Decoding Healthcare

Episode 4: Innovative chronic care

  | November 15, 2017

When it comes to caring for the most vulnerable populations, the social determinants of health can be varied, broad, and unexpected. Sachin Jain, M.D., the CEO of CareMore, talks about a new initiative to treat loneliness in senior citizens — and the lessons he learned from helping to develop the Affordable Care Act.

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TRANSCRIPT

 

KEVIN BAN: This is “Decoding Healthcare.” I’m Kevin Ban.

JOANNA WEISS: And I’m Joanna Weiss. And today we are going to talk about relationships.

KEVIN: Whoa. Hold it right there. Are we changing the flavor of this podcast? Are we the new “Dear Sugars”?

JOANNA: You never know what this podcast will become, but today we are talking about relationships in the context of healthcare and health outcomes, and we’re talking to somebody who you have a relationship with.

KEVIN: That’s right. Sachin Jain and I have been friends and colleagues now for several years. We met here in Boston and have worked together on several different projects.

JOANNA: So you may know the fun fact about him which is that one of his hobbies is being a matchmaker.

SACHIN JAIN: I have set up five marriages.

JOANNA: That is a pretty good track record.

KEVIN: It really speaks to Malcolm Gladwell’s concept in the tipping point of the connector. Sachin is very good at building relationships. He is also very good at connecting the dots.

JOANNA: And he has followed some of those relationships to interesting places. He went with a couple of college professors to D.C. to work at CMS at the time the Affordable Care Act was being developed.

KEVIN: And now he is the CEO and president at CareMore and really pushing innovation.

JOANNA: And one of their newest innovations really gets to the heart of relationships. They just appointed a chief togetherness officer for patients and they’re starting an initiative to fight loneliness.

KEVIN: I have to admit, this one, Joanna, really took me by surprise. We’ve had a lot of conversations here at “Decoding Healthcare” with healthcare executives. Never did anyone mention loneliness as a disease.

JOANNA: And Sachin does, so let’s get right into the conversation.

SACHIN: Loneliness is one of the biggest problems as seniors age. This is a problem that I think has accelerated in the last 30 or 40 years. In the ’50s and ’60s you had multigenerational families, you had people who continued to live in the communities in which they grew up. Modern life doesn’t really enable that anymore, and many people are living longer but also more alone. And so we believe that this is a real barrier to people achieving good health outcomes. So, we have been very focused on trying to, number one, provide targeted outreach to the people who are loneliest within our patient base, and then, number two, connect them to programs and resources that we have available to help them connect with other people. And so each one of our care centers, as an example, has a senior-focused gym that has a significant amount of social programming, classes like Cane Fu and Senior Zumba—

KEVIN: Hold on a second. “Cane Fu,” I love that. So they’re exercising together, but help me understand how that impacts relationships.

SACHIN: We actually have a number of marriages that have come out of people meeting each other in these classes, and so we’ve got a lot of senior-focused programs that are really aimed to bring them together, and then we also do things like provide weekly telephonic outreach to some of our loneliest members, which gives us the opportunity to really connect with them, make sure they’re taking their medicines, make sure they’re scheduled for their medical appointments if they need them, and just being a regular touchpoint, somebody who checks in on them to make sure they’re okay.

KEVIN: One single phone call weekly, I mean, does that really change patient behavior?

SACHIN: It sounds like a small thing, a weekly phone call 10, 15 minutes in length, but if you’re somebody who doesn’t really have anyone in your life, if you’re somebody whose kids live far away, whose spouse has passed away, who is mobility-impaired and can’t get out into the community and talk to other people, go to the local diner, that one phone call is incredibly meaningful.

KEVIN: We’ve had a lot of conversations here at “Decoding Healthcare” with different people around population health and their strategies. This is the first time that anyone has talked to us specifically about loneliness and how it impacts care. So I just want to stop you there and say where did this concept come from?

SACHIN: It actually comes from my years in college when I was simultaneously taking courses by two great professors. I was an undergraduate at Harvard, and I was lucky to take a juniors seminar with a guy named Robert Putnam. He is famous for a book called Bowling Alone, which is about the observed decline in social capital in American society from the 1960s to the early 2000s. [At] roughly the same time I was taking a junior elective with Don Berwick, who you know is a major quality scholar. At the time I had no idea who he was. Candidly, I had just followed a woman into the class, Kevin.

KEVIN: Thank you for your honesty.

SACHIN: But he talked about the importance of group visits and some of the innovations that were taking place there where diabetics were. At the time, there were a number of groups that were experimenting with diabetics teaching other diabetics. And I thought, “Wow, this concept of social capital is very powerful and is really untapped within healthcare.”

KEVIN: How do you make that work for a Medicare population?

SACHIN: You realize how socially isolated many seniors are. And I was actually fortunate to participate in the Aspen Health Innovators [Fellowship]. It was one of my co-fellows, a woman named Kathy Kenworthy, who said, “It seems to me that your passion in life is really bringing people together.” And this is after I told her that I was a matchmaker. She said, “What could you do to bring the patients in your system together?” And it all kind of snapped together then, kind of this thread between Putnam, Berwick, and the opportunities to really use the healthcare system as a vehicle to actually bring people together to proactively improve their health.

KEVIN: The first time you sat down in a meeting, tell me about that moment where you said, “You know what, I’m really interested in loneliness and how we can work against it and how that is going to impact healthcare for our patients.” How was that received?

SACHIN: You know, it’s funny, we have introduced a number of new innovations to CareMore in the last couple of years. We’re integrating dental care and heart disease management at the chairside, we have introduced our own diabetes prevention program. This is the idea that most captured the whole company, and it’s because any of us who have seniors in our lives recognize that this is a problem, and it’s not a subtle problem. It’s a problem that is around us everywhere that most of us feel powerless to [remedy]. And one of the things that we have started to say is that loneliness is actually a treatable disease.

KEVIN: A treatable disease, what do you mean by that?

SACHIN: I don’t mean that it’s a medical condition that is worthy of chapters in Harrison’s Principles of Internal Medicine. By calling it a disease, and a treatable disease, we begin to think about actually solving it. As physicians we tend to not ask patients about problems that we can’t solve for them. That is at least how I felt in taking care of patients. … I’m not going to ask you about something that I can’t help you with, but if I actually have a prescription that I can give you for a problem, there is a high sense of efficacy and a feeling that I can actually do something for you.

KEVIN: Sachin, I know you to be someone who is deeply driven by metrics, and you’re always trying to figure out what works and what doesn’t work. So as you’re thinking about this new initiative, how exactly are you thinking about measuring it, and then what does success look like?

SACHIN: These are early days for us. The early data—just looking at what patients are saying about the outreach, and are they happy to receive the phone calls, are they happy to be connected to these programs—has been overwhelmingly positive. And I think in the drive towards quality metrics and HEDIS measures, we forget sometimes that making someone happy is good enough, it really is. And I don’t think we think about that enough, the importance of the patient experience, consumer experience. When we do we talk about it in terms of survey results, we don’t talk about it in terms of just the pure joy that we’re able to give someone.

From a pure joy perspective, I think we’re doing great.

KEVIN: I agree 100 percent, but do you think you’re actually impacting cost at all?

SACHIN: I do think that we’re going to be able to influence medical costs over the long run. If we can get people to take better care of their chronic diseases, get some of their underlying behavioral health issues like depression under better control, and get them social and connected to the community, that we’re going to be able to lower overall healthcare costs, and so we are looking at that data for some of our members who are participating in these programs.

JOANNA: Kevin, that is such an interesting concept, thinking about joy as a function of the role of doctors.

KEVIN: That is not the everyday of a physician, right, but it ought to be. People go into medicine because they want to impact lives, and the end result being joy is a really cool concept and not one that we talk about.

JOANNA: Right, and if your medical practice is creating marriages clearly you’re impacting people’s overall well-being.

KEVIN: All of a sudden you’re saying, “Let’s think about this person and let’s think about the relationships they have in their lives, because those are the things that are going to make them want to take your medications [and] make sure they see your doctor.” When you’re in a relationship and you really care about being healthy all of a sudden those things matter.

JOANNA: Or someone is on you saying, “Hey, honey, did you take your pills this morning?” The other thing that I like about CareMore is the way the organization uses language. He had mentioned “Cane Fu.” I looked it up. It’s exactly what it sounds like. It’s a class for seniors. You practice balance and aerobics and you use your cane as a martial arts weapon.

KEVIN: I’ve got to pick up that one. It was awesome. The truth is that language matters. We’re seeing with all of these changes there is a language that is following, whether it’s value-based care or population health management itself.

JOANNA: But Sachin, as much as he buys into those concepts, is not always happy with the language that we have developed. Let’s listen.

KEVIN: Value-based care, it’s a really big term, population health management, used all over the place. Just comments, thoughts on population health and value-based care?

SACHIN: I absolutely hate both terms. I think both terms have created mass confusion about the role of clinicians, and I have been really concerned, Kevin, as the language we use in the insider baseball of kind of healthcare policy and the healthcare venture world kind of makes its way into how we think about and talk about patients. Patients are not looking for value-based care; they’re looking for really good care. Patients are not looking for population-based healthcare; they’re looking for people to care for them.

KEVIN: Most physicians are doing a great job of taking care of the patients who are in their office, but the truth is they really don’t have visibility into the patients who don’t come into the office.

SACHIN: That is a mentality that has existed in pockets of American healthcare for way longer than the terms “value-based care” and “accountable care” and “population health.” Ultimately the care delivery model is shaped by the payment model. We need to move away from fee-for-service to more delegation of risk to the people who actually have the opportunity to influence care, which is the doctors who are actually delivering that care. Most of the things we’re really talking about here are really common sense. Is it better to prevent disease rather than treat it after it’s fully progressed? Absolutely, common sense. Is it better to kind of think about your patients who are showing up in your office as well as the ones who aren’t showing up in your office? You’ve got to do both.

This is about creating payment models and delivery models where the individual judgment of clinicians and common sense is really able to flourish.

KEVIN: As we talk to more and more healthcare organizations, these models, the ones that they have built out, are around fee-for-service, and they’re still largely compensated through volume. For them, the joke is, “Hey, we’re spending millions of dollars here to lose money.” So, what is your take on a large healthcare organization that previously had no risk—what would motivate them to get into this space?

SACHIN: Most healthcare organizations in America, many of them—mine is not—are nonprofit organizations and mission-based organizations. It’s really, really important for these organizations to really focus on their mission. And there are examples of great delivery systems in this country who have done that. The best example of that is Mount Sinai [Health System in New York, which] has made significant investments in population health, that has recentered what success looks like as their beds being empty, not full. And we have to—

KEVIN: Yeah, but I’m going to push back against that in a second. I’m going to guess that Mount Sinai—and I agree with you directionally they’re doing the right thing, but they are more likely to be driven by fee-for-service than they are value-based care at this point, and so if all of their beds were empty, while directionally it’s a beautiful thing, in actuality they would probably go out of business.

SACHIN: And you know what, wouldn’t going out of business be the right thing for all of us?

KEVIN: It’s true, I know.

SACHIN: And I say that only half in jest. I mean we just have a just a gross misallocation of where our healthcare dollars are going. We need to be spending more on the upstream management of these conditions than we do on the downstream management of highly and truly preventable complications. We’ll pay tens of thousands for hospitalizations to amputate someone’s leg, but we won’t spend that money to actually invest in their better management of their hypertension diabetes or hyperlipidemia. This is a travesty. It’s a travesty. It’s so unfortunate.

And I’m offended by the question—and not by you, obviously—but I’m offended by the question that as an industry we’re talking about this like everybody has to profit the same or more always, as opposed to really reflecting on the fact that there are going to be winners and losers, that there should be winners and losers, that organizations that do prevent complications of chronic disease will win and then that the ones that don’t will lose, and we need business models that enable that and support that. And we’ve had steps in the right direction in the industry writ large, but we need bigger steps and we need more courage.

KEVIN: Courage. I love that concept, but what does courage look like here?

SACHIN: A diabetes prevention program is a great, great example of that where we knew, the paper—I read that paper in my first year of medical school, 2003, I read it and I was excited to read it because I’m a son of a diabetic, and I thought, “Wow, there are modalities that we have that are like exercise, like diet, like early use of Metformin, that can forestall the progression of diabetes.” But we didn’t have payment models to support that in our country until more than 15 years later. Something is so wrong.

KEVIN: That leads me right into the next question … you went down to Washington with a group of people, led by Berwick if I remember that correctly, to make some of these changes with CMS, and that was, I’m sure, a very rich experience.

SACHIN: I was really lucky. I was in the early stage of my career and was able to follow two of my school mentors to work with them in the Obama administration. The first was David Blumenthal when I was at [the Office of the National Coordinator for Health Information Technology] and then Don Berwick when I was at CMS. What just was incredible about that experience was the recognition and realization that healthcare in this country is so diverse, that this is a country that is so large, and each locality is so different and the needs are so different, and we as a country try so hard to come up with simple answers to very complex problems.

KEVIN: Talk about complexity. You guys put together the Affordable Care Act. What were the things that really went well, and then what were the things that didn’t turn out the way you had hoped?

SACHIN: If I tell anyone that I worked on the county implementation of the meaningful use provisions of the High Tech Act I usually have to duck afterwards. I had the fun experience of sitting in an ophthalmologist’s office for a routine eye exam where I was legitimately concerned that he would poke my eyes out once I told him that I was working on driving the use of EHRs in practice. [At the] same time, when you look at the national adoption rates, where they were pre–High Tech and post–High Tech, we’re in the 80s—in the high 80s according to the last data that I looked at—and that is a remarkable transformation of an industry that was previously living in the paper-and-pen age still in most pockets of the country.

I think the Congress, the President, the bureaucracy, the HHS can feel good about that. There were things that didn’t go well, like interoperability, which is a big deal that, frankly, should have been emphasized more strenuously in the process. I think there was a perspective that we would get EHRs in the country and then figure out the interoperability later. I think what David Blumenthal would always say is that interoperability is not a technical problem, it’s a political problem, and I think that that is exactly right. People use information as a competitive advantage as opposed to a source of improving patient care. They try to use it as a source of stickiness. So, it was a missed opportunity to create greater alignment around interoperability.

KEVIN: Where are we headed? When you look down the road 10 years from now, where is this all going? What is your prediction?

SACHIN: Oh, man. Sometimes I think it has to get worse before it gets better. I do think that. I think the biggest crisis that we have right now is the engagement of the American healthcare workforce. I think EHRs have burned people out. I think new payment models have burned people out. I think change management has not been a skill set that has been hugely well developed within the healthcare industry, and we need more operators, people who roll up their sleeves and do stuff and stop going to meetings to talk about doing stuff. I think we have a broken culture of healthcare administration in this country where we have focused on alignment and bringing people along and creating consensus as opposed to biasing towards action, and I think it’s a big problem. So I think these are the things that we need to work on together, and I’m optimistic. There [are] a lot of amazing people out there doing a lot of amazing work, but 15 years ago we were talking about the failure to spread and scale that great work, and today we’re still talking about the failure to spread and scale that great work.

JOANNA: This all reminds me of a conversation we once had about scurvy, Kevin.

KEVIN: Yes, I remember it well.

JOANNA: He is talking about how change comes slowly in healthcare. And now think about it—some of the work that he did on the ACA he is watching potentially getting unraveled, maybe not all of it.

KEVIN: There certainly is plenty of uncertainty about healthcare and where it’s headed, but in some ways the horse is out of the barn. We’re not going to roll back meaningful use. We are not rolling back how we use data now to help us act on populations. And so a lot of the work that was done is going to continue.

JOANNA: The question is how fast, and the thing about Sachin is he has this sense of urgency, when you get him going he does not want this to be a slow, methodical building process. He wants change now. The question is, can he bring other people on board?

KEVIN: That’s a great question, and in fact we’re going to talk to a former hospital CEO and, quite honestly, he thinks maybe we won’t.

JOANNA: Yeah, he is going to pour a little cold water on the idea that we can move quickly because of some of the real financial challenges that you and Sachin both just touched on. But he is also going to talk about some changes that really could drive healthcare toward a better future.

KEVIN: Yeah, it feels like we’re kind of transitioning from the optimist over to the realist.

JOANNA: It is time for a reality check, so stay tuned and thanks for listening.

KEVIN: “Decoding Healthcare” is a production of athenahealth.

JOANNA: Our producer is Nikki Zais. Our engineer, composer, and all-around jack of all trades is Mike Moschetto.

KEVIN: You can rate and review us on Apple Podcasts, Stitcher, and Google Play or wherever you get your podcasts.

JOANNA: And you can follow us on Twitter @athenahealth. I am @JoannaWeiss.

KEVIN: And I’m @KevinBanMD.

JOANNA: And for more stories and perspectives about healthcare in America today, go to athenainsight.com.

Episode 4: Innovative chronic care