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FORTUNE Brainstorm Health: The COVID-19 Ripple Effect on the US Healthcare System


About this webinar:

A discussion on how the pandemic is impacting the entire US health system – preventative and chronic condition care, telehealth, everyday doctor visits and elective procedures – and how data is informing and impacting the decisions medical personnel make about patient care. We were joined by Dr. Arif Nathoo, CEO & Co-Founder, Komodo Health; Dr. Steven Corwin, President & CEO, NewYork-Presbyterian; and Dr. Vivian Lee, President of Health Platforms, Verily Life Sciences.

Webinar Transcript:

0:00:00 Michal Lev-Ram: Hello, everybody, welcome to Brainstorm Health. My name is Michal Lev-Ram and I'm a senior writer at Fortune. I'm thrilled to see all of you today. Thank you for joining us for this community gathering focusing on health and well-being. Today is the first in a series of special conversations taking place over the coming weeks and months, including a two-day event on July 7th and 8th which we'll delve into the new paradigm created by COVID-19.

0:00:26 ML: Today, we're excited to partner with Komodo Health, to talk about the pandemic's impact and how data is playing into the decisions made about patient care. So we're going to be speaking with Komodo Co-Founder and CEO, Dr. Arif Nathoo. Dr. Steven Corwin, President and CEO of New York Presbyterian Health System. And Dr. Vivian Lee, President of Health Platforms at Verily Life Sciences, and author of the book; The Long Fix: Solving America's Healthcare Crisis with Strategies that Work for Everyone. Good timing there.

0:00:57 ML: In just a moment, I'm going to hand things over to Fortune Editor-in-Chief and Brainstorm Health Coach, Clifton Leaf, who's going to be leading the conversation. But first, just a few quick procedural notes. Our event today is on the record and it's being covered by a Fortune reporter. If you'd like to tweet, please include our hashtag FortuneHealth. Please use the chat function to submit your questions, and we'll call on you during Q&A, so you can ask your question on camera. Please identify yourself and your organization when you're called upon, and make sure that your camera is turned on and you're unmuted. We ask that you please keep your questions and comments brief, so that we can get to as many of you as possible today. And again, thank you for participating. And with that, I'm going to turn things over to Clif.

0:01:43 Clifton Leaf: Thank you, Michal and good morning everyone. I just wanna see if we can hear everyone say good morning. I wanna know what that's like when you get it on a Zoom call. Let's try it.

0:01:52 S?: Good morning.

0:01:55 CL: That's pretty good. Thank you all for joining us for this kick-off Zoominar, for our Fortune Brainstorm Health. Our conversation today is the COVID-19 Ripple Effect on the US Healthcare System. But before I turn to our fantastic panelists, and they are fantastic. I thought I would just take a minute or two to set the stage. So over the past five months as the novel Coronavirus has rampaged through the world, we've seen some extraordinary heroics from those on the frontlines, nurses and doctors, and hospital staff, and first responders, and scientists, and so many others. And I don't think we wanna lose sight of that, that's certainly has been, I think, the big story in many ways, but at the same time, the US healthcare system itself has seemed ever more fragile.

0:02:44 CL: When the virus crossed our shores, we were unprepared to test it, track it and contain the disease. As we're now seeing in 21 US states, where Coronavirus infections are rising, we're still not able to contain it. When infection surged in March and April, predominantly in New York in the northeast, we found ourselves woefully short in protective equipment and in medical supplies, ventilator, ICU beds, staff in some cases, to safely treat patient and also contain the spread of disease. And again, as of today, we seem to be going through this ordeal in no less than nine US states, largely in the south and west. Just to give you one recent data point, in Arizona, new hospitalizations are rising so fast that the state health director told its hospitals yesterday to fully activate their emergency response plan. We're seeing the same kinds of trajectories in North and South Carolina, in Texas, in Oregon, Arkansas, Mississippi and Utah; Vivian, where you used to work, and possibly even California again, which reported its highest one-day increase in confirmed cases, 3,593 new confirmed cases just on Friday.

0:04:05 CL: So striking as that all is, we've also been coming to terms with the financial fragility of the healthcare system. We're seeing hospitals and health systems go bankrupt, furloughed doctors and nurses just when we think we need them most and cut physician pay, even in places like the Mayo Clinic. To cite one statistic, in April, the American Hospital Association estimated that hospitals were hemorrhaging more than $50 billion per month, $50 billion dollars a month, and we're seeing those kinds of statistics on a state-by-state level. It's very consistent with that.

0:04:44 CL: On top of that, you have the built-in inequities of the system that have been bared in recent months, particularly where we're seeing Black Americans in state after state and city after city having dramatically higher death rates from COVID-19 than White Americans, Asian-Americans or Latino-Americans. And we're seeing the challenge of too many Americans not getting the care they need or have it significantly delayed for cancer, heart disease, diabetes and other chronic conditions, as patients have stayed away from hospitals and doctors offices for fear of infection.

0:05:19 CL: Yes, we've seen some good ripple effects too, and we'll talk about those from a new inventiveness in medical care and surprising collaborations, through the rise of telemedicine, to a new-found recognition about the power of data analytics, and all of these things we'll talk about. But when you add up all of these individual ripples in the system, we talked about this ripple effect, it looks like a tsunami just hit our gaunted healthcare system. And so the big question for all of us today, and not just our panelists, is do we start getting out the buckets and the sand bags and the shovels and rescue the current system from the flood? Or do we use this tragic and seismic event to start rebuilding a new more resilient healthcare system? And if so, what would that look like?

0:06:07 CL: So we got a big order for us today. Steve, let me start with you. There are a few people on the planet that understand as well as you do the challenges of running a hospital, and think of a pandemic, we haven't had too many of them. And when you and I spoke on April 3rd, on that day, there were 10,841 new confirmed cases in New York alone. We were very close to that New York City peak, we were about a week away or so, and at the time, you told me you were going through 700,000 masks, just for your system, your hospital system, 700,000 masks per week, just to give everyone a visual metric of this overwhelm. So obviously, we've gotten through the deal, but what have you learned about your own system's resilience and that of US health care in general?

0:07:01 Dr. Steven Corwin: Well, I think to a certain extent, we all do emergency preparedness exercises, but I think nobody, certainly my hospital system, anticipated the level of this pandemic in terms of magnitude. So you mentioned one statistic, we were using 4000 masks a day for all sorts pre-COVID, and at the peak of this we were using 100,000 masks a today. We thought we had about a five-week supply, excess supply of masks based on doubling the mask from 4000 to 8000, we woefully underestimated how many masks we would need, N95 and others. We had an ICU surge plan that would add 100 ICU beds. We added 450 ICU beds. So we re-deployed 2000 doctors and 1000 nurses. So there were a range of things in terms of the magnitude of this that exceeded anything we had planned for. And I think that one of the things that has come out of this, in my mind is you really need flexible facilities. It was quite clear to us that the corner stone for getting through this was ICU capacity, specialist ICU capacity. So you need flexibility around that type of physician and the training associated with it, the training associated with nurses and so on. We tend to be so super specialized, we don't have people who have basic knowledge in things like ICU care, you have to now incorporate that into your training practices.

0:08:43 DC: So there were a range of things from the hospital standpoint, at the tertiary, quaternary end of the equation, where people assume that we're great at tertiary and quaternary care, we are. But we were limited in terms of what we actually had available and we had to improvise to extend that. So there were a range of lessons that we learned from this. And I think in the broader context, you have to have, you can't have a failure of imagination. In emergency preparedness, you've gotta think of extreme events. So as we talk about climate change or the hurricane season, I think you have to think about what's the worst thing that can happen? Or domestic or international terrorist event, what's the worst thing that can happen to our hospital as opposed to, "Here's the most likely scenario." Unlikely scenarios happen.

0:09:32 CL: Was one of those lessons that the business model haven't change in some way, because all of those things in terms of preparation for the worst case scenarios, you don't really get paid for it, you get paid for all the other stuff, elective procedures and surgeries. And so you can grap some pretty big losses, just even being prepared for something like this.

0:09:54 DC: Well, there's no question about the fact that you have to prepare differently. And there's no question that one of the larger issues that we have around healthcare is what should you be funding and how should you fund it? We've been volume-dependent, the more volume you do, the better you do. And we've depended upon private insurance, subsidizing Medicare and Medicaid. The reason that you mentioned so many of these institutions losing money was if you lockdown the economy and you limit elective procedures, you are limiting a major source of funding to offset the losses from Medicare and Medicaid. So that's got to be re-thought. Clearly given the excess mortality in black Americans and people of color, you've gotta rethink the Social Determinants of health, you've gotta rethink preventive care. There are a lot of hypotheses around this, including crowded housing, people seeking care later during the course of the disease. So we have to acknowledge that. And unfortunately, this, the COVID-19 now relates directly to Black Lives Matter, they are, in my opinion, are inseparable in terms of what we've seen as outcomes, so I think we've got a lot to chew on in healthcare.

0:11:14 CL: Yeah. And I definitely wanna come back to that subject in a big way later. Vivian, it wasn't that long ago, that you were running the largest health system in Utah, State of Utah, which I just mentioned, and that litany of states, that was sort of in the thick of it now. It's in the eye of a storm. Is the odd state ready for something like this?

0:11:41 Dr. Vivian Lee: Well, you know, I just wanna start by saying that I so admire Steve and his whole team in New York for all that they were able to do, just the fact that the very fact that even the worst case scenario was an order, two orders of magnitude almost below what actually really happened and yet, you were still able to serve the community in such a fantastic way, that's just... My only contribution is every night at 7:00, I go out and cheer for everyone, so I just want to say that on behalf of all the other people in New York, thank you for all the incredible work.

0:12:16 DC: Thanks.

0:12:16 CL: I just wanna add that on April 3rd when I spoke to you, you sounded just as cool and calm and collected, as you do now, so I don't know what sort of herbal tea you were drinking but...

0:12:27 DL: Well done. Well done.

0:12:28 CL: It was kind of remarkable.

0:12:30 DL: Yeah. And I completely agree with what Steve is saying. I think that one lesson that we've learned, of course, is that prevention and a better public health infrastructure would have served us really, really well. And in the course of everybody is doing the Monday morning quarter backing on this, it's, I think that for decades, we've known that these epidemics come and go. I know that there were some reports about George Bush really fearing reoccurrence of the 1918 pandemic launching a whole effort, which I know that Mark Weber was very much involved when he was secretary of HHS putting out a pandemic plan under President Obama with Zika and with the various pandemics that he was managing, Ebola. We've had these plans, but we haven't really been able to put them in action, short of getting into the ICU, what we really needed was a process by which we could see it coming. It's not as if, this is an infectious disease that came from outside of our borders, so to not have enough lab testing, to not be able to actually connect the data from various health departments to manage the spread.

0:13:46 DL: I think we've learned a lot of lessons of that investment that we will need, and as Steve said, a big factor is that our health system is so much invested in this volume, fee-for-service, reactive tertiary care situation and just not really... The financial model of healthcare is not designed to reward non-service generating, non-fee generating services like prevention, like our investments in public health. We have the plans for the country, we dusted them up, but now we need to see them through, we really need to make those investments.

0:14:21 CL: I'm just drilling down a little bit into that issue about the business model. My friend, Bryan Roberts, likes to talk about hospitals as being these big buildings with fixed assets, very expensive fixed assets, and the only way to make that model work is if you're using those assets and filling up those beds, and doing those procedures. For a while, that's worked. It's working for the bigger hospitals, it's worked for the hospitals that have been able to combine and get that economy of scale, but it's a lot harder throughout the country, rural hospitals, smaller hospitals, intercity hospitals. How do we rethink that business model?

0:15:03 DL: Yeah, there's no questions hospitals are essential to our existence and our absolute core, especially in rural areas, and so what we're seeing now is that the fee-for-service model that we have means that our hospital systems are living hand-to-mouth. What we were seeing with COVID is that many of the systems that have proved financially more resilient are those that have had the consistency of payment guaranteed. So whether they are some of the Medicare advantage programs like ChenMed or Iora Health, where they actually have been able to be assured of a monthly payment, they have not had to furlough doctors and nurses. They've actually invested, they've used some of that guaranteed money to invest in supporting their patients who are multiple chronic diseases or afraid to come into the hospital clinics, by delivering medications to their home by setting up an urgent care facility in their clinic, for example, so that those seniors don't need to go into emergency rooms.

0:16:04 DL: And then parts of our health system like the military health system or the VA health system, where they are on a global budget, they've actually been able to withstand, of course, the ups and downs of payment. So I think we do have a need to figure out how we modify our payment model to create a much more resilient healthcare system. We can't be laying off 1.5 million doctors and nurses and healthcare workers in April alone, just when we need them the most, as you said.

0:16:32 CL: It does point to a lot of the challenges of data in terms of understanding and forecasting these kinds of challenges. We never really had anything like this, but we've also never had the kind of sophisticated data analysis that we have today. And Arif, that brings me to you and some of the stuff that Komodo is doing, but I was looking through one chart, and Michal, I wonder if you could put that into the chat room so that everybody could see this. But it is a... Look at the number of colonoscopy within 2020, to date, versus 2019 at the same time, and what you can see here is a remarkable example of what I was mentioning to you earlier. I don't know if you can all go in and see that document here. What you're seeing is obviously not a question of me, you're seeing a challenge of the fact that people aren't going and getting the care that they need, and the Coronavirus has bared this out, and there's a real danger in this. We know, for example, that the colorectal cancer, the earlier you diagnose it, the earlier you start treating it, whether through surgical cross-section or through some other treatment, the better your likelihood of preventing it on time. So it's a striking chart and you could only see it when you're actually looking for the data. This isn't a fact that just pops up.

0:18:18 Dr. Arif Nathoo: Yeah, that's absolutely right. I feel like one of the profound consequences of going through the last eight weeks, and this harkens back to something Vivian was describing, about the importance of primary care or preventative care, is that you completely shock that entire system. And so now you've got, essentially, three months where preventative care, chronic disease management and everything from routine screenings for cancer all the way to management of your diabetes hasn't happen. And what's amazing about it is that it the change is so profound that when we think about the system coming back, we make assertions around how long will it take for folks to come back to the system.

0:19:02 DN: I don't think we have any clue what kind of latent disease we've essentially fought faster in our populations over the last 12 weeks to the effect that it's gonna take many, many months and potentially years to recover from the other side of this, which is that we're not diagnosing cancer, we're not addressing chronic disease in the right way or as aggressive as we can. And the shining light there is the fact that we've developed and started to see a whole host of services that are coming up to support the system. So I think one of the real deep questions around resilience, and it was where you started this whole conversation, is how does the healthcare system really rethink the way it operates, because the way that we do things today can't sustain shocks like this.

0:19:50 DN: First of all, as Steve alluded to on the procedure volumes, that's dictating a lot of the closures that are going to happen to rural communities and in areas that absolutely need the healthcare system. But then more to that point, when does that capacity come back, what does that capacity look like? And I think that's where some of the biggest problems we're gonna see is that the capacity just won't be there for the number of people that will need that support, and so what we're seeing in the data is that the disparity is held through differently across the countries. In some places, the capacity we think will be there and the hospitals will survive, in other places, they won't. And so how can we better use data, to your point, to help us figure out where that's happening and where we should probably invest the resources, either from a policy standpoint, institution standpoint, as we're trying to drive new innovation to allow that capacity to be built into places that need it most?

0:20:48 CL: I think this issue of capacity building and making sure that you have enough capacity for something like COVID-19 when we all need as a nation, and yet not so much that it becomes a financial drain if you're not filling each bed with in-patients. I know that, Vivian, you ran a health system, a big one, obviously, Steve, you run one now, how do we think differently about capacity building? Because that's such at the core of what we're talking about here.

[overlapping conversation]

0:21:23 DC: No, please, Vivian, once you go and I'll [0:21:26] ____.

0:21:28 DL: One of the things that I think is clearly an opportunity, you alluded to telehealth, is thinking about how we really care for people outside of the healthcare system, outside of the four walls of the clinics and hospitals, which of course has been a critical need right now. And the people who we need to provide the most care for are those who are at the greatest risk of COVID, whether it's heart disease or diabetes, and so on. As you know, digital health has really been taking off and we've seen, with some of the solutions that we work with and with others, that there's a huge, huge opportunity. So one of the areas that I've been the most impressed with is in the diabetes space. For example, one of the companies that we manage called Onduo is a virtual diabetes clinic. Here, we're talking about a large percentage of the population. And besides thinking about the telehealth piece, because you have the ability to chat with a coach or video conference with a physician, that's wonderful, but I think what's even more powerful about these solutions is the ability to enable people to care for their own chronic conditions better.

0:22:37 DL: So the use of a continuous glucose monitor, for example, which until COVID was really mostly not reimbursed, Medicare wasn't covering it, now it actually is covered. So now instead of requiring diabetic patients to prick their fingers multiple times to check their blood sugars, this technology... We happen to manufacture one of them but there are many others, so I'm just speaking about this technology in general. But the continuous glucose monitor, you put it on your abdomen or your arm for a couple of weeks, and you actually, for the first time, can see your blood sugars 24/7, and then you can see how your blood sugars are actually responding to the meals and snacks that you're eating.

0:23:16 DL: Obviously, it's a phone, so you can take pictures of your meals and snacks, easy, and then you can visually make that association, and use a little bit of artificial intelligence, which then can actually make observations that you may not make. So I may know, for example, that maybe I shouldn't be having that second slice of pecan pie, even though I love pecan pie. But it can actually show me, "Vivian, the last three times you made that decision, here's what it did to your blood sugars. Other things that might be more subtle like soy milk versus whole milk in your coffee, this is what it did to your blood sugars," for example. So enabling people to bring that healthcare just much closer to them, much more personalized. How I respond to a bowl of cereal and fruit and how you might, Cliff, would actually are gonna be very different biologically.

0:24:01 DL: So it's personalized care, it's accessible, it can maybe start to address some of the health disparities, particularly, for example, on my old part of the neck of the woods in Utah with large rural populations who just don't have access. I think there's just enormous opportunities that we realized were there but with the COVID crisis, maybe some of the funding was supported. Also, of course, they need to be held to the same standard of delivering value, I will say. We can't be volume-driven there. But held to that same standard, I think there's huge opportunities for thinking about how we can decentralize some of that care back into people's homes and into their life. Huge opportunities.

0:24:39 CL: Telemedicine has that advantage, Steve, not just of being cheaper to implement but also keeping patients out of hospitals, where there might be a raging infection. But in addition to that, it allows you to check in on people and implement a little bit more of a preventive care ecosystem, if you will.

0:25:03 DC: Yeah, we were at about 4% of our outpatient visits were telehealth visits pre-COVID. During the crisis, 85% of our visits were telehealth. So the physicians basically crossed the Rubicon and everyone got comfortable with it, everyone understood what it could be used for, what it couldn't be used for. As remote patient monitoring and better point-of-care testings becomes more and more available, we're gonna use more and more of that.

0:25:31 DC: So let me give you some examples. We were using it in tele-psychiatry. Virtually, 95% of our outpatient psychiatry visits now are telemedicine. During the midst of the crisis, with remote patient monitoring, pulse oximeter, blood pressure, et cetera, patients that were not ill enough who had COVID, not ill enough to be hospitalized, were sent home, monitored by a physician, monitored by a nurse on a daily basis. We were doing COVID monitoring at home. Hypertension visits, chronic obstructive pulmonary disease visits. Now post-COVID, as we started to reopen, we're at about 45% of our visits were telehealth visits. So it clearly is something that... The horse is now out of the barn, everyone's gotta do it, and there are some very practical reasons. You can't have 30 people in the waiting room, you can have to 15 people in an elevator, you have to spread out office hours. And so a typical physician now, the physicians, let's say, hypothetically, seeing 20 patients pre-COVID, right now, eight patients may be physically seen, 12 patients may be tele-health visits during the course of those office hours. That's changed dramatically, and there's no going back from that, and you need to have that in this type of world. So, I think that will only become more and more dramatic.

0:26:54 DC: Now, having said that, we've had grants on tele-health that have allowed us to do tele-health in underserved areas. You have to have for rural areas last mile broadband, and for urban areas, you have to have connectivity. Otherwise we are gonna exacerbate the health equity divide. We have to pay attention to the basics of that, whether it's urgent care, whether it's chronic care, etcetera. So that's a big deal.

0:27:26 DC: The other point I wanted to make about capacity, Cliff, if I could, is you have to rethink the way a hospital, the big box, if you will, operates. So how do you add a 100 ICU beds if you need it? How do you have the staffing around that if you need it? And that means you have to have flexible staffing, that means you have to have flexible facilities, it means you have to think about the box differently to create the necessary capacity for the three standard deviation away from the mean event. It doesn't mean you're gonna do that always, I can't have 200 extra ICU beds lying fallow every day. So you have to rethink the way that you do these things, and I think that that was there. Just a final point about capacity, when you're getting overrun, you just can't do elective cases. You can't do the colonoscopies. We were tracking people with tele-health. We were making sure that they would keep their appointment for the colonoscopy post-COVID. But whether there was a deleterious effect from delaying the breast biopsy, delaying the colonoscopy, we'll only know after a period of a few years.

0:28:40 CL: Yeah, absolutely. Both you and Vivian talked about the rural-urban challenge here, rural-urban divide. Recently, on an MPW call, a Most Powerful Women call, we had Beth Ford, the CEO of Land-O-Lakes talk quite passionately about this divide. Chuck Robbins, the CEO of Cisco, was talking about it with regard to this disconnect on connectivity and broadband and how serious that is. I know we're lucky, we have Phil Polakoff, who actually studies rural health. And Phil, I wonder if we could unmute you or have you talk about some of the challenges that rural health facilities have here?

0:29:23 Phil Polakoff: Oh, it's an honor to be part of this participation with all of you. It's been a real challenge because it's more than just health and healthcare. It's all about the other social determinants that evolved into rural America across, from coast to coast, north to south. And I frame it in the 6-Ps. How do we deal with personal care from the bottom up. So we listen to the people, not just talk down to them. How do we deal with population health, so we get to all the data that we need? How do we deal with public health, which has been downgraded over the last 50 years? How do we deal with political will, so we cross going past to future and stop the red and blue divide? How do we deal with place because each part of the place is slightly different? Mississippi and Utah have similarities, but they have different cultures and different ethnicities. And then, how do we deal with this issue between prosperity and health, and illness and poverty?

0:30:21 PP: So by bringing people together and listening to them and telling stories, I think it's really crucially important that we tell the stories of success and share them more often, and look for public, private connectivity, then we're in a better space. So I do believe that's a Presbyterian thing. The past is in the past, but there are new models. The bricks and mortar one are the past. And one last point, which is of interest, a few statistics. 43% of all CFO's of rural hospitals, this is the first time they've ever had that job. 50,000 people in public health were taken out of the agenda over the last 10 years. And lastly, if you look at the budget and healthcare in this country, it's over three trillion dollars, 18% of the gross domestic product. However, when it comes to public health, it's less than 3%. So, Cliff, let me leave you with that because this is an interactive forum you put on.

0:31:19 CL: Yeah. No. I think those are great questions. Arif, I'd love to actually bring you into dealing with how do we track these trouble spots and what do we do about it, from your area of expertise?

0:31:33 DN: Well, the reality is that we already know. We see it every day. One of the things that we track is administrative data on over 300 million patients in this country. And so we can see essentially where care is not happening, and we can compare it period over period, month-over-month. And one of the interesting things, especially in rural care is not only you're not seeing the ability for patients to actually get to providers and see those providers, but you're also seeing a limited infrastructure on the tele-health side that's prevented many of those folks from getting the treatment they need during this time. And I do wanna say that even though you won't know for a few years whether the lack of screening is gonna impact outcomes, you can almost predict based on just the fact that 70%-80% of new cancer diagnoses are happening now compared to a year ago, you can model out based on the average stage that you find people, just how much later people are gonna get diagnosed. And whether that plays into... In certain conditions, that's gonna have a major effect, in others it won't.

0:32:32 DN: One of the things that we have to take into account is that that disparity is gonna be felt differently. So in rural areas which are not adopting tele-health, it's interesting. When you do this analysis by state, you'll find certain states like New York and largely due to the incredible efforts at the hospital systems there, have an 11x increase in the number of providers that are using tele-health and other states, Georgia, South Carolina, all the way through the Midwest, we're seeing a far smaller increase in the amount of tele-health visits, either as on a per capita basis, on a per physician basis. And so, what you end up having is a system that one has to rely on folks getting back into the system in order to take care and address that disease in order to address the screening, and that's more acutely felt in certain environments than not. So, I think Phil's point around what you need to do in order to build that infrastructure, you can absolutely see in the data, and quite frankly predict where six or nine months from now, you're going to see a real challenge with the population. I think that's very powerful, and it's something that we all should be thinking about as we formulate policy, knowing well in advance what we think will happen.

0:33:48 DC: Cliff, We use the term renew as opposed to reopen. And we deliberately chose that term because if you turn back and assume you're going to go back to what you did after this tangent, however, horrific it is, I think that's a huge mistake. And everything we're talking about, and you heard Phil say is, you've got to get to a different normal in a whole host of ways. The public health issue is an extraordinary one. We had a complete collapse of the public health system in this country, which is a patchwork anyway, at the start of this, put everybody behind the eight ball, we're still suffering from the ill effects of that. And then you also have to recognize that we've got to... We as a healthcare industry, have to work against red-blue, rural-urban, white-black. These are all polarizing issues, and the most poignant polarizing issues are mask/no-mask. Why are we arguing about that? Why is that a political discussion? It is astonishing to me that we've become that polarized, that that becomes a political football.

0:35:09 CL: Absolutely. That's a great point. We have a lot of really good questions in the chat room on really even going beyond tele-health. What are those options for a home health solution? Actually, a remarkable thing happened to my mother-in-law. She's 89, and normally her doctor tells her to come in and get this blood test. And during COVID-19, they actually sent a nurse practitioner to her house to take the blood test and I thought, "Wow, that's progress." [laughter] We went back 100 years, but it worked. Vivian, why don't you talk a little bit about this, just from the perspective of what Verily is doing, and how you're sort of bringing in health right into the home, if you will.

0:36:00 DL: Yeah. And I will say that as much as I'm disturbed as everyone about the polarizing of healthcare or just of the country. I also have this little seed of optimism, which is that this crisis, if nothing, will be driving us to pay a lot more attention to these critical questions, and really start to make some forward progress, that's what I hope. The needs to be able to provide people with care in the home, leveraging technology, whether it is, as we've talked about before, some of the examples that Steve alludes to, whether it's home monitoring devices or also, I think another element that I think is really important to emphasize is the need to maintain that sense of community. So one of the stories, for example, that I talk about in this book. So I really like your point, Phil, about sharing really good stories. And so what I've done in this book, which I will just show you because I'm very proud of it. It's like a new baby. For me, the long fix is sharing stories from around the country. It's really for the public to try to ensure that people understand what it is that we need to do with our healthcare system. And one of the stories that I share in there is the group in Pittsburgh, the Jewish Health Foundation, has put together this virtual senior academy to just bring... Anybody can sign up. I'm shocked to say that they define senior as anyone over 50. Skip over that quickly.


0:37:38 DL: But what they do is, people, whether they're in their homes, originally was you could go to, for example, the public library, and people could do, whether it's book clubs or have a cooking lesson, and then peppered in there are some health-based trainings, whether it's how to cook a good meal or some tips about hypertension. So I think on the digital space, whether it's continuous glucose monitors or other home monitoring devices, and the ability to interact with health care professionals or social elements and retaining some sense of community and addressing some of the issues of social isolation and loneliness. I think those are a couple of really, really important advances. And then I'll say one other thing, which is right now, we are also really trying to think about how to care for people with COVID and how to prevent the spread of COVID.

0:38:34 DL: And I think they're... The use of... And this may be much more in Arif's space as well, but the ability to actually collect the data at a population scale and do the right kind of analytics, so that we can provide the right levels of care to the right people in the right environment. And to do it in such a way that brings together some of those social determinants. I also talk about Mandy Cohen's work, which many of you know about in North Carolina and the large data-driven approach that she's had, where she says, "It's not just about referring my Medicaid patients to the right doctor in the right hospital. It's around making sure that they're in the right food stamps program, that they have the right legal aid, that they have the right social services as well." So I'd say I'd like to add that layer to what we also can provide in terms of digital offerings.

0:39:23 CL: Yeah. And Vivian, I have to say, I'm very impressed with how you put your book up like that. It's great to promote your own stuff here.

0:39:30 DL: Yeah, there you go.

0:39:31 CL: And actually, this is a perfect cover to talk about, because it's on artificial intelligence, and much of what we've talked about, and we mentioned in the beginning, is the opportunity for innovation. You know, as they say, necessity is the mother of invention, but when you're really in the thick of it is when we've seen an explosion of new vaccine candidates, we've seen lots of new clinical trials being put in in terms of potential treatments for COVID-19 and some other things. And I recently was talking with the CEO of Medtronic, he was talking about the first truly remote ventilator, that they had created with Intel, reducing the need for respiratory therapists and others to go into a patient's room that might be infectious, and then don a whole new set of PP and E to get in there, and the ability to reduce those kinds of visits by 50% within the hospital, and yet have better monitoring of someone's ventilating machine. So, I'm wondering if the three of you could talk a little bit about some of the innovative models that have come out of this, or some of the partnerships that you're excited about.

0:40:57 DC: Well, I can start.

0:41:00 CL: Yeah.

0:41:00 DC: To your point about ventilators, we've established now the ability to do ICU care outside of the room. We never had thought about that before. So, you can have all the equipment outside of the room and minimize the amount of time you go into the room. So that's just one very simple example of how you can do that. We've innovated tremendously around staffing models. We had to improvise staffing models around ICUs, so that we actually develop a pyramidal structure, where the most capable intensivists were at the top of the pyramid, less capable intensivists, in terms of experience, were at the next level, and then so on down the line. So you could actually care for extremely critically ill patients with one extremely good critical care nurse taking care of three or four patients, when usually they were taking care of one.

0:41:50 DC: So staffing models, the way that you actually rethink the physical space in an ICU, are two very clear examples of innovation. And then, everything associated that we did with Telehealth. All of our heart failure patients were being visited by paramedics at home, so that they did not have to come into the institution. So, this idea of home care, expert home care, and it relies on Telehealth, because you're connecting in with the physicians, the nurse practitioners, etcetera. And to Vivian's point, the innovation around other aspects of somebody's social milieu is really important. So you can do Telehealth where it's not just me as the doctor seeing you, Cliff, as the patient. It's me as the doctor seeing you, Cliff, as the patient, and the social worker and other people are there, examining these things of, "Do you have food insecurity?" "Is there an air conditioner in your home if you're a heart failure patient?" "How do we make sure that your transportation needs are met?" Those types of things. We can envelop the particular visit with, so much more that it really helps the entire patient experience.

0:43:03 CL: We've got some amazing people on this call. I see Toby Cosgrove, the legendary heart surgeon at the Cleveland clinic. We've got Greg Simon; I wanna ask you a question about government if I can, in a minute. Cathie Reid, who runs an entire healthcare group in Australia, where they're down almost to zero new corona cases, I believe. And also I saw Margo Georgiadis of Ancestry.com, the CEO there. And I'd love to just... Margo, just in terms of looking at data, the conversation picking up on where we left it about what you're seeing on the genetic front, in terms of how we can speed up our analysis of say, drug response and things like that?

0:43:54 Margo Georgiadis: So, Cliff, thank you. We're at the very early stages. We launched a significant piece of research to try to get the largest real-time dataset on COVID, so that we would be able to really understand and be able to see the genetic linkages, since much of the early research at Stanford, New York Presbyterian, elsewhere, highlighted that it was possible that the people that were having adverse reaction that didn't have other comorbidities could be genetically related. And so what we've seen is an outpouring from consumers, over 600,000 people responded in just two emails to participate in this live survey with ongoing development. And I think it just shows the power of our ability to gain real-time engagement with consumers, as many people were talking about earlier on this call, that can help us better advance the understanding and treatment of disease more quickly, by having this real interaction in real-time with consumers at large scale with 18 million people in our network and willing to participate in these initiatives.

0:44:57 MG: I think we've barely scratched the surface of what's possible. As we think about this concept of population health, understanding a much broader set of data elements, and how we can all collaborate to understand how and where we treat people, the advancement of disease, what kind of symptoms and other things are correlated. As part of our research, we've gathered a lot of data on our customers understanding what medications they're taking. So we have a much, much broader dataset that can be analyzed.

0:45:27 CL: You know, it's interesting, you talk about the data analytics part of it and the genetics part of it, but the third part is this really wisdom of the crowds, and the willingness of the crowd itself to participate in the knowledge exploration. Arif, I'm wondering if you might touch on that, just a drop about what you're seeing in terms of crowd-generated data the way Margo has been able to procure?

0:45:51 DN: Oh, there's an incredible appetite. I think what we've seen over the last few months is just how many people are actually willing to share data for the purpose of understanding population health better, and Margo's work is right in line with the thesis that [0:46:07] ____, then we can start combining various different streams of data at the patient level, then you can start to get to the deeper insights. And the challenge is that you wanna take that genomic data, but you also wanna look at, from who is showing up at the hospital with COVID, and what kind of, you know, the severity of their infection. And some of that stuff is in the clinical list, some of that stuff is in the administrative data, that may not be the types of data feeds that Margo can link together. And so, the insight is really happening at the confluence of many different things.

0:46:37 DN: When we study or build an algorithm that looks at patients with rare disease, we're often comparing and looking at a history over many years of what's happened to them, the presentation of disease, and linking that up to effectively their genomics. And it's only through that that you can actually get to a better predictive model. But that requires a lot of people to come together. It requires the patient to say, "It's okay to share." It requires people who are administrators, like whether you're an insurer, you're a hospital, to share that data. It requires all the labs to say, "Hey, we're gonna bring that together." And that is really where we find the hardest part of this is that no matter how much will there is, the possession of data is kind of like, as they say, nine-tenths of the law.

0:47:18 DN: So the reality is that so much of this is just sitting on various people's sides and various servers, but it's not being brought together in a way that allows us to perform true population level analytics. But you know what, I think it's changing, is the recognition that unlike in other segments, maybe in advertising or in finance, the aggregation of health data for a population in a kind of way that protects privacy has benefits to public health. If people band together and can do this, we can actually start making real progress to understanding genetic drivers by looking at a lot of data together and not just the more traditional randomized clinical trials. So, we think there's just this incredible outpouring of support on wanting to participate. We see a lot of companies that enter that make it feasible for patients to start sharing. I believe a lot of the large companies that sit on population-level data come together to make that happen.

0:48:18 CL: Arif, you seem to be preaching the gospel to one Greg Simon who is standing by, in the idea of the possibility of not only being able to share data across disparate sources, but having an interoperable system where there's the ability to actually be able to make sense of that data in different systems. Greg, I know this is something you've been working with trying to solve for a long time, both inside the government and out. How close are we to having true interoperability in our electronic health record systems, and outside of that, in systems like Verily and Komodo and others? What do you think? You're muted. You're muted, my friend. Yeah. There you go.

0:49:09 Greg Simon: I assume we're all sitting down, because I've been doing follow-up work with [0:49:19] ____ on vital cancer initiatives called FEMCO, minimum common oncology data elements. And Epic has agreed to incorporate it into the system. So everybody just think about that for a second. So, Epic has now agreed that they will allow this common lexicon to be incorporated into all the cancer medical records for diagnostics treatment, clinical trial match. That is a small step forward for mankind and a big step forward for Epic. But we still have a long, long way to go. I'm sure as many of you have, you may have had a lot more interactions with the healthcare system in the last two, three months than you had in the last two or three years, and I have, as well. And I can tell you I'm still dragging things around either electronically or physically from one doctor to another.

0:50:12 GS: So I think we have a long way to go. But it's not technology, it's culture, as you know, we've been saying this for a long time. It's culture, not technology. The other problem is, even if we do everything right, we do not have a society, we have several societies. The doubling of life in the 20th century was almost exclusively around public health improvements. The 21st century, we all thought was gonna be on personal health improvements, through treating cancer, and nervous systems, nervous system diseases, etcetera. But now we're being dragged back into the public health thing. And what we found is, our society thinks it's more important to get a haircut. And obviously, I don't. And/or sit in a hot tub in Lake of the Ozarks than to follow the rules.

0:51:07 GS: And if somebody said, "I think today I'm gonna start dumping my sewage in the gutter outside my house because I have a gun and I have the right," I think we would all agree that's a bad thing. But when someone takes a deadly virus into the public and says, "It's my right to risk everybody else," we have to go through these enormously complicated fights to shut that down. So getting the data is gonna be really important, but I go back to my organizing principle, which is we have to get people to do the right thing for the wrong reasons. If people did the right thing for the right reasons, we wouldn't be here.

0:51:47 CL: Toby Cosgrove, just in your illustrious career, you probably have studied the culture of medical science longer than anybody, just in terms of understanding how doctors and nurses and others in the hospitals interact. Are we ready? From the medical culture, forget about some of the stuff for a moment, we'll just table for a minute the broader societal readiness to participate in social norms. But do physicians themselves see a need for change in the hospital system that we have? Do I still have Toby there? If not, I will... Well, I don't know that I still see Toby here. Cathie, while we're waiting for Toby. Cathie Reid. Australia has had, just like New Zealand, has had an extraordinary response to COVID-19. And I'm just curious, as someone who runs one of the largest health systems in Australia, what were the lessons you've learned and can pass along to this group?

0:53:04 Cathie Reid: Hi Cliff, and I'm not turning my camera on, 'cause it's 01:30 in the morning here, and I'm actually sitting up in bed in my pajamas listening to this. [laughter] I mean, yes, Australia has done really well. And we've been really fortunate that I think, largely, really extensive testing and track-and-trace really early. Back in the very early days, I know I got back from a flight from Europe where someone on that plane tested positive, and we immediately got a notification from the health authority. We had to self-isolate. We've been now home for around 14 days. Every day, someone from the health authority called us to check, were we displaying any symptoms, to confirm that we hadn't left the house, and we had that really rigorous and very, I guess, intensive approach from the get-go.

0:54:02 CR: And there are some natural advantages here. We don't have the population density, so that mass movement... Particularly, there's nothing like the New York subway here, and that really helps to contain the spread. But yeah, it's really been testing and tracing, that's allowed it to shut down here. But some of the things, certainly from our... We've been able to continue to operate all of our cancer clinics through Australia. Singapore and Hong Kong have been a different story; things have been a lot more challenging there for patients to be able to continue access. But we're also watching and quite concerned for what that ripple effect is, in people not being able to access the staying home during the COVID quarantine period, and not being able to actually have that diagnostic piece, and what that does to the delay in cancer detections, and what impact that has on people as their treatment is delayed in commencing, is something that we're watching with great concern.

0:55:06 CL: Thank you, Cathie, and thank you for staying up for this. It's not exactly pillow talk, what we're really here. We have just a couple of minutes left, and really I would love to just get some final perspective from Vivian and from Steven, from Arif, on whether on that issue of renew versus reopen that Steve mentioned, and how serious we are about it really being renew rather than reopen. If we had to sort of suggest a percentage share of what really is gonna look different, how much it would be renew versus going back to the ways we've got it. Vivian, you've got the book, and if you wanna show everyone again, feel free. The Long Effects.

0:55:53 DL: I just wanna point out The Fortune. I was inspired by The Fortune magazines behind you.

0:55:57 CL: Oh good, okay, great.

0:55:58 DL: Well done, well done.

0:56:00 CL: Fantastic. So why don't you take this one first, how different will it look, will this system look, 10 years from now?

0:56:07 DL: Yeah, I think the observation I think we've all made is that we really need to fundamentally change the business model of healthcare to one that is really not paying for action or fee for service, but for really driving value, better health outcomes, and lowers costs. And everything follows from that. If we are fundamentally rewarding health systems, physicians, pharmaceutical companies, device manufacturing, and technology companies, for driving value, the focus will be on areas that reduce the cost of care the most, which is prevention. It will naturally drive us to make the right investments in prevention in public health. And I believe that it will also create a much more resilient healthcare system, as we talked about, instead of closures and furloughs when we need them the most. We will be having a much stronger healthcare system, and it will also drive care much more to the home, to the caregivers. We didn't talk about the caregivers that are burdened. We talked a lot about social determinants, but it will drive us to make the right investment. So, fundamentally, I think that's what we need to see happen.

0:57:18 CL: Steve, it was your framing the renew versus reopen? What do you think?

0:57:26 DC: I think we don't have a choice. I think we don't have a choice as a country. I think that renew means much greater emphasis on health equity as a piece of social justice; we can't afford as a country not to deal with this at this point in time. I think that home care and telehealth, that's an irreversible trend. I think that payment for value is gonna become an irreversible trend, because the business model as it's currently constructed is broken, and this finally broke it. So I think if you look at all three of those things, you end up saying, "We're gonna renew our commitment to our patients, but it's gonna look different in 2020 than it did in 2019, and let's try to make this a better healthcare system as opposed to revisiting our past healthcare system." I hope as a country, we can find the will to do that. There have been a lot of attempts in the past, but I think that this time, maybe with the convergence of all these factors, people will get it.

0:58:37 CL: Yeah, well said. Well, Arif?

0:58:40 DN: Yeah, just briefly 'cause I know we're out of time. We've seen the inequities of the healthcare system play out, and I think the question is, Can we build a more equitable future that's built off of technology? I think we all want to believe that digital solutions are just as equitable. Anyone can get on them, anyone can use them. But the reality is that right now they continue to perpetuate the same inequities that exist in the healthcare system. Until we recognize that racism is a public health issue, that we have to build institutions and build systems that actually are designed to be anti-racist and designed to actually reduce inequity, and unless we take that orientation, you're gonna see a digital infrastructure that looks like our real infrastructure, which is based on where has and have-nots have a big divide in their access to care. And so I think this is a really good wake-up call and challenge for all of us to say, What does a better digital future look like where we can actually be more aggressively addressing inequity through the fact that technology can get us there, and do it in a way that's consistent with our values as a country.

0:59:48 CL: Beautifully said. Thank you, Arif Nathoo, Vivian Lee, and Steven Corwin, I wanna thank you all for this great conversation, and thank all of the rest of these terrific guests and those who volunteered some comments. Michal is gonna take us out in a minute, and we hope you'll join us for the next call. And see you all at the rest of Brainstorm Health. Thanks.

1:00:08 DL: Thanks, Cliff.

1:00:09 ML: Thank you, Cliff. And another thank you to everyone for joining us today and a special thank you to Komodo Health for partnering with us on today's event. We apologize that we didn't get to all of the amazing questions. I know there were a lot of them, but we definitely intend on addressing them and following up with you all as quickly as possible on those. We're looking forward to seeing you for more Brainstorm Health gatherings in the weeks to come, including our two-day event, July 7th and 8th, focusing on what we've learned from the pandemic, how we can reinvent healthcare to weather the next storm, how we can address healthcare inequities, and much more. Please check out fortuneconferences.com for more information.

1:00:51 ML: Next week, we're going to be putting together another conversation on reimagining employee mental health, a really important topic, and wellbeing, hosted by Brainstorm Health Co-Chair and CEO of Thrive Global, Ariana Huffington. Please keep an eye out for further details on that. Again, thank you so much for joining us. Stay well, stay healthy, and so long.

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