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      SDOH and Mission Based ROI with John Gorman

      Healthcare Rethink - Episode 6

      Join John Gorman, Government Health Programs Expert and SDOH Investor, on Healthcare Rethink. Find out how John has made a business out of alleviating poverty and racism in healthcare.

       

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      Healthcare Rethink: Hear from Leading Changemakers

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      Brian Urban: [00:00:22]
      There it is. This is the Health Care Rethink Podcast. I am your host, Brian Urban, and today we have a very special guest. John Gorman is going to help walk us through how you achieve a mission based ROI and incredible background. He was serving for the HCFA before it turned into CMS. A board member of several businesses started the first CEO venture capitalist group in the US with amazing success and has gone on to actually lead his own podcast, The Health Equity, now producing 17 episodes with a renowned guest list. And you know what, John? You've got to get season two on the books because I was actually just listening to more episodes last year this this past week. So without further ado. John Gorman, welcome to the show.

      John Gorman: [00:01:15]
      Thanks so much, Brian. It's great to be here.

      Brian Urban: [00:01:18]
      So, John, with every episode we do on our show, we usually open things up with a Q&A or a fun icebreaker. But for you, because you have such a deep background, I don't want to waste any time with that. I want to get to know you before you became the John Gorman. Really, and help our audience know who you are as well. So growing up, having a renowned physician as a mother who changed policy. We talked about that a little bit. And then your experience through government and private and venture capitalists, you've done so much. I really want to walk through the journey of who you are, where you came from, and then we can get really into the mission based ROI stuff.

      John Gorman: [00:02:04]
      Oh, sure, sure. Well, I was born and raised in Detroit to two parents who met at Wayne State Medical School in Detroit during the the height of the Detroit riots. My mom was running the E.R. at what was then Detroit receiving hospital, and she couldn't get home for four days because the snipers were shooting over the highways. So I grew up in turmoil and the only white kid in about a five mile radius in downtown Detroit, which was awesome and a very rich experience for me as a kid. Mom was probably my my greatest influence. She she trained in emergency medicine, transitioned to primary care, and became a legend in primary care and family medicine. And, you know, my mom was. She was an incredible humanitarian. She was on the first wave of medical personnel into Chernobyl. She was in the refugee camps in Macedonia during the Bosnian war. She was in Sean Penn's camps down in Haiti after the earthquake. She was on the first wave into Fukushima after the meltdown there. And her idea of retirement was to serve. As for six years running the biggest AIDS orphanage in South Africa. So she was probably my greatest influence. Second would probably be Stevie Wonder. And third would be Prince.

      Brian Urban: [00:03:44]
      My crew to be an influence on your life in the space. And thank you for sharing that. I tell you, if you haven't started your own personal biography, then you should and you should dedicate, obviously, the first probably ten chapters of that to your mother.

      John Gorman: [00:04:03]
      Yeah, she was really an exceptional woman. So I. I came to D.C. 32 years ago to work for my hometown Congressman John Conyers Jr, who's passed now but left an incredible legacy. And within a year I was his chief of staff. You're after that. In 92, I was helping to run Bill Clinton's campaign in Michigan. And when we won my plum was that I got appointed to HFA to help start the first office of Managed Care, which was going to manage all of the Medicare risk programs, as well as all the Medicaid managed care programs, when they were just really beginning to grow in the early nineties. And I was there for three years, really helped get the office on a very solid footing. It's now the Center for Beneficiary Choices in CMS. And when I was when I was running the office back then, Bryan, it was like 3% of Medicare was enrolled in these private health plans. It was like this little novelty program over here on the side. Now we're approaching 50% enrollment in Medicare Advantage, as it's called today. And man, I told myself I wouldn't cry, but it's so nice to.

      Brian Urban: [00:05:26]
      See my babies all grown up. And you got to be proud with that. And we'll talk more about the growth of Medicare Advantage, really, since about 2014, 2015, 8 to 10% year over year. That's unbelievable. I mean, you see many businesses maybe outside of Amazon growing like that rate. And to go back to the influence of your start in the space with your mother, it shows not only did you get into so much with your venture capitalist group, Nightingale, but you got into it not just to turn a one off profit. You help create sustainable business models. That was a blend of actually helping other humans and then actually having health care, unnecessary health care spend reduced year over year. So you've proven out the model, and I think for a lot of the health insurance organizations, big the small Blue Cross private and even health care and now social tech, I think a lot of people see you as an altruistic, purely philanthropic mission and that's it. And and it's flat and that's not the case. And I think that's one of the tragedies in terms of how this has been deployed in the market. But I wanted to understand how you first saw this as an opportunity to do both to help people make a really strong business case that could be multiplied.

      John Gorman: [00:06:53]
      Sure. Well, when I came out of the government, I started a consulting company called Gorman Health Group. And for the 23 years I ran it, it was the biggest consulting and technology shop in government health programs. And when I sold it and I took a year off to just kind of take it easy because I'd done about 3 million miles during those 23 years and it was nice to just spend a year with my family. I really had always been fascinated with social determinants of health. And let me just say from the outset, Brian, I freakin hate that phrase. It's just it's just four fancy words for poverty and racism. Like with what I grew up with in Detroit, and I wanted to find a way to help make a business imperative out of investments in alleviating poverty and racism in health care. Because what wasn't lost on me was that 60 to 80% of what we spend on health care in this country is attributable to. And I like to say that in health care, poverty charges, interest. And so in Medicare in particular, if you lived in poverty your entire life, you're going to be at the higher end of that 60 to 80% spending spectrum. So seniors, especially low income or newly eligible seniors who also qualify for Medicaid, those are the most expensive and vulnerable and neglected populations in the health system. And if we could find a way of sustainably financing interventions to alleviate poverty, we were going to get outsized returns in terms of savings down the road.

      John Gorman: [00:08:50]
      So let me give you an example. The one project that made me want to be an SDO investor, if you will, was during the year I was goofing off. After I sold Gorman Health Group, Geisinger called up and they realized they had been spending almost a quarter million dollars per patient per year on their uncontrolled elderly diabetics. I mean, that's just a staggering number, right? And when we looked at a bunch of the data and factors for what could be driving that, it was evident that, you know, this was central Pennsylvania. Most of what these folks were eating was junk out of out of a Wawa or something that you find in in rural Pennsylvania. And it was exacerbating these conditions hugely. So we said, let's start a pilot program for 1000 members and we're going to do a medically appropriate meal delivery program for them. And 14 months later, we had that average cost for those thousand members, down to 48,000 per member per year. So net of the cost of this meal preparation and delivery, we were saving $192,000 per member per year and that's a 35 x return on investment. And man, you will not see a margin like that anywhere else then dealing with poverty in health care. And I said, that's it. I mean, all we have to do is find a way of monetizing these savings and we've now got a sustainable model for financing, anti-poverty benefits and services. And that was what propelled me to launch Nightingale.

      Brian Urban: [00:10:43]
      Amazing experience to kick off your deep investment in the space, not only financially, but the sweat equity that you put into this, the brain equity as well. And that's just one population. You mentioned early diabetic like you can you can have that across different populations. And being a creative problem solver I think is often a challenge for a health plan that might not have a care side. But Geisinger has both of those sides. So I love that example. And going back to the terminology stage, yeah, it was it was definitely coming from an academic white guy, white gal in a high up institution where social drivers, real human health, there's so many better terms, they now are kind of popping up. You know.

      John Gorman: [00:11:30]
      For me, SDO is always like, you know, it's like how we call cow meat, beef or pigmeat pork. It's like it's just designed to make it more palatable to white people that are uncomfortable with the notions of poverty and racism.

      Brian Urban: [00:11:44]
      It's a few degrees backed up from the core issue that it's supposed to be hitting at. You're absolutely right.

      John Gorman: [00:11:51]
      It's called what it is and deal with it.

      Brian Urban: [00:11:53]
      And in terms of actually marketing, I want to get into kind of this to kind of really get down into how health plans and health care really need to invest in this space. So anyone that utters the word health equity or so at a conference, better back it up and better have more than just marketing. They've got to have a team, they have to have analytics, they have to have an actual objective set that they can hit. So in terms of what the government has started to do, going back to 2020, now they've changed the customer experience measure, the CAPS survey. They have more of a weighted impact on stars. Medicare star ratings are very different with health plans than they are with with health care, obviously. So now they've gone from like about 20% weight on a star rating to about 60%. So now health plans are being held truly more accountable for grabbing incentive dollars that are quality bonus payments that are paid out. If you hit these measures, if you stay within the five star rating. So it's quite it's quite interesting, about 68% health plans in the US are at that high. Already four and five, but those that are stuck in the four and lower, I guess what would we say to them? Your words here. How do you turn around? You can't just screen people and then try and put soft interventions in place. What are the top investment areas health plans need to do to have better star ratings to not get stuck in and gobble up more quality bonus payments? It's a new line of revenue for them. Let's remember, attrition essentially comes from this, too. If you're a better experience for your members, so what are the things that a health plan, if they're stuck in that four or lower star rating they've got to do or even the five got to do to keep that going, what would you say?

      John Gorman: [00:13:44]
      You've got one. You've got to stop being so timid about these types of investments. You know, I can really judge the seriousness of a plan's efforts around this by the number of commas in the budget. You know, if they're throwing two and one half million to a food bank, that's a PR stunt. That's just marketing. If they're throwing 25 million into an integrated food insecurity initiative, that's going to entail a regular, healthy food option for all of its members. A medically appropriate option for those with, say, diabetes or kidney disease, and then fresh fruit and produce for everybody, which requires a whole separate supply chain and a delivery approach, then that's a serious initiative. And you want to remind the plans that these types of benefits and services are the absolute stickiest that you can offer in terms of what breeds member retention and loyalty to keep these members with you year over year. So you actually realize the savings from these investments, right? It doesn't make any sense to bring a member in. Throw $10,000 worth of food, drug benefits and primary care at them and then watch them walk out the door. The next open enrollment period, you know, you want these people to stick around. And, you know, I think it's it's just fascinating to me when you look at the impact of everything from food to non-urgent medical transportation to housing to maybe the deployment of community health workers to help folks navigate the health system and clear rocks from the road for them. There is nothing that that delivers better retention and member satisfaction on the CAP survey and other measures in star ratings than than these types of benefits and programs do. So you've got to you've got to take this seriously. You've got to stop being quite so timid about it and just sticking her toe in the Times past for that. I think these benefits are going to be the basis of competition in Medicare Advantage for the foreseeable future.

      Brian Urban: [00:15:57]
      I love that note right there. That is how you are going to have the most share of members is investing into this going through the next decade plus. And I think you bring up a really interesting point when you mentioned community based organizations, community players, those are that are deployed boots on the ground. And you and I talked a little bit about this before, but organizations that have a referral system, basically a network defined help like a health ify, and they come presenting it on a platform. So very cool tool. A lot of tech involved, a lot of relationships involved in different neighborhoods. But the one challenge here is for these organizations, how do they jump to the next step? How do they evolve? Because capacity for a Meals on Wheels program in a small neighborhood, there's only so many meals they can make, and then their supply chain is messed up with how they get those foods prepared to those that need it. So how are these referral based platforms going to change or are they just going to do more maybe need based algorithms or are they going to do relationships with providers now? How is it going to change for them?

      John Gorman: [00:17:09]
      I am a little skeptical of these companies that emerged to do this through technology as a very capable referral platform because very often they're going to end up sending these patients into the ether because the capacity to serve them just doesn't exist. A lot of area agencies on aging are not even capable, and many are just not even interested in serving a bigger population. Meals on Wheels. You know, in a lot of suburban or rural communities, it's a half a dozen lovely church ladies in a basement somewhere making meals to deliver. The next day. They are going to need a lot of nurturing and help to grow much bigger than that. So I knew Nightingale wanted to. We wanted to focus on building capacity to deliver these services in these these underserved and neglected communities. And so there is an element of partnering and nurturing community based organizations that are already on the ground and helping them do bigger and better. And the second is building additional capacity where it's needed. If those nice church ladies, half dozen church ladies in a basement are producing 100 meals for delivery the next day, we need them to prepare and deliver 10,000 meals a day.

      John Gorman: [00:18:35]
      We're going to have to build them a commercial kitchen. We're going to have to maybe get them a fleet of vehicles to do the deliveries. And we're going to have to get a whole lot more people involved in preparing those meals in order for it to be effective. So, you know, the hand-holding and the nurturing of community based organizations is essential in this kind of work, because the one thing we have to think about is investors is a lot of those community based partners have come up either on the goodness of their own hearts or in philanthropy. Most of them have never submitted a bill or an invoice, much less to an insurance company for service. And they don't have the first idea what value based care means and especially what it means to the services they may provide. So there really is a very big handholding component, and this stuff is always hyper, hyper local, like down to the the individual, the house, the neighborhood, the block. I mean, this stuff has to be targeted and nurtured on the ground. So that's really where a lot of our focus is these days as well.

      Brian Urban: [00:19:43]
      A very fragile ecosystem that being pushed to its thresholds. And I'll tell you what, it's it's great in theory, it's good in application, but now what's the next step to evolve? So I love your take on that and I definitely have more questions on that. But I want to actually go back to policy stuff. So we talked about the customer experience measurement side being a higher weight now. So in 2023 there's an additional measure being handed down through NCQA as a hiatus specific measure on social needs, screening and interventions. I think it's the sense e measure that it goes against. So they haven't rolled out to what I've seen yet the specific measures and how they'll require documentation of this. But it seems like it seems like a soft step in the right direction. There's no disincentives. There's no firm incentives that have come out. So, John, do you think your work with Clinton and Obama and even more recently with this administration is was this a strategic step to get the ball rolling more or is this just a soft step? And there could have been more of an aggressive policy put in place? What's your take on it?

      John Gorman: [00:21:03]
      Well, I think what that measure in particular recognizes, Brian, is that a lot of the plans need data first before they know what the problem areas are and where those people live. It is not lost on me that over 80% of Medicare Advantage plans don't have the first idea of the race or ethnicity of their members. I mean, I don't you can't design these things and intervene successfully in a culturally competent way unless you know who is intimately the patient population that you're trying to address. So and secure is there, recognizing that first we need data and it sets up an incentive for them to go out and screen folks for social determinants to better collect race and ethnicity data and to provide it in a framework that is actionable in the years to come. And we're going to see a lot more of that in the future. I mean, this administration has made health equity an absolute priority in everything that they're doing, and there's actually some big grant programs and in other investments rolling out right now to help insurers and others collect this information so that we can be more effective in fielding interventions. You can't know your world population enough when you're trying to do this stuff. Like I said, this is hyper, hyper local, deeply personal stuff. And and you need data to really be able to direct your efforts so that the money is spent in the most cost effective way.

      Brian Urban: [00:22:45]
      That point right there, I think a lot of people think that you can zoom forward and I'm a big proponent of let's let's go, let's go, let's go. But we've got to take a step back and say, well, how well do we know our population as a health plan or our population as a country or subsets and communities, neighborhoods, households, And then you can really have more of a precision focus for who you're helping and how they need help and validated?

      John Gorman: [00:23:10]
      Exactly.

      Brian Urban: [00:23:11]
      So that's that's a really good perspective. And I think obviously, you know, this it's really tough to get policies through. You've seen it through many administrations. And I'm curious with the current administration, the hunger program, there was a conference back in September in D.C. President Biden announced this new hunger program initiative to really kind of be.

      John Gorman: [00:23:33]
      Very involved in it, too. Yeah.

      Brian Urban: [00:23:35]

      I got to know, from your experience, how has this program been received in D.C. and how how likely is the success of it? Is it stage success you're looking for, or do you think it's going to be a big wave of success that's going to be really reoccurring?

      John Gorman: [00:23:53]
      Well, I mean, the president and and all of us surrogates involved in this effort managed to raise eight and one half billion dollars for this initiative, which is serious, serious money. And you've got a lot of players in the space contributing pretty heavily to it. I mean, Kaiser alone threw 50 million into this thing. Kroger threw in a quarter billion into this. And there's a lot of actors that are very engaged. And I hope that that will drive this program to success of eliminating hunger in the United States by 2030. That is a very, very ambitious goal because, you know, you're trying to do it across the country in neighborhoods that are both inner city and neglected to rural communities that have been forgotten. And, you know, to really get this with enough reach into all types of communities, because one in five Americans are hungry right now, that's going to require a Herculean effort at the community level to see this through. And I think the president and the staffers working on this recognize that that, again, this is hyperlocal stuff, and we're going to really have to have a national, regional and local distribution capability here to to realize this program success.

      Brian Urban: [00:25:28]
      Probably one of the biggest programs in terms of investment that I guess you could probably say you've seen since maybe the AIDS program going back into the eighties and nineties. There's probably a few really big ones in between. But in terms of what our biggest challenge is in terms of disparities by race, this one by far takes it.

      John Gorman: [00:25:50]
      Hunger is, yes, epidemic in this country. It's like the epidemic underneath the pandemic when one in five Americans reports, which means the number is probably actually a lot higher. But when people report that they are food insecure, that's one in five people in this country. And that's just that's just horrible in the richest country on earth.

      Brian Urban: [00:26:14]
      You know, and with producing the most food waste and the most health care spend as well, by far, even at the per capita, it's astounding compared to other countries, Pacific, Asian, Pacific. So, John, you mentioned something really interesting. So food access. So the surveys that have been proposed and will be held accountable to health plans, they focus on food, transportation and housing. Those are really tough things to figure out. You talked last year to rape. Kushner, executive director of the Center for Social Impact. I talked to him recently as well. And they have proven out a very strong model for having economic stability and the cycle that they have for employing people that they help. So it's a very, very rich model. And I loved your conversation. So that type of model works out really well for an integrated delivery network. You have the payer and provider working together. Do you think that can be deployed with a Blue Cross Blue Shield entity that doesn't have a health care affiliation that's purely working off maybe sense? Is data and claim data. They just see that clinical profile don't have a social profile. Do you think it can be adopted quickly there in certain pockets, or does it really take an IBM to start making change like UPMC has?

      John Gorman: [00:27:40]
      Well, I mean, you can certainly jump into this and try a carpet bombing approach and we're just going to feed everybody because we don't really know who's really in need. I mean, again, the point is of all the analytics on the front end that you do before these efforts begin is to really understand where the people are who need this help the most and direct the most resources to them. I mean, that's really what we're after here. Now, health systems and health plans can get, as I said, like a carpet bombing approach and just make this available to everybody and you're going to waste an inordinate amount of money in doing so. The ability to have that analytic front end to really hotspot where across our service area folks need the most assistance and then to be able to bring those resources really just to those communities in greatest need gets you the best bang for the buck, which is what makes these programs sustainable. I mean, you've got to be able to show results. And generally a food benefit, like any Sdoh intervention, is routinely going to show a 3 to 8 x return on investment, 35 X like Geisinger was an outlier. But those are those are achievable. I mean, the Commonwealth Fund just put out a study last week with all of the ROI evidence of social determinant interventions in the literature, and they found that a meal benefit routinely was delivering over 3000 bucks per member per year in savings.

      John Gorman: [00:29:18]
      So, you know, you really to do this well, you've got to have an absolute command of the needs of your service area and your enrolled population, and you want to have the ability to target these types of benefits and services to the folks who need it the most. And that's where you're going to get the best return on investment. And that's what makes these types of investments sustainable. Food is one in particular, Brian, where once you begin to offer this benefit, you can't go back. Then you can't stop offering it, say, two or three years from now. So generally, once you start a food benefit like other social determinants interventions, you have to really be able to sustain it financially because the last thing you want to do in an era where the member satisfaction numbers are 57% of your star rating is to offer a life saving benefit like food security and then not offer it again next year. You're in this for longevity, and so you've got to be able to do this well and targeted to make sure it's effective.

      Brian Urban: [00:30:30]
      And that's the best I say theme across our conversation so far is once you're investing in, it's not a one off, it is a reoccurring business model that you need to grow and be adaptive to the different populations that you'll see coming into your health plans, whether it's in the MA space or commercial IFP, whatever. You bring up a really interesting point in terms of you deploy a program, but you've got to keep people engaged and Nightingale, your your venture capitalist group, invested a lot into broadband access. Yes. Breaking up the digital divide and McKinsey had a report back in 2018, about 70% or so dual eligible citizens in the US had access to a smart device, a phone tablet, something like that. So that that's probably closing a little bit more and you're having a little bit more of an intuitive population overall with smart technology. But what did you find when you were researching and going through that investment? And then what were some outcomes too? Because we forget about that, that that's still a challenge globally, let alone the US, but that's a challenge.

      John Gorman: [00:31:42]
      Well, I mean, it's one thing for duals and other neglected populations in our health system have smartphones. That doesn't necessarily mean that they've got connectivity to the Internet regularly or affordably. And what we found in our first couple of interventions was that upwards of 50% of the people we were trying to reach were not connected to the Internet on a regular basis. And that made engagement very difficult. And these types of interventions hard to be effective if folks aren't connected. I mean, you have to have Internet access to even get a COVID vaccine now and to have any hope of care management. For somebody who's chronically ill or has multiple comorbidities that goes out the window if they're not connected to the Internet. I mean, you you will last see them when they leave the doctor's office and you won't have any idea what's going on with them until they show up back at the doctor's or in an E.R.. So we knew that broadband Internet access was the new super social determinants of health. And if we wanted to really have much higher levels of engagement with the most neglected populations, we needed to provide broadband right out of the gate. And in our first project where we offered broadband, we were trying to intervene on about on behalf of about 5000 members on a diabetes program. We found we were getting two and a half times the rate of engagement with members. We provided broadband Internet access to then those we didn't in a control group and that engagement rate helped drive the success of that intervention. So in that example, we put a half a million bucks into Internet access for a couple of big public housing units in the city we were working in, and that half a million dollar investment ended up yielding $6 million in savings after the first year. And that that's obviously an investment you want to continue to make and then you want to expand it to make it available to more folks.

      Brian Urban: [00:34:04]
      That's an amazing. Example of reduction cost avoidance. That's your indirect revenue in this this type of business model. And I think that sometimes is a very intangible thing, and it's tough to realize that. And I think a lot of health plans still think that SDO needs to be a turnkey ROI. Like you invest in like 30, 90, 180 days, you're going to see return. It's a journey because you're talking about the human condition at play here and your involvement with changing behavior. You're giving access to food and water, transportation. So I think in your experience, what is the average kind of return on investment here? Because otherwise there's a risk of ignoring and you're just going to keep losing numbers, having high health care spend, not knowing where they're at, transient populations, especially Medicaid. So I guess what do you see in average turnaround time? It's a journey for sure.

      John Gorman: [00:35:08]
      Well, the typical.

      Brian Urban: [00:35:10]
      Examples, that's probably tough.

      John Gorman: [00:35:12]
      Yeah, no, not actually. I mean, the typical CEO investment, as I mentioned earlier, is going to yield you consistently a 3 to 8 x return on investment. Certainly in the case that I just gave you, that that was also the case. Usually depending on the intervention, this stuff can take a year or longer to see results. Diabetes is, you know, is a tough condition because it's really involving changing behavior at a fundamental level and then trying to make healthy resources available to these patients in the hope that they'll actually use them. Most care managers know that any sort of chronic disease intervention is going to take you 2 to 3 years to start to see consistent results. We found food takes a little less Geisinger. Geisinger is example was about 1415 months before we started to see some big results. But you see similar impacts in things like non-urgent medical transportation. That's a big one because you see almost immediate improvement in people getting to their doctor's appointments and avoiding unnecessary E.R. admissions. So that's usually one that has some pretty quick results. Housing is a profoundly impactful intervention, but the problem with housing is, is the time from capital deployed to service offered. You know, if you're building housing, you know, you're looking at a year or two before you start to see before you can even house people, you know, because you've got to rehab units, you've got to get all this stuff ready.

      John Gorman: [00:37:02]
      Now, if you've got housing that's relatively immediately available, we did a project in LA, which was a nightmare because zoning in LA is just horrific and NIMBY politics is awful. And so we knew it was going to take us two or three years to find actual properties we could develop to for a housing and security village. So instead we had to go to a corporate housing vendors like a Candlewood Suites, and they were they were completely empty during the pandemic, still are. And we went to them and said, Look, could we take a block of 1000 rooms for a year? And we'll assure you that none of the folks that are going to be in these units are going to have serious mental health issues or substance abuse issues. In this example, it was newly emancipated foster kids who were 18 with no money, no skills and no place to go. And one of the most vulnerable segments out there and Candlewood Suites said they take that deal in a nanosecond. And and we got a couple of thousands of those kids housed relatively immediately. And the effects of that were profound and very quick to see. So it really kind of depends on the intervention, the population you're trying to intervene with. But generally you can expect 3 to 8 X or Y and results generally within a year or two.

      Brian Urban: [00:38:35]
      That is very helpful. I think, for the broader audience to understand there is a sunk cost to initially invest, but over time you are going to see returns that are substantial and sustainable as well. So very much intervention dependent and population dependent as well. Exactly. You brought up something very interesting earlier. You mentioned hot and cold spots and there is a lot of analysis that actually became quite popular. Dr. Brenner of the Camden Coalition and New Jersey back in 2000, 17, 18, something like that. Sanjay Gupta interviewed him through CNN and walk the streets of Camden, New Jersey, with him and helped, I guess, the broader US understand what is hot and cold spot analysis. I've been involved in some study outside of Fin thrive here in regards to that for generational poverty relative to economic stability. But in terms of what you've touched with zip code analysis, basically down from community individual, how helpful is that for health plans, health care to adopt to better understand what is a whole hot and cold spot, high health care spend or generational poverty or low access, low transportation, that sort of view, how helpful is that to adopt and start to have that as a routine set of data for health care economists, data science teams?

      John Gorman: [00:40:06]
      I mean, over the long term, it's absolutely essential. I mean, one of my dreams has always been to have a social determinants database that would sit on top of an electronic medical record, be agnostic to the EMR, but that would would make that data available to the providers in the network just as freely as anything else in the EMR would so that they can actually see a more complete profile of the person that they're serving across the the exam room. And I think that that kind of data is absolutely essential. A lot of plans will tell you it's really just confirmatory, like we know where the rough neighborhoods, neglected neighborhoods are in our service area. For instance, I live in DC Ward seven and eight on the east side of the city are where all the poverty is focused. I mean, DC is one of the most segregated cities in the country and we know here in DC most of our effort has to be on the east side of town. But when you do really serious analytics, you can't just be looking at the stuff that's available from the credit agencies. You can't just be looking at income and age and race and ethnicity. When we are preparing to do one of our interventions, guys, we're looking at 5000 different sources of publicly available data on the front end analytics. We're not just looking at income and race and ethnicity. We're looking at who checked into a homeless shelter in the last two years, who checked into a food bank in the last two years, who had a car repossessed or a house foreclosed on. Those are all publicly available data points that are incredibly helpful in really painting a picture of the social needs of a population. So you may know where that neighborhood is, but only by really getting into point analytics can you see house to house, block to block where the needs vary in that population. So you know how to target your resources and your interventions to where they're going to be most impactful?

      Brian Urban: [00:42:24]
      I love that you took it to that level. The adverse life events. Someone that maybe recently had a car repossessed, had parents or loved ones pass away. Loss of a pet too. There's a lot of different variables to our human behavior and condition that can affect how we maybe stay adherent to medication or have access to a health care visit, things like that. So that type of social profile on top of clinical is a real person profile. And you mentioned kind of a longitudinal or a utopian EHR, really. So I think your experience back with with Geisinger, I think Dr. Feinberg's now at Cerner. So we're going to we're going to hit Cerner up and see what they think about evolving the space. So we're going to we're going to see if we can get those folks on the show.

      John Gorman: [00:43:11]
      But let's just hope Larry Ellison doesn't screw the whole thing up. But we'll see.

      Brian Urban: [00:43:17]
      That's a whole separate talk track. Yeah, that's a whole other podcast. But I love the example you go back to with Geisinger and the fresh Food pharmacy's developed that now is multiple locations in Central Pennsylvania. It is a staple in communities. So you think about Blue Cross Blue Shield licensee. Their community health. They market themselves that way and they're starting to get deeper in the space. I think Michigan Blue Cross Blue Shield is a good example of things they do Highmark Health as well. Now, having an Allegheny Health Network as a care side, they have a food distribution site. They have a full investment into this space. So the starting place that you've gone back to several times is knowing your population, having a precise target and then building out specific interventions that you can track and actually deploy and staff the team. So it's a whole cultural shift. So this is this is an investment into culture and investment not only into dollars but into programs that you have to evolve. So an amazing journey you took us through there. So, John, I have one closing question for you. Oh, boy. Okay. We're talking at the top level right now. We're talking CFOs, CEOs, SVP of Health Equity. They're building out programs and trying to adjust to policy. And they have so many balls in the air. What would be your advice to focus on going into 2023 to really make an impact? Where do you tell them to start to simplify it for them? Because they are they're looking at all the shiny things, platforms, data tech and where do you start to get them laser focused on how they can impact and reduce health care spend?

      John Gorman: [00:45:06]
      Well, the first thing would be. Eliminate co-pays and deductibles. I mean, and that's a shocker to a lot of people. Right. But co-pays and deductibles are the most regressive thing that health plans do. They are literally economic barriers to access. I mean, why the hell would you have a $25 co-pay on insulin? You know, these are life saving drugs that without them spiral into hugely expensive cases and episodes of care. So for first, get rid of co-pays and deductibles for services and products and drugs that you need your members taking regularly. So insulin, there should be no co-payments or deductibles on things like insulin. There should be no co-pays or deductibles. In fact, we should be offering a coupon for these folks to go see their primary care physicians. Right. So first start there because that if you really want to talk about poverty and eliminating barriers to access, get rid of the economic barriers first like those. Second, I would say in all of our work, we've seen very consistent patterns show up in the data. The thing that's most needed by any Medicare Advantage or Medicaid population right now is food security. Inflation is way up. Commodity prices are way high. A dollar just doesn't buy you as much. And a dollar of snap or food stamp money buys you even less. So we have to recognize, especially for seniors on fixed incomes or for desperately poor people on Medicaid, food insecurity is the number one need and where you'll see the greatest results. Secondarily would probably be. The deployment of community health workers to the most complex and needy patients, neglected patients in your system, giving them a guide through the health system, somebody to enroll them in programs that they're eligible for and maybe didn't know, like food stamps or housing vouchers or low income heating credits is immensely helpful and consistently yields a $3,000 per member per year savings just by having a friendly face, helping you through the health system that I think community health workers are going to be probably the biggest headcount at a lot of health plans and health systems.

      John Gorman: [00:47:55]
      I think by the end of this decade than more of us realize. And yeah, as they should be. And by the way, that's also awesome economic development in these neglected communities. You're literally giving folks great entry level jobs right off the street to do what a lot of them are already doing for zero pay right now, just out of the goodness of their hearts to now deploy them, trained as a social worker, basically without the license to just help people through the system is immensely powerful and extremely effective. Third would probably be transportation. Because generally speaking, in a lot of areas, public transportation is pretty awful. And being able being able to help people get to a doctor's appointment or to a pharmacy to pick up their meds or even to a grocery store if they live in a food desert is really powerful, very impactful, and results in tremendous savings as well. So those are the probably the top three that we see most commonly in the projects that we're doing right now.

      Brian Urban: [00:49:09]
      I love that. So to sum up, it's remove the economic barriers the CO pays aren't working. I know it's a direct line of monies, but it's causing more harm than it is. Good. Straight out. So you've got to incentivize. If anything, you've got to remove that. So number two, you have to address food and invest in food. The community health worker is really, to sum it up. That is the best community health street level, neighborhood house to house that you could invest into. And that's a growing space for workforce and high retention opportunity as well in terms of keeping workforce and growing them organically. So I actually love that. So CFO CEOs, keep your ears open. John Gorman has plenty more advice to come out and we got to talk more. I think the next time we catch up on pharmacies are becoming primary care spaces and and the change in clinical trial diversity. We have a lot to catch up on in those subjects. But I want to thank you, John, for joining our little show. I look up to you in so many ways and thank you for being a leader, a leader and a really good bully in this space. You're helping people along. That's what we need, man. So thank you so much, John. And for more exciting excerpts and information on our show here, please visit finthrive.com.

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