an issue that is so much larger, so much more devastating, and so much more in need of reform than most of us are aware. There are over 50 million family caregivers in the US, and they suffer financially, emotionally, psychologically and physically with negative consequences that persist for the rest of their lives. The solution, according to our expert guest, comes down to funding and policy: to provide the funding through Medicaid’s Long-term services and supports (LTSS) and remove the stringent requirements that grossly limit appropriate access to those funds. 

During this episode, we’ll dive into the underlying systemic social biases around the elderly and the disabled – a bias that is preventing the policy and funding changes needed to alleviate the heartbreaking suffering of caregivers and their loved ones. In this interview, Professor Laura Mauldin will distill the learnings from her research, as well as from her own personal experience in caregiving.  She also provides recommendations for what needs to be done to remedy the situation.

Laura Mauldin PhD is a writer and scholar based in Brooklyn, New York. She’s currently an associate professor at the University of Connecticut. Laura’s research focuses on disability care and technology. Her first book, Made to Hear: Cochlear Implants and Raising Deaf Children, documents the structure and culture of the systems we’ve designed to try to make deaf kids hear. Laura is currently writing a book – scheduled to be published in 2025 –  on spousal caregiving which weaves together research, memoir and cultural commentary. 

In this interview, we’ll discover:

Professor Mauldin is a remarkable scholar.  As a highly trained qualitative researcher, she intentionally decided not to take a neutral stance in her research on caregiving and caregivers. Instead, she infused her work with her own lived experience of being a caregiver.  She infused it with a studied understanding of the political and social biases that are root causes for why the situation isn’t being addressed and remedied. She infused it with the power of story and not just with the power of statistics.

In this interview, Laura Mauldin shares her own story of caregiving and reveals what most of us have little to no understanding of – a world that is so radically different. She talks about the daily “terror” and “exhaustion”, the “isolation” and a sense of being “invisible”.  She also describes a profound “demotion” in her relationship with her partner – a shift from being a “lover” to being a “life support system”. The stories she shares, her own as well as those from the dozens of families she studied, are heartbreaking and informing. 

Laura points out that the suffering of caregivers isn’t limited to their emotional, psychological and physical health.  It also has a profound 3-part impact on their financial health. First, caregivers are largely unpaid for this in this country. Only about 7% of Americans can afford private pay care-giving, which means that well over 90% of caregiving goes unpaid for in the US. Second, if family caregivers have a job, they often see a marked decrease in their earned salaries, due to the time they must spend caregiving. Third, caregivers suffer a marked loss in their retirement savings, in part, as a result of the compounded losses in their job salary over the course of years. 

One of the most enlightening parts of the dialogue was Professor Mauldin’s articulation of ‘ableism’, which I had never heard of before. I found it to be inspiring and liberating – yes, liberating. This sense of liberation comes from her shining a light on a part of our lives that is hidden from view, a part of our lives that has been cloaked in shame and bias, and a part of our life in which we desperately seek to maintain some semblance of control and independent living. She explains how our culture “devalues disabled people, disabled bodies, and people who are viewed as unproductive.” And she connects this ubiquitous indoctrination of ‘able-ism’ to the ‘institutional bias’ policies embedded in Medicaid, and then directly to the suffering of caregivers and their families. She points out how these biases embedded into policy and payment prevent us from maintaining our independence as we age, or as we become infirm or disabled.  

The sense of liberation stems from two things. First, just naming the indoctrinating bias that we’ve all been engulfed in removes, or at least softens, some of the stigma and fear. It opens up the possibility for new understandings and new ways of relating to ourselves, to our bodies, to one another, and especially to those whom we love dearly. Second, once we name it, we can reframe the situation, pull back the cloak of silence, and shine a light on these hidden biases, stigmas and fears. We can examine them in the light of day. We can talk about them. We can actually begin to collectively do something about them. Beliefs and biases hidden are unassailable. Fears and stigmas unspoken fester in our individual and collective consciousness. To that point, Lauren illustrates this in a story she shares about her personal experience as a caregiver – bringing a group of physicians together around a table – and hearing nothing but soul crushing silence and inaction. Revealing the truth is the first step toward healing. It is a gift – a gift that Professor Mauldin shares generously. But, as she points out, taking action is the next step. What I learned is that we need more activism around changing Medicaid policies and funding. We need to very specifically change the policies and funding of the “long term services and supports”, and the “home and community-based services”.  

Professor Mauldin’s contribution to our understanding of caregiving and caregivers is revealing and moving. She connects the dots on the issue of caregiving in a way that I’ve never before experienced. I had the opportunity to listen to her present in an online forum and was absolutely mesmerized by her eloquence, her intellectual integrity, her scholarly brilliance, her honesty and her courage in discussing an issue that is so very personal to her. I believe her upcoming book, which will be published by Ecco Press in early 2025, is going to be a landmark contribution to this important issue. I believe that Professor Mauldin should be listened to and her recommendations heeded.

[In order to provide accessible content, here is a full transcript of this interview]

Until next time, be well.

Friends,

This is a super interesting and fast paced dialogue about a topic that is poorly understood by most, including healthcare executives and policy experts. The topic is employee health plans. Our guest today, Dave Chase is a remarkable healthcare entrepreneur with decades of experience who has been one of the most brilliant thinkers and activists in reforming employee healthcare benefits. He and his colleagues at Health Rosetta have really unearthed the core underlying problems and are doing something about them. They do, in fact, have a blueprint that is replicable, scalable and sustainable; and they have numerous examples of success. Given that nearly 50 percent of healthcare is paid by employers, this issue has broad impact and significant implications for American healthcare and for the financial welfare of working Americans and their families. 

In this interview, we’ll discover:

Of all the opaque and confusing aspects of healthcare delivery, the legal agreements of employee health plans, may top them all. This wouldn’t necessarily be an issue except for the incontrovertible fact that what they’re hiding is literally decades of misaligned incentives that reward increased pricing rather than high quality care, positive health outcomes, cost effective pricing, convenient access and consumer-oriented navigation. What’s hard to comprehend is how many hands there are in the pockets of the American workers, siphoning off decades of hard earned wages and retirement savings. The irony is that these employer health plans benefit the insurance companies, third party administrators, health benefits managers, PBM’s, and hospital systems more than they benefit the employers or employees.  

And let’s be clear – this is not a minor issue affecting a small percentage of the population. This is a huge issue affecting the majority of working Americans. What we’re talking about is not being able to afford healthcare and having to forego it to pay for housing costs, food, clothing, child care and transportation. What we’re talking about are tens of millions of Americans who can’t afford preventive medical care, medications and much needed medical procedures.  Here are some stats that Dave provided – a sobering and alarming perspective on the severity and magnitude of the situation.

The situation is dire but there is some good news and positive momentum. It’s taken decades but it’s heartening to learn that regulatory policies and laws are finally beginning to protect employees. As Dave informs us, the Consolidated Appropriations Act of 2020/2021 will put the onus on employers as “plan sponsors”, but will also empower them by requiring transparency and prohibiting contract terms that harm employers and employees. The Department of Labor has been charged with enforcing the law and is already demanding documentation from employers. Plan sponsors will be required to prove to the federal government that they are good financial stewards of their employees’ health benefits, and transparently demonstrate to their employees that they are contracting for cost effective, high quality healthcare. From a political perspective this Act is supported by the previous Trump Administration as well as the current Biden Administration, and has the full support from both parties in Congress. I realize it’s a bit in the weeds but I think it’s important and helpful to share a a few examples of what this law requires (as in present tense):

The title from a reference article by Leah Binder in Forbes.com (Feb 28, 2022) that I used in writing this copy really captures the current situation. “This Federal Law Will Completely Overhaul Company Health Benefits. Nobody Is Ready.”  Regardless of the short term compliance hassles and costs imposed on employers, this is a great oversight for employees and their families. It will not erase the decades of tremendous harm imposed on working Americans, but it will prevent harm for future generations.

Another complementary positive step is the work that Health Rosetta and others have been doing to create the mechanisms for improving health plan benefits. While the Consolidated Appropriate Act law is a forcing function, the tools that Health Rosetta has been developing are actually paving the path forward. As Dave states, “Our goal [at Health Rosetta] is to transform employee health plans from being the number one driver of inflation, poverty and bankruptcy to delivering what they should be: a driver of well-being and wealth”.  Dave goes on to make a foundational reframing point toward the end of the dialogue:

Dave Chase and his colleagues at Health Rosetta have spent years studying what works and are offering that to employers and benefits managers. Their approach is replicable, scalable and sustainable as evidenced by the numerous case studies they’ve published and posted. It’s also the right thing to do for employers and working American families. There is no question about that. The only question is – ‘why aren’t more employers, payers, third party administrators, benefits managers and consultants adopting their approach?’ 

If you’d like to learn more and hear about their successful case studies, check out the health rosetta website https://healthrosetta.org and their upcoming annual symposium, https://rosettafest.org which is happening this August. 

Zeev Neuwirth, MD

Friends,

I began this interview in a fairly calm state of mind, but I was shaken by the end. Throughout our dialogue, I could not help repeating the word ‘startling’ as our two expert guests shared stats on the state of primary care in their home state of Massachusetts and across the country. For example, were you aware that only about 5% of the total healthcare spend in the U.S. is in primary care? That is startling given that the literature repeatedly demonstrates primary care to be the keystone in any effective healthcare system. It is troubling in that this is a far smaller percentage compared to other developed nations. And, it is of national concern given that the health outcomes in the U.S. continue to lag every other developed nation. In fact, a recent presentation at a NCQA forum #qualitytalks2023 (data derived from the KFF) showed a major dip in life expectancy in the U.S. whereas other developed nations continued to show improvement.  Early on in the interview, I asked Dr. Gergen Barnett how she would assess Primary Care, if it were a patient of hers. Her response, “It’s on life support”. 

They say you can’t fix what you can’t measure. To that end, we’ll also learn about a critical new step the Massachusetts Health Quality Partners (MHQP) and the Center for Health Information and Analysis (CHIA) have taken in beginning to measure the health of Primary Care through an annual dashboard of ‘vital signs’.  What gives me some hope are expert champions, like our guests this episode, who are dedicating their careers and their keen skills to solving the primary care crisis in our country. 

Barbra Rabson has led Massachusetts Health Quality Partners (MHQP) since 1998. Under her leadership, MHQP has become a national leader in the measurement and public reporting of healthcare information, with a particular focus on measuring and improving patients’ experiences of care. She serves on numerous state committees and boards including within the MA Dept of HHS, the Massachusetts Health Equity Data Standards Technical Advisory Committee, the Betsy Lehman Center Task Force on Measurement and Transparency. She also serves on the Board of the Massachusetts Health Data Consortium. Ms. Rabson received her Master’s degree in Public Health from Yale University and her undergraduate degree from Brandeis University.

Dr. Katherine Gergen Barnett is the Vice Chair of Primary Care Innovation and Transformation in the Department of Family Medicine at Boston Medical Center (BMC).She’s a Clinical Associate Professor at Boston University School of Medicine, an Associate at Harvard’s Center for Primary Care, and a Health Innovators Fellow at the Aspen Institute. Prior to joining BMC in 2009, Dr. Gergen Barnett attended Yale University School of Medicine and worked at the National Institutes of Health. She is a practicing physician, an active researcher, a medical educator and is involved in local and state health policy. She is also a regular contributor to The Boston Globe and Boston Public Radio.

In this interview, we’ll discover:

Some important points I took away from this interview.

It is well known that primary care is the keystone for a viable and sustainable healthcare system. Without it, the system crumbles under its own weight. There have been numerous studies and reports verifying this, including a seminal report last year from the National Academy of Science Engineering & Medicine which stated, “Primary care is the only health care component where an increased supply is associated with better population health and more equitable outcomes.”  Another conclusion from that report, “… primary care in the United States is fragile and weakening… [it is]… not configured to provide… comprehensive, preventive and chronic care needs…”

By all accounts, our primary care system is in bad shape and getting worse. It’s not a stable situation. You can get a sense of this by going onto the MHQP/CHIA website and reviewing the Primary Care Dashboard they’ve constructed.  There are also some additional links at the bottom of these show notes, provided by our two experts.

Despite the failing state of Primary Care, we are continuing to see gross underinvestment and a relative lack of research. I was shocked to discover that only 0.2% of all NIH funding goes toward Primary Care research. Research is always the first step to a better future. This stat demonstrates that we’re stepping backwards, not forward when it comes to the state of primary care in the U.S.

While MHQP, CHIA and others, such as the Milbank Fund, are measuring and monitoring the state of affairs, it does not appear that political leaders at the state and federal level are aware of the looming crisis and its ramifications. 

We all need to do more to raise that awareness, or face the consequences.  And time is of the essence. From my perspective, we are heading into a perfect storm – an increased need and demand, a decreased supply, and rising costs and inequities of care that will leave a majority of Americans without access to care. To that end, I’ve included a number of links to further inform you and catalyze action.

Final thought – there are two scenarios – two situations we might find ourselves in a few years from now.  

One scenario is a crisis – and I suspect that we’ll be looking at one another and wondering why we didn’t act, especially when the facts were so apparent. 

The other scenario is a crisis abated – and I suspect we’ll be looking at one another with gratitude that we did act.  

Which one of those two scenarios we find ourselves in is a direct function of what our leadership – our healthcare leaders and our political leaders – do today. It’s a function of what we do today. I left this interview dumbfounded, frustrated and inspired to speak out even more. I’m curious how it leaves you. And even more curious about what you’re going to do about it. 

For starters – please share this podcast with anyone and everyone you know, including your congressional representatives. It is nothing less than a matter of life and death. 

Zeev Neuwirth, MD

Friends,

The day after we recorded this interview, I picked up the May 2nd 2023 issue of JAMA and discovered that one of the leading research studies was about the rising trend in mental health-related ED visits among youth. https://jamanetwork.com/journals/jama/article-abstract/2804326

The stats were shocking and of serious concern. Between 2011 and 2020, the percentage of pediatric ED visits attributed to mental health issues had risen from 7.7% to 13.1% – and the annual absolute numbers had risen from 4.8M to 7.5M – an average annual increase of 8%!  Even more startling was the 5-fold increase in suicide-related pediatric ED visits, which had leapt from 0.9% to 4.2% of all pediatric ED visits. Think about it. One out of every 25 pediatric ED visits are due to suicidality, and one out of every 7 pediatric ED visits are related to mental health! 

The study authors stated that “these findings underscore an urgent need to improve crisis and emergency mental health service capacity for young people…”   This study was timely – but more to the point, this episode of Creating a New Healthcare’ was timely – in that we’re going to discover and hear about a company that has created an evidence-based, highly effective and accessible solution to the “urgent need” and “crisis” of acute mental health issues amongst youth in the U.S.  

Our guest today is Carter Barnhart. Carter is the co-founder and CEO of Charlie Health, the largest virtual provider of high acuity mental health treatment for youth in crisis. You’ll hear much more about Carter’s background and the reason she founded Charlie Health during the interview. Prior to Charlie Health, Carter was in the C-suite at Newport Academy, a teen residential treatment program.

In this interview, we’ll hear about:

Some important points to note about Charlie Health:

First – When Carter and others refer to IOP as “Intensive” Outpatient Programming, they mean it. The Charlie Health treatment experience is customized to the needs of the individual client, and it’s comprehensive. Charlie Health’s virtual IOP includes 9-11 hours of evidence-based care weekly, via support group sessions, individual therapy, and family therapy. In addition, they have 24/7 emergency crisis care available to their clients and families. 

Second – Carter and her colleagues have been incredibly diligent in implementing measurement-based care practices and outcomes transparency – both of which the behavioral health industry has been slow to adopt. They frequently partner with academic medical centers to study and publish peer-reviewed articles that demonstrate the efficacy of their program and track patient outcomes. What we know is that we now have an evidence-based program that is highly effective.

Third – Not only is the program effective, but it’s accessible in an unprecedented way to youth across the country, due to its being a virtual-first program rather than a place-based IOP. As Carter states during the interview, over 95% of the people in this country do not have access to mental health treatment. Charlie Health has solved that problem of accessibility for those struggling most acutely – not discounting the fact that internet connectivity is still a problem for many Americans.

Fourth – One of the profound advantages – and secret sauces – is that the virtual access enables Charlie Health to match the client with a therapist and a group of peers that are more like them – which Carter shares is a well known and critical success factor for sustaining engagement and achieving positive outcomes. Place-based brick and mortar programs have a far more limited selection of therapists and clients to match from. 

FIfth – Another profound advantage of Charlie Health is that they partner with hospitals and emergency departments. This sort of integrated care is absolutely critical if we are going to solve the mental health crisis. Patients do have the ability and opportunity to access Charlie Health directly if they are experiencing a mental health crisis, but they can also be transitioned to Charlie Health in a timely way from an ED or from an inpatient hospital-based unit.  

Finally – Charlie Health is a multi-faceted organization. In addition to its robust multi-modal IOP, they have a significant research arm, and they offer a “Charlie University” – on-going CEU training to their own therapists as well as for therapists outside of Charlie Health. One final significant activity is that they are constantly advocating for payment codes for IOP – what Carter refers to as an “uphill battle”, but one they seem to be winning as they are now live in 23 states!

The problem of acute mental health crises amongst youth in our country is alarming, and continuing to worsen. As I said multiple times during the interview, it’s nothing less than heartbreaking. The problem is compounded by the lack of access to care, and even more than that, by the lack of access to care that actually works and helps these young people. Charlie Health has taken a proven highly effective treatment approach – Intensive Outpatient Programming (IOP) – and made it much more accessible, more customized, and I would suggest, more effective. The work Carter and her colleagues are doing to obtain payment codes for IOP is also life saving. 

I’m overwhelmed by the magnitude of this heart-breaking problem, but even more overwhelmed by the empathy and effectiveness of the solution that Charlie Health has developed at scale. We need Charlie Health, and other virtually-enabled programs like it, deployed at many more hospital systems and ED’s across the country – as soon as possible.

Zeev Neuwirth, MD