Policy in Plainer English

Bonus Intro: Designing Better Health Care Systems

November 02, 2021 Season 4 Episode 2
Policy in Plainer English
Bonus Intro: Designing Better Health Care Systems
Show Notes Transcript

With some commentator's license, this episode uses a presentation by Dr. Shantanu Nundy to set the stage for a new season of discussing food and health care. It reviews key concepts from previous podcast seasons and considers changes to the systems for primary care that we might see in the near future.   

Thank you to the Northeast Telehealth Resource Center and Dr. Nundy for permission to use this audio, which is taken from the closing presentation at the 7th Annual NETRC conference. Commentary added by the Policy in Plainer English podcast is our own and does not necessarily reflect the opinions of the original presenter. 

Links referenced in this episode:

LABUN: Welcome to the Policy in Plainer English podcast, I’m your host Helen Labun.

Today we’re bringing you. . . part two of the introduction to Season Four? A prologue to Season Four? A bridge to the chorus that is Season Four?


I don’t know. The point is that having a podcast where episodes build from each other was a lot easier when I only had a half dozen episodes, not almost fifty, so we’re taking some time to summarize before diving into the next season. 


If you missed the previous recap, the important point as it relates to this episode is that when we talk about food access and health care, it sometimes helps to make a distinction between a public health goal of generally healthy diets for everyone and an individual health goal of working with patients to integrate food into treatment of their specific condition. In practice we want these two goals to be part of a holistic health care system, but it’s useful to know which part you’re focusing on in a given moment. In this episode the focus begins with the whole system, then looks at individual treatment. 


To get there, we’ll be pulling in ideas from Season Two: Telehealth. Appropriately for that theme, this episode will be made up mostly of clips from the closing session of the Northeast Telehealth Resource Center’s annual conference featuring Dr. Shantanu Nundy. Thank you to both NETRC and Dr. Nundy for their permission to use these segments! 


And I’ll let Reid Plimpton from NETRC introduce our shared guest speaker. This audio was recorded from a larger conference hall, so please forgive imperfect sound quality. 



PLIMPTON: Doctor Nundy is a primary care physician, a technologist and a business leader. He serves as the chief medical officer at Accolade, which delivers personalized population health services to millions of American working American families. In addition to that, he's a primary care provider in the greater DC area. Doctor Nundy was also a senior health specialist at the World Bank Group in its health, nutrition and population, global practice where he advised countries across Africa, Asia and South America on health system, innovation and technology, his work has been recognized by the MacArthur Foundation and featured in the Wall Street Journal, the Washington Post, the Harvard Business Review, the Atlantic and many, many more. He's most recently the author of care after COVID, and that is sort of when I came across Shantanu’s brilliant mind.  I'm very excited to have you guys all listen to him and with that I'm going to stop talking and turn it on over. 


It's all you Shantanu.


NUNDY: Thank you.



LABUN: Well, it’s not quite all his because the first portion of the talk was excellent for a conference, but heavy on visuals, so to make the podcast conversation I’ll also be doing some narration to summarize.   

The theme of this talk is health care after COVID. One of the key elements that Dr. Nundy considers is what we’ve learned about the implications of a U.S. health care system where we have fixed assumptions about where patients receive medical care. The assumptions we make about patients coming into a medical facility as the default option aren’t mirrored elsewhere in the world, and you’ll hear him reference the example of Ashanti, a community health worker in Mozambique who made house visits and uses a phone app to connect with the larger health system, including data like supply chain information for medications, that adapted well when there was a natural disaster that disrupted systems in her country.  

NUNDY: A lot of people talked about COVID as an anomaly. It's like wow. Look how the health system couldn't figure this out. But I think as we've gone through the pandemic, it's actually much more like a magnifying glass, right? These are long standing failures of the system that this has just magnified, right?


The health system’s been inequitable.


It's been unaffordable.


It's been inaccessible, and this has just magnified those challenges for everybody.


And part of it is structural. So, for example, you know when we go back to that story of Ashanti, part of what enabled her to be so resilient was well, even if her, even if the local clinic or hospitals flooded, guess what? Because she's going household to household. It's not that every single household flooded, right?  She's able to maintain her care because care is happening not just in one place. It's happening in many places.


It's like putting your eggs in, you know, many baskets, versus putting your eggs in one basket. It also realized that the people. . . by putting all of our medical care in the hands of clinics and physicians in fixed places like clinics, what that means is that if people can't access the clinic, they also can't access testing if people can't access the clinic, they can't access vaccinations. The fact that we rely on the clinic to do everything creates a real break point for our system. There's a huge lack of mental health resource primary care resources, another big one.


I think a lot about this. I don't know if this happened in your clinics, but at one point in my clinic when we started getting a handle on COVID and case came down, the scariest thing was my clinic was empty.


What happened was COVID cases went down, but people weren't coming back for their primary care and chronic care, and that's in part because our systems are reactive. We wait for people to show up and then we take good care of them. We don't have systems to proactively bring them into care and that was really magnified, at least for me, in that moment when I walked into clinic and saw an empty schedule.


And as we've talked about a lot as a country, systemic racism, mistrust, public health systems, these are all things that complicate the situation.



LABUN: The chronic conditions referenced here connect both to the podcast season theme of food and health, and to the national policy conversation about why our health care system can’t go back to business as usual. Prior to COVID-19, you may have heard of the 3-4-50 campaign, which draws focus to three behaviors – poor diet, lack of physical activity, and tobacco use – that increase risk for 4 diseases that account for more than 50 percent of deaths in Vermont. One of those, Type 2 Diabetes, will be the focus of the example we’re about to hear from Dr. Nundy. The Centers for Disease Control and Prevention, CDC, found that diet-related health conditions tripled the risk of COVID-19 hospitalization and separate study published in the Journal of the American Heart Association found that 63.5% of COVID-19 hospitalizations could be attributed to the impact of comorbidities of diabetes, obesity, hypertension, or heart failure. These diet-related illnesses are not evenly distributed in our population, they are part of a set of social risk factors. A health and health care context that led to poor outcomes prior to a pandemic led to a concentrated disaster when COVID arrived. 


So, we’ve got a major disruption the form of a pandemic, and specifically a disruption to location-bound health care and all the assumptions and limitations that went with that. Here our speaker goes through different pieces of the system and ways this disruption caused a change in expectations around how health care should work. 


NUNDY: To me, the bigger change is the sort of cultural change that's happened. Physicians, providers, we now trust care that's outside of a clinic. I know for myself, I actually think that for mental health, virtual care is better than in person care in my experience - and I think that's really important for patients.


I know as a patient I never had a virtual visit myself. I got a little girl. Who when she goes to the doctor's office she's super shy and always hides behind us. On virtual, when she's in her own home and she's on video with her doctor, she’s a chatty Cathy and she's able to interact with her doctor in ways that she doesn't when she's in a sterile clinic environment. 


Health systems are changing as well.


We’ve been trying to push the move towards value based care, but health systems are seeing how one of the many problems with fee for service. One of them is the fact that it makes their revenues much more susceptible  to things like climate change or to pandemics.


So the point is, there's been a lot of shifts that I think will have impact regardless of what happens at the superficial level. With policy this will have created a tidal wave of opportunity over the next several years, if not decades. 



LABUN: A critical piece that was mentioned briefly here is payment systems and the feedback loop they create with delivery systems, in particular the idea of fee for service payments versus alternative models that focus on outcomes. We went into this in some detail on our episode about audio-only telehealth and also mentioned it in our lifestyle medicine episode. I’ll link both of those in the show notes at PlainerEnglish.org. An important high level takeaway is that in health care policy when someone asks ‘how will we pay for’ something – that isn’t just another way of saying where will the money come from, it literally means how – what structure should we use?  


Okay, we’ve reached the moment when the charts and done and we’ve got to the story at the heart of Dr Nundy’s presentation. You’ll hear one reference to a picture of his mother where you’ll have to use your imagination and trust that she looks lovely dressed in green and gold.    


NUNDY: So what does this mean? On one end, COVID showed how broken the health system is, it magnified that. On the other, we saw – through necessity, we saw – changes and we saw deep cultural changes that are underneath. 


And do if you put those two things together, the fact that we all understand the system needs to change and the fact that we've actually started to create these new care models, I think that there's this opportunity for this to be a catalytic moment for health care, and we need to have a clear view of where that needs to go, so I'm going to share a personal story.


I actually became a doctor largely because of my mom. My mom developed Type 2 diabetes when I was in middle school and and she's had it for 25 years and she's been on insulin for 10 years and hardly a day, she's actually had her diabetes control. Much to my chagrin, as not only a son, but a doctor that I can't get my mom's own diabetes control. But what happened during the pandemic is as she kept hearing about how people with COVID and diabetes are at higher risk, she said:  “Enough's enough.” 


So, she went online. She found an online program where she was given a connected weighing scale and a connected glucometer and ketone machine. She was given a 24/7 health coach, so someone who can work with her on under her nutrition. She was given a virtual Doctor Who she actually saw as often as twice a week in the early weeks of the program, and she was connected really importantly to peer. My mom was from India. My mom has an Indian vegetarian diet. She was connected to someone who had an Indian vegetarian diet who's been successfully on the program longer than her.


The result of all that was, 25 years of Type 2 diabete, 10 years on insulin --- and, for the physicians out there, 25 units of insulin -- and within three weeks my mom went to zero units of insulin. She got off of insulin completely and that was 15 months ago. My mom hasn't taken a single shot at insulin in 15 months and that's my mom recently. . . and that's the power of where we can go, right?


My mom’s diabetes is reversed, her life trajectory has changed, and it's important to understand that it wasn't technology that did it, but it was a very, very different kind of health care, right?


So what was it?


Well, the first is this. The idea that that health care needs to be distributed. We need to meet people where they are literally and where they trust. Right now, care starts the moment you walk into a clinic or a hospital. We need to have care start at home. So, for my mom, that meant the ability to receive coaching and care from her own home, much more frequently than you could otherwise.


The second is it has to be digitally enabled. Health care is about care, it’s bouat people, it’s about relationships, about trust. But we can use technology to enable that, right?


So, often, when my mom would have a visit, they'd say, well, you know, do these 10 things and we'll see you back in three months. And then of course, three months later, she'd come back and she wouldn't have done all those things in part because she had barriers. But the digital enablement that she had in this new program?  What they were able to do is they actually changed her medication 10 times in the first two weeks of the program. That's how she was able to get off of insulin in three weeks. That kind of connectivity was transformative for her.


And finally, it has to be decentralized. We have to put more resources in the hands of doctors and patients, and I'm going to give an example of what I mean by that in just a minute.


So first is this idea of distributed, so you know again, as you guys are going back to your day jobs on Monday I want you to think about distributed and the reason I do is because when you say “virtual” or “home-based”, I think it does us a disservice. First of all, we know that not everyone is online and so when we say we want to meet people where they are. If they're not online, that's not where we should meet them. We should meet them where they are - whether that's online, in church, at their home. So’ “distributed” to me is a much more inclusive way to think about this.


The second reason why distributes is so important is because you can't do everything online and you can't do everything at home. Distributed connotates that it should be connected, as you maybe start care at home or online, but then you might need to get a lab test or you might need to pick up a medication. If we have to think about the whole journey as connected, otherwise we're going to lose people, and we're going to risk fragmenting care more. And distributed is key from an equity perspective. I know that's so important to all of us here. 


Too often our quality improvement or innovation efforts start in clinic.  Why is that bad? Well, the challenge is like let's say we want to improve colon cancer screening and we say, OK, we're going to have our medical assistant recommend it and we're going to maybe make a flag in the EMR. Well, guess what? That's only going to help people that come to clinic. But the biggest problem is people who aren't coming to clinic. The 20 to 40% of people who don't have a doctor, don't come to clinic. So , our innovation, even though it's well intended, actually will not improve health equity and actually will worsen it. And so we have to get out of our clinics.


If you think about the vaccine rollout, if we only had the vaccine in clinics, we would be way farther behind than we are, but because we put it in football stadiums and churches and at the bar for a free beer, we are able to get many more people mobilized than we would otherwise. And that's a really important muscle that we need to keep building on.


And digitally enables. So again, this is about relationships about trust, right when I text message my wife, it's not because I'm trying to replace her with the robot, right? I'm texting her because there's a more efficient way for us to be in touch more through the day while she's busy being a cancer doctor and I'm busy doing what I'm doing. We can stay in touch. And that's the same idea. We need data and technology to strengthen relationships. And it was that kind of connectivity and to different types of people --  having that peer across the country was really really important to my mom because he was able to translate the diet that she had to be on into the recipes that she actually could make because of the fact that we come from India and we eat an Indian vegetarian diet.


And finally, it's decentralized. I want to explain this one, cause this one is a little bit less clear to understand. But, if I describe a story, it’s usually helpful.


So a few years ago I had a patient who was in and out of the hospital with heart failure, you know, and after one of these hospitalizations, she came to clinic and I sat her down. I said, you know, remember if your weigh its up by a couple pounds give me a call, we might increase our medicines. And I walked out. Bust on that day I decided to walk back in, and I say, so you have a weighing scale?



And she looked at the ground and she kind of was very embarrassed to say that she didn't have one because she couldn't afford it and I ran around my clinic . . . I'm sure all of us have that experience of running around clinic trying to find something. We didn’t have and I just gave her $20 in my pocket and she bought a weighing scale and literally never got hospitalized again.


And the reason why that's an important story -- All of us have that story, by the way, that’s not a unique story, we all have that story -- but the reason why it's so important is because of who said what this patient needed.  It was the doctor and the patient. And while the move to value based care is really welcome, the big problem is it takes resources from a health insurance company administrator and it gives those resources to a health system administrator, neither of whom are sitting in front of the patient and understand what that patient needs.  And that is really core to this idea of decentralization.


The same was true for my mom. If you thought about it, she actually paid for that online service out of her own pocket. But guess what? Today she's not on insulin. She's saving the insurance company hundreds of dollars a month.


So, in a decentralized world, the insurance companies say: OK, Shantanu, you have two choices. You can either see an endocrinologist in a clinic every few months and get your insulin strips and your insulin, or you can go on this program we’ll pay for. You can decide what you want to do.


That's decentralized care. It's putting the resources in the hands of the patient and the frontline care teams to decide.



LABUN: I’m going to pause the story here to highlight a few elements of what’s been said. Don’t worry, I’ll give Dr. Nundy the final say in his own presentation – but before I do, I want to emphasize parts that will be important framing for future conversations about food and health care.    


When we build up to look at health care at a systems level, there’s a tension between flexibility to meet an individual patient’s needs and appropriate safeguards to protect quality of care and cost of care. The program for managing Type 2 diabetes that we just heard described was not reimbursed by traditional health insurance, and it took advantage of some flexibilities that have historically been hard to incorporate in payment models. This program relied on high frequency engagement. As part of facilitating this engagement, it was what we might call modality agnostic – there were connected devices, an app of some sort, maybe phone calls were used, in some multi-modality programs there would be a combination of in-person visits and virtual connections. Telehealth talks about this evolution a lot. First there was in-person care, then an option to directly replace that in-person visit with videoconferencing and the concern was making it the equivalent to the office visit. Here we’re talking about a different path of change – instead of starting with a traditional office visit model and assessing what technology produces the equivalent service, in Dr. Nundy’s examples providers are assessing what will best serve a patient’s particular goals and life situation and then matching the modality of care to that


Along with engagement and platform, a third key flexibility was in who participated - this example used the skills of both licensed clinicians, who could contribute services like making a care plan and adjusting the insulin prescription, and unlicensed peer advisors, who helped with brainstorming recipes and encouraging each other.   


Now, this example came from a telehealth conference. Let’s say we were talking about managing a chronic condition that responds to dietary change at a food and health conference instead. In that context we would likely dive into an additional complication – paying for the food itself. Say that we had a patient participating in the same program but unable to afford the food that goes along with the diet that can treat their condition. Should that food be covered for the course of the treatment, much like we might have a cost sharing reduction on pharmaceuticals? 


I’m running the food access and health care consortium so our answer is yes, we should have a way to cover food as part of a medical treatment. But that’s a tricky chicken and egg issue. If using diet successfully to manage chronic conditions requires a different way of approaching medical services, something with the flexibilities we just highlighted, then which comes first – changing how we provide the health care services or changing how we pay for food to support those services? If we change the model of service delivery before removing barriers to getting the right food then patients may not be able to adhere to the new diet; if we pay for food without changing the service model then we could be using health care dollars for something that, at the end of the day, has no clinical impact. It might look like the interventions were unsuccessful, when in fact they were simply incomplete. 


That idea of necessary but not sufficient will be a theme that comes back in the food and health care conversations. Investing in everyone having access to healthy food, investing in healthy food as part of prevention, that’s necessary – for treating individual patients who already have diet-related health conditions, it may not be sufficient. The opportunities that Dr. Nundy is describing for system-wide changes could get us closer to the whole package. Keep that in mind during the next segment where he presents recommendations. The examples used are from telehealth, but the concepts are supporting much larger goals.  


NUNDY: A few closing thoughts. The first is include these interventions, by themselves, will not automatically reduce disparities.  We have to actively plan for them right? We have to actively find out: Do people have devices? What devices are they using? Let's leverage the communication channels we're on for my clinic. I'm so glad we didn't buy some expensive software for telemedicine. We use WhatsApp. We use FaceTime. Because we know that that's where our patients were and that's what they had access to, so the same is true for us.  And so it's just important that from day one that equity is part of the way we design these systems.


The second recommendation is we have to develop design principles. You know, design is something we think about, maybe with architecture or with mobile apps, but I think one of the biggest places we fall down in health care is we don't think about the end user experience, all the steps that they have to take in their care. Then we often wonder why things don't work out, so an example I give is, a couple months ago my older daughter on a Saturday night couldn't breathe. And as parents we were scared. And I thought about it in my head. I said, well, if I go to the ER they're going to laugh at me and say, well, why are you in the ER? You don't need to be. And if I go to clinic on Monday, they're going to say: Why did you wait until Monday? You should have contacted us earlier. 


But the reality is, in that moment on a 7:00 PM on a Saturday night when two parents are scared. If they're scared looking at their child, how are they supposed to know that? How can the system start and what does their experience look like? For me, what happened is I called the clinic, and guess what I found out? They first said call 9-1-1, number two was call your insurance, number three was you can leave a voicemail and they didn’t tell us how long it would take them to get to that. And so we have to look at that every little inch of that experience, and understand what that looks like for our end users,  

for our patients and their families, and we have to think about that. We can’t just have a program – if they don’t know about it and it’s not simple for them to do, patients are going to go down the path of least resistance, which is oftentimes not necessarily where we want them to be. So we have to really design that end-to-end process. 


Last is, lead. You know, I think a lot of our clinicians are feeling like this person on the screen here, right? Not only have we dealt with this incredible amount of burnout, but on top of that, we're dealing with incredible amounts of fatigue from the pandemic. And now from the fact that the pandemic is not seeming to end. And I think that that’s something we have to be thinking about, and so the phrase I use is “frontlines first”. Everything we do has to be frontlines first, and there's a lot of components to that, but I think one of the most important ones -- and something I hope to talk about in the Q&A a little bit more -- is really how we communicate the value of what we're doing. When we wanted to move telehealth visits from 0 to 80% we didn’t say “hey, here’s this new billing code” right?  We didn't say, you know, here's this new piece of technology is going to help you. What we said was how is this going to be a lifeline for our communities? And we saw the rapidity at which people were willing to make the change. People need to understand the change, emotionally connect with it, and that's a really key part of feeling like you're part of the solution.


I know all of us are more tired than maybe we've ever been, but I've talked to a lot of physicians who have said, you know what?  I'm actually more fulfilled, I'm helping my community respond to a pandemic. This isn't about working hard, it's about it's more about the value of what they're doing and connecting to the purpose of why people went into medicine in the first place.



LABUN: There now, I’m glad that we could solve the entire health care system together. 

And, also, everyone is now up to date on key elements of the previous 47 podcast episodes before diving into Season Four unprepared. Just imagine what we might have gotten through if Dr. Nundy had been a real guest instead of being a nice guy who gave me permission to borrow whatever I wanted from his presentation – we might even be on a first name basis by now. As mentioned at the top, Dr. Nundy does have a new book out, Care After COVID, and I’ll link it in the show notes at PlainerEnglish.org.


If you want to learn more about the Northeast Telehealth Resource Center, I highly recommend their website netrc.org. Be sure to subscribe to their newsletter and take a browse through their reference library.

Next up the wait will be over for the full start to Season Four of the Policy in Plainer English podcast. We’ve got it all – from truffle hounds, to cookie dough ice cream, to the career possibilities of being a cat food taster. Remember how this episode discussed the flexibility bring in health support beyond licensed clinicians? Get ready to double down on that concept as we invite a creative cast of characters to the virtual interview studio starting with food writer Rowan Jacobsen in the next episode of the Policy in Plainer English podcast.