The Future of Health-Care Technology

Thursday, May 6, 2021

Chief Innovation Officer, Clalit Health Services

Chief Executive Officer, Aledade, Inc.; Former National Coordinator for Health Information Technology, Department of Health and Human Services (2011–2013)

Executive Vice President, Health & Wellness, Walmart


Senior Fellow for Global Health, Council on Foreign Relations; President and CEO, Resolve to Save Lives, an Initiative of Vital Strategies; Former Director, Centers for Disease Control and Prevention; @DrTomFrieden

FRIEDEN: Thank you so much. Thank you so much for joining us. We have an amazing panel today. Three of the most accomplished, distinguished people who I know in health care in general and certainly digital health care. I'll introduce them first starting with Dr. Cheryl Pegus. Dr. Pegus is Walmart's executive vice president of health and wellness. She is developing Walmart's health-care vision. She joins from Cambia Health Solutions where she was president of consumer health solutions and chief medical officer. She's practiced in private practice as a cardiologist. She's worked for Pfizer and Aetna and was the first chief medical officer of Walgreens. She is the cofounder of A New Beat, an organization dedicated to improving cardiovascular health and careers of women and under-represented minorities. She's on the board of the American Heart Association and the immediate past board chair of the Association of Black Cardiologists. She received her bachelor's from Brandeis, her medical degree from Cornell, and her public health degree from Columbia.


Moving on to Ran Balicer. Dr. Balicer is a public health physician, manager, and researcher. He is the director of health policy planning at Clalit, Israel's largest health-care organization. He's founding director of their research institute, a WHO collaborating center, and does strategic planning and development of organization-wide interventions for improving health-care quality, reducing disparities, and increasing effectiveness and care integration, including the introduction of data-driven tools into practice. He got his medical degree from Tel Aviv University, a PhD in health-care management, and a master's in public health from Ben-Gurion University. He's a professor and track director in the MPH program at Ben-Gurion and has written more than 150 peer-reviewed publications focusing on use of databases to improve health and policy applying and assessing innovative models of care. He serves on many advisory groups for the World Health Organization and is chair of the Israeli Society for Quality in Healthcare. He's also a council member of the International Federation on Medical Informatics and the International Foundation for Integrated Care.


And last but certainly not least, Dr. Farzad Mostashari is cofounder and CEO of Aledade. He spent his career at the forefront of health-care policy and health information technology. He is the former national coordinator for Health IT in the U.S. and served as distinguished expert at the Brookings Institute's Engelberg Center for Health Care Reform. He founded the NYC Primary Care Information Project, which equipped more than fifteen hundred physicians in underserved communities with electronic health records. He's written and spoken extensively on issues of health IT, accountable care organizations, and published quite widely. He received his MD from the Yale School of Medicine and master's in population health from the Harvard T.H. Chan School of Public Health.


We have an amazing panel. And we're talking about something that people are really excited about, which is the future of digital technology, the future of health IT. Now I come to this as a public health physician. I focus on population health and how can we get the most health for the most people. I break that down into fairly simple things. How do we improve access? How do we improve quality? And how do we make sure that we do that in a way that's affordable so that more people can get good health? So let's start with the issue of access. What can and can't digital technology do to promote access to health care? And maybe we'll start with—who would like to start?




PEGUS: Thanks for that volunteer. So I think digital technology helps in access in a couple of different ways. One, you've got to know where to go to receive care. And I think many times we start out thinking about care of, "Well, is it a decision of do you have health insurance?" It's actually more than that. It also is if I'm experiencing heartburn, is that something that I'm deciding to go to the emergency room because I think I'm having a heart attack or is it something that I think I can treat at home myself? Or can I make an appointment to see a primary care physician? So when you think of digital, it's a way to allow you to make decisions of the right side of care. And so digital tools really matter in that forum. The important piece of this, and the way I look at, is that it's digital that allows you to triage to a human if needed. And so if it is that you've looked at it and you've answered specific questions, be it from an algorithm that's available, and it says based on your risk factors or your particular situation we'd like you to connect to a clinician. And by the way, I'll use the word clinician broadly. It doesn't always have to be a physician that allows you to do that. It saves money in you going to an emergency room. It saves time, particularly if you're caring for your family on a Sunday night. You now have a place to resolve that. And it also saves the ability for you to feel as if you're learning how to manage and self-manage your own care based on the ways we've made health care literate. So I completely believe that there's a role, particularly at the front end, in allowing people to be empowered to make the right choices. If we're playing telephone, I'll send it over to Farzad.


MOSTASHARI: Thank you, Cheryl. So at Aledade we are focused on all three of those, but cost and quality starts with access. And in particular for us, as Cheryl talked about, it starts with access to primary care. And what we found was, yes, tele-health can be very important. But more important than tele-health for us has been "tele-phone." [Laughs] Actually fixing the "tele-phone" has been the most important thing in both directions. So what happens when a patient calls? Do they even know to call their primary care practice? Are they able to get into the scene that day? And just enabling that was a huge cultural change, workflow change, and yes, required a technology change. Can you schedule yourself for an appointment online? Can an emergency room get you in to see your primary care physician the next morning? Those are all access points. And one of the first things we found is we needed to change the answering machine messages and the insanity of like where you can't actually reach somebody if you're calling the practice, much less calling the practice at noon, right? Like, no one picks up the phone at noon in your average primary care office. The second was outbound. So we always think of access as when the patient says, "Oh, I need to go see somebody." But actually what we need to do for population health is to reverse that. And someone needs to call you. We are seeing this with COVID now. The people who are going to sit there and refresh, refresh, refresh have gotten their vaccine. The people who are left need to be called. Someone's got to call them and bring them in and pull them in. That is access, too. We can't be passive when it comes to access.




BALICER: So, you know, in Israel, I think that we have the unique situation in which the main focus is really on general practice more than anything else. Not on specialty, not on hospital care. Most of the money, some of the best paychecks actually go to general practice in the sense of family practice because it is, in my view, you know, in the combination of public health and population health, the only type of medicine that on the mass scale can actually transform the quality of care that you provide your patients, especially with chronic diseases and multiple chronic diseases in the long term. And so we are fortunate enough under those settings to have every one of our patients have their own GP with a specific amount of patients that he cares for and he knows and he has access to. Access to your GP generally is within twenty-four hours, except, you know, unique cases. And so we, in that sense, had the access figured out on many of these skills. That being said, there's always the overnights and there's the weekends and there's all of the other aspects where telecare and telemedicine had made a huge quantum leap in increasing access just in time for those patients to get the type of care that they need. We've been doing this for over a decade providing our patients with access. Again, telecare started with pediatricians online, then went to family physicians online, and then went onwards. Then then came COVID-19 and everything basically became digital. So, I think that in the essence of where we put most of our efforts in terms of digitization, the key was more to focus on improving quality. We had access, in essence, pretty much figured out.


FRIEDEN: So we've heard three really exciting things. First, that digital is important because it facilitates connection with a human being—from Cheryl. Second, that there's a really exciting technology that can transform health care. Alexander Graham Bell would be very proud—it's the telephone. And third, that you really have to have a primary health-care system in place if you want to start addressing quality issues. Now I'll do a retroactive advertisement. A week or two ago we did a workshop here at CFR about the politics of primary health care. And we spoke with leaders from Thailand and from Costa Rica about how it came to be that primary health care ended up being politically popular in those countries because that's generally not the case in most countries. We've struggled in the U.S. to get political salience to primary health care. We might get back to that later and learn from Ran what led to that change in Israel.


Let's move on to the question of quality. And let me be really blunt here. The U.S. does a terrible job. It really does. Now, you can make excuses. You can say it's social determinants, it's the pervasive racism in our society, it's the disparities, and if you look at, you know, rich areas, they do pretty well. But really, I don't buy it because many years ago Farzad and I were in my office as we were implementing electronic health records throughout New York City in Bed-Stuy, Harlem, and central Brooklyn. And we asked this really dumb question, which was how can you save the most lives through health care? And we both looked at each other blankly and said, "We don't know." So we sent some graduate student off to do a search. Ten million articles at that time in Medline and not one answering this question. Not one. So we had to do the analysis ourselves and it turns out, far and away, it's hypertension control. And even in the years since that analysis that result is much stronger than it was then because the value of primary prevention with aspirin is much lower and because the sprint findings and the epidemiologic findings show that lower is better in terms of hypertension. So if you want to solve for the simple question, how do we save the most lives in health care? The answer is improving hypertension control. And yet, despite enormous effort in the U.S., the Million Hearts campaign, we had weekly meetings with the secretary of the Department of Health and Human Services, we had the entire department involved, we were able to move the needle from 54 percent control to 44 percent control. We moved the needle in the wrong direction. And this really emphasized to me that something fundamentally is not right when we pay $4 trillion and we can't get the single most important thing right even half the time in the U.S. So quality—how can digital technology help us with quality? Let me start with Ran because you've got a very different environment there, and maybe kind of an optimal location to be thinking about digital technologies. And I know you've done a lot with population health. So, Ran?


BALICER: So I think the first most important point would be to disillusion us from the thought that digitization will solve anything. You know, you take a broken, misguided process, you digitize it, and you get a digitized, misguided broken process that is likely more expensive and is more likely to channel the funds in the way that it was intended. So I kind of want us first of all to understand that the key thing in digital transformation is the transformation, not the digitization. You first have to map how you want the process to look like and then ask whether digitalization might really allow this to happen and whether the entire system is incentivized to go there and whether the work process can accept that. Eventually the most important of any intervention processing health care is workflow engineering. At the end of the day, this needs to make sense to the exceedingly busy practitioner that's working far more than they should and they have zero tolerance to anything that would not fit their workflows. And in many instances some of the digitization processes try to push down their throat, this steel gizmo, that's supposed to make things better either for the patient but usually actually for the system, and they will probably resist in many different ways, very, very creative ways. So workflow engineering, I think, is a key thing to take into account. The things that worked best was when we worked with the frontline workers to design the process and at the very end of the road came in to digitization. And I will give a few examples later on, but I want to give the others a chance to relate.


FRIEDEN: Let me just turn to Farzad because this must be music to your ears. I understand the two of you have never actually spoken before, but everything you said could have been verbatim from Farzad based on our past conversations. But I do want to share one thing from our own work at Resolve to Save Lives where we're working around the world to improve hypertension control. We've built a small app to empower nurses to manage patients with hypertension and diabetes. And the design team, which is fantastic, went to them and the main thing the nurses said was, "Don't make our lives harder. Our lives are already really hard. Please don't make them harder." And that was essentially the mantra, that was the dictum of the design team. And so they designed a system that has now seven hundred thousand patients on it and takes eighteen seconds for all of the follow-up information to be added. And it's something that's kind of almost a joy to use, you can say, and provides real value for the health workers. Farzad?


MOSTASHARI: Yes, I was going to say, Ran, I loved everything you said. Let me give a real example, though. In Mississippi and the Mississippi Delta, we work with a network of federally qualified health centers, community health centers. Their blood pressure control rate was not 55 percent or 65 percent. It was 79 percent. So it can be done. And we're still not satisfied. We're now looking at racial disparities in severe, uncontrolled blood pressure. And even despite all the work we've done, they persist. So we're by no means done, but we rely on the information technology. If that information was stored on paper, there's no chance that we would be able to put in place the new workflows that we do put in place. So the technology is not sufficient, but it's necessary if you really want to be able to do this population health at scale. And so, Tom, I think we maybe had to miss this as a slight misdiagnosis, but single-agent therapy doesn't work. You need double- or triple-agent therapy against this scourge?


FRIEDEN: Cheryl?


PEGUS: So I'll say a couple of things because I think Ran's first point is important. Don't design solutions for people without asking them what solutions they need or can use. And it's not just for physicians, but it's actually for consumers and people as well. And so Farzad brought up just the high rates of disparity in hypertension in particularly African-American populations. And by the way, if you look at the data that population actually sees their physicians incredibly regularly. The high blood pressure is almost ignored. And so there is a piece here of how do you flag that hypertension if we use technology within that here setting is a high-risk condition. We have to help do that. So I think we've talked a little bit here of how do we incentivize the right behaviors. And so this is Medicare data, right? It doesn't show that people aren't seeking care. So that's the first thing that, by the way, here's what normal blood pressure is and anyone you're seeing over the next five years who has the same number and is on same drug, there should be some feedback loop about here's what you're not doing correctly.


The second piece that I would say is that for hypertension in particular, there's some of this, you know, Tom, you mentioned using nurses, just a lot of this that does not require a physician to help manage. For those of you who follow just literature from the past year, some of the best hypertension control studies that have been done was a call to barber shop studies. And they were done in barber shops because it's an environment that is trusted. It's an environment that allows you to use digital tools. So you're able to do ambulatory blood pressure measures, but you get to talk about what contributes to high blood pressure in a culturally appropriate manner that allows you to talk about diet, talk about exercise. And to today, and I know Farzad and Tom, you're feeling like you failed, those studies, the original studies were actually done by the Association of Black Cardiologists. Those studies to today still stand the test of time and when they come back they really speak to this team-based approach to care, care being in your community setting utilizing community health workers, pharmacists, and others to do that. And at Walmart, you know, we've just started our clinic, our primary care centers, and we've started with community health workers as a key component of that care team. And moving from a community health worker to a care coordinator, to then a pharmacist, to then a nurse, to then a physician, if not only lowest cost in the system overall but the ability to relate to the people in your community because you're from that community and they trust you. We're actually seeing some really great improvements in things like blood pressure and in diet. And I think our approach has to be tech enabled but human centered and continue to stress that that's what success will look like.


FRIEDEN: So Cheryl, you bring up the idea of team-based care, which I've always thought of as a win on so many fronts. You end up with better care because it follows the protocols better, it's more accessible to patients, it employs more people, and it's more cost effective. So everyone is practicing the top of their license. What's the role of technology in promoting team-based care? Farzad, what's your experience or Cheryl, do you want to start?


PEGUS: I was just going to say, you know, it's interesting, and Farzad's going to dig in on this. I'm going to set it up for him. It's about the incentives that allows you to utilize team-based care. And I say that to say no one gets up to not do the best quality job that they can. And I believe that. And I believe that particularly in health care. It's how do we help you make those choices to what Ran started saying in a very busy day, in a very busy schedule. Those are the types of strategic leadership opportunities that we've got to utilize to allow a physician to say, you know, "I know you're going to go get your prescriptions here. I may not know as much about all of your other meds. You should have a conversation with your pharmacist." We don't yet utilize the opportunity to even embed that team-based training early on so everyone feels like the handoff is occurring and then what you get back into your electronic database allows you to then make the next right decision. And now I will cross it to Farzad.


MOSTASHARI: The technology, obviously, communication, health care, and medicine is about information. It's an information sport and communication is vital. And when you don't have it, when one hand doesn't know what the other hand is doing the patient suffers. You can't coordinate care. But to follow up on Cheryl, when we want to say, "Oh, let's give this service to the patient." It can be a pharmacist. It can be a behavioral health expert. It could be a psychiatrist. It could be a substance abuse counselor. It could be a social worker. The number one question that stops us is can someone get paid for that? And that just a lousy way, right? And you know what we're paying for is literally people sit there and calculate how many minutes of someone at what salary level, right? And so you're literally hard-coding the incentives in the system where you get paid the most if it's the highest-paid person doing the work. So guess what? Now we have high-paid physicians doing work that they don't need to be doing, right, because that's the payment system that creates those incentives. And I think when you see systems like Kaiser's, Kaiser Permanente, when you see systems like Ran's where they are really taking full advantage of team-based care, it's where they can say, "I don't care. I'm getting paid a set amount for this person and I can do group visits, individual phone visits, nurse visits, home visit. I don't care who provides the service as long as we provide the service.” So that to me is the two keys, right, is we need a payment system that incentivizes total health, and then we need the technology to be able to enable that. And again, like these are almost coequal, almost. But technology is, again, necessary and can be transformative in the right context.




BALICER: So I'll start by saying that I don't think that we've really deciphered how digital health would transform the issue of teamwork. I could say that what we know for sure by now is that there is no chance of treating a multimorbid patient properly for the long term without that taking place. And so what you need to get is a true interest of everybody involved to get the patient well-balanced and overall with good outcomes. And then once you have some training to all of the relevant staff of all the different professions and to have them at the right place at the right time to be able to work together, it should happen. For instance, you know, when we try to kind of review the literature on what kind of programs actually made a difference in multimorbid patients that actually transformed their care and were able to keep them balanced for the long term and reduce costs, the single word that was repeated in every one of the studies that have shown actual success, the one word that was repeated was the word “nurse.” Not a specialist. It was if you had a nurse-led program or an embedded program with true teamwork, with a tandem of a physician and the nurse working together, it worked. If it didn't, it did not. And so we can use and we are using some of this to allow each one to have their meetings with a patient and share some of the notes and some of the, basically, daily life schedules of the patient that were performed that were done with him and share them one with or the other. That makes life much easier to make that happen. And that's where digital health comes to play. But I think the most important thing is to understand that this kind of work needs to be done, that the patient cannot, you know, the basic facts of multimorbid life is that you have nothing to eat, right? If you have diabetes, and just to take one example, if you have diabetes and heart failure and chronic kidney disease, which this combination exists in about one-third of the CHF patients, okay, so my question to you is what can they eat? We can go ingredient by ingredient. Sugar? No, right? Protein? No. Water? Not so much. CHF not so good. Salt is also an issue. I can go on. You will see that if somebody needs to [inaudible], they have nothing to eat. And then along the medication, they completely negate each other and it could go on and on. Without teamwork, this will fail.


FRIEDEN: So a note that next Wednesday, May 12, is International Nurses Day. And nurses are the essence of good care in so many systems if they're part of a team and are empowered to be running things. I learned how to take care of tuberculosis from a nurse who had done it for years and knew exactly how to treat people. I was an infectious disease fellow. I knew nothing compared to Ms. [inaudible] who had been doing it for thirty years in a TB clinic. So what we've heard is that incentives are enormously important. And not just incentives in the sense of some quality incentive, but actually the structure of incentives for a system, the approach to capitation. I want to handle two other issues and then we'll open it up for questions more broadly. The first, going to Ran first, the use of digital technologies for surveillance, for epidemiology, in COVID, for predictive analytics, I think you're really at the border of showing what the future may look like in a system that's joined up and electronic.


BALICER: Thank you. I do think that we've had the chance in the last decade or so to try and experiment with many ways of using predictive medicine in practice. And, you know, because we have this integrated data sets that allows us to create our cohorts, retrospective boards, and create predictive models, you can actually for every single patient try to say what will be their exacerbations, what will be their future illnesses year by year, in five years from now, in three years from now and use it in order to approach them proactively. So the key thing about prediction is what you do with that and it should be the move from reactive to proactive care. And if you're able to do that then it's really transformative. So in preventing kidney disease, that's the easiest example by identity. It's easy to identify patients that will have [inaudible] disease five years from now and the changes you need to make right now in order to change their path is pretty simple. So we did this, and we saw amazing reductions in kidney disease in the longer term. We now did this for about ten different chronic illnesses putting the predictions into practice.


And the latest thing we've put in is a whole platform that allows the physician to see all of the different patients he needs to proactively care for and then rank them according to the need of who you want to see first and what do you want to deal with first. So you can actually, again, put it into your work practice and do the right things right the first time and by the right ranking. So that's on the potential benefits. But there's perils coming with that. And we need to take that into account. One of the biggest problems that we have right now in health care everywhere is overdiagnosis and overtreatment. The choosing wisely thing is something that we're not talking about enough. And there is a strong risk when you use predictive medicine, especially with sensors, that you will begin seeing a hoard of unneeded therapy and diagnostics and tagging of patients with diseases or pseudo diseases that would have nothing to do with their outcomes. You will start overtreating them and you will make a bad situation even worse. So the issue of pretest probability and the actual benefits, the patient and the number needed to treat a number needed to harm should be guiding us more and more in the future because it sounds really sexy to have all of these gadgets, send all this information in, and you do something that looks futuristic and you actually just add futile care on the good side but in many instances detrimental care that would actually reduce the level of health the patient has.


FRIEDEN: Farzad? Briefly.


MOSTASHARI: So, Ran is talking about a system where clinical data and administrative data can be brought together and seeing the tremendous power for understanding, understanding the world, understanding what's happening, understanding the patient of combining those two. In the United States we have very few systems, certainly not half of the population the way it is in Israel or more. But what we have now is we have collaborations between, for example, Cheryl, when she was at Cambia, and our group of primary care providers where we were able to combine their data, their administrative and payment claim systems, and our data, the deep clinical laboratory medical information that we had. And we are able to create extraordinary, better predictions in this example and to do surveillance. So I'll just say, I don't think we can replicate Ran's system exactly, but once payers and providers come on the same side of the table and share that information and combine that information, we are seeing extraordinary results from that.


FRIEDEN: Cheryl?


PEGUS: And that value, the ability to see what that complete value can be that you can take out of the data is really important. I would also say is an interoperability component here in ensuring that data is getting to the people who actually need to use the data. There's a little bit of great data, but it's hoarded somewhere in the back. And the person who is actually providing the care may not know that you now got two or three drugs added on and this is not just because of EMRs. There's a bit here of how do you take good pharmacy data and make sure that it's brought to the forefront and it's a huge, missed opportunity, right? If we're talking about quality, it's about adherence. It's about drug-drug interactions. And it's about understanding the cost component of this. And so if you are treating patients and you're providing great care and you've picked what you think is a wonderful drug and they can't afford it or it's not on the formulary, we've all done everything we thought was great until they get to one of my five thousand pharmacies. And now that's where the solution solving for how to improve care is actually occurring. And so we've got to bring that in front end. I would say, right, I will own the fact I did not train well in pharmacology. I actually need help in being able to do this right. And even though we're giving information to groups like Aledade, we're not always saying to them, "And here is the cost." Ask the last time someone writing a prescription knew the cost of that treatment. And so we leave that to individuals to go solve on their own. Those front-end technology pieces, we don't think about it as quality, but they are absolutely key. And we must make it part of the answer as we take care of populations. And so interoperability, data to the right person, and what's the right pieces of data that you need to be successful in improving outcomes.


FRIEDEN: Before we open it up I want to talk about money because we've talked about how incentives are really important. They're not well aligned in the U.S. system. They're not aligned to maximize health. We've got a big industry now built up around the poorly structured system we have in the U.S. So how can the private sector contribute to health improvement and not just leveraging some aspect of our reimbursement system or capturing some part of savings, but actually how can the private sector help Americans live longer, healthier lives? Cheryl, I'm going to put you on the spot.


PEGUS: I'm okay starting with that. So you raised this a little bit earlier. So what's good health? What makes up good health? 40 percent of that is social determinants. I think I might have shared, you know, 20 percent of that is personal behavior as we've been talking about that a little bit. By the way in the data somewhere between 20 and 25, that's where clinical care falls. We spend a lot of our money there. But that's where that falls. And then there are all the other environmental genetic components. So how do we begin to solve this? I think you look at are we ensuring that there is just fresh food. Ran talked about this, right, when you think of multimorbid populations. Just fresh, healthy food accessible and affordable. And why aren't we writing prescriptions for that? You know, Farzad has known me for a while. I think, you know, you walk into a place like a Walmart and you hear that we are the largest producer of fresh, healthy food in the country and at the lowest cost. And I think forget cardiology. I'm just going to write prescriptions for fresh food and get it delivered to you because that's what we need to address. And how do we ensure that it's not just nine to five, Monday to Friday, but it's Saturday and Sunday evenings and it's at night that you've got a place to go to get health care? That's how we address it. Access matters. Fresh, healthy, affordable solutions that you have to self-manage also matters. And then the third piece of it is making sure that you're in the right place to do this because health care remains local. It's not just technology that helps you to reach populations where you're not. It's when you need to reach out to someone, technology helped guide you to that local place that's available anytime that you need it. And I know we're going back and forth about technology. We absolutely need technology to succeed. We just need more of it. And then we need to understand how we use the humans within the health-care ecosystem to have the technology to help them be better every day. Not drained and overburdened but better every day. And that's the charge, I think, for many of us. We're excited about the techno optimist.


FRIEDEN: Farzan? And then Ran.


MOSTASHARI: So you said how can the private sector, what's the role of the private sector in creating health? And I've been speaking to folks in the administration and also journalists who are increasingly concerned about the role of private equity in health care. And you can see why when you look at what happened with surprise billing. Whenever there's some sort of, you know, loophole or arbitrage opportunity, then like, literally, that's, you know, in a way, what capital does, right? Capital will go to where it can create returns and using that arbitrage. But that's short term, and the job of the policymaker is to align private profit with public good. And my advice when people say like, "Oh, you've been around Washington. What would you advise us? Is this going to be changed? Is risk adjustment going to be fixed so that we don't have as much arbitrage?" I'm like, "What would you do?" Like assume the policymaker is, A, smart, and B, wants the best thing for the country, right? Assume those two things then eventually they're going to do the right thing. And if your calculus is how can I get in and get out before like the gig is up, that's not a great, you know, I don't think that's a great use of capital for even for your own [inaudible]. But on the other hand if you understand that the policymaker wants to get better care, higher quality, more access at lower cost, and if you can put capital to work making that happen, like then you got nothing to worry about because all the regulatory and policy doors are going open in your direction instead of against you. And I think we're now seeing more and more people who have access, who will have a responsibility to increasing their capital returns saying, "Ah, is there anywhere in health care where it's not a game, it's not a gaming thing, it's not an arbitrage thing, and it's actually aligned with societal benefit?" And I believe in those double-bottom lines.


FRIEDEN: Ran, very different system. Any perspectives?


BALICER: Yes, it's hard to imagine how different it is. And indeed, just for those who don't know it particularly well the care in Israel is public. All of the care is provided by health organizations. It's universal health care. You get your GP services for free. You get your medications from almost free because there's a cap on everything, and there's even an additional cap when you have chronic diseases. And so when you go to a hospital it's generally free.


MOSTASHARI: Stop showing off, Ran.


BALICER: That's why questions [inaudible] not only there's no surprise bills, but there’s also no bills. That makes it a little difficult for me to address. But I have to say that, you know, every health-care system is broken. That's a fact. In different ways according to the problems and incentives and the way it was built layer by layer, which always creates a lot of overwork and very little benefit. And I think that at the end of the day what really some of these innovations can do is try to fix a lot of that in many different ways. One is to help make it possible to have fewer and fewer over ailments and needs to be addressed by a physician because of empowering the patient is the biggest change that will happen to health care. There are so many things that are driven towards the physician and nurse that can be fixed with decision support on the personal level because it's not rocket science. I'm sorry. I mean, we're all physicians in this call and we have a lot of respect to our profession. But so much of what we do is just plain simple checklists and flowcharts that can be followed by almost anyone. And by putting this into the handheld device of the patient, we can free him in so many instances. And that would be a huge, I think, tremendous change that would affect every health system regardless of the incentives and disincentives that characterize it.


FRIEDEN: All right, Carrie, can we go to the audience and you can repeat the instructions and we'll hear the questions.


STAFF: We'll take our first question from Reynold Barrett. Please accept the "unmute now" button.


Q: The question I would ask, you spoke about compensation and also the collaboration among different providers. We know that many health-care workers, especially pharmacists, have in the last twenty or thirty years have been educated at a much higher level of expertise. But there is no insurance model for compensating them for their service. Therefore, we are [inaudible]. And we have enough data that says that the local pharmacy sometimes is the important point of contact especially when connecting with private practitioners. What are the impediments that prevent us from actually creating the value compensation model, especially now that in COVID through the pandemic we've learned significant access to the pharmacy and pharmacy as [inaudible]?


MOSTASHARI: I can take a stab at that. You know, Dr. Barrett, you're in Louisiana? Louisiana? We have a group of health centers.


Q: Yes, Louisiana.


MOSTASHARI: Yes, we have a group of health centers and private practice physicians who are using now pharmacists quite effectively. What made that possible was a payment model where if we were able to prevent hospitalizations, we and the primary care docs and the pharmacists and the health centers got to keep a portion of those averted costs from the hospitalization. And it turns out hospitalization is so darn expensive that you can pay for a lot of pharmacists' time and a lot of primary care time if you reorient the incentives that way. And so I think a lot of the discussions around reimbursement historically has been can we pay this group or that group for this service or that fee-for-service? And I think Dr. Pegus would say that when you're on the payer side everyone says like, "Oh, if you pay more for this, it'll cost you less." But few are willing to actually guarantee it. And I think what we need is to move in the direction of that skin in the game, that guarantee that being at risk with the payer and say, "If you pay for this, we'll guarantee it. We'll be on the hook for this. If costs go up, we'll pay you. If costs go down, then and only then would we accept payment."


PEGUS: I would just add on to that. So there are two pieces to this. One is absolutely how you structure the payment model because it's not just how do you include a pharmacist, it's other care workers onto this team. And when your contracting model allows you to do that—by the way, you know, we haven't talked about burnout. But even burnout goes down in those practices when you know who the rest of the members of your team is. So it's that piece of ensuring that that type of value-based contracting continues to grow in our country. And I think we've learned a lot and I'm hoping those learnings persist when we look at COVID-19 and how the ecosystem of pharmacists and other types of health-care professionals really were able to provide care. But it's not just payment. There are also state regulations that have to be addressed in how we allow different health-care professionals to perform at the top of their license. And there are some states that are further ahead than others that allow pharmacists to prescribe or to care for populations or to do a diabetes prevention program. It's not consistent, and those are the areas that we have to work on. So there's a policy as well as a payment component to this. And technology, by the way, enables this and so I don't want to lose that. It allows you to know and stratify who are the people who you should just let the pharmacist manage. There have been great studies on a number of cardiac conditions that show management just by pharmacists producing great results. So this isn't a question of good quality care. It's can we align these two other roadblocks, regulatory policy as well as payment models, to allow us to continue to use that talent and skill.


FRIEDEN: Great. Carrie, can we go to the next question?


STAFF: We'll take her next question from Jannine Versi.


Q: Hi, my name is Jannine Versi. I am the cofounder and COO of a woman's health startup called Elektra Health. We help women navigate the menopause transition five to ten years of their lives with interventions in that midlife phase that have implications for good health in later decades—the 70s, 80s, 90s and beyond. And my question is as an early stage, innovative company, the question of how to sell into the health-care system, you know, is often direct-to-consumer or to health systems or to employers, and there's been so much discussion of fatigue among employers in particular. As you know, HR teams are not necessarily trained to be managing health benefits or different vertical slices of the health-care experience. And so I was just curious if this group had any thoughts or comments that might pertain to how, you know, innovative companies that are entering the space might go about reaching those populations?


FRIEDEN: Either Farzad or Cheryl or both of you.


PEGUS: So I'll kick off on this because it's an important question. So there are a couple of things, right? First, is there a demand for the solution and services and have you demonstrated that? Because you first got to say here is the target market that we're trying to reach, and we've heard from them that they deserve and need more care solutions. And we've also looked at what's out there today and know we've got a better offering. So you first have to make sure that you're standing out in the offerings that you have. The second piece of this is what is it you're trying to solve because if it's that you're trying to solve a consumer-solution offering, you might start with the payer in looking at if they are looking to provide more solutions to their members? And is this a solution that fits into that for them? The other group that when you're at this early stage is also to look just directly at large employers, self-insured employers, to see, again, are they trying to help their employees solve a problem or solution. Part of the reason you start in those two places is you've got to build data and some outcomes to say that your solutions work. And for health systems and providers they need that proof to say that, "Yes, we're going to integrate it into our care ecosystem and here's how that fits in." Along the way as you build all of these relationships, the real important piece is to continue to collect your data on your ROI and results not just in care, but in being able to lower costs because investments today are asking for both. And your technology, just to stay on the theme of this meeting, is how is technology making it easier either for your end-user consumer or for the people who have to integrate it into what they already do to see this as an opportunity for them. And so a couple of different points to really bring home but the important ones that allow you to get some stickiness and allow you to enter some of these ecosystems


FRIEDEN: Farzad, anything you wanted to add?


MOSTASHARI: Yes, I would just say the fact that Ran’s probably thinking like, "What? Like employer? What does that have to do with health insurance?" The fact that that we have tied, you know, health benefits and employment together and then we ask our, you know, human resources and benefits people to, you know, figure out how to how to pay for health care and so forth makes no sense. And I think we are not seeing the same sort of innovation in the self-insured employer space as we are seeing in government programs, Medicare Advantage, in particular, or even in fully insured commercial populations. They're, you know, only slightly below Medicaid in terms of the innovation that we're seeing on payment reform and delivery reform with self-insured employers because that's not their business. And so I agree with Cheryl that working with the payers is if you can, you know, do that might help this thing scale. With employers you can often get a foot in the door, but you can't get it to scale and it's just tough.


FRIEDEN: Carrie, I think we have time for one more quick question.


STAFF: We'll take our last question from Eddie Fishman.


Q: Thanks so much. My name is Eddie Fishman and I lead health access transportation at Via. I have a question that actually pertains to what we've just discussed. You know, we have seen so much innovation in Medicare Advantage and other sort of capitated models where you could actually go at risk. What is the key to actually getting some of those models put into the biggest share of the market, which is, you know, of course, employer-sponsored health insurance? Is it community policy reform or is there something the private sector can do without policy reform to make that happen?


FRIEDEN: Farzad, Cheryl, anything you want to say briefly?


MOSTASHARI: Hagan was going try to do that and, you know, it didn't work because they couldn't get through the TPA barrier, the carriers, the ASO. I think what we need is a 2.0 kind of TPA that really sells on the basis of value and cost corridors, not on the basis of fake discounts off of fake prices.


FRIEDEN: Cheryl, anything you want to add?


PEGUS: Can't follow that, I think that's captured.


FRIEDEN: Okay, so now we've got just two or three minutes and I want to ask each of you, if you could change one thing that would allow digital technologies to result in substantial improvements in health, what would it be? I think, Farzad, you've got an answer here. So we'll start with you and then go to Cheryl and end up with Ram.


MOSTASHARI: You would think that I would have my ready answer. I'm going to aim my comments at maybe the new administration. I think it's to hammer the nail all the way in when it comes to interoperability. It's been ten years. We've made a lot of good steps on the technical side, on the policy side, on the payment side. There's just a bunch of stuff that's like almost there and just needs to be hammered in all the way in terms of information sharing being the expectation.


FRIEDEN: I thought you were going to say capitation.


PEGUS: And so I would say you hear a lot that you can't do good digital health if you don't have broadband. I think Farzad started this by saying "tele-phone" is also a tool. Smartphone access is also a tool. Let us not start with what we can't do. First, let's optimize what we can, see what our measures and success are, and then learn and build upon. But we've got tools today to use. I do think we've got to maximize them. They're important; people need them. And if we start there it allows us to then pivot and see what else is nearly needed. And I think we as leaders have to take that approach as we'll just keep sitting around saying, "Oh, there's more that we need to do to get started." We've started. How do we measure and continue and then build upon?


FRIEDEN: Great points. Thank you. Ran?


BALICER: I think that before we invent something new we should make sure we use what we already have and so our key problem is that human usability and the joy of life of using whatever we have right now. Currently in too many instances the technology, especially in the offices of the physicians, make them miserable and it doesn't have to be this way. So I think this is something we can work to make, you know, digital appliances to be fun. It should happen in the physician offices as well and actually help them do their work better. And I think that would be a great change from the current status quo.


FRIEDEN: Start with what we have available, make it fun and enjoyable to do, and make it interoperable. On that note, back over to you, Carrie, and thanks to all three of you for a terrific conversation. I've certainly learned from it. I hope our participants have as well. Thank you.



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