Service Innovation Panel

Uploaded by stanfordbusiness on 31.05.2011

Welcome everybody. I am Arnold Milstein, Director of
Stanford's Clinical Excellence Research Center, and welcome
to this panel discussion of those brave enough to innovate
in health services.
Innovations in services of any kind are not for the faint of
heart. There are several categorical problems. #1, they are
rarely, if ever, subject to any intellectual property
protections. So you come up with a better round strap. It's
often a matter of time before somebody, if it's working,
rapidly replicates often with more money than you started
with. Secondly, they are notoriously hard to replicate. So
you have a service model, it's one thing if it's a
relatively simple service model that you are trying to get
somebody who is on the nightshift in Motel 6 to operate in a
certain standardized way, that's one thing trying to manage
a diverse team of clinicians, some of whom don't regard
themselves as anybody's employee is something else. I have
assembled today a group of those who are not faint of heart.
They have punched forward into the world of health service
innovation and, in every case, have had the good fortune of
making substantial progress.
Innovation is a little difficult or challenging for me to
talk about since most of my life I am about standardization
and replication and process improvement these days. But I
did give some thought to it. I have always been the
operations person and actually I was the COO of
HealthSpring, not the CEO, so it was my job to take the
brilliant ideas and make them live in clinical practice
which I find somewhat more difficult than thinking out the
idea. Thus I subtitle my talk where brilliance gets crushed
by reality.
I want to talk about three examples of innovation in
delivery service and the first one is paradigm shift then
about adopting and repurposing and then just some kind of
common wisdom or what I call the no-dust solution. I wanted
to begin by talking about a delivery system that I ran
across in my context of HealthSpring in South Florida in the
Miami area called Leon Medical Clinics. And it was very
interesting, high-performing organization. As I was around
it more, I realized they never talked about any of the
things I knew to talk about in health care. They operated
differently. The key turned out to be an epiphany that their
leader Ben Leon had, and he had been in the business a long
time and knew all about managing cost and turnover time of
rooms and all of the things we look at. But it came to him,
he says that Disneyworld, that the reason this business
didn't work was because it isn't about managing cost, and
it's not about managing care, it's about patient loyalty.
And it was just the notion that if he could get patients to
be loyal to his organization, he could invest in their
health care status, and there was plenty of time to recover
that investment cost if he could count on them being there
10, 15, 20 years. So that notion then led him to the concept
of the patient's experience of that organization and to
really a career of obsessing about making sure that patient'
s experience was consistent, exact and perfect. And you
would talk to him. He would say there is five things you
have to know about my business, patient experience, patient
experience, patient experience. And he did things that I
have never seen done before. His employee training people
are actually former - this is a Cuban system so everything
is Spanish - but a former Spanish soap opera star and some
cast members and they actually train people around the
notion of how to hold your body, how to act, how to convey
so that you present the common experience even when you are
not feeling like it.
So it was that kind of shift to focusing on what the patient
wants out of it. He also said that people like me look at
things that for patients are inside baseball, and he
described going to a ball game. Most people are there for
the beer and the sun and the fun, and they are really not
caring how fast ball is being thrown or how many string
counts they are not keeping box scores. So the notion of
seeing the world from the patient, and it turned out to be
probably the most effective business from all the objective
measures that I have ever been around, both profitability
but also the quality scores were off the charts and the
complaint file was zero. And so I wanted to talk about the
innovation process there was this realization that led him
to this new paradigm that if we can retain patients and then
that would drive his profitability. So we totally changed
the business model.
The second one is when I was at MHN, we were a behavioral
health service company and we had this requirement, the Fort
Worth Police Department had decided they needed to outlaw
smoking, anywhere in uniform, anywhere near the building, in
the jail or in patrol cars. So they needed a police
department, people who were 20, 30-year veterans to go cold
turkey over a two-week period and then they were going to
begin enforcing the no-smoking rule. So one of the things I
took from was do not drive in Fort Worth during that 30-day
period. You do not want to explain why you ran a STOP sign
to somebody who had been going through smoking withdrawal.
We had a - and it was an possible situation because these
are policemen. They are out in the field; they are in their
patrol cars; they are working 24x7 shifts. And we were
supposed to provide group support for this smoking
I handed it off to clinical physiologist we had who was
particularly adapt at technology. And he came up with a
solution set of essentially adapting a conference call
methodology and running groups by telephone, therapy groups
by the telephone that the policemen could log in and out on
based on when they had time when they were sitting in patrol
cars and so forth. And we ran that for about eight weeks,
did individual counseling support all on the telephone and
got really very spectacular results in that the way we
majored that is generally the smoking nonsmokers after one
year. And we had like an 82% persistence rate which is very
high for smoking cessation programs. Very innovative use of
existing technology so the adopting and repurposing.
Then the third thing I want to talk about was I was at a - I
am doing a lot of work with patient-centered medical home
and one of the common wisdom things we know, I work with
poor people right now is that poor people aren't able to
utilize computer portals in the light because they don't
have computers in their homes. I was at a patient-centered
medical home in Seattle, and they were telling us it had
been harder to get that population to understand what was in
it for them. But once they figured it out, they were as
active users as the low-income population or the regular
population. And it turned out that the secret was they all
carried a computer, almost every single patient, including
most of the children, had one of these, and they had simply
adapted cell phones to the patient portal operations. And we
were able to provide communications to the patients, and
then patients began finding other ways to use other things
like look at their data and so forth, either doing internet
connections through cell phones or even in a few cases
public libraries and the like. So it struck me as an
interesting innovation of grabbing something that the
patient already had in their hand, and I am sure we are
going to come up with an app for that. And if not, you can
get to work on it because we need it.
What I thought I learned about innovation from this was that
the best results come when you asked the right question, and
almost to all of these innovations came about as an answer
to a question. The second one is the innovations that seemed
to make the biggest difference started and ended with the
patient, not with the technologist, not with the provider
but with the impact on the patient. And the third one is
that it's only valuable when it's accompanied by disciplined
execution back to the ops guy. But when I mentioned Leon and
their focus on the patient and the fact they spent tons of
money on making sure that experience was perfect, some
people think that sounds like a warm fuzzy organization. It'
s not. It's extremely disciplined in how they make sure that
experience is the same every time. And so the disciplined
execution follows the innovation, and that's what creates
the value.
So my correct question which I think if you solve this
question for me, you will have to generate lots of
innovations is if we know what to do and we do, I have been
involved in patient-centered medical home, advanced primary
care practice for long time. I can tell you we predictably
get 10 to 15 points drop in MLR run rate when you let
primary care actually do what primary care needs to do. The
question is why don't we do it, and solving that problem of
what are the things that keep us from doing this right and
innovating around that I think will be the next source of
innovation. Thank you.
[Informal Talk]
-- as Jerry was talking and I was, might have been a few
places where in terms of your digestion of this, it might be
helpful for me just to briefly elaborate. When Jerry
referred to the Leon example of being Cuban, he was
referring to a Cuban American section of Southern Florida. I
am not literally in Cuba. And what's interesting was Jerry
wasn't responsible for taking that model and replicating it
in radically different cultural environments such as rural
Tennessee, downtown Houston, places where uniformity of
culture and population were very different. Secondly, for
those of you, who don't know what MLR is, MLR is for any
delivery system that has global capitation arrangement or
something close to it in the way of a shared savings
What the insurance company basically wants to know is what
percentage of the total premium being paid in for the
patients who are taking care of is eaten up in health care
expenses, either doctor fees, hospital fees or drug fees.
And so a 15% reduction in MLR means the amount of money that
health insurance company is paying out for care after the
innovation is 15% lower per person per year across all types
of service category. So it's a very big gain. If in the
United States, we can reduce American health care spending
by 15%, we multiply that times $3 trillion, I will let you
do the math. Tom Lee.
Hopefully, I just approach this with the panelists a little
bit more informally in terms of conversation. But just so I
have a little bit of context of the Audience, I just saw
hands for people who were here to learn something about
health care services just kind of for their own
understanding. Is that kind of where people are? And then
how many people are doing something or interested in doing
something entrepreneurial in health care services?
[inaudible] it's a brave world to kind of attack out there
in health care service innovation. It's traditionally not
the sexist place to attack, certainly coming from Stanford,
there is many other options to look at. And all I can say is
it's where the core fundamental transformation is needed. So
we need entrepreneurs in the space but it's also equally
difficult. And I think there is a lot of people tried and
failed, and it's not a very attractive space, and it's a
difficult space for a variety of reasons. But to give you a
little context about what I have done and what we are
working on One Medical Group, I will give you a little bit
background in context as to kind of
[inaudible] may kind of inform you about your journey and
also there is some generalized place that Jerry makes it I
think our resonant. But briefly, I am trained as an
internist out of the Seattle and Boston, and it was pretty
clear as I was going through the training system, despite
the values and rhetoric of medicine that we weren't
delivering on the promise of the patient care. And it was
not done through ill intent, it was done through ill
systems, systems that are financed and organized in ways
that are antithetical to great patient care.
And so there was enough people complaining about it, and I
just figured somebody had to try to figure it out. And I
knew there were enough inputs coming into the system, it's
not an issue of resource. We are spending more than any
other country per capita, and the outputs are so poor. So
there is some inherent flaw in the system if you take a look
at the system at a much more macro perspective. And it's
inevitably inefficiencies, it's transactional
inefficiencies, overhead inefficiencies and kind of
misalignment of what organizations are doing to deliver what
people want which is health care.
So I began my journey as a completely naive physician. So I
can relate to the physicians that Jerry mentioned that are
not used to working with administrative types because it is
very different world. It's a world of scientists, a world of
people who are completely motivated on the patient values
but then trapped in the system that isn't really working for
them. So I understood that but I had no idea of the business
world, and I think that's where the insight really came into
how the health care system is structured and how irrational
it is.
So kind of through this process of discovery, there is this
raw belief that there is just enough waste in the system
that if you came up with a more sophisticated business
models and kind of people system to deliver the care that
you wanted to do, you could kind of destruct the system from
inside and out. So that's our approach is to take the
dollars that are in the system but repurpose them for better
use. And for most people who are reasonably well informed
about the health care system, it's a volume-based system,
it's insurance driven and third party reimbursement driven.
And so therefore this system is doing exactly what is
incented volume. And unfortunately, providers over time has
developed high overhead in the their practices to not
support that and so they have to increase the volume
further. So that's why we have this system today
[inaudible] for anybody.
So our approach has been to clean slate the primary care
model. There was always an inherent public policy belief
that primary care should lower total health care cost and
deliver better value. And in the practice of care, it makes
the most sense. When I have patients who know me over a long
period of time, they can email me a quick question, I can
answer them without having to ask them what their
preferences are. Facebook is powerful because you know your
friends. It's not powerful in it itself. It's a shorthand
for extending the relationship. So what we decided to do is
clean slate the model and build it completely around the
patient along the lines of Leon but with a very different
intent which was to scale and that's the other kind of
challenge in health care innovation, particularly in
services. There are great models across this country. One
off doctors that are doing great jobs around this country
and then large systems like Kaiser that are doing great
jobs. The challenge has been why haven't they scaled, and so
we wanted a scalable model that can attract capital, that
can attract great people and build the software system
around that allows us to deliver higher quality care at
lower cost. So that's kind of the basic premise.
One Medical Group, just for those who don't know, is a high
touch kind of practice. It's a primary care group practice.
We offer same day appointments, longer visits with your
doctor. You can email your doctor; you can mobile text; you
can schedule your appointments through your phone or online,
very basic things that are well known to the system but we
actually do it within the insurance system, and we have
worked that through lowering our administrative cost, and we
have been able to kind of offer that value back to the
patients. So we lower our total administrative cost, give
back to the patient in terms of patient and kind of
experience. And then we ask the patient to support our kind
of practice model by supporting with a nominal fee of couple
of hundred bucks a year. So it's very affordable. It's
intended to be skin in the game rather than a concierge
So that's kind of what we are about. I think just highlight
some themes or the most kind of obvious thing to kind of a
consumer-oriented view is not necessarily the way it will
get deployed in health care. So as the business models are -
the way health care is financed is very
[inaudible] so you have to kind of disrupt the natural
incentives of the economic system and the payback as much
longer. So you have to be patient associated with that but I
think that's related to Jerry's comments.
Thanks Tom. Paul.
[Informal Talk]
The reason is that I wanted sort of combined what I can say
with what I can show, and I think the particular points I
wanted to make are innovation isn't about a point in time,
it's about creating sustainable change over time. And hence,
it has to be both the function of the idea you start with
but also how the idea evolves because the other thing about
health care is that the environment is so dynamic. So I
think that the challenge is going to be how we can live with
credible ideas, make them scalable, make them sustainable
but also make them flexible.
So the leadership issues are pretty profound when we try and
think through that. So I will just tell you a little story
that basically just grew out of this innocent conversation
we had about 10 years ago when we were sitting around and we
said, we do pretty well at Kaiser Permanente taking care of
people that have chronic health conditions, what if we
started a disease management company. We started the same
questions as Tom, and we take care of eight million people
in the Kaiser regions. But if we weren't anything, that we
could actually translate into providing care for chronic
conditions in a much larger market, like how hard could that
be. And that sort of started a journey that was again trying
to leverage things. So we have been pretty well recognized
for trying to think about how care for people with chronic
health conditions could be packaged and then delivered as a
service that could complement and extend the work that
clinicians were doing.
So it sounds sort of hopelessly naive now, it was naive and
actually going into these things with some naivety sort of
is not a bad idea because it actually allows you to not know
the answer going in. So a lot of innovation has been willing
to listen to what's going on and think about what's going
on. We did have a core strategy which really boiled down to
much in light of we heard earlier today that it was about
figuring out what the right thing was and then trying to
make it easier. And making it easier, it's very much
sensitive to context. So within Kaiser Permanente, there are
variety of ways that we can make things easier
systematically, and we went into this thinking well, that
must work in other places still.
So we did create a company. Even creating a company within a
place like Kaiser Permanente is kind of an interesting
exercise which is probably another whole discussion that we
won't have. But we also had in a sense what was ultimately
problematic opportunity to test the idea about what this
company would look like for delivering disease management
services using an internal client, one of the Kaiser
Permanente regions. It did give us some advantage to
actually get our feet on the ground and test what was going
on. But it also sort of perpetuated that what works inside
and then integrate a delivery system like KP would actually
be credible outside the place like KP. Now, the relevance as
you think about all the things that are coming on now, about
payment reform, about changing systems, about assuming the
doctors can play well together, you need to actively test
those hypotheses because there isn't a whole lot of evidence
to suggest that doctors play well in the outside.
So if you are going to create accountable care
organizations, think about where they may be places where
physicians collaborate now but also realize that there is
probably through the working class phenomenon that says that
what works there has some principles so you can carry
forward and you are going to have to be really thoughtful
going forward as you go. So one of the things that I did
sort of naively back when we were running our programs
within KP is we contracted one of our research centers to
evaluate our programs and to help us understand that we were
actually making a difference. And this is an interesting
article if you would like to read it. When you read the
title, your takeaway would be no, they don't save money, why
the hell do we do this.
If you actually read the article, what you find out is that
compared to tran there were several $100 million worth of
savings. The quality improved for about everybody that was
there, the way that you get this published and also the way
that you end up getting your next brand is to make
statements like discuss and save net dollars. All of which
are true but again the issue was to understand what the
marketplace is looking for and the marketplace was actually
looking for something that might be a little bit better even
if it was segued into curing not necessarily the all time
This also was amplified both by expanded hope through
Medicare advantage. CMS got into the disease management
business whole hog, structured in a way that looked like it
would reveal powerful answers by running it as a very large
trial. And then the industry got all excited about this. It
looked like a huge opportunity, and the expectations weren't
fulfilled in the final analysis, didn't reach the cost
saving target. So if you actually again read the paper,
there were fairly substantial learnings, fairly substantial
business opportunity created but Medicare health support was
seen as a failure.
So here we are implementing a disease management company, an
environment where we are publishing our own literature that
basically says it doesn't work. Medicare comes out and says
this really sucks. And so it's kind of like how hard could
this be. Well, the good news is that there were some other
things going on too. The employer was actually reformulating
the value proposition, and they were saying it isn't just
about paying for services, it's actually being an active
participant and supporting in incentive services. And they
began to understand that also that a huge amount of what
they were looking at were patients with chronic health
So the market was changing a little bit, and the concept was
changing a little bit from being around disease management
to thinking about how we improved the health of a
population. And then places like Safeway began to really
start thinking about how do they actually almost become
surrogates for health delivery, if not health delivery
organizations, and began to increasingly ask who is the
infrastructure support that can help me create healthier
workers, which is a little value proposition than the
question about how can you actually improve the care for
people that have diabetes. But the delivery services are
very closely aligned. And fortunately, we were able to
recognize that there was a changing environment that we had
capabilities that allowed us to support a market-based
Part of it also
[inaudible] saying okay, we have got to rebrand this
[inaudible], we have got to clearly differentiate these so
if something different it's associated with Kaiser
Permanente but it isn't Kaiser Permanente, you want Kaiser
Permanente, a joint Kaiser Permanente place. But if you
happen to be in a place where it doesn't exist, we can help
bring this. And we also had to think about what the
portfolio of services were.
So at the core of this are the ability to actually support
behavior change often through a coaching encounter but there
are a variety of other ways to support behavior change and
the end of behavior change was to support people in making
better decisions to share decision making and to be able to
support employers and thinking about where their particular
population had opportunity in delivering services
[inaudible] and then to promote health that again aligned
very closely with employers. And it also meant that our
customer base evolved from being our original thinking about
being small regional health plans to largely being huge
employers that had the need to meet many employers at the
same time.
Good news is there is actually a fair amount of literature
validations that work. One of our strategic partners Health
Dialog has a very large randomized control trial that was
published in the New England Journal which shows that this
stuff works. You can't change behavior. It's not necessarily
about changing health care. This is the modest activity in
the midst of all of health care which is also important to
keep in mind what your scale is and what your scope is. And
scale has a dimension of not only how many people you touch
whether you are trying to solve the whole problem all at
once or you are trying to create a meaningful intervention
that you can actually scale across a lot of settings.
So the branding is changed dramatically to really thinking
about this range of services and support of the wellness and
condition management being focused on the person who has the
diseases, not the diseases the person has, which is a
critical change in how you think about framing, to think
about who the target base is and then for those of us that
are old enough to remember,
[inaudible] disease management under the fourth paragraph.
But it's also to think about part of the brand as to link to
but not totally mirror things that are done within the place
like Kaiser Permanente.
So if you - just sort of musings and how I think those could
translate in the guidance, one of the warnings for us is
that you are well familiar with where you start and you have
got to realize that almost always it would be fundamentally
different than where you start. So adding integration to a
marginal system is fundamentally different than adding
marginal value to an integrated system. And a lot of the
things - and this is going to be important as you think
about a lot of the things that are being promoted in Health
Reform that are based on what's happened in settings that
are fundamentally different than the ones we are trying to
So there is a reason why primary care docs and specialists
don't play well together in most of the American health care
because they are not incented to do so. So we have to think
about how we actually understand what are the incentives
that are being driven and think really closely, and I think
what are the ways that we can actually change that. I will
come back to comments that were made before. Ultimately,
relating this to the patient is probably a common thread
that will take us all the way through because it's
ultimately the patients' money whether they are getting it
directly or not getting it in their check because this is
going to health services. And being able to relate this to
the needs of the patient at the macro level is important as
we will see it gets more important as we go down.
It's also hard to realize that you really have to keep very
close eye on the people that you choose to work with and
realize that they may have a shorter haul picture. The
evaluator we used, the way that they actually promoted
things, to me, was kind of silly because it wasn't like we
hired them again. And I am thinking about you want people to
be in this for the long haul with you and think with you
about how you actually frame and share information. So it is
important to be able to be flexible and purposefully
diversify what you are doing and choose your partners really
well but also realize that if you are on a path where your
partner is getting you or you want to go or where you think
the market needs to be going, you have got to get rid of
A really critical issue is in dynamic markets like this,
creating change is only the first dimension of what you have
to do and the issue is how you actually sustain change. And
the way that you sustain change is to change pretty
dramatically yourself. So the trick is to change and
sequence with the market so that the leadership issues are
really pretty profound, and we have very fortunate to have
leaders who can be grounded, can execute. But part of
execution is to always be using something next year that's
different than what you are doing this year because the
marketplace is going to have changing expectations, and you
will only get there if you are thoughtful in that way.
And the last part about this is just coming back to the
patient that health care service is frankly an oxymoron in
most of American health care, I mean health care is lack of
service. It's a burden. And so thinking about how to reduce
the - whatever the verb would be - but making it less of an
oxymoron is really critical. And I think that the challenge
is for us as clinicians or as people to try to define these
systems, to realize that health is extraordinarily personal
and almost all the knowledge base has been derived for
collections of people or populations. And it's about trying
to think about how do we actually create personalized
services. So patient centricity is sneaking in. There is a
lot of thinking around that.
I think the genomics industry has done some huge favor by
sort of pointing towards the opportunity to focus care on
the individual. But going forward, care for the individual
is going to have far, far, far less to do with the genome
than it is around the other things
[inaudible] individuals. And I think that we heard this
morning talking about preferences and values, supporting
people and choices. There are ways to do that systematically
but in order to do it well systematically, it's much more
around mass customization than it is around cookie cutter
coming up the solid way. So I think that going forward, is a great example of how things are
changing. I think that medical homes, ACOs and exchanges at
what we are going to be innovating within, that's the
environment where successful innovation is going to be
What's going to go forward, what does this mean for a place
[inaudible], well the question that I have right now is who
is the infrastructure provider for the medical home in the
absence of somebody who can bring predictive modeling, who
can bring registries where a risk of building several
hundred thousand
[inaudible] homes on the priory, and that won't necessarily
help us to improve the service. You have heard examples of
how that's playing out but I think that as we think about
how to create personalized accessible services, there will
be the need for people to supply a whole range of
infrastructure, and I think it will be an interesting time.
So thanks very much.
So while you are digesting these presentations and thinking
of the questions you would like to ask them, I am going to
ask the panel to sort of briefly address the question that
occurred to me as I listened to each of them speak. It keys
off of Paul's last comment that there has to an underlying
reason why so often health service is - why service in
health care delivery benchmarks so poorly against other
forms of human service. My intuition from when I was a
clinician was that it has to do with the fact that patients
are so appreciative of what you are doing for them. It's
easy for the people who are providing that relief to sort of
get into the mindset of patients as supplicants rather than
patients as customers and people who deserve outstanding
Each of these innovators had to think about how - thought
they differ in their objectives, they had to think about how
to transform the front-line clinical workforce that was
interacting with the patients into a force that felt
differently that was willing to recognize that even though
they were providing very helpful services, they also had to
be with - I guess we could simply call - very nice in the
process of doing it. I know in the case of the Leon example,
the place that Mr. Leon started, and like Jerry maybe
reflected on this, was he reasoned very simply. I refer this
as sort of lizard brain thinking. He simply asked himself
where did he feel most wonderfully treated now that he had
this new objective of retaining from 865 on the eternal
loyalty of these Medicare advantage patients that Mr. Leon
was serving in his primary care clinic, and the answer that
occurred to him was when I am at Ritz Carlton Hotel, people
could not be nicer. And that turned out to be just the
beginning of Mr. Leon's solution to how he went about
training a clinical workforce to be extraordinarily and
consistently nice to these seniors who were their primary
care patients.
Similarly, in One Medical, I mean the reason I have stayed
with One Medical is it's wonderfully convenient and there is
no waiting when I get there. I am treated well. They are
there familiar with my record. That doesn't happen normally
in health care. Clearly, there is something that Tom is
doing to sort of structure the work and also select who
works there in order to make that happen. And last but not
least, I can imagine something more difficult to do then as
a third party operating from a telephone, from some offsite
location, change people's behavior at work not only in the
health domain but also in terms of their role and
productivity as employees. I mean it just seems impossible
that you could build the relationship that would lead to
those kinds of changes on the phone in order to be
successful on that business or to solve that problem.
So maybe you can each just in a minute or two reflect on as
each of you had a different change objective but they all
very much depended on the customer feeling, treated very
much better than people are typically treated in American
health care. How did you do it?
What we began do was actually look at what the customer
wanted and I know that sounds silly to say that but I have
been in health care all of my life and really that was not
high on the equation. We talked about customer service so
answer the phone calls in three rings or last dial when you
answer, that kind of thing. But we really didn't spend a lot
of time asking what it is the patient wants. What we found
was the patient wants not only the nice treatment but they
want comfort, they want to feel guided, and they want
certain expectations that matter to them every time. When we
were trying to replicate what Leon was doing in rural
Tennessee, we were charting patient satisfaction almost on a
weekly basis. And you could run the chart, and one of the
things we found in that particular population was when you
said I will call you back with your lab results, for them
that was a contract.
And when you didn't do it for all the reasons in busy office
practices that you don't get around the things, when you
didn't do it, you could see that satisfaction
[inaudible] because that was not important to the doctor, it
was not important to the delivery system, nobody was going
to get paid. But it was that contract, that trust
relationship that would get broken, and it was probably the
most difficult thing we did was how to work on how do we
guarantee, how do we create an organization that meets those
expectations every time, and we had to quantify the
expectations, quantify. And it sounded pretty easy in the
lab but to get the behaviors from the staff, to get the
organization change, one of the reasons we often didn't
return the calls was that supervisor there wasn't authorized
to okay over time. So we have to change the organization
I mean I think there is a lot of literature out there
[inaudible] from the top and building systems that supported
in hiring good people and we just do that. Most people don't
do that. They say that but they don't do it. And there is a
big difference between your actions and kind of your words.
And so at the end of the day, we are in executional business
so I can say the customer comes first easily. But making the
customer truly come first, hiring people care about it
equally, giving them the degrees of freedom to deliver on
that promise is a very different thing. And so it's a lot of
tactical details that are intangible and it's what makes
service industries interesting, compelling and
[inaudible] this interesting context about how protectable
they are. There is a protectable element whether there is
cultural or kind of the people systems you have. Starbucks
is pretty easy to copy business I would argue but they
figured out a people formula and a business model that
works. And so similarly, there are other kind of great
service models that are figuring out but only a few at a
scalable level. And so we focus on actions in addition to
warnings but more in actions.
I think it's obviously about relationships on one level but
it has to do with sort of releveling relationships and the
relationship you have with your provider doing your
appendectomy is different than the relationship you have
with your provider managing you over time. And I think that
a lot of health care has been late to get that that you can
treat people. And so I think that respect is one part of it.
But it's also respect manifested in a whole lot of different
ways. So it's realizing that it's a busy professional -
well, just a question for you, what's the average time for a
primary care visit in Northern California?
So I think about how you answer that because what if your
mom who was in Walnut Creek and you are going to see a
provider in Oakland, and you have got to drop your kids off
to your mother's house, you have got to go through the
tunnel, you have got to park the car, you have got to wait
in the waiting room. You are going to see the doc for eight
minutes, and then you have to reverse that. How long is your
primary care visit? Do you feel respected during that period
of time? You might feel intensely respected during that
eight minutes or somebody sucking up to you but is that
respectful of you as a person, as a professional?
And there are other pieces too. When you come into the
office and they make you repeat where you have told them 17
times before, how much does that make you feel like they
remember you and they respect you as an individual? I think
people should become intolerant of people who aren't capable
of remembering what you did in the last conversation and
then they bill you for it, and then they call that
reimbursement for their time and
[inaudible] reimbursement figure time. So I think there is a
whole lot of sort of nested issues.
The other part there was a relevance issue where I think
that the reason that health care is getting it finally is
that I think what health care has figured out is that most
of the things that actually drive health care cost don't
have anything to do with health care, they have to do it
health, and they actually have to be outsourced and cross-
sourced to the patient if there is ever going to be success
and making any impact on the kinds of things that mostly
impact people's health now. So I think that there is a
recognition just as a business driver that's almost the
competitive thing to realize if you actually want to be
impactful on people's health, you have to form a
relationship, you have to respect them, you have to have
their information available.
[Informal Talk]
Maybe I could ask Paul to elaborate on one thing that I am
dying to hear from him and that is, it's hard enough to
build a relationship that conveys respect in carrying face
to face but what about over the telephone, how did you go
about tackling that problem
[inaudible] telephonic disease management, they have never
met these people before, how did you induce that?
Well, I think part of it's also, relationships are built
over time and relationships are also solidified in exactly
the things that I was just remembering about understanding
what's important to you, being able to support you. A lot of
times people, we talk about how could a nurse on the phone
ever come close to what a doc does in the office. But you
know what, that nurse on the phone is going to remember
everything that happened the last time you talked. She is
also going to remember the name of your dog or she is going
to remember what was important to you the last time. And you
think about what makes you actively contemplative around
thinking with someone working around behavior change.
And then contrast to that with sitting in the waiting room
and reading that Jennifer and Brad are still together in the
waiting room for God's sake. So I mean it's thinking about
how you can actually support it and it's realizing that
behavioral change is a little bit, it's the tiny steps that
were earlier. And I think that oftentimes the ability over
the phone, using people that are specifically trained in
coaching, not in telling but in understanding and listening,
being able to reflect that back can often form a more
durable relationship than the suitable relationships we
create in the office.
Thanks Paul.
Thank you. My name is Bill Evans. I am here in this
particular session because I actually work on the device
side of chronic disease management, and I think you can't
obviously do that for very long without realizing that it's
very much a systemic issue. And I really want to just ask
the panelists, do you think that though the two sides you
talked about the service model differences that need to
change and I think clearly there is some issues you need to
change in the device side, do you think there is enough
integration, there is enough communication going on between
those two different parties in that equation?
[Informal Talk]
BT is obviously, it's a huge spend area but it's not - if
you have just a device-centric approach, you end up creating
things that are good for your business model as a device
producer. When really probably from a public health policy
point of view, it's much more about some of the service
model innovations we are talking about here. I am well aware
of what Kaiser is doing in that area for instance. And I
wonder if there is enough communication between the two
sides to enable the most successful innovation to take place
and --
Yeah, I guess my response would be that if you have looked
on, if you try to say have we been able to see a major
movement in this way now. But the other point is and I think
that these innovations need to be disruptive and they need
to be - you don't want to start out with
[inaudible] because I think it's killed off before there is
a chance. I mean I thin the whole point is it's small and
there are a lot of islands. The other piece that I think is
really important is that it has to be parallel process.
There won't be a single thing that will work for everybody.
There have to be a whole lot of different innovations in a
given space, parallel processing rather than thinking there
is going to be one thing that will necessarily work.
So I mean mHealth is a wonderful metaphor where a year ago,
who knew what mHealth was and how many people were actually
thinking about it? But it's a wonderful way to realize that
you are trying to reach people at home using information
technologies once you are out getting them over the computer
or getting them over the phone, it's kind of
[inaudible] now. But for so much time, we talked about how
we elderly don't use the Internet. So I think that it just
changes as we begin to see the different innovations. There
are some of these
[inaudible] than others.
Jerry, Tom, you would like to add?
I think it's a great question. I mean I think there is going
to be a need for device companies to move a little bit more
in alignment with what providers will be. But today, that's
just so lagging. I mean I think the only large delivery
organizations like Kaiser probably have the best potential
to kind of create and shoot that market but I don't think
it's happening to the extent it could. We would love too but
we are still too small. But I do think that looking at how
devices transform the care experience within that lens is a
very different approach and could be pretty
[inaudible] at the right stage. But I think it's the
financing and usage issue.
I think one of the contributors to the overall chaos in
health care system or non-system, as it is, is what I call
the many-to-many conundrum. Lots of insurance companies who
feel they ought to be stepping in management of patient,
physicians who feel they should be managing the patient,
hospitals who feel this is their community they should be
setting the tone and all right thinking well meaning but it
creates gridlock. And so when you start introducing
innovation, it seems to come in slices. This innovation will
only apply to 12% of your practice, and I don't know how we
break through that but somehow we have got to be able to
have clear channels of responsibility so we can actually do
I think Jerry
[inaudible] good point. I mean there don't need to be only
the point innovations, there need to be bundlers, there need
to be ways of these things to actually begin to be
accessible to practices without having to choose all the
different pieces. There will be different ways
[inaudible] maybe IPAs, maybe management firms, maybe health
plans, maybe companies. But I think part of what we are
going to see is there will be aggregations so that a
physician doesn't have to sort out all the different pieces.
They can access the service.
And that's right, putting the plug for a comparative
effectiveness, having to - again the many to many, having to
originally do the research on everything you want to bring
into a practice or set of practices is just daunting. So the
notion of having a reliable standard that you can say I can
rely on these claims and it will fit my population is
something we don't have. So we have to rely on salespeople.
So my question reflects around social disparities and what's
going to happen with the Affordable Care Act which all of a
sudden now is going to cover 32 million more people. And as
I listen to these great presentations on how service
innovation is going to leapfrog around innovative mHealth or
e-mails, this is going to be a population that doesn't have
access to that, and I am curious is to how each of you are
going to approach this large population with quite a
difference in access in social disparities.
So just to elaborate on this, so the missed people who are
going to now have health insurance who didn't have it before
are what's referred to as the near poor people who didn't
quite make the old Medicaid, the eligibility cutoffs. And
Michele is right, they tend to have fewer resources, and we
will need customized approaches if they are going to benefit
from the enhanced coverage.
I am working currently with an FQHC which is a community
clinic organization. It's one of the largest in the country
so we would say good sized enterprise. But core part of
their mission is to reduce disparities in health care
outcomes for Latino and other minority populations. So it's
kind of their reason for existing, and it's very complex.
The one thing I have begun to learn is that people are not
as access limited as you might think that they can embrace
and do embrace the technology. And again, they kind of skip
the home PC. But we are finding that everybody is walking
around with the cell phone, and we were slow to get that.
When we ask for people's phone numbers, we have got a home
phone, mostly they are disconnected. But now what we need is
your cell phone. But that's part of the cultural relevancy
of figuring out how you work with specific populations and
how you make that accessible and it's not always high tech.
[Informal Talk]
The thing that we tend to migrate to technology is a focal
point for how this could all happen. But I think that a KPM,
anybody else has ever tried to implement technologies,
whenever you make a big mistake, it's usually not inventing
the technology, it's understanding the social processes that
go along with using the technology. And so the trick here is
don't let your IT guys design the solution for disparities,
it ain't going to happen. But it's involve them in the
discussion. And then there is always to me the dominant
thing is how you figure out whatever we call workflow in the
professional setting but how people think, how they act, how
they get the services. I mean that's the power of
[inaudible] in different cultural contexts. So a lot of it's
going to be to figure out who do people self-identify with,
who do people seek respect from, how can they actually have
information exchange in a way that's durable. And a lot of
times that has much more two people talking than having a
device in between, and I think that's where a lot of the
promise is.
Hi, my name is Shubhra Jain. I am a physician and a student
at Stanford. My question is geared around One Medical kind
of a system. So in a system where patients are actually
allowed to text physicians to ask questions or schedule
appointments, it is very convenient from the patient's point
of view. But looking at it from the physician's point of
view, it also puts an additional burden on our already so-
called busiest professionals in the country. How do you plan
to manage for that while optimizing it from the patient's
point of view and providing good service?
Yeah. So this is kind of one of the key concerns about
improving access. You improve access, what kind of access
and you don't want text messages about random things. So I
think the key issue is forming a relationship that's built
on trust and access but feedback on inappropriate access. So
there is a couple of things. We budget the time to manage
appropriate communications, digital or physical. But
inappropriate digital or physical encounters get feedback
back to the patient, and it's a dialog saying this probably
didn't need an e-mail or this probably didn't need a visit
or in the future, you can do x, y or z. So it's a language
and a learning process that people need to develop new norms
for, and it's behavioral. And so that's what we do.
Good. So it's also very subjective. Like there is no hard
and fast lines so how do you kind of decide where to draw
the line?
The line is to
[inaudible] of the patient. So if the patient believes that
they are having a heart attack and we know they are not,
come on in, we will see you. Now there is the other side
where we are a little bit paternalistic on a clinical side.
If we think they are having a heart attack and they don't
think they are having a heart attack, we will force them, we
will act
[inaudible]. So there are two elements to having it. But by
opening that communication channel allows you to have that
dialog rather than not have that dialog. And it's a human
communication between both the consumer or the patient and
the physician and the providers of our team, and we trust
them to figure out the right solution at the time.
Another thing that we found key here in North California,
40% of the primary care contacts now are the virtual through
either e-mail or by phone, mostly by e-mail. And the other
advantage that the clinicians have found is that the
asynchronous nature of those unloads, some of the tension of
the office. So there is also - and for workflow, it also
means that if your service delivery is to respond within 24
hours, that means that you can actually go to the soccer
game. You can be home for your kids. You can do the e-mail
at some other time after they are in bed. And it's also to
think about how you have accountabilities and workflows so
you don't look for people into the crowd to do it. But we
found it gives much more flexibility on the clinician side
to actually take care of the practice than forcing everybody
to come in for eight-minute visits.
[Informal Talk]
Hi, I am Eric Bier from the Palo Alto Research Center. We
talked a lot about the patient experience in this panel. But
I am also very interested as a patient when I do need
treatment, how can I be sure that I am being seen by someone
who is qualified, that they are up-to-date on the latest
possible treatments, that they are using the latest
information, that I am getting as good or better value than
I could get from some other organization? Basically, what
information do I get from your services and your networks
that I am getting the value that I want to be getting?
[Informal Talk]
I mean I guess I am going to take liberty since I no longer
work for Kaiser Permanente, I will tell you my personal
view, is that physician should be accountable for being able
to reflect the service that they deliver. And I think that
that means that they should be personally accountable for
how they perform and they also have an accountability to
work with the system that will give them the support the
patients need. So I mean if that means that we have to have
reporting down to the individual physician level on how they
are doing a range of things like satisfaction and
everything, I personally would favor that. But that's again
my personal opinion.
Probably, we will elaborate but I think it works in some of
the additional implications of the questions. So for
example, patients want to know that when it comes to being
referred to a specialist versus they may be handled by a
primary care doctor, I think what I would want to know as a
patient is that I am not just being rapidly turfed off for a
problem that the primary care physician could solve for me
right there and they are confident to do so that they would
do it. On the other hand, I also don't - I want to like to
have the confidence that if the right answer is based on
current clinical guidelines and the capabilities of the
primary care doctor, that the right answer is I would be
referred out, I would like to have the assurance that that's
going to happen.
Right now, that's sort of very much a grey zone or a peak
zone for patients who kind of hope that it's happening. But
you really have no way of assuring that you are being
continuously matched with the right level of clinical skill.
Any thoughts as to how we might better assure patients that
they need not worry about that that - I mean I think
[inaudible] in the world of Kaiser Permanente, the issue
often occurs with respect to quaternary services, things
that we don't want Kaiser Permanente to do, we want them to
refer to UCSF or UCLA or Stanford or whatever.
I mean I think if the patients like me think, so what you
would want to know is what happened to the last 15 women who
wanted to know about having bone marrow transplant for
breast cancer in 1996. There were some questions like that.
And I think that people won't have access to that kind of
information. You may very well find out that none of them
ended up seeking a bone marrow transplant because they felt
that their questions were adequately answered. So it also
makes the point that you have to understand what the metrics
are. And I think there is a lot of development work that we
have to do around appropriateness of service, not just
quality of service. And appropriateness we have a patient
dimension and other clinical quality dimension, is that, for
example that a dimension that we might expect forward
[inaudible] responsible medical group in the future might
want to report to their customers as to this is something
they monitor and when patients do need referral out there,
they are getting it because it obviously is a source,
particularly, especially among very discerning customers,
it's a source of concern.
Right, and don't
[inaudible] because I am very sensitive about what
[inaudible] earlier that we don't want to set up the
practicing guide as a single point of failure either. So I
think it's very important that we respect panel size and
variety of other metrics. And the other thing is it isn't -
service quality isn't just letting the patient have just
whatever they want. It's about having a relationship and
having a dialogue and about having boundaries. And I think
to me, I want to know that I am in a health care system that
can understand the boundary that then can respect my needs
as an individual within the boundary, not the cookie cutters
[inaudible] one particular process. But I think we have the
metrics to reflect that.
I think you said the keyword which was in a system of care
so you are not a doctor and then sent to a different doctor.
But there is a system of care, and you have learned to trust
that system of care, and that's been built through your
experience with it. How are you treated, how your questions
are answered, it is that transformation that we have to make
away from care from being a practice by individuals to
systems of care that we can sort of define and be able to
say I trust that system or I don't.
My name is Rajib Ghosh I work for of Bosch Healthcare. My
question is to the panel that as you are talking about
innovation in health care service delivery, how do you feel
about or how do you think we should approach as an industry
to integrate the telehealth services or home care based
services to improve patient engagement, patient's overall
health, population health management, and who should be the
driver for that? I mean other than the CMS, whatever they
are doing and we heard talking about this morning but from
the providers like Kaiser Permanente or the new innovative
designs like One Medical, I mean how do you guys think that
we should proceed with that?
Well, I have spent a lot of my life dealing with
disconnected, disjointed health care well meaning but where
one insurance company uses a nurse space, call panel,
another insurance company sends help buddies home, yet
another payer does something different. Primary care
physician doesn't know any of that's going on, doesn't get
of that back in the medical record or what's being found.
Patient comes in and says some lady called me and so the
patient ends up kind of conflicted around that. And I know
it can be done well but for the most part, it hasn't been
done well. So that would be my first and foremost point is
whatever we do really needs to coordinate and integrate as
part of the process in a consistent way rather than be sort
of independent silos of each other. And that's that many to
many, I mean not bad people but it's a bad system.
I think
[inaudible] ways that we can build on that, ways that we can
extend relationships. And so part of this is to not have it
as a way to cut into the practice of your primary doctor
anything but is to create the opportunity for the doc to
bring services to patients they wouldn't have had otherwise.
So when I think a lot of about the Medicaid world, access to
specialist, it may be much more credible to create access
through vehicles like telehealth than it will be to
necessarily be able to use bricks and mortar based services,
and we shouldn't enter into this with a premise if that's
going to be the worst care.
The question is what would it take for that to be better
care, how can that support the primary care clinician about
creating access they couldn't do before, that can expend
their relationship. And then the other thing that we have
encountered is that if you actually do the telehealth visit
while the patient is in the room, I mean involve their
primary care doctor in the room, there is also a continuing
education opportunity for the doc to get direct learning
from the specialist. So there are variety of ways you can
connect the dots that might not be possible by sending the
patient all over other place.
Yeah, I mean the key issue is just the economics of it and
having the population to justify that. So if you are
accountable for that broad population that's just for
geographically, it's fantastic. But I think there is only so
many models that will support that. Our models at some scale
are going to support those type of technologies.
[Informal Talk]
[inaudible] one of the residents here. I have a question
about sort of one of the big elephants in the room with all
this is sort of the litigation that we have in America in
terms of the fear that here we have as clinicians of missing
something that somebody is telling us on the phone, they say
they have a fever, something always, it ultimately may
require additional workup. Have you noticed that in your
business models, you have noticed that this rapport that you
build with your clients that you have had less incidents of
sort of cases that have gone wrong where they haven't been
willing to sort of undergo aggressive litigation against
your firms? Or is it still something that remains in the
backburner where you are very conservative on your
telemedicine or with your phone calls if something gets
brought up by a patient, then you all immediately bring them
in to get evaluated DER? And has that caused more cost or is
there any internal analysis being done on this from a
litigation standpoint as well as from the cost standpoint?
All right our cost at KP are down, and I think we attribute
that to being able to amplify with the pieces you put your
logic chain down at the very end is that patients are much
less likely to sue if they feel that they have a
relationship and that relationship or the things that we
talked about before. But it's not just having a friendly
warm hug from your doc. It's about being treated with
respect; it's about having your information there; and it's
also the ability to realize that your doc is a person too.
So I think there are all those things that sort of amplify
my mind.
Thanks for your participation. Please join me in thanking
the panelists.
[Informal Talk]