Rhythms of Change: A Mixtape for Health Equity

Brian Urban:
Yes, this is the Healthcare Rethink Podcast. I'm your host, Brian Urban, and today we have two chief medical officers and me. This is probably one of the coolest episodes that we've done in our little show here, and we are so excited to get deep in the initiatives that Commonwealth Care Alliance and Mass General Brigham are bringing to the market today. Who else to do that for us than the Chief Medical Officer, Dr. Nazlem Hagman of Commonwealth Care Alliance and Dr. Lindsay Jubelt the Chief Population Health Officer of Mass General Brigham, and the Chief Medical Officer of Mass General Brigham, the Health Plan. Welcome to the show.

Dr. Nazlem Hagm:
Thank you, Brian.

Dr. Lindsay Jub:
Thanks, Brian. Excited to be here.

Brian Urban:
This is going to be fun. We've gotten to know each other in different settings, but to have Commonwealth Care Alliance and MGB on the same call is going to be so, so cool. We love to start every episode off with having our audience get to know our guests a little bit more. Let's start with Dr. Hagman. Nazlem, take us through who you are before the CMO title, maybe even before practicing medicine in Dusseldorf, Germany. Tell us who you are and how you came to be in this fascinating role today.

Dr. Nazlem Hagm:
Oh, wow. Okay. How far back do you want to go, Brian?

Brian Urban:
We'll go to second grade, but just a little bit after that. Yeah, yeah.

Dr. Nazlem Hagm:
Maybe second grade is exactly the right time to start because I had rheumatoid fever as a child and that was the first time that actually I stayed in a hospital, got in contact really closely with medicine, and made up my mind that I'm going to go into the field of medicine. So when I graduated from high school, I was in the German high school in Istanbul. I went to Germany to go to medical school, and I would say that was my first experience as an immigrant, which is an important experience for me to bring back to my work here at CCA.

During that time, I went from thinking about going into immunology, becoming a researcher, to deciding to become a psychiatrist because I felt the field of psychiatry really brought out the problems that were sometimes hidden within the texture of the society, the community, and gave really a good insight. Then I immigrated with my husband in '96 to United States, and since then I have been a proud Brooklynite and did my residency here and always straddled between clinical work, working with individuals as well as looking from a systems perspective, how we can improve the system from a whole person perspective.

Brian Urban:
I love you for sharing that Nazlem, because that speaks to a common thread we do here on the show quite a bit is an experience people have with healthcare earlier in their life or a loved one, facing pain and suffering and going through a challenging healthcare system, whether in the United States or abroad, and how you later in life wanted to make a positive contribution. A beautiful story, and I love your background in psychiatry as well. I think that plays a lot into what you see on top of the system level, which we're going to get into in a little bit as well. So thank you and so excited to have you here. Dr. Jubelt, Lindsay, take us through the story here. Let's go back even before your leadership days at Mount Sinai, which is extremely impressive, all the work you did there, and of course now with Mass General Brigham, but why did you get into healthcare and how are you here in front of us today?

Dr. Lindsay Jub:
Brian, thanks so much for asking that question. Always so fun to get to tell one story, healthcare was in the family, family business. My grandpa was a child of immigrants and was the first one on that side of the family to go to college, and he had lost his sister when he was six. She was nine to pneumonia, and so he became a pediatrician and he went to small-town America because he wanted to save his sister, go somewhere where there are no pediatricians, and hung a shingle, and in the morning he would see patients in his office. In the afternoon he would see patients in their homes, and he started the first mental health clinic in the community and he was the Boy Scout troop leader way beyond when he retired and had a huge impact on the community. And during my white coat ceremony, he said to me, "Lindsay, your job as a doctor is to serve your community and you don't get to pick your community. It's all those that live around you."

That really stuck with me. And I also had a father that was a clinical investigator, physician, a neurologist, who was an awesome basic science researcher, did a lot of awesome work with MS and stem cells, and he passed away this December and I learned a lot of the scientific method from him and the excitement of studying things from a more systematic standpoint, but marrying those two together, I just thought, I want to chart my own path.

And I don't think it's being just a doctor on the ground seeing patients one-on-one only, nor do I think it's in the lab, but I think there's some way to marry these two where I can serve my community, but in kind of a more disciplined manner, the way that research brings. But I'm more of a doer than a researcher and writer, and I'm more of a people person than someone who just likes to sit alone and write papers. And so I thought, I really want to have my impact on bringing the voice of the people that my grandfather really empowered and instilled in me with the discipline of my father. And so that's how I got into wanting to bring value to the healthcare landscape that we live in. And there's just so much potential in America to improve the value that we deliver in healthcare, whether that be for employers, payers, consumers, there's a lot of opportunities. So we'll all be employed for a long time.

Brian Urban:
We will. Hopefully maybe one day we're put out of work because of all the good things we've done. There's no longer a need but probably not-

Dr. Lindsay Jub:
Or the computers and AI will do that would be great. They figure it out.

Dr. Nazlem Hagm:
I'm not quite sure about that. We are always going to need people.

Brian Urban:
I love it. I didn't even think about talking about AI, but maybe we'll jump into that. But Lindsay, thank you for sharing that on your background. Great lineage in terms of your family and obviously generationally, how that expertise has kind of been woven into your DNA perhaps in some sort of unique way or sitting on top of your DNA, but that's really exciting that you're able to live through your grandfather and your father's legacy in medicine clinical investigation and making an impact today with your work at MGB.

So fascinating to have you both on the same call. Let's shift it back to Dr. Hagman here for a second. Nazlem, tell me a little bit about social needs and health populations that you've seen at CCA. And I'm thinking about your experience even taking into your system level and your psychiatry background. You have a lot of lives across the country in Medicare Advantage, and we're seeing more people adopt Medicare Advantage plans at a clip of about 8% growth a year since 2010-ish and probably growing, and there'll be some challenges ahead in terms of beneficiaries and some premium changes in the future on different policies we have. But looking at the social needs first, what have you seen been driven out of the last few years in terms of non-clinical needs from these lives that you serve at CCA? Any insights?

Dr. Nazlem Hagm:
Yeah, I think even before we went into MAPD, right, Brian, if you look at the history of CCA, we really started actually a primary care organization taking care of the most needy and then became a dual eligible health plan, Medicare and Medicaid. And what we have observed, and I would be interested in Lindsay's impressions as well, but really tons and tons of social determinants of health needs, whether it is housing, whether it is transportation, whether it is food, especially for the older population, but also for the newer, we see a lot of social connection needs. I think the Surgeon General of the United States has written a book about how important it is to be part of a community like Lindsay pointed out, and how many of us, and many of our members actually are lacking that relationship. So at CCA in all our populations that we are currently taking care of, those are some of the things that we are really trying to pay attention.

We have a wonderful program that we call a friendship program that we started with one of our providers where we connect people who have no connections either to staff or some of other members of our provider community. So I think there is a lot to do and social determinants are really important. That being said, I think we also need to be very critical. The reason why I say that is we do know that social determinants of health really influence health outcomes, but I am always critical in terms of thinking whether healthcare and health plans are the right place for addressing social determinants of health. I do think that we are taking on that because many other structures of our society is unwilling or unable to do it, but I also do see as an organization like CCA that we have the responsibility to partner with overall our community to make this visible and push for legislature to change that.

Brian Urban:
I love how you put that, and I think what's so interesting is health plans should or should not be the forefront in addressing a lot of social determinants of health needs. And then the relation to healthcare spend utilization, right-sizing that, but it takes a village. It definitely takes a community. And I think the programs that are developed of health plans speak a lot into the next generation phase of what health plans are doing. And that leads me to asking you Lindsay about this amazing project that you lifted up in partnership with CCA. It's called the Integrated Care Management Program, the ICMP Plus Program for delivering in-home care to patients and members that do have a lot of complex care needs, but also a lot of social health needs along with that too. So tell us what the MGB team has learned and how this project has been going the last few years.

Dr. Lindsay Jub:
Yeah, I'm so glad you asked about it, Brian, and this has been such an awesome partnership with CCA. So at Mass General Brigham, we have about 130,000 Medicare members that a little bit more that we're accountable for in our ACO, and about 140,000 Medicaid members. And not all of those patients need the same degrees of care or need the same things. And about 0.5% of them are the sort of highest of needs. And our models at Mass General Brigham with our care management programs, which we call Integrated Care Management Program, ICMP, have really relied on people coming into care within the practice. And we've found that that model works really well for people that come into care, integrating care management into primary care results in better outcomes, because it's not just a nurse on a phone trying to call a patient that isn't integrated with the care team.

You're really part of it, but not all of our patients and members come into primary care. A lot of them have a lot of barriers with engaging with care, and in that case, you need to go out into the communities and meet them where they're at. And this is where our partnership with CCA has really been incredible. I think that there's a lot of ways that we all compete in the marketplace over offering great quality services and access, but there's, I think more ways that we need to think about partnership because we're all at the end of the day, really should be motivated in terms of increasing value for our communities.

And I think this is such a wonderful example of where CCA and MGB our competitors in some areas have been able to be wonderful collaborators. So the ICMP Plus program, what we did was we expanded out our ICMP program out into the community leveraging the partnership with CCA, and we have two models of it, one model where the staff of CCA are extenders of our primary care, where the care management team goes out into the community, meets with the patients in their homes, or at a Dunkin' Donuts, wherever the patient and member best thinks is best for them and engages with them.

And there are times where they're not engaging with us in primary care, and then the CCA team takes them on and serves as primary care. And so it's really fitting the model to whatever best serves the patient at hand and it's been phenomenal. We've had great results in of feedback from these patients. We've had great outcomes in terms of improving their health outcomes and lowering unnecessary hospitalizations such that it's been published in peer-review journals, and we're really proud of it. Some of the things that made it work was the true integration. So we were able to credential the CCA team into Mass General Brigham, we were able to get them access into our EMR. And so they document on the same platform that our MGB employee care managers do, and the care team, the primary care physician, and the rest of the MGB clinical care team doesn't distinguish them in any way.

They just see them as care management, don't know if it's coming from CCA or MGB, doesn't matter. They're all labeled the same. They're all documenting in the same tools and so it really enables the team to communicate and all be on the same team caring for a patient. And so that's been that leveraging technology to make it feel seamless, even if you're not within the same bricks and mortar has enabled the team to come together. And I'll say the last thing is that we participate in group meetings together. We have regular business meetings between the two organizations, but the care teams meet regularly about the patients and have care reviews. So it's really been a seamless integration and a wonderful connection for our two companies.

Brian Urban:
I love the story because as you noted, in some facets, there is a competitive overlay, but the puzzle fit in large part is helping the individuals that there's an overlay with. And I love it because you're moving the needle on what it means to be co-opitive or collaborative in it from a competitive standpoint. Because if we're not addressing the needs of individuals that we're all serving, then no one's really going to win. We're going to keep doing the same thing that we've done for decades and it won't make sense. So I love that as the basis of it.

And speaking of meeting members where they are and technology, I'm curious from the CCA side, a dual eligible life population that you serve, Dr. Hagman. Are you seeing those lives start to adopt technology in terms of remote patient monitoring, more of a matrix of apps that they're using for wellness and engagement? What's kind of the curve there in terms of health literacy and adopting new technology? Maybe anything that you're seeing today or what you're starting to see perhaps?

Dr. Nazlem Hagm:
Yeah, I mean, I think COVID has been really instrumental in moving the needle there. I think before COVID, especially in Medicaid, but also in Medicare population compared to commercial population, I do think that a lot of telehealth models were not as popular. Even apps were not as popular. But I can tell you maybe bringing in also my experience prior to CCA because I joined CCA end of 2022. But in my previous plan also, we were really surprised about the adoption, especially by the Medicare population of telehealth modality. And we were looking at CCA in the last month in terms of our... We do regular engagement of course, with our members, sending them questionnaires and doing interviews in terms of understanding their needs as well as their use. And traditionally when we looked in the history, when we sent, for example, emails, we got very little response.

And in the last review, we got more than 60% response rate, which is really high. It is not immediately relating to healthcare, but it really shows you how the society is changing in terms of embracing these models, whether it is like Lindsay was saying, staying at home, bringing care into home, making sure that we put distant monitoring right into their homes and learning and monitoring from outside, but also engaging with us through telehealth. We are seeing more and more of that, and I think we are going to see it more and maybe some AI-supported models in the future.

Brian Urban:
I can tell Dr. Hagman wants to get into AI. You've dropped it twice now.

Dr. Nazlem Hagm:
I think it is really exciting and important, but I also do think as health professionals, we really need to understand that to make sure that we are using it in the right way in an ethical way. And again, we are talking about social determinants of health. In my mind, social determinants of health and health equity goes hand in hand. And when we are talking about AI, health equity is really an important lens that we have to adopt and understand.

Brian Urban:
I have to ask with this, and maybe we share the same thinking here, this question is for you both. We have AI up front. Maybe it has a lot of administrative burden kind of work it needs to do as we're feeding and building out these large language models and it feeds over to a human output, so the human is still helping the person. Is that the maybe starting point or maybe the utopic vision or where are you thinking AI's first application is maybe around your current work today? And we could start with you Nazlem, because I know you have this on the front of your mind. So what are you thinking?

Dr. Nazlem Hagm:
Look, I think from my perspective, AI has different stages. I mean, where I see it first to be used is in predictive modeling, right? I mean, this is a use of AI and predictive modeling, and Lindsay from a population health perspective is something that we need to really use to be more proactive. And again, coming back what I said before, doing it in a way and making the model learn it in a way that is in line with what we want to accomplish for health equity is really important for me in the work that I'm doing with our analytics team at CCA.

Brian Urban:
Lindsay, I got to get your take. How is the application AI starting to maybe hit the strategy of leaders at MGB? Don't divulge anything to yet if you've got some exciting stuff, but please do if it's a first for the podcast. But curious of where you're thinking it.

Dr. Lindsay Jub:
Yeah, I think we're doing a lot of work and research into this on a research side, on our clinical side, on the administrative side. So there's so much potential here. I tend to be very bullish on it, and I think that there's areas where the risks are less that we can move more quickly, and certainly on the administrative side, but I even think on the clinical side, there's a lot of care bread and butter care that we just don't have enough providers to do. When I think about chronic disease management, so much of that is about multiple touches and it's very algorithmic. It's not like you have to discover something new. Once the diagnosis is made within a certain algorithm and parameters. You need to tweak meds. You need to understand where's the patient encountering barriers and how do you keep moving forward with getting them to adhere to a treatment plan that works for them.

We don't have enough clinicians to do that, to have enough touches to do that. And I see AI being able to jump in there very quickly, not only with the algorithms, but even some of those human touches, and beginning to be a texting buddy or a phone call buddy. The AI is getting better to be able to have these empathetic responses that can engage patients and leverage that. And then when they really run into barriers or things get escalated or they need a different algorithm, okay, then put a clinician on it with a human brain that can make that switch. But I think around a lot of this, we need, if we're going to get better health outcomes for the people in America, it's going to require a lot more engagement and behavior change and relationship building and touches, and there just aren't enough people in the world, so not enough clinicians. I think that's a great example of where it can help.

Brian Urban:
I love where you're going, Lindsay, because the way that we engage across the healthcare ecosystem, especially with vulnerable high-need populations is critical to being able to advance how healthcare is trusted, let alone how healthcare is sought and used by the lives we serve. So in thinking about engagement, I'm curious, Nazlem, can you help me understand from a dual eligible population, or maybe just we'll focus on the Medicaid side for a moment? Traditionally, how has CCA engaged with Medicaid lives that's maybe different in your experience being the last few years here at your executive role, that engagement is now maybe multiple touch points or with different modalities that weren't thought of before. Can you tell me a little bit about how some of the engagement approach has changed for Medicaid lives with CCA?

Dr. Nazlem Hagm:
I'm not a hundred percent sure that I would say the engagement itself changed, right? I mean, yes, clearly that we are using more technology when possible, but engagement in the end still very much for the Medicaid population that we are seeing remains a person-to-person relationship. And I think what we have seen at CCA and really what drives our model of care are two thoughts. When you look from a systems perspective, I think the two biggest barriers or problems that US health care system is facing is single point of entry and continuity of care. And that those things, coupled with how member-centric or patient-centric we are, how well we are able to listen to them, really helps you to determine whether you are going to be able to engage a member or a patient, right? And I think overall, our care management model has been really looking in terms of how are we making it easy for our members to have one point of entry into the system.

And we are the missing link when it comes to the continuity of care. And coming back maybe to the program that Lindsay very astutely described the ICMP plus program. I would say that is really a good product of how we are thinking about it. We see ourselves as imbibed into our community, and as such, we want to be this missing link when it comes to our providers. And in my experience as a psychiatrist, I have seen it again and again with severely mentally ill, which in Medicaid population are often the most difficult to engage. And if you make their life easier, if you help them to negotiate the healthcare system as you are listening, really trying to find out what their needs are, you have a high engagement rate. And once you engage someone, actually they will then do what is necessary to reach the good health outcomes.

Brian Urban:
I love that very clear message, make it simple, one point of entry, one voice that is probably the dream and the sweet spot of not only having a strong trust as a foundation in engagement models but also sustaining that long-term. And I think the investments that you're talking about in terms of community health, they're on so many fronts, Nazlem. So thank you so much for going deeper into that route. And it's a perfect setup actually, because I tell you what Mass General Brigham is bringing some serious investment into community health. So Lindsay doing a little bit of research, I looked back since the fall of 2020, MGB has been really bringing out these huge series of investments and thoughtfulness into community health strategy. One of them called the United Against Racism campaign, and that's being led by Dr. Elsie Taveras, the chief community health officer there.

And it's amazing because you're addressing societal fissures, a lot of societal challenges that have been in generations before us with this work, but also a huge $50 million pledge to address community health needs, maternal health, housing, mobile units, increasing screenings. It's like everything this investment is hitting. So I'm curious, in advancing health equity Lindsay, how are you starting to see these initiatives unfold in the communities that you're serving and any insights you can share in terms of partnerships you've developed along the way and some of the impact being made?

Dr. Lindsay Jub:
Yeah, Brian, thanks. This is a great question and I want to tie it back to what Nazlem was talking about before. So I think Nazlem's point earlier about what is the role of health plans and health providers in solving some of the inequities in our society. What do we take on versus what do we not? And I think one of the things that we can take on is payers and providers, is measuring the differences, the outcomes for different groups of patients, the outcomes we really see in healthcare. And we need to be able to describe those, describe who they're affecting differently. And one of the areas that we're making big investments in is making sure that we're tracking the demographics of the people that we serve in their own words. And so not assuming someone is a certain race or ethnicity based on what the provider or plan enrollment person prescribes them to be, but rather that it's in their own words.

And so we're spending a lot of money sending out surveys to have patient determined ways of identifying themselves so that we can appropriately categorize different groups of people and understand where the equity gaps are. So that's huge thing that I think the healthcare plans and providers can do. And I think then it begs the question of how much can we solve? And I think adding onto that, some of the areas that we're making investments in, we know that in cardiovascular care is the number one cause of death of Black and brown people in Massachusetts. And so we're making big investments there, and that's a great area, which is bread and butter to healthcare. But we've lost sight of that focusing on maybe more higher complex care and lost sight of bread and butter care. And so recently we just went through leveraging technology to close the gap between Black and Hispanic patients and white patients on hypertension control.

Went through an eight-week sprint and what we did there, we had started with community health workers thinking that the barriers are going to be, oh, they have trouble getting into care. They need to engage with someone that's similar to them. That's how we're going to fix this. And we'd get them into care and the provider would check their blood pressure, maybe they prescribe something and then they'd get lost to follow up. And weeks would go by and nothing would happen. And so this is where like we need a different solution. And so we leverage technology plus some patient incentives and some pharmacists to go after this quickly. And within eight weeks for about 200 patients that were out of control that were Black and Hispanic, we were able to close the gap to the white patients and get their blood pressures under control. And it meant frequent touches, fast data, and we engaged them through multimodalities.

So we used phone calls, text messaging, email, and secure messages. And the modalities that were most effective was text messaging. The phone calls were sometimes needed in order to have conversations around, we need you to... We're considering a new medication, or let's talk about how to use it. We teed those up with the text message first, are you available at this time so that the phone call would be successful? And so we've found through trial and error that this combination of quick being on top of a group of patients, rapid follow-up, using text messages, using algorithms with a set of pharmacists behind it that don't need to wait for a primary care doctor to wait for them to have an appointment to prescribe that can have the authority to prescribe, got this group of patients with their blood pressure under control. We were really excited to see that result in the closing of that equity gap.

Brian Urban:
I love to hear the strategy unfolding because it's so thoughtful at fine level of tactics that you walked us through there, Lindsay. So I guess the exciting part about this is the continued learnings that you'll derive and feeding that into more program development and being able to share that outwardly through not only your health plan side, but your healthcare side, and hopefully the rest of your partnerships in the healthcare ecosystem abroad. So just exciting to hear that. And with that, I want to get us to a big finish here. I want to get around our little mini-round table. Nazlem I want to start with you, what's next for addressing the needs of underserved populations? Can you tease us with any projects or big initiatives that are coming out in '24 or beyond at CCA?

Dr. Nazlem Hagm:
Yeah, I do think that, so without giving too much, we are taking all our experiences over the years, right? From a care management, but also community health workers perspective. And I do think that we are going to move more and more to a much more specialized model than we have currently, right? Continuing this idea, single point of entry, but really supporting from the background, much more evidence-based and specialized model that is going to drive outcomes and how we are going to be measuring those outcomes.

Brian Urban:
That is exciting to be able to know that you're putting together a lot of your learnings there. And I'm trying to read between the lines, and it seems like you have some really exciting stuff. Maybe a follow-up episode coming on with yourself, Dr. Hagman. So excited to hear all the good work CCA is coming out with in this year and beyond. Lindsay, round it out for us here. We just talked about big investments, big work that you're doing on the health plan and the care side. Anything that you can tease us with in terms of big stuff that you're coming out with this year that might hit the news or next year projects in development, or even what your biggest contributions might turn into from the recent investments that you started to make at MGB?

Dr. Lindsay Jub:
Yeah. Well, we have a lot of exciting things coming down the pipe, but Brian, one of the challenges of our delivery system, and I think this is true for many provider groups across the country, is just there's a lot of demand and not enough capacity. And so we're starting to think about how do we move care out of our hospitals, out of our offices into the home? So we've got the largest home hospital program in the country. We're starting to get creative in other ways about moving care into the communities. And as you said with your prior question, partnerships, this is going to be key.

And so I think moving out of a, we can do it all within the Mass General Brigham ecosystem to say, "Hey, we're going to need a lot of different types of partnerships." Everything from care delivery to engaging in the communities, to thinking about how do we do the plan side of healthcare? And I think there's a lot of regional health plans that are looking to connect with their communities in deeper ways, both their community service agencies and their provider groups. And so thinking about some of those needs I think are really scalable in terms of what we can bring out to the market.

Brian Urban:
I love that it has to be partnership-based, not thinking just now, but in the future, and how can we sustain it, scale it over time, so it's not just a one-off, it's not just stuck in a place in time. I am so excited to see what continues to come out of your brains as leaders, but also your teams and all of the lives that you're serving and making good impacts that I think all of us across the ecosystem could take lessons and learnings from. So Chief Medical Officer of Commonwealth Care Alliance, Dr. Nazlem Hagman, thank you so much for joining. And Dr. Lindsay Jubelt, the Chief Medical Officer for Mass General Brigham, the Health Plan, and the Chief Population Health Officer of Mass General Brigham, the system. Thank you so much for joining our show. I loved the conversation we had here today.

Dr. Nazlem Hagm:
Thank you, Brian. It was a pleasure. Thank you, Lindsay.

Dr. Lindsay Jub:
so much, Brian. Thank you so much, Nazlem. It was a lot of fun.

Dr. Nazlem Hagm:
Same-

Brian Urban:
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