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      Healthcare Needs a Long Fix

      Healthcare Rethink - Episode 66

      The Healthcare Rethink podcast, hosted by Brian Urban, prominently features healthcare transformation as its central theme in the recent episode with Dr. Vivian S. Lee, the author of The Long Fix: Solving America's Health Care Crisis with Strategies that Work for Everyone and Exec Fellow at Harvard Business School.


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      Healthcare Rethink: Hear From Leading Changemakers

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      Brian Urban:                                           
      Yes, this is the Healthcare Rethink podcast. I'm your host, Brian Urban, and today we're looking deep inside healthcare, not just on care delivery, but tech policy and everything in between. We're so thankful to have on our show here today, Dr. Vivian S. Lee joining us, famed author of The Long Fix, and I'm so excited to have you on our show here today. Dr. Lee.

      Dr. Vivian S. L:                                    
      Great to be with you, Brian. Thank you.

      Brian Urban:                                           
      This is going to be so much fun. We've gotten to know each other a little bit here, but definitely more through our conversation. And before we dive into this book here, one of, I'm assuming maybe possibly more, I definitely want to have our audience get to know you personally as well. So your background is incredible. Just off the top, Harvard Medical School NYU MBA, before Scott Galloway's days there, he's quite a disruptor, troublemaker at times. And then you went on, I think most impressively your PhD in engineering science from University of Oxford. There's not a degree you don't have. You're so curious in nature and you're very well-educated in terms of academia, but also your experience. But who's Dr. Vivian Lee behind all those degrees? How did you get into healthcare? And then we'll get into the book here, but how did this all come to be?

      Dr. Vivian S. L:                                    
      There aren't any doctors in my family, so I didn't really know much about medicine before. Although my parents, my dad is an engineer and my mom is a statistician. These days, if they were marketing themselves, my mom would call herself a data scientist and my dad would call himself an AI expert, just going to say. But back in the day, they were just a statistician and an engineer, and both of them worked in healthcare related areas. My dad was an inventor of different kinds of things, like a talking typewriter for the blind. My mom did a lot of research with the Native Americans in Oklahoma around diabetes. And so I had an inkling about healthcare. But then the transformative moment was when I was introduced to a local internist in our town, a guy named Dr. Hal Belknap, who took me on rounds with him. And I just fell in love with it after that.

      Brian Urban:                                           
      That's amazing because that's actually how you open your book. There is in the area of Norman, Oklahoma, and you were doing these ride-alongs with Dr. Belknap. And as an internist, you got an amazing view of what care delivery was at that time. And in your early part of the book here, it helps the reader see your transition through science and then into your executive world here whenever you later became the CEO of the University of Utah Health, which was amazing. But I want to start back in those early days in your younger years with these ride-alongs. So how did this happen? What did a unique experience, and this really probably coded some unique ideas in your brain to follow the path of medicine, I would understand.

      Dr. Vivian S. L:                                    
      And sometimes these things are just so haphazard. It happened in something like maybe seventh or eighth grade when one of our school teachers who's just one of those really zippy, do good type of people, really selfless, decided that she was going to match each of us up with a professional in the community so we could learn more about something, broaden our horizons. And so really just randomly, I got assigned to Dr. Belknap.
      And the next thing you know, one of the most prominent doctors in our town, highly, highly respected, really just a wonderful human being as you can imagine, because who else would volunteer to pick up a 13 or 14-year-old, whatever I was at the time, kid from my house, drive me to the hospital, take me on rounds, and then bring me home and introduce me to all of his patients. I must've been the most awkward teenager ever in the history of mankind. And yet he was so kind and he would just say, "Oh yes, well, Mrs. Jones, why don't you explain to Vivian here just what do you think is going on with your heart or your breathing problems" or whatever it was. And he brought me into the relationship and it was amazing. It was so incredible. It was just the coolest thing I'd ever seen or could imagine to be a part of.

      Brian Urban:                                           
      And you referenced earlier in your book around this time here, the sitcoms at the time that were physician oriented and then future Doogie Hauser and M*A*S*H and all those different sitcoms that came later in time with entertainment. You were on the edge and the cusp of it back in the day here, so it probably suited you so well going through your residency years to understand what true bedside manner is and how can you understand who the person is behind the patient. And I would imagine, right? Because who has this type of opportunity at this age? This is unbelievable.

      Dr. Vivian S. L:                                    
      Well, the interesting thing about it is I ended up going into a very tech field. I became an MRI radiologist and I ended up doing a lot of engineering and my research, and then I worked at an alphabet Google company for five years. But back in the day when I was hanging out with Dr. Belknap, that was before electronic records, so everything was handwritten notes, really cat scanning and imaging, those were just reserved for really serious situations. Everyone just relied on physical exam and your stethoscope and really good judgment, which he had in spades. And so I think I learned very early on that a really good doctor is a really good listener, somebody who can really piece together the story that the patient is telling you and then obviously have a really good understanding of how to do a good physical exam and then uses some of these tests additionally, but doesn't rely on them. I think sometimes in the world of high-tech, we use the tech almost as a crutch to replace our diagnostic capabilities and we lose sight of the human connection. And so that's something that Dr. Belknap always taught me. It's really about your relationship with the patient. And that matters almost more than anything.

      Brian Urban:                                           
      And that's so foundational to, I think, a lot of your experiences that you took in a very techie world, noting some of your executive experiences there that you just commented on. I love the part of the book you get into on new data frontiers and the emerging space of how healthcare delivery is changing and blending. But before we jump into that, I'd be remiss to comment on where your career trajectory went after your residency. You had the opportunity to go into NYU Medical Center and become a researcher there as well. And then from a lot of your learnings there, you had this amazing opportunity. You're actually trying to recruit colleagues to go with you to Utah, but you made the leap and you became the CEO of the University of Utah Health, a very different culture of health I would imagine in the Mountain time zone there. So what was your experience at Utah? You were there for over a decade. How did you see healthcare IT starting to transform at that time?

      Dr. Vivian S. L:                                    
      Right. Well, yes. So I was actually, it was really interesting. When I was in New York, before I went to Utah, I was very fortunate to work with a new leader, a guy named Bob Grossman who had come from the University of Pennsylvania in our Department of Radiology, and then he became the dean and the CEO at NYU and brought a bunch of us with him. So the next thing you know, I'm actually responsible for research. I'm the chief scientific officer at NYU and learning a lot about all different kinds of research that happens in a medical school that I wasn't familiar with before. A lot of the basic science research, clinical trials research.
      And it was really at that time that I had an epiphany, which was we're doing so many incredible things in our research labs. It feels like we're curing cancer in mice every day, but at the same time in our emergency departments every day patients would be showing up with heart attacks and strokes and conditions that could have been prevented with a 10 cent a day pill, a blood pressure pill, for example. And so it was at that time that I became really, really interested in this question of why aren't we fixing healthcare? Why isn't the health of the population getting better and better given the amazing miracles and advances that are happening in science?
      And that's what drew me and my family to the University of Utah where I served as the Dean of the Medical School and CEO for six years there and really had a chance to work in an organization that had already been very highly rated for quality. Actually, the year I was being recruited there, the University of Utah was ranked number one in quality among all university health systems in the country by Vizient. And then it was called University Health System Consortium, but now it's known as Vizient. So the system was already top in quality. And then when I was brought in, we were working on improving patient satisfaction. And then finally the holy grail for us was really how could we reduce the cost of care? How could we really start to make a dent in probably the biggest challenge of healthcare, which is inexorably rising healthcare costs.
      And so I had been very well-trained in NYU, I got a lot of great preparation there, but faced some pretty interesting challenges when I got to the University of Utah.

      Brian Urban:                                           
      It's amazing that you did note the ranking too, in that portion of your book. Number 10 at the time in terms of quality ranking, NYU and then number one, Utah. How could you not think about passing that up? You got to make that leap, and it's so amazing that just in this short period of time, you were on the research side, you're at the bedside, academia and now you're an executive level and then dean as well. So it just seems like things went so incredibly fast, a hundred miles an hour for you.
      And to fast-forward a little bit, in your book, this is where I find it truly fascinating. You had a unique opportunity to see new data frontiers. So this is something I mentioned earlier, and as you were describing your experiences and a lot of the happenings across the healthcare landscape, you noted North Carolina's Health and Human Service Department and how they were integrating social health indicators, amazing project that helped get food to families. It was very fruitful. You made a lot of amazing comments around that progress.
      And then you started to talk about the promise of big data and policymakers. And my question here for you is big and small data. I think the biggest thing we've heard pre and now through and post pandemic is whole person care, is social determinants of health. And I feel like the modern electronic health record, it's not being pushed upon from regulation to incorporate socioeconomic information, but are we at the cusp of starting to pull that into policy or are you thinking we're still far behind where we should be or are a lot of these programs that are one off across the country going to start to maybe unify into a standard requirement or a standard push, whether that be through NCQA's affiliation with CMS or otherwise, or Section 1115 and some of the good things coming out of that? What's your thoughts on big data and small data getting put into EHRs and helping a physician see the whole person but then supporting that physician as well along the way?

      Dr. Vivian S. L:                                    
      Okay, that is such a huge and really important question. I'm really glad you asked it, Brian. And I think to start with, it's really helpful I think to take a step back and say, why is this so important? Why is it so important to have data about a person socioeconomic status, for example, in their electronic health records? And the reason for that, for folks who have not been thinking about this all the time, like you and I probably have, is when you start to look at what the biggest drivers of a person's health or a population of people's health is, it turns out, even though we are singularly focused on what happens in the operating room, what happens in the hospital, what happens in the clinic, it turns out that the vast majority of the determinants of a person's health take place outside and are tied to their socioeconomic status, are tied to their health behaviors, which are of course very closely related to their social status as well as environmental factors, which are again, all connected. And probably maybe about 70% of a person's overall health status is dependent on those factors.
      And that's why we've seen this move over the last decade or two for those of us in traditional healthcare to say, Hey, we need to think outside of our typical box and really start to understand people, as you say holistically. We need to understand the whole individual, the whole human, and how we can help them the most effectively may not necessarily be just prescribing that medication. It may be figuring out, oh, you know what? They don't have the transportation they need to go and pick up that medication from the pharmacy or they don't have the money to cover the copay or whatever the extenuating circumstances are in their lives that prevent them from getting that.
      And so it's that recognition that is driving us all to ask for less siloization of data and more integration of data. It's also the fact that we have a really, especially post COVID, but most of us were quite aware of it even pre COVID of all the enormous health inequities there are in this country. And that's also, I think, in a large part due to the fact that we don't have enough of understanding of all these different dimensions.
      So I think there's two or three factors. One is we need to have a way to integrate data from across different sources. We need to have more standardization and interoperability of our systems, and we also need to have more ways of being able to invest in the infrastructure that's necessary to build these kinds of data systems. So there's a lot of things that all need to work together to happen.

      Brian Urban:                                           
      I love that you put it in those terms, having, paraphrasing here, a way to have a social health data infrastructure lifted up and integrated into the healthcare ecosystem. It's something on my mind. So it's a very biased question from my perspective obviously wanting to hear from your experiences and your perspective, but it's totally where we need to be and where we're hopefully going as well.
      So back to a couple other favorite portions of the book that I have here, and I wanted to make our audience aware. Employers as the insurer. So you took a really interesting historical look here for the reader going back to the government's alignment and push forward post World War II era that had the employer be more involved in affording health insurance, health coverage for their employees. And it was interesting because it was clearly not the same sophistication of knowing how health was connected to the economics of our society back then, but fast forward populations has exploded since then. And then you went into the eighties and you talked about the high trend of being self-insured, and then also there's fully insured options that became popular for a while with large employer groups.
      But it's amazing now that there's so many different group purchasing organizations and employers having more skin in the game and saying that they want to control and define their own provider network for their employees and have certain total medical cost benchmarks. It's amazing. I'm hoping it pushes the needle for more quality in terms of outcomes and really knowing the people that are being treated. From your days as University of Utah Health CEO, and even into Verily as well, you seen it from so many different perspectives. How have you seen the insurer, the payer market start to change in terms of trends align to employers taking more skin in the game? What's your perspective on that? Because you saw the evolution really unfolding in real time.

      Dr. Vivian S. L:                                    
      Well, Brian, one of the reasons why I wanted to write The Long Fix was because I felt like so much of our healthcare system today, it's so complicated, first of all. Very few people can really get their heads around it. And a lot of it is the consequence of some decisions that were made a long time ago that differentiate us actually from the rest of the world, make us very special, but also make our system very complicated. And maybe some of these decisions need to be undone a little bit.
      So as you alluded to, the reason why employers are responsible for the healthcare of half of all Americans in this country is because it was created as a perk back in the day, quite a long time ago, before my time to try to attract and retain employees, Hey, we'll offer a little healthcare. No one imagined that healthcare would take off and become a $20,000 per employee per year a deal as it is today. And no one imagined that all of these HR benefits managers running businesses from car manufacturing to pizza stores to grocery would be responsible for healthcare for goodness sake. Very few HR benefits managers I've ever met have said the reason I got into this was so I could run healthcare.
      And so it's just created this very tangled web and as a result, it's really put a damper on I think the global competitiveness of our large employers in this country. How can you compete when you have this enormous economic burden? And then at the same time, we just don't have, since we've decided to make healthcare mostly a privatized, mostly a capitalist driven economy, which I don't think serves it well. As a result, we have a very fragmented approach with all these employers trying to step it up, trying to lock arms and say, Hey, we're going to drive for quality. Hey, we're going to do. But so far in the last two or three decades, it's not really working. The costs just still keep going up, and that's putting a burden on everybody.
      So I think it may be time for us to rethink how this model really works and maybe start to say who would be better? How would it be better to have governance of healthcare across our working population? We might be at that tipping point, if not now, pretty soon.

      Brian Urban:                                           
      Yeah, it feels like we're at a breaking point in a lot of ways. And things have gone on notice for a long time. Health plans have so many different boots on the ground in term of lobbyists in DC literally writing in the laws. And then to what you're saying too, I have many good friends that have had a great career as brokers and also HR benefit managers, and it's a rate game. And it's no longer about people and maybe even access. It's purely about rates and what can be afforded in just purely a transactional business model, which is not what healthcare was ever intended to be.
      So where you were going with maybe it's time now to rethink what we've done, and you leave the book with three guiding principles that is your advisement to The Long Fix that you were alluding to throughout the book in various experiences and evidence that you pulled for the reader. And it's amazing because it's now our opportunity to redesign things and to know there are lots of failures that we can recover from. And you talk about your three principles that the problem is a bipartisan solution. So the problem in healthcare is there, but there's a bipartisan solution. It's possible for both sides of the aisle to work together because of the economics at hand.
      Then you talk about paying for results on action, so going from a volume to a value or pay for performance, everything you can think of in terms of paraphrasing what we need to go toward, which is more controlling healthcare spend at a population, making healthcare more personalized, controlling costs and value-based world. And then you comment on making health a strategic comparative here for us, and I think it's so amazing.
                                                             Can you walk us through in your words, these three principles and maybe what's the most important one for I think the US healthcare ecosystem to think about today? Regardless of your perspective, tech, government policy, plans, anything in between. I'm curious of what's the highlight of those three that you would emphasize the most?

      Dr. Vivian S. L:                                    
      Yeah, so part of the reason why the book isn't called the Quick Fix and is instead The Long Fix is it is so complicated. And when an industry is one fifth of the US economy, any significant change is going to be facing quite a lot of resistance just because it upends or has the potential to upend and disrupt so many people's lives, which of course we don't want to do. So when we think about the overarching principles of what we need to do do around The Long Fix, the idea that health is a strategic imperative for the country is really tied to how do we think about governance and healthcare? Do we run it? Medicare and Medicaid are really just insurance payment programs. And they do have some influence on policy obviously, but we don't really have at the national, or even we have more really at the state level, departments of health where people use the social data. They might, for example, in North Carolina, she had purview over education as well as transportation and health so that we could have this more integrated strategic approach around health.
      Now at the state level, it's really just focused on Medicaid patients, but how could we think about that applied to the broader population? Is there a strong enough infrastructure there that could support people outside of the Medicaid program, for example? Would that be possible?
      But thinking about it as a strategic imperative, the reason I talk about that is because I looked at how the military looks at health. I looked at the military medical system and just how vitally central to the whole military strategy good health is and shouldn't that apply to the rest of our country, to the civilian side? So thinking about how we do that overall I think is really important.
      The second piece is around paying for value. I think we are trying to move more towards value-based care, but we don't really know how to do it. So we've been talking about it quite a long time. One of my favorite stories in the book is about how at the University of Utah, we really worked on figuring out our costs, really understanding our data about patients in terms of the quality and outcomes, but also figuring out per patient what it cost us, not what we were going to bill our claim, but what it actually cost us to care for patients. And that was the first step into trying to figure out how we could reduce those costs. An example I provided was just the artificial hips that we were using or artificial joints. There was a threefold difference in cost, and we'd never seen that before. So unless you give us some insights into how much things cost within our systems and then give us an incentive structure that enables us to actually lower those costs, at the front lines where you really have the most opportunity to move the dial, we don't have it.
      So if we're going to move down the value path, we need to do things like build back to what we talked about before, Brian, build that data infrastructure, include the social determinant factors that we talked about and include the costs of care and make it really transparent and visible to the people who are caring for patients and rethink the value programs that we have right now in the country, which I'd say are working but could be supercharged a little bit, if we could leverage that big data.
      And then of course the bipartisan issue, red, blue, purple, whatever country, we all need better health. The rising healthcare costs are breaking everybody's bank, not just one side or the other. And so we have to come together to really solve this problem. And I hope that now employers who are getting fed up with the responsibilities can band together and actually drive some of that change. I think it has to come from that group, and I think that's going to be really important. And maybe I'll just finish with a note about the future.

      Brian Urban:                                           
      Yeah, please. [inaudible 00:27:32].

      Dr. Vivian S. L:                                    
      I'm actually working on the next book, so plant the seed on the next book. Shall I?

      Brian Urban:                                           
      I knew it. I knew another one was coming. Okay, take us there. Take us there, Dr. Lee.

      Dr. Vivian S. L:                                    
      Yeah, so I think that there's just an enormous opportunity in taking some lessons from big tech, particularly now with the advances in data, in AI, and even generative AI. I've been actually doing quite a few lectures about this topic, so it's really top of mind for me now. Not only about the data and the AI, but also from tech. Some of the lessons that I learned when I was working in the alphabet landscape was about really thinking about user-centered design, about behavioral psychology, about engaging people where they are in terms of what their needs are and being able to do that at scale. So leveraging some of those capabilities, plus making the most of our data to create a really learning health system. What are some of those lessons from tech that we can apply to healthcare, to supercharge and accelerate the progress that we need?

      Brian Urban:                                           
      I love that.

      Dr. Vivian S. L:                                    
      So stay tuned.

      Brian Urban:                                           
      [inaudible 00:28:40] might be a better way to say it. If that's not part of your title in the next book, I would be very surprised. Super charging healthcare through tech acceleration, something along those terms.
      Dr. Lee, so thankful to have you on our little show here today. You are a body of insights. Your experience in industry across tech, healthcare, delivery, and your academic prowess is just phenomenal. I am just in love with The Long Fix and I can't wait for whatever else comes out next. And we're happy to support you along the way. So again, thank you so much, Dr. Vivian Lee, author of The Long Fix. Thank you for being on our show today.

      Dr. Vivian S. L:                                    
      Thank you so much, Brian.

      Brian Urban:                                           
      And for more exciting insights and excerpts, please visit us at

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