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      Beyond the Walls, Healthcare Outside the Doc's Office

      Healthcare Rethink - Episode 65

      In this thought-provoking episode of the Healthcare Rethink Podcast by FinThrive, host Brian Urban engages with Dr. Zeev Neuwirth, a Renowned Author and Yale University Professor, to explore beyond the walls of healthcare.



       

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      Brian Urban:                                           
      Yes, this is the Healthcare Rethink Podcast and today we are going across the US landscape, everything from health systems to the titans of industry, disrupting and embracing a lot of new care technology. Thankful to have Dr. Zeev Neuwirth, author of a smash hit growing popular book here Beyond The Walls. Dr. Neuwirth, thank you for joining our show.

      Dr. Zeev Neuwir:                                    
      Oh my god, Brian, thank you so much. I've become such a big fan of yours and we need more people like you in healthcare, so thank you for what you do.

      Brian Urban:                                           
      It goes both ways. Thank you for saying that. You've definitely kicked off my day in a good way. Thank you, Zeev. So your background is incredible. We always like to get our audience familiar with our guests. Tufts University by background, Harvard MPH. You practiced medicine for 15 years. You teach at Yale, you teach a lot of industry leaders, a lot of really important things basically week to week. So you've written an amazing book here. You're working on a third book as well. You've had a podcast well over 300 episodes. It's just like, what can't you do? It's incredible, but tell us who Zeev is before the MD, before all the podcasts and the books? How did you get into this work? How'd you get into healthcare?

      Dr. Zeev Neuwir:                                    
      Yeah, so like you said, I've had on paper, I've had a fairly traditional career path. I'm like one of those kids who just always wanted to be a doctor. What can I say? And I'm wired in a way where I just feel good about myself if I'm helping other people. It just is what it is. And so like you said, medical school, residency and internal medicine. I did do advanced training and got that master's in healthcare management at the Harvard School of Public Health. Was a practicing physician for many, many years. Then a process improvement, quality improvement, innovation, population health officer, chief medical officer, chief clinical executive. And so it is sort of a trajectory many, many years over 30 years in hospital systems and large multi-specialty practices. So I've been in the belly of the beast.
                                                             
      I would say that maybe the difference, and maybe it's not so different, because as I talk to executives, I'm sort of hearing some similarities. I, almost from the beginning of my career and I've written about this in both my books, Reframing Healthcare and Beyond The Walls, I've had a sense of frustrated awe. And I borrowed that term from Reid Hoffman and amazingly... In awe, let me just first say this, in awe of everyone in healthcare. I mean just all the colleagues I've met, they're so brilliant, so passionate, so professional, so expert. It is just amazing to me what they do and what we do day to day.
                                                             
      The nurses, can't say enough about it. Frustrated almost from the beginning, literally. I remember being a medical student on the floors of the university hospital at U Penn as a second and third year medical student. And just, I couldn't believe with all this amazing resource and people, how poor the system actually worked and how poorly it delivered on its promise.
                                                             
      It's a situation where the whole adds up to far less than the sum of its parts, which is a very, very sad situation. And it translates into people suffering, patient suffering, their family members suffering unnecessarily, avoidably unnecessarily. And of course, as we now know, and I've known for 15 years, physicians and other providers suffering. I mean, I was doing research on burnout back in the 1990s before anyone even... I published on it. In fact, I published in Newsweek, an article in the 1990s or around 2000 called The Silent Anguish of the Healer. And so I was aware of how people were suffering in healthcare.
                                                             
      And so my career sort of diverged early on and I began to be a student of not only process improvement, but human centered design, the whole notion of really asking questions and listening. And I began to deploy positive deviance looking for those exceptions, those people who were out of the norm off the track, but really getting amazing results. And I began to study those positive deviants, those divergent thinkers years ago. In fact, I would probably say at least a decade of highly intentional, thousands and thousands of hours of seeking these people out, studying them in depth.
                                                             
      The podcast actually was just an artifact of interviews I had been conducting. I mean, I just would record, I would find these people, record them, transcribe those recordings and listen to them and study them and out of that-

      Brian Urban:                                           
      Way before podcasting was popular, this was 2017, you kicked that off, right?

      Dr. Zeev Neuwir:                                    
      Way before. Yeah, a different era. It was, I didn't even know what a podcast was when I launched it. I mean, literally I went online and took a course on how to launch your own podcast, because there were not producers out there that could help you. So the podcast was really just an artifact of what I'd been doing anyway. And then book number one, Reframing was sort of the playbook I saw these people using book number two was the larger strategy I saw emerging in healthcare. And again, my purpose here is to share that with leaders and up-and-coming leaders in healthcare, whether it's policymakers, hospital leaders, payers. That's my hope, that's my goal. That's why I'm doing what I'm doing.

      Brian Urban:                                           
      And it shows not only in your background but in what you do on a daily basis. And it's so interesting, I don't want to give too much away of the book. I found such uniqueness in the way that you opened the reading and you talked about, I love your analogies with cinema by the way, throughout the book. It was really well done. And Greek philosophers and others as well. You talk about The Matrix and you talk about three matrix moments in your life that changed your career trajectory and the way that you started to study the change of the healthcare ecosystem.
                                                             
      And you made a comment about your mother passing away from a hospital-acquired condition, a hack. And it was very unfortunate, very sad. It was lovely of you to share that because that's a very connected thing I think a lot of people can resonate with. And then you talked about a friend as well, that was a co-physician, a colleague in your days, and he had passed away from suicide and you had all these just relevations of like, "Hey, what is healthcare doing to us and what is it doing for us?" It seemed like, and then you walked into the book and your research and your conversations, but those matrix moments for you to reflect on them is amazing. I think that is so gravitating for a lot of readers new to your work or even new to understanding what's being disrupted in healthcare.
                                                             
      So take us through why you chose to open the book in such a unique way.

      Dr. Zeev Neuwir:                                    
      I would say the three things I shared, which happened about a decade ago in rapid succession were catalysts. They were sort of a wake-up call bringing me back to my original purpose, which really quite honestly, and I've known this almost from the beginning, my mission is to humanize healthcare delivery and it's very much in need of that. I think, and by the way, my approach is not blaming. I just want to be very clear. I don't have that sort of critical mindset. My approach really is to recognize truth and reality as best I, and we can because in service of actually doing something to change it, if you don't recognize reality and you don't know where you are, it's highly unlikely you're going to actually be able to move anywhere and definitely not in the right direction with any intention. So three things happened. One is like you said, my mother died from a completely preventable situation, completely preventable.
                                                             
      And what's important to note about that for those for others is that the same day my mother died from an avoidable complication and preventable complication, there were probably 500 to a thousand other families who experienced the same thing. That's what the literature tells us every single day, somewhere between 500 to a thousand. And you could argue the literature and say it's a little bit more, a little bit less, but in that range, 500 to a thousand families are devastated by an error that happens in our medical care system every single day. There is no other industry that would tolerate that or allow that to happen. And then if you look at the statistics on quality and realize that about half of all people with high blood pressure don't have it controlled, two thirds of people with diabetes don't have it controlled, heart failure, it's probably down in the single digits of percentages in terms of the number of people that have that chronic condition controlled.
                                                             
      The same thing for pulmonary disease, COPD probably about 1%. You look at those quality and safety numbers and listen, I've been in this for 20... Well God, if I'm going to be honest with you, I've been in it for over 30 years and I've been in the quality domain and safety domain, and we've not moved the needle. The quality chasm has not been crossed by any means. And so if you look at that, and then as I was mentioning the disparities, a lot of talk about disparities in care, the truth is it's gotten worse, not better. When you look at the aggregate numbers in the US and in terms of longevity lifespan, the rich and white people are living longer and people of color and poor people are dying younger and that is just the fact. And so you look at the way we treat old people, older people, the ageism, the racism, the sexism, the ableism, the reductionism.
                                                             
      These are the isms that are the reality in healthcare. And I point that out only to say that if we recognize that, let's do something about it. And there's so much we can do about it. The Matrix, it really feels like the matrix. It feels like we're living this sort of surreal existence, this sort of opaque existence where we're not really pulling back the sheets, not really looking at what's going on and therefore not addressing the issues. I don't blame anyone for it, I understand it, but for me, I had that matrix moment, something clicked and I just decided to take that, I think it was it, the red pill. I always forget which one Neo took in the movie, but I decided to make a shift in focus.
                                                             
      And again, everyone has their role to play. As it turns out, my role is to really uncover the truth, share it, and also most importantly, share those exceptions to the rule that are actually radically improving healthcare and in a timely way. And I think that's, when I talk to people around the country, I would argue that in some ways we are getting better, but it's highly incremental. It's so slow and I realized years ago that this was unsustainable and we were heading for a really bad situation. I think it's much more evident now that that is the case.

      Brian Urban:                                           
      So after all those amazing findings that the Veterans Healthcare Administration had seen with doing a whole person clinical support model, there's still a lot of challenges to actually implement that in the rest of the healthcare ecosystem and scale it. A lot of that you started commenting on just based on purely on the payment models that we have as a common thread with really fee for service being the majority of it's still in the US, but take me through that whole person health section? That must've been so just much of a passion section for you to dig into.

      Dr. Zeev Neuwir:                                    
      Yeah, that section of the book, part two is really focused on the whole, I would say, humanism movement in healthcare. And I wish I could have spent much more time in that section. Book number three may be expanding on that. I think there is a strong movement afoot, and I think we need to really point the narrative in that direction and start to get more action, but this is one example of an exception to the rule, and I'm just surprised over and over and over again how the VA system in our country is radically transforming American healthcare for the better.
                                                             
      And in part, one of the catalysts, one of the enablers they have is it's not fee for service and so it is a value-based payment model. And so they have the ability to actually invest in the care of their patients in a way that is far superior than the fee for service system allows. And to invest in what we know are the primary movers of health, the primary levers of improving health, which are largely the non-clinical factors. They far, far outweigh the clinical factors, which is still shocking and surprising to me, but that's what the literature tells us. So they've been investing, and this is not sort of a flash in the pan, they've been working on this for probably two decades, and they've come up with this whole health model, because they realize that the non-clinical factors are critical in health for engagement and for outcomes.
                                                             
      And they also realize something important, which is that purpose and meaning, and I know this sounds sort of fufu and this notion of purpose and meaning, but they realize that they're not going to engage their clients, their patients, unless they really tied into something that's important. By the way, I was trained this way. I mean the attendings who trained me and I trained internal medicine residents for years, we talked about this informally, but what has happened is the VA has formalized that with science and with an amazing operational process.
                                                             
      And it boils down to there's so much, and people could go on to va.gov/wholehealth and you could literally see their program, but it boils down to two questions. The first question is, what's the most important thing in your life right now? The second question is, what's the one thing you can do to move in that direction and support that? What a brilliant, simple set of questions. And then they have a whole system to help the veterans accomplish that. And they're seeing some amazing results with it even early on, yeah.

      Brian Urban:                                           
      And that's amazing because those two simple questions are the social needs screening. I think it's amazing work that NCQA has developed and as integrated into a screening methodology through CMS, and a lot of physicians are adopting that now and capturing data, and there's still a Z code connect disconnect and application there, but you don't need to ask 20 questions like PRAPAR survey has been around for 20 years. You can ask the question as a human to a human, not as a transcript and I think that is amazing, because honestly, I wouldn't expect that from a government, oriented government employee, veteran-focused healthcare administration, but you have it.
                                                             
      And because they had such a know-how to be able to address things upstream in a human way. I love that you highlighted that. That is a gap across the industry and you've talked to a lot of physicians. You've trained a lot of physicians. Do you still think that's a big gap in not only medical education but also experience on the floor and that the bedside?

      Dr. Zeev Neuwir:                                    
      It's huge. I mean, currently we're still at the stage across the country of just requiring, just beginning to initiate the requirement that you ask these questions, these social determinants of health questionnaires on an annual basis. I mean, that's barely a start, right? I mean, that's so inadequate. I mean, they really should be asked... Let me take that back. I realize that it's actually people using it at every encounter and every visit as well, but still, and I talk to people at the frontline who are delivering care. It's really clunky, really hard to do. One of the things I admire about the VA is how digitally savvy they are. So I think in order to do anything today, there are two requirements that I've observed, and this is sort of the thesis of the book. In order to humanize healthcare, you need to really leverage state-of-the-art, digital tech.
                                                             
      There's no way around it. In fact, it is the great enabler. And the other thing is we really need to transform our business model, how we make money, how we compensate, the whole model of business. And I think you see that in the VA. You see a business model transformation coupled with state-of-the-art, digital technology, really humanizing healthcare. The other chapter in that section was about something called contextual care. And this gets into factors that are what I call the micro economics to the macro of the social determinants of health.
                                                             
      So patients get discharged from the hospital and we sort of ignore the fact that they're actually people. They're not automatons. So you just had some major surgery, you get back from the hospital. If you've spent time in the hospital, you're probably, not probably, you're exhausted. If you're older, you could be experiencing delirium, you're probably nutrient deficient, you're sleep deprived and you're in pain and you're probably scared.
                                                             
      And then what about the resources you have, and they fluctuate. What about you have other things in your life that are competing responsibilities and completing issues. And so all these sort of day-to-day changes, all these psycho emotional and relational issues, these go beyond the classic social determinants of health, finance, employment, education, food. These go beyond that and I think that we are literally just at the bare beginning and my hope is that we accelerate this, so this is not a 20 or 30 year process. We don't have 20 or 30 years. I think we really need to start to think in terms of two to three years and how do we bring this in?
                                                             
      And for hospital system leaders, let's just be clear, if you've reviewed MedPAC's recommendations from this January, 2024, they're very clear. And I've talked to economists in D.C about this healthcare economacy and policymakers, they're very clear. The philosophy I think is moving to not providing more money to hospitals, but actually using fiscal constraint, financial constraint to actually force hospitals to get hospitals to think differently. That to me is the writing on the wall. People may disagree with it, whatnot, but I think we've shifted into a whole new era, which is again, it's just the old way of doing things was untenable, it's unsustainable.

      Brian Urban:                                           
      Yeah, it's not working and it's very obvious not only from an affordability standpoint, but also from a free cash perspective. If you look at the economics, and part of your book goes into the titans of disruption as well. The large retailers, large private health plans, health plans right now have a ton of free cash. They have the power. They've had the power for a long time. Same with a lot of pharmaceutical manufacturers for a long time, historic there as well, and healthcare tech in between and it's amazing. There needs to be more of a balance and collaboration or there's been more of a conflict and friction than ever at the industry down kind of level.
                                                             
      So the part of your disruption book, disruption section in your book is really interesting. I've spent a lot of time at Cigna, spent a lot of time at Walgreens and have felt the culture there and some changes that occurred in my time. You mentioned them, you mentioned Amazon, and you take a really cool perspective talking to Dr. Robert Pearl. He was an executive in the Kaiser healthcare family for a long time, and then now he's a professor of medicine and science at Stanford. And he talked through a section with you that said why these large healthcare disruptors almost doubled their top line revenue growth through the pandemic and health systems struggled mainly because of fixed cost, capacity, workforce oriented, but also consumer access to healthcare, and then how they use that to invest and buy more. So, so interesting to look at this. What was your learnings from this portion of the book, The Titans of Disruption?

      Dr. Zeev Neuwir:                                    
      Yeah, so this is a trend I've noticed for literally over a decade and have been talking about it for over a decade. So it's not a new trend, although some people are surprised at what's happening. So point number one, there are no swim lanes in healthcare anymore. There's no such thing as a payer. If you look at the payers, they're payers, they're providers, they're telehealth providers, they're PBMs, they're analytic companies, they're pharmacies and specialty pharmacies. So there's no such thing. There's no swim lanes. We are playing water polo. Everyone's in the same pool playing one game, one ball, one goal, okay?
                                                             
      So that's really important to understand. And as you point out, when you get down to the business level, there's a lot of confrontation right now, and it is water polo when you look at what's happening between hospital systems and the traditional insurance carriers, particularly around payment, a lot going on there and a lot of competition around the continuum of care.
                                                             
      So 5, 7, 10 years ago, the traditional, these retailers like Walmart, Amazon, the insurance carriers like Humana, Optum, CBS, they were saying things like, "Hey, listen, hospital system's providers, don't worry about it. We are just going to provide around the edges, fill in the gaps." That language changed a number of years ago, probably around 2017, 2018, where they said, "No, full on, we are going to provide care across the continuum." And if you look at the investments that the traditional insurance carriers have made in care across the continuum, and Robbie said this, and I completely agree with that, Dr. Pearl said this, they're investing in assets and capabilities across the continuum of care, right?
                                                             
      Huge. Billions, if not tens of billions of dollars of investment. By the way, they are not doing what traditional hospital systems do, which is try to build everything. They're just buying those assets and they're really, they're making the leap, right? And then they're integrating them, curating them, putting them together, which is a challenge. And keep in mind, they've got revenue diversification, which hospital systems are struggling now realizing, "Oh, we need to diversify our revenue." Where have you been for years because your competitors have been doing that. You're right. Let's do that now.
                                                             
      And also, the payers have an advantage in addition to their size and cash as you put it. The advantage is that their business model is much more aligned with what the feds and the employers are needing, which is lower cost, more efficient value-based care, because when they save money through the care they deliver, they actually make money on the insurance side. And so they have some advantages having said that, and so they are the titans of disruption.
                                                             
      Although Brian, language is important to me, and I actually put this in the book, Beyond The Walls, we talk about disruption. Disruption is a side effect. The more important question and the more important point is they're not disrupting healthcare. They're actually advancing healthcare. And what hospital systems and providers, I believe need to do, and I make this point, is the question is not how do I disrupt myself? How do I advance healthcare and the value proposition? That's really the set of questions to kick off.
                                                             
      And I just say this, Brian, the last chapter of my book is fully devoted, if not the last chapter and a half fully devoted to the number one question I get when I speak, which is, "But Zeev, what can I do?" That's the number one question. And chapter number nine, that's the beginning of the answer.

      Brian Urban:                                           
      I love that. We're going to leave that as a hanger on for the audience here. You want to find out, you got to get the book, you got to learn a little bit more, and then you'll be able to create your own change. Zeev, I love where your book leaves off because you get into platforms and you get through the embracing disruption, advancing healthcare as how can we accelerate it, what are these titans doing? And we left off with a really interesting quote. You took it from Elie Weisel, a Nobel Peace winning author. And it said, it stuck out for me here, "When God created us, God gave Adam and Eve a secret. And the secret was not how to begin, but how to begin again." And it's the message of recovery. It's the message of trying to get better, fixing and learning from our failures and I see that for healthcare.
                                                             
      I think you're an optimist in a lot of ways. You see that because there's a promise that a lot of different organizations are bringing into fruition, short-term and hopefully long-term. I want to leave our audience with a question for you is what do you see happening as another mega trend in the next five plus years in healthcare? What's really going to start to shift the economics or the care delivery for the people that healthcare serves today?

      Dr. Zeev Neuwir:                                    
      Well, I think the untenable and unaffordable costs of care are going to have a major impact. It's actually, I think it may be either at the tipping point or beyond the tipping point. People can just not afford healthcare. And this is not 10 or 20 million people who don't have health insurance. I'm talking about the majority of working Americans and their families and people in retirement. I think we're going to see that pressure really, really surface, and the need is there. So it's not like people don't need healthcare. People need healthcare, and they can't afford it. And I think that's going to be a bigger crisis than we have imagined or have experienced to date.
                                                             
      I also, and in response to that, I think what we're going to see is the further consumerization and retailization of healthcare. I think there's going to be tremendous pressures on the federal government, which is again, Medicare, Medicaid, 40% of payment. I think you're going to see tremendous pressure on the other major payer, which are employers. Those pressures are the regulatory requirements now for employers to be fiduciary responsible for their healthcare benefits has increased. Most people are not even aware of the regulations that have been imposed on employers.
                                                             
      So I think you're going to see that cost pressure and that affordability pressure really, really hitting providers and hospitals, and then you're going to see a response from the retail space. I think the retailization of healthcare is a very, very real thing. Again, the new entrants, the relatively new entrants, they don't have to transform healthcare. They just have to make it better than what exists today and yeah.

      Brian Urban:                                           
      Amen. Yeah. What can be better today? And I highly recommend the book, love getting to know you, Zeev. Beyond the Walls. You can get this obvious on Amazon, but the title says it all, how is healthcare extending beyond the traditional walls of where care has been delivered in the US? And there's so many good insights here. Dr. Neuwirth, thank you for joining our little show today.

      Dr. Zeev Neuwir:                                    
      Brian, I really enjoyed talking to you. I love what you're doing. Thank you.

      Brian Urban:                                           
      Thank you again. And for more exciting insights and excerpts, please visit us at FinThrive.com.

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