0:03

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0:35

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0:43

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1:21

Welcome

1:23

to In The Bubble.

1:37

This is Andy Slavitt.

1:41

The healthcare system is one

1:43

of the most important parts of our society.

1:46

It's complex and it's super dynamic. When

1:49

it changes, it changes in a way

1:51

that impacts all of us. And

1:54

so we're all deeply concerned. It's

1:56

also true that it's very hard to change.

2:00

Think of some of the major changes over your

2:02

lifetime. They've

2:04

largely been the result of government action in

2:06

some form. Obamacare ensured

2:09

millions more people. And before that, the

2:11

children's health insurance legislation in the

2:13

late 90s. And before that, well, right around

2:15

that time, a little after that, prescription drug coverage

2:18

for seniors. Before that, the

2:20

roots of Medicare and Medicaid, which

2:23

covered tens of millions of people who are low

2:25

income or on fixed incomes. And

2:27

before that, the rise of employer-based coverage

2:29

in the US. In fact,

2:32

when you look at it and compare it to predictions

2:34

that people are often making about the healthcare system,

2:37

these changes tend to come pretty slowly.

2:39

And it seems like, for

2:42

me, that's why when a very smart person

2:44

is willing to go out on a limb, it

2:47

makes some predictions, I'm interested. So

2:50

Zeke Emanuel has

2:52

done such a thing, releasing

2:55

what he calls the nine changes,

2:57

the nine megatrends, that he anticipates

2:59

coming to the healthcare system. Who

3:02

is Zeke Emanuel? I've often

3:05

wondered that myself. Zeke is

3:07

a professor, a physician,

3:10

a former policy official in the Obama administration,

3:13

a former bioethicist at the NIH. He's

3:16

also the author of many books, and

3:19

he's been a friend for more than a decade now. I think

3:21

that's right, but Zeke can verify that. I've

3:24

always been able to count on Zeke for

3:26

his edgy and opinionated commentary.

3:29

He may have an opinion about that. While many

3:31

others are still being more careful or

3:34

trying to collect more data, Zeke is

3:36

often the first one out there with a point of view.

3:40

Something else that's different about today's show, and

3:43

I wanna tell you that we're experimenting with a new and

3:45

unusual format. We've

3:47

invited a panel of

3:50

some 30 of the leading healthcare innovators

3:52

in the country

3:54

to ask questions, to

3:56

poke holes if they can, and

3:58

to provide a little bit of their own point of view.

4:00

So we're gonna spend the first two segments of the show

4:03

covering those predictions that Zeke

4:05

has made in the final segment taking

4:07

questions from this panel

4:10

and I will introduce panelists as they speak

4:13

and hopefully this will make for a lively

4:16

conversation and

4:18

of course this follows our first live episode

4:21

which was a huge success we did in Aspen,

4:23

Colorado with Dr. Amida Seshamani.

4:27

And so you can listen to that and if you want to talk about real

4:29

change talk about that with the person

4:31

who is actually negotiating to bring

4:33

down the cost of prescription drugs.

4:35

So

4:37

we may talk about that with my friend and

4:40

pundit and doctor and everything

4:42

else

4:43

Zeke Emanuel. Zeke welcome to the bubble.

4:45

Great to be here with you Andy thanks for the introduction.

4:48

Is it true we've been friends for a decade is that about right? It's

4:51

actually a little more than a decade yes that is true

4:54

and I can tell you who first introduced us. Okay

4:57

well maybe we'll get to that but

4:59

let's go let's go back a little bit further Zeke and just

5:01

to learn a little bit about you you could

5:04

come across as a curious and fearless

5:06

person. Someone who delves

5:08

into tough topics, someone

5:10

who stakes out a point of view. What about

5:14

the way you grew up? Give you the confidence

5:17

to be that type of person or do I have it wrong and you're

5:19

just a ball of worries like everybody else that

5:21

you just put on a good show? Probably

5:24

a combination. For one

5:27

thing you know I had the good fortune

5:29

of having parents who asked us our opinion.

5:32

It didn't mean they always respected our opinion

5:34

or took it but they did want us to

5:36

have an opinion. When we went

5:38

into school and sometimes

5:41

presented our opinion and

5:44

it didn't necessarily go well with the

5:46

teacher my mother would

5:48

come to school and defend us and

5:50

defend our right to have an opinion.

5:52

So I will just tell a story.

5:55

I was in I think it was a third

5:57

or fourth grade gym class.

5:59

And we were a bunch of rambunctious

6:02

kids and the gym

6:04

teacher just blew his

6:07

top, lined us up and

6:09

said, you know, I expect

6:11

you to behave and I expect you to call me sir.

6:14

And anyone who doesn't think I should be called

6:17

sir, please step out

6:19

of line.

6:20

So I stepped out of line. And

6:22

he sent me down to the principal's office, mom

6:25

was called and I explained, I

6:27

think being called sir is something you

6:30

earn, it's not something you can command students

6:32

to do. And- How old were you

6:34

when this happened? This is like third

6:36

or fourth grade, so eight or nine years old. So

6:38

eight or nine years old, you had the temerity

6:42

when a teacher said to call you sir to

6:44

decide you weren't gonna do that. That's right.

6:47

And mom came down and defended

6:50

me and said, you know, I

6:52

think that's a pretty reasonable view. Teacher

6:54

has to earn that respect. He

6:57

wasn't earning the respect, he was just yelling and

6:59

commanding and they weren't doing anything

7:01

violent. It's not like we were doing something terrible.

7:03

We were just being kids. So

7:06

we had an experience of, you formulate

7:09

a view, it doesn't have to be popular, go

7:11

out there and express it. We also had a

7:13

view that, you know, learn. You

7:16

may

7:17

create a view that doesn't have all the facts,

7:19

doesn't have all the information, listen to other

7:22

people, engage in debate.

7:24

And, you know, I'm

7:26

happy to say there are many things I've changed my

7:28

opinion on because other people have educated

7:31

me. So while I express my

7:33

opinions very strongly, I

7:36

also, you know, respect other people

7:38

to have different opinions. And, you know, I

7:40

think when I've run departments and

7:43

groups, you know, I encourage people

7:46

to not necessarily agree with me.

7:48

And no one gets penalized for disagreeing me and

7:50

saying that I'm wrong or stupid,

7:53

including the youngest people and

7:55

the team.

7:56

I think people do mistake confident

7:58

people for people who...

7:59

won't listen and sometimes I think people

8:03

are less inclined to want to disagree

8:05

with someone who comes across very confident. I

8:08

think you're 100% right. That's certainly

8:11

an experience that I've had.

8:13

People somehow feel intimidated or they

8:15

think that, oh, he's never gonna listen to me. And

8:18

in fact, I've regularly

8:21

had younger people, my

8:23

students, research assistants

8:26

tell me, nope, they don't agree and here's why

8:28

and convince me that I need

8:30

to change my opinion. So I'll just give you an example.

8:34

Early on when I was at the NIH in the late 90s,

8:36

I thought that paying research participants

8:39

to participate in clinical

8:41

trials was unethical.

8:43

We had a guy right out of Dartmouth

8:45

College, I wanna say, and he

8:48

had a different view. He wrote up

8:50

a paper and he persuaded me. You

8:53

know, he had to be 21 years

8:55

old, you know, half my age, but

8:58

he had very good arguments and I listened to those

9:00

arguments. Okay, let's talk

9:02

about the healthcare system and

9:05

I wanna take it into a few pieces. And

9:07

I really wanna paint a picture for Americans

9:10

listening in

9:12

and I think our guests in

9:14

the audience today will help us down

9:16

the road. I wanna talk about first,

9:19

some of the things that are gonna impact people's care, how

9:22

long they live and how well they live. And

9:25

let's start with some of the new, how we should

9:27

think about some of the newest treatments. Now,

9:30

you know, this year, you know,

9:32

the big story, of course, is Ozempic,

9:35

a promising drug for people with diabetes,

9:37

a promising drug potentially

9:39

for people with a lot of weight, lost

9:42

needs. But we also have a

9:45

set of things that are here or coming,

9:47

better diagnostics

9:49

for cancer, for earlier detection, better

9:52

treatments for cancer. There's

9:54

hope even with Alzheimer's that

9:57

we'll be talking about Alzheimer's in a very different way in 10.

9:59

or 20 years. Tell us what you expect

10:02

here. Radical change,

10:04

improvements, what's going

10:07

on? Oh yeah, oh yeah. So

10:09

I'm an oncologist, I don't know that you mentioned that,

10:11

and I do follow the cancer space reasonably

10:15

well. This is a heyday for

10:17

cancer. And we've

10:20

had lots and lots of innovation

10:23

over the last, I would say, decade.

10:25

Real important breakthroughs. And

10:29

when I was training, we had chronic myelogenous

10:32

leukemia, and basically

10:34

we would have patients perk along, and then they'd do

10:36

something we call blast off. They'd transform

10:38

into acute leukemia. We couldn't do anything, and

10:41

they died invariably within six months,

10:43

no matter what we did.

10:44

GleeVac came along, made it a chronic

10:46

illness, and made these people live normal lives.

10:50

Talk about

10:51

transformation. We've had CAR T therapy,

10:53

pioneered by my colleague,

10:55

Carl June at the University of Pennsylvania,

10:58

takes people who've failed every

11:01

regimen

11:02

and resurrects them. It's

11:04

really an amazing, amazing story.

11:07

And we're just gonna get more and more of

11:09

these, because I think we have

11:11

figured out where the genetic

11:14

defects, what the targets are, and we just have a

11:16

better game plan

11:18

for doing that. As

11:20

you say, we've gotten out drugs

11:23

that affect weight loss. I have

11:25

to say, I'm of two minds about that. Hooray,

11:27

fantastic. And I guess the latest data,

11:30

literally out yesterday, about 24%

11:32

body weight loss with this new Eli

11:34

Lilly drug that's not quite approved. But

11:36

I'm a little worried that's gonna, it's gonna

11:38

sort of, we've had this

11:40

enormous increase in body mass

11:43

index in the last, I'll call it 50

11:45

years. And it's

11:48

not due to

11:49

genetic changes, it's due to

11:52

behavioral changes and the social

11:54

environment in terms of food. And

11:56

we're gonna now medicalize it. People are gonna still

11:58

get

11:59

heavy.

11:59

are gonna have a high

12:02

body mass index get obese, and then

12:04

we're gonna treat it later with a drug.

12:06

That is the wrong model.

12:08

That is the wrong therapeutic intervention.

12:11

And it

12:12

means that we won't feel any compulsion

12:15

to change the underlying cause, and

12:17

I think that's a huge mistake. Zeke, isn't

12:19

there, haven't we also learned that

12:22

this notion that it's just all about willpower

12:24

in terms of being able to lose weight, is the wrong

12:27

notion? That there are physiological

12:29

things, there are certainly psychological

12:31

things. And there's social, there's the environment.

12:34

There's

12:35

McDonald's and Coke and Pepsi,

12:37

I totally agree. Sure, all that. And

12:39

then in those things, great cravings, social political

12:42

things. So I guess I'm- Andy,

12:44

I would totally agree with you. That's

12:46

why I said I'm of two minds. I think this is fantastic

12:50

for people.

12:51

What I worry about is that

12:53

the underlying problem is not gonna be addressed,

12:55

and we're gonna actually perpetuate the underlying

12:57

problem, because we have this magic

13:00

bullet instead of addressing the

13:02

whole food system

13:04

and how we provide nutrition to

13:06

people. There's no doubt we'll take the easy

13:08

way out when we can, no doubt about it. And that's a really

13:10

bad thing. Okay, but writ large,

13:13

if people step back and say, the

13:15

kind of treatments that are out there for whether

13:17

it's making cancer more of a chronic illness, whether

13:20

it's diagnosing cancers early,

13:22

whether it's things that lead to diabetes

13:25

and heart disease and weight loss, But

13:28

what about the cost impact

13:31

of all of this? I mean, if

13:33

theoretically you can screen everybody

13:35

in the country for colon cancer, but it costs $500,

13:39

but you could detect it super early in a

13:41

blood test, we can't afford

13:43

to screen every, we can't afford to screen every

13:45

senior. And that's just one

13:47

example. All of these new things

13:49

are gonna have to be paid for somehow, how

13:52

should we think about what's gonna happen there?

13:54

We don't have a model for that.

13:57

We have not worked out as a

13:59

society. how we're going to think

14:01

about it. Now, other countries have

14:03

worked out, whether

14:06

it's Britain or Norway or

14:08

Israel,

14:09

Germany, they thought about pricing

14:12

of these interventions and how they

14:14

ought to be priced. They

14:17

use cost effectiveness. How

14:19

much is this health improvement worth

14:22

in terms of

14:24

our willingness to pay? And

14:27

I, you know, is cost effectiveness, the

14:29

be all and end all, solve all

14:31

the problems? No, but it does

14:34

give you a rigorous way of thinking

14:36

about how you want to pay. One

14:39

of the things I would say that

14:41

we have to actually get

14:43

to is paying for health

14:45

improvement. And by the way, that's not just

14:47

for drugs. I think it should be for all of our

14:49

interventions, whether it's surgery

14:52

or what doctors do in their

14:54

office. How much is this,

14:57

what you're doing, going to result

14:59

in health improvement? And

15:01

if we did that, I think we

15:03

would have a more rational way of

15:06

not only using drugs, using

15:08

surgical procedures, but also using

15:11

those adjunctive

15:12

things we call them, right? Whether it's, you

15:14

know, transportation to get to the doctor,

15:17

it's nutrition, just to report out today

15:19

about the impact of giving people

15:21

nutrition after hospital admission,

15:24

decreasing their hospital readmission and

15:26

decreasing their mortality.

15:30

Whoa, food is

15:33

medicine right there. So

15:36

I think one of our problems in

15:38

confronting this issue of how are we going to pay for

15:40

all of this is we have

15:42

been reluctant to say, all

15:44

right, we should pay in conjunction

15:47

with the health improvement we're going to get.

15:49

And those interventions that don't give us

15:51

health improvement, maybe we should pay

15:53

a lot less for them. And

15:56

we should be consistent about that. What

15:58

I worry about is...

15:59

the move that's happening now, both on

16:02

the left and on the right, to say, oh,

16:04

when the government negotiates with

16:06

drug companies about prices, they shouldn't take into

16:08

account cost effectiveness analysis.

16:11

I don't understand. That

16:13

does seem to me the answer, an

16:17

important element to how we

16:19

consider it. Sure. Clinical

16:21

improvement at what cost? Well, let me take a quick break. We've

16:23

got to do commercial. We're going to come right back. We're

16:25

going to talk about some very fun things like

16:28

how is AI affecting healthcare

16:31

system, mental health care, how

16:33

care delivery itself is going to work. We'll be right back. See

16:36

you in Manual.

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you get your podcasts. We're

18:44

back with Zeke.

18:46

We were talking about

18:48

some of the treatment changes, but

18:50

let's talk about patient care

18:52

itself.

18:53

It feels like at one point we had a system around

18:57

a doctor and a patient, we're talking

18:59

about decades ago, and

19:02

then we would go to see a doctor when we're sick, maybe

19:06

they'd pay a house call, it was all reasonably

19:08

affordable for many people, and

19:10

then we came into a system which I think healthcare kind of industrialized.

19:14

We're talking about a lot of the treatment that's

19:16

available in the medical field.

19:18

Came into a system which I think healthcare kind of industrialized.

19:21

Big hospitals, big corporations,

19:24

big programs,

19:26

costs went up,

19:27

and it was a very institutional experience.

19:30

And we kind of lost some of the personal

19:33

feel in healthcare for all the

19:35

gains that there may have been. Nobody

19:37

feels like they had a particularly great experience, with

19:40

the exception of maybe wealthy people who do concierge medicine.

19:43

And now people are saying that the new

19:46

horizon is the home,

19:47

that through technology,

19:50

patient monitoring, the fact

19:53

that as you write about hospitals

19:55

are closing, there's

19:57

more things can be taken care of in the home.

19:59

Is that one of the transitions we're going to see

20:02

how and where we seek care? Absolutely.

20:06

And I think we have

20:08

seen that thanks to COVID.

20:12

You know, let me just give you a concrete

20:14

example that was in my health affairs

20:16

article that happened at Penn, right?

20:19

We had,

20:21

like everyone else, shut

20:23

down most of the delivery

20:25

system, shifting to focus on COVID,

20:27

except for emergencies, right? I'm an oncologist.

20:30

What do you do with cancer patients who are in the middle of chemotherapy?

20:32

You have to continue. So we began doing

20:35

chemotherapy at home. Now, when I trained,

20:38

although these 30 years ago, if

20:40

someone had told me, Oh, you're going to be doing chemotherapy

20:42

at home, I would have said, are you kidding?

20:45

What hospital, what drugs are you

20:47

on?

20:48

But now we're there. And

20:51

you know, it's like crazy that

20:54

we're able to do

20:56

that. And

20:57

if you look at also hospital admissions,

21:00

Andy, I'm sure you've done this in your

21:02

prior lives, you know, hospital

21:04

admissions in America on both an absolute

21:06

and per capita basis peaked in 1981, we have

21:09

been declining in hospital admissions

21:11

over time because, you know, we're doing

21:13

more out of patient, you know, hip replacement,

21:16

knee replacement, and an ambulatory surgery center,

21:18

I mean, all of these changes,

21:20

um, now with greater

21:23

technology, you can do an ultrasound at home

21:26

when you couldn't do that before. All

21:28

of these changes are going to expand,

21:31

certainly with the advent of better

21:33

sensors,

21:34

better monitoring

21:36

in terms of AI, being able to ferret the

21:39

signal from the noise, uh, and

21:41

we're going to be able to not only monitor

21:44

at home,

21:45

but intervene at home virtually and,

21:48

uh, for serious cases,

21:50

send people to the

21:53

house. And you see this in all sorts of areas,

21:55

chemotherapy, just one, but you know,

21:57

for decades, we did not

21:59

do.

21:59

dialysis at home, right?

22:02

We prefer dialysis and paid

22:04

more for dialysis in facilities. Well,

22:07

that's gonna switch. We're gonna be doing

22:09

a lot more dialysis at home.

22:12

And these are just examples of how

22:14

we're evolving. It's gonna

22:16

be

22:17

less expensive.

22:19

And I think it's gonna be much better for patients

22:22

in the sense that when you're addressing

22:24

chronic conditions, doing it at home

22:26

as opposed to coming into a bricks and mortar

22:28

facility is just gonna be a lot

22:31

better. And that's critical

22:34

because I think, again, we often don't

22:37

fully appreciate 85 cents of every dollar

22:40

now is spent on chronic illness, not spent on

22:42

acute interventions. And

22:44

so being able to

22:47

do interventions more continuously at

22:49

home virtually, but also if

22:51

someone has to visit, that's the

22:53

way to the future. It

22:57

strikes me that anybody

22:59

who's ever been to a hospital and seen a hospital bill

23:02

knows that

23:04

it's incredibly hospital. You walk in the door

23:07

and for some reason you're gonna get four bills and

23:09

each of them is gonna be $1,000 and

23:11

you don't know what to expect. And

23:13

as much as we've known about this problem

23:15

for the last number of decades, it's only gotten

23:17

more and more and more expensive. And there's reasons why we've

23:20

gotta pay nurses more. There are

23:23

challenges to having to cover

23:25

people who don't get insurance.

23:27

There's a whole bunch of reasons hospitals

23:30

aren't all that efficient.

23:32

But it seems like the

23:34

answer is to say rather

23:37

than being able to reduce

23:39

that cost, which we haven't been able to, what

23:41

you're talking about is just

23:43

maybe there's a lot of things that we go to the hospital

23:46

for or to a doctor for even,

23:49

or get a test for whatever, that we don't need to. And

23:51

if there's a future that you're laying out here

23:54

where a

23:55

lot of the things you're used to going places for, I'm

23:58

getting virtual PT at home right now.

23:59

By the way, I love it. Physical therapy for my

24:02

Achilles. People are obviously getting

24:04

behavioral health therapy sessions at

24:06

home. How far will this go?

24:09

And when you look at like a combination of the

24:12

phone and some of the other tools you talked about

24:14

and the home, will it be a

24:16

transformation akin to the kind of transformation

24:19

that we've talked about that have gotten us this

24:21

far?

24:22

Absolutely. I think we have no

24:24

idea how far this is going to

24:26

go at this moment. One

24:29

of the things I think we can say is sensors

24:32

are going to get a whole lot better.

24:34

The AI is going to get a

24:36

whole lot better. And I think

24:39

from the diagnostic and outside

24:41

of taking blood, I think we're going

24:43

to be able to do a whole lot more at home.

24:46

I think the real challenge is how much of the therapy

24:49

can we do not just

24:52

virtually, but without human

24:54

intervention. Like there's a lot of the PT

24:56

that you could probably do without having

24:59

someone, a physical therapist at the other end.

25:01

And that's true for occupational

25:03

therapy,

25:04

for speech therapy, maybe even for mental

25:06

health, as well as other things. And

25:09

I think that

25:10

we just don't know. We can confidently

25:13

say that's going to expand

25:16

what the limits of that expansion are. I

25:19

think it goes beyond crystal balls

25:21

at this point because it's a 10 year, 15 year phenomena.

25:25

What's your view of AI? Bright

25:27

and rosy. Again, I think-

25:30

The Zika manual, bright and rosy guy. I

25:32

love it. I'm an optimist. First of all,

25:35

I think in terms of drug discovery,

25:37

you're going to see its impact very, very soon.

25:40

I think probably in medicine,

25:42

you're going to see its impact in two places

25:45

quickly. One is administrative

25:48

functions. And

25:50

there's going to be an incentive to use it because of the

25:52

labor shortage and administrative

25:55

nonsense that we had some of which I

25:57

document in the paper.

25:59

Will that part make people's lives easier? Will it be

26:02

easier to get the treatment you need? Or will

26:04

it be easier for them to say no to you? I

26:07

think one of the worries I have is that both

26:09

could be true and it could be a war,

26:12

mutually assured annoyance. Destruction,

26:15

yeah. But there is a way

26:17

of solving that, I think.

26:20

But that's gonna take some payment reform. The

26:23

other place I think you're gonna see it is in decision

26:25

supports where you're gonna see a lot

26:27

of AI go in and tell doctors,

26:30

here's what we recommend.

26:32

But it'll ultimately be the doctor's choice

26:35

because we're not gonna be sufficiently confident.

26:38

And I've been working with a company that looks

26:40

at medications and people's

26:43

past medical history and will

26:45

predict who's at high risk of getting

26:48

a complication in the next four months

26:50

and making recommendations about switching

26:53

the medications to forestall that

26:55

and prevent hospitalization. Now

26:58

that's the kind of thing

27:00

that I think you're just gonna see a lot

27:02

more of that has high

27:05

fidelity, picks out

27:07

high at risk patients and picks out recommendations

27:10

on how the physician should intervene.

27:13

Because they're not perfect yet, you're still gonna have

27:16

a lot of,

27:17

still, you're fortunately gonna have a lot of physician

27:19

judgment on top of it, but the better they

27:21

get, the better care we're

27:24

going to get. And

27:25

forestalling complications and adverse

27:27

events from drug-drug interaction,

27:30

that's great. That'll save money

27:33

and it'll also mean people won't suffer.

27:35

So you're describing a world of way more good than

27:37

bad. And there are

27:39

people who did talk about AI,

27:41

our executive producer, Kyle Shealy, believes it's gonna be

27:44

the ultimate end of us. But that's a different,

27:46

I think that's true. I am not

27:48

a big fan of things like social

27:50

media and other parts of the

27:53

technology world in other

27:55

realms. And I totally agree

27:58

with that. I actually worry that.

27:59

that unless we figure

28:02

out a way to check it, social media could undermine

28:04

democracy big time and that

28:06

worries the shit out of me, frankly.

28:10

That would be the worst thing. Yeah, I mean,

28:12

we used to go out worrying about nuclear weapons. I think

28:14

this is, social media may be

28:16

worse than nuclear weapons

28:19

in terms of the impact it can have. I wanna switch

28:21

to talk about mental health. Attitudes are changing,

28:24

no doubt in a healthy way. We're able to talk

28:26

about mental health, we're able to talk about

28:28

mental illness in a way that feels

28:31

safer. I think some of this is driven by the new generation,

28:34

some of this just out of necessity. Yet

28:36

we have problems. One big problem we have

28:38

is we don't have nearly

28:40

the number of mental health professionals

28:42

that we need. Secondly, they're

28:45

not always in the right place

28:46

and the system is very confusing and if

28:48

we think it's confusing to know where to start when you've got

28:50

a physical health ailment, that's when

28:53

it's confusing to know where to start when there's a mental health ailment,

28:55

it can be really, really concerning and be fuddling. Yet

28:58

we come from a system

29:00

that was based on isolating

29:02

people with mental illness from society. We're

29:05

now in some state where we're gonna change

29:07

that, I think.

29:09

What do you see happening there?

29:11

I totally agree with you and

29:14

I just tell a little anecdote that's

29:17

in my book about which country is the world's best healthcare.

29:19

We went to Switzerland and we're asking

29:21

them, we had a set of standard questions about mental

29:24

health and the guy in Geneva

29:27

pointed out the window and he said, yes, our

29:29

mental health, we have a hospital there,

29:31

it's near the prison on the border with France.

29:34

Told you everything you need to know about their attitude

29:36

towards mental health, right? It's near a prison and

29:39

we're pushing it into another country. Yeah,

29:41

particularly the French. Anyway,

29:44

I agree with you, attitudes have

29:46

totally changed and

29:49

I've been pounding on mental health.

29:51

I became a convert, I think, in 2014 about

29:53

how important mental health was to

29:56

getting costs under control, to getting patients

29:59

better treatment.

29:59

to making them live longer. And

30:02

I think it's here, in part because

30:04

COVID exposed so many people to

30:06

stresses of isolation and

30:09

increased anxiety, increased depression, increased

30:12

loneliness. And we don't have enough

30:15

people. As you're right, 500,000 mental health providers when

30:18

you get psychiatrists and social workers

30:20

and nurse practitioners and psychologists, that's

30:23

nowhere near enough for 330 million Americans. But

30:26

I do think we're getting parity. We've

30:29

got the big insurers like

30:31

United and Humana and CVS

30:34

saying we're gonna put this forward

30:37

because it's good for cost control. And

30:39

then I think figuring out how we're

30:41

gonna get all the people routinely

30:44

screened when they come to the, engage with

30:46

the healthcare system for anxiety and depression

30:49

and then being able to hook them up with some,

30:52

most likely gonna be virtual therapy.

30:55

And the crazy thing is,

30:57

I think a lot of this is going to be

31:00

machine-based. It

31:02

turns out that the original AI was

31:05

actually a therapist. Joseph,

31:09

I think Weitzenbaum at MIT created

31:12

a therapist, a very simple program

31:14

and people actually liked it. And he was shocked

31:17

and horrified. The one thing I will

31:19

say also that's changing Andy that

31:21

I predict is the normalization

31:24

of psychedelics.

31:26

What do you think about that? I've been

31:28

involved in some research on it and I have to say wildly

31:31

impressed. The study we've done,

31:33

we were just about to submit another is

31:36

first of all, these are cancer patients

31:39

with depression.

31:40

Within one week, you can assess

31:43

them and they get benefit. Not

31:45

all of them, but we're talking about 70%, which

31:48

is better than most medications. Much

31:50

better than most, which drug is specific?

31:52

Psilocybin. And then you

31:55

see the first study we did followed them

31:57

out to eight weeks, fine.

32:00

Now we're out to 18 months. We

32:03

haven't published this yet. So 18 months

32:05

and 50% of them are still fine.

32:10

That changes the game,

32:13

I think. And I think

32:15

makes it very, very

32:17

big difference. And

32:19

so I think,

32:21

again, you're gonna have to have providers who

32:23

are trained, who can administer this. We

32:26

have to make it more efficient. You can't have one person

32:28

for one patient, but I do think

32:30

in the next five years, completely

32:33

different attitude on these

32:35

things and they're gonna be normalized.

32:38

Well, I hope maybe we get some questions from

32:41

folks when we get to the question and answer portion

32:44

here. I wanna take a big topic and

32:46

try to mush it together into

32:49

one thing. It's

32:51

something that people who are inside the healthcare industry,

32:53

like our experts today, understand

32:56

very well. It's something that the general public has

32:58

not been kept well informed of. And

33:00

that is this idea of the roles

33:03

and the way the payments in

33:05

healthcare work and may be changing.

33:08

By roles, we're talking about the fact

33:11

that your friendly hospital

33:13

may now own or be owned by an insurance

33:15

company. They may be buying physician

33:18

practices. They may own lots of other things. They're

33:20

more of a corporation.

33:22

And insurance companies,

33:24

likewise, many of them now

33:26

are not just your insurance company anymore. They

33:28

own doctor's practices. They own chronic

33:31

disease management businesses. They

33:33

own all those sorts of things. There used

33:35

to be very clean lines. My insurance

33:38

company, and I like to say to remind insurance

33:40

companies that the one thing consumers expect from them, pay

33:42

my damn claim.

33:44

Don't engage me in all this other nonsense

33:46

until you pay my damn claim.

33:48

But they're increasingly taking

33:50

on a bigger role. And then the payment piece, which

33:53

is something that is driving a lot of change

33:55

in healthcare, maybe some of it good, maybe

33:57

some of it not, you'll have to tell us.

33:59

The idea that we should, as

34:02

you talked about earlier with prescription drugs,

34:04

be rewarding

34:06

the healthcare system when they take better care

34:08

of us, keep us healthier, keep us out of the

34:10

hospital when we don't need to be there,

34:12

and penalize us, penalize

34:15

the system when it doesn't do those things. That

34:18

has adopted a moniker that everyone on

34:20

this call is very familiar with called Value-Based Care.

34:23

So help us make sense

34:26

of what you see happening

34:28

in these two very related areas. Right,

34:31

so

34:32

I think it's really

34:34

important. In the old days, the days

34:36

my father practiced it, we

34:38

had 100% fee for service. That is,

34:41

you got paid for doing things and the things

34:43

you did,

34:44

you got paid for. And if they didn't

34:47

pay for doing something, you didn't do

34:49

it. And that incentivized

34:51

doing more,

34:52

doing often unnecessary things, more

34:55

tests, more treatments. It

34:57

wasn't

34:58

varied by what

35:00

the quality of care was. It wasn't varied by how

35:03

much it improved your health. And

35:05

that led to just

35:07

more money without more health. Value-Based

35:10

Payment is an attempt to change

35:12

that, to incentivize doctors

35:15

in the health system to keep people healthy, keep them

35:18

out of the clutches of the system, avoid

35:20

complications. And it's done

35:22

through incentives like a lump

35:24

sum payment with greater

35:27

payment for things that are

35:29

higher quality or are

35:32

more efficient and lower cost. Keeping

35:34

your disease under control out

35:37

of the hospital and following the guidelines

35:40

that our experts, doctors

35:43

have said are the best way to treat patients.

35:47

That evolution has been

35:49

slow to go, many, many reasons.

35:51

One, hesitation that it was just a way

35:54

of taking money away from doctors so they were nervous.

35:56

You have to contract

35:58

so it's... subject to contracting

36:01

and sort of, you know, those

36:03

intricacies.

36:05

And we've also learned a lot about what doesn't

36:07

work. We're getting to lift off

36:10

with value-based payment. Simultaneously,

36:12

as you point out, we're going to integration.

36:15

I predicted that in 2014, the

36:17

Kaiserification of American healthcare.

36:20

Remember, Kaiser is the model of this

36:22

integration where you have an insurer

36:25

with a provider, with hospitals,

36:28

with doctors, all in one rubric,

36:30

and they're responsible for your care, given

36:33

a fixed amount of money. And

36:36

Kaiser ranks very, very well in

36:38

general

36:39

on patient satisfaction, keeping costs

36:41

under control, et cetera. There's

36:44

more they could do, I know that. And

36:46

that's a direction we're going. When you go

36:48

that direction, this value-based payment makes

36:50

sense. Paying for keeping people

36:53

healthy makes a lot of sense.

36:56

People don't know how to evaluate quality

36:58

all the time, but they really know how to evaluate

37:00

simplicity, and they know how to evaluate

37:03

ease, and they know how to evaluate access. And

37:06

we're at a point in this healthcare system, and we're going to come

37:08

back and start to take

37:09

questions after this break. But maybe

37:11

we'll kick off by talking

37:14

about how some of these

37:16

attitudes that people have about what they really want

37:19

are often ignored in conversations like this.

37:22

And that many of these payment models that

37:24

people are supposedly a party to, i.e.

37:27

you are in an accountable care organization. I

37:29

don't know what that is, and no one ever told me about it. So

37:32

let's come back, let's do one final break, and

37:34

then I hope that the expert

37:36

innovators out there are ready to ask questions,

37:39

because we're going to launch into those when we come

37:41

back.

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to Last Day wherever you get your podcasts. Okay,

39:00

we're back

39:01

with Dr. Zeke Emanuel, and we're about to

39:03

get to the experimental

39:05

portion of our show, which is where

39:07

we have an expert panel of

39:10

innovators that I'm gonna call on in a second.

39:14

And Zeke, they're going to either

39:16

challenge you or

39:18

ask you to go deeper into the show. So

39:21

let's get started. So

39:23

let's get started. So let's get started.

39:25

So we're going to either challenge you or ask you

39:27

to go deeper

39:29

than I was able to

39:30

do.

39:31

Let me start

39:33

with Andrew Clifton.

39:35

Andrew, why don't you introduce yourself,

39:38

keep a sentence on what company you come from,

39:41

and then fire away at Zeke. Oh,

39:44

thank you. So I'm Andrew Clifton,

39:47

I'm the CEO of a company called Zing Health. We're

39:49

a Medicare Advantage company focused

39:51

on serving underserved populations,

39:53

minority populations, and chronic SNP populations.

39:56

Zeke, no acronyms, Andrew. Can you tell

39:58

us what those acronyms stand for? Oh, so-

39:59

sorry, chronic special needs plans. So

40:02

plans that are built for people with certain conditions

40:04

in the Medicare space of folks disabled

40:07

or generally over 65. So, you

40:09

know, Medicare advantage is interesting

40:12

because it's at the forefront because where the premium

40:14

dollars are, meaning there's a high amount

40:16

of spending in Medicare. So a lot of

40:18

what we're talking about with managed care, a value

40:20

based care is obviously very focused.

40:22

One question I want to ask is we were talking

40:25

earlier about the changes

40:28

of the hospital systems and hospital systems kind

40:30

of being the center of the ecosystem and new

40:32

advancements with technology, new

40:34

advancements in home care. You know,

40:37

care has been moving away from hospital systems for

40:39

a while, but hospital systems have acquired or

40:41

integrated, you know, going forward. I

40:44

was just curious on your thoughts on how some of these

40:46

advancements with home based care, virtual

40:48

care

40:49

could impact the finances of hospital systems.

40:51

And then what you see as the role

40:54

of hospital systems going forward, you

40:56

know, if you go 10, 15, 20 years down

40:58

the road with some of these changes?

41:01

Great question. First of all, I

41:04

do think hospitals have acquired

41:08

the mass of delivery

41:11

platforms, including outpatient

41:13

facilities, physician practices

41:16

and home care. And that's because,

41:19

again, you know, a lot of hospital

41:21

systems, most of their revenue now over 50%

41:24

of the revenue is coming from the outpatient, not

41:26

the inpatient. And the

41:29

smart ones have seen the writing on the wall and

41:31

are trying to get those

41:33

other assets and delivering

41:36

care in different locales.

41:39

And I think that's probably a good and important

41:41

thing. You don't need to come into the center

41:43

of Philadelphia to the University of Pennsylvania to

41:45

get a routine colonoscopy

41:48

or routine echo. And we should

41:50

be thinking about doing these interventions

41:53

in other places that are both

41:55

lower cost and more efficient. What

41:58

I worry about is that that's awful. driven

42:00

by this financial incentive for Medicare that

42:02

once you become part of a hospital, you can charge more

42:05

and there's no added advantage and all there is

42:07

is higher costs. And that seems

42:09

to me to be the wrong direction

42:13

to go. I do

42:15

think you'll, as I said,

42:17

I think we're gonna see a lot of shift

42:21

in the site of care and

42:23

my suspicion is hospitals

42:26

are not necessarily gonna be, or health

42:28

systems are not necessarily gonna be the main

42:30

providers of this care at home or

42:33

in other settings because

42:36

they are gonna be more expensive. They're

42:38

not gonna be as agile

42:40

and we are gonna go to a more asset-like

42:44

delivery system where the bricks

42:46

and mortars of these facilities

42:48

are gonna count

42:49

less and less. And

42:51

so I'm gung-ho

42:53

on the outpatient delivery of more complex care.

42:56

Not that gung-ho on health systems

42:59

being the leading survivors

43:02

in that going forward.

43:04

Well-run healthcare systems probably, but

43:06

I think a lot of startups are

43:09

gonna

43:10

most likely do it more

43:12

efficiently.

43:13

Okay, let's go to the next question.

43:16

Dr. Nzinga Harrison, please introduce

43:18

yourself

43:19

and let your question. Thanks,

43:21

Andy. Good to be here, Dr. Nzinga

43:24

Harrison, Co-founder and Chief Medical Officer

43:26

of Eleanor Health. We do Population

43:28

Health Management for Communities and Individuals

43:30

with Substance Use Disorder or a Psychiatrist

43:33

and Addiction, Medicine Doctor. So

43:35

I really, really appreciated your

43:37

comments. Good to be here, Dr. Nzinga

43:39

Harrison, Co-founder and Chief Medical

43:41

Officer of Eleanor Health.

43:43

We do Population Health Management for

43:45

Communities and Individuals with Substance Use

43:47

Disorder or a Psychiatrist and Addiction, Medicine

43:49

Doctor. So, I really,

43:51

really appreciated your comments on creating

43:54

space for people to disagree with you, even

43:56

when you have a very definitive voice.

43:59

vignette that you shared with us about changing

44:02

your thinking about the ethics of paying people

44:05

for clinical trials. And

44:07

so I wanted to click one

44:10

level deeper in that, like I truly believe

44:13

transformational leaders are

44:15

not only skilled at listening and hearing

44:18

other opinions, but proactively

44:20

seek to challenge their own deeply

44:23

held beliefs and ethical values.

44:25

And so if

44:26

you had to think through a deeply

44:30

held core belief or a deeply

44:32

held ethical belief that you

44:34

had that is now different, what

44:37

is that? And what drove the evolution

44:40

to where you are now?

44:43

You're getting really personal.

44:45

I'm a psychiatrist. It's

44:50

a good question. Well, I'll tell

44:52

you one.

44:53

So when I left government, I did not

44:56

do any for profits and I wasn't

44:58

doing any companies. And I said no to

45:00

lots of opportunities. I went

45:02

back to my academic work. And

45:05

then 2017, I joined

45:07

a venture firm and the major

45:10

change, actually, this will

45:12

probably be interesting, was provoked

45:15

by Bill Gates. We

45:18

were talking about ideas we had

45:20

for how to change physician behavior and how to

45:22

make the system more efficient. And he was very

45:25

insistent that it had to be a company. It

45:27

had to be a company because you couldn't scale things for

45:29

not for profits. And so that actually

45:32

was a really important insight of

45:35

scaling really doesn't not for profits.

45:37

Don't do that. You know, what's

45:39

my incentive as an academic get it published in

45:41

the New England Journal or JAMA or Lancet. But

45:44

how many people take it up? How many people

45:46

get

45:47

affected by that?

45:48

Not my interest, right? No impact

45:51

that way. My impact that I

45:53

get evaluated on is, do

45:56

I get published in good places? Do I get more

45:58

money to support my research? And the

46:00

idea that it's really important to scale

46:04

and that scaling happens by for-profit

46:06

startups,

46:07

I changed my view. I'll give you, now

46:11

I'm really gonna roll. The

46:13

importance of automation

46:15

for standardization of practices

46:18

and reducing the cost. Again,

46:20

that came to me through a

46:23

collaboration with this company called

46:25

Solaris, which is trying to produce

46:27

cells for CAR T therapy that

46:30

I work with. And the whole

46:32

point of the automation is to take

46:34

out the variability in quality and to

46:36

standardize it through robotic procedures.

46:39

And that also turns out to reduce costs

46:43

substantially, 50 plus percent

46:45

on preparation of those cells

46:47

for transplantation.

46:48

Well,

46:50

if you had asked me before a deeply

46:53

held view, would I have thought that automation

46:55

was gonna be that important in medical care?

46:58

I probably would have been very skeptical.

47:00

So there you've got two changes

47:03

of my views in addition

47:05

to the ones, and there are plenty

47:07

more, plenty more.

47:09

Let me go to the next question for Zeke Emanuel.

47:11

We'll go to Dr. Mira Mani.

47:13

Mira, can we unmute? Mira and half her asks

47:16

the next question. Great, thank you,

47:18

Andy. Mira Mani, partner

47:20

with Town Hall Ventures, we're an investment

47:22

firm focused on healthcare

47:25

solutions for underserved populations.

47:28

My question is this, I'm happy to

47:30

hear you say the future of AI in healthcare

47:32

is bright and rosy, but what,

47:35

if anything, is terrifying about the

47:37

future of AI in healthcare to you, and

47:39

more importantly, what's to be done about it?

47:42

Whoa, I am not

47:45

an AI person. I

47:47

have assembled an AI machine learning team

47:50

to do certain things like help with risk adjustment,

47:53

try to fix the Medicare risk adjustment model.

47:56

What concerns me is people

47:59

with bad intentions.

47:59

or even where

48:02

their intentions are not necessarily

48:04

bad, but their intentions lead

48:07

them to do things that are orthogonal towards it to

48:09

improving people's health. You see this

48:12

with, you know, Facebook and Twitter,

48:14

where what they want are eyeballs that

48:16

stay on their platform for a long time. And

48:19

what they end up doing is keeping people

48:21

in bubbles rather

48:23

than exposing them to alternative views.

48:26

And that kind of either

48:29

bad motivation or motivation

48:31

that isn't directed at health

48:34

and improving people's health is what worries

48:36

me about AI. Not so

48:38

much that the AI itself is going to

48:41

overtake us, but that the people

48:43

are gonna use it in ways that aren't

48:46

directed at improving health. And

48:49

I think that's always what

48:52

happens, or that's the worry,

48:54

right? One of the things, you know,

48:56

early days, Google was, you know, do no harm,

48:58

whatever. All of these things end

49:01

up going off the rails because

49:02

either

49:03

bad people take them over and

49:06

they have nefarious goals, or even

49:08

they get perverted to, it's just in the money.

49:10

We'll do whatever it takes for the money. And

49:13

that's too easy to happen in

49:15

general. And so if you ask me, where is

49:18

not just AI, but all sorts of automation things

49:21

gonna go off the rails, those are the two places

49:23

I see it. To

49:26

go back to the previous question, the downside of startups

49:28

is they end up doing bad

49:30

things in the pursuit of money. And

49:33

that I think is what is, you

49:35

know, that's the flip side. The

49:37

good thing is they wanna grow and they wanna

49:40

spread their innovation. The bad

49:42

side is that they will often compromise

49:45

things and goals for

49:47

the goal of making dollars and

49:50

making profits. And getting people

49:52

whose core mission is,

49:54

we are gonna do the right thing no matter

49:56

what the dollars, even if it means less

49:58

dollars.

49:59

I think that's really important.

50:01

Yeah, yeah, people

50:03

really want incentives to fix

50:05

everything in healthcare, but the reality is

50:07

incentives can't turn

50:09

rapacious people into good people. Better

50:12

said than I did, yes, you're right.

50:14

Let's go to Steve Shulman who has a question.

50:16

I think we got time for maybe a couple more. Steve?

50:19

Hey guys, this is Steve Shulman. I

50:21

run my own family office and been

50:23

banging around healthcare for 50 years,

50:26

running hospitals and payer

50:28

systems starting at Kaiser and Zeke, we're both

50:30

old enough to appreciate this isn't the first

50:33

time we're going at this. I would say

50:35

generation one of managed care broadly

50:37

was PHO's physician hospital

50:40

organizations. And then the

50:42

market got excited about PPM, physician

50:44

practice, management companies that

50:46

all went public and they flamed out. So

50:49

value-based care in my opinion is again,

50:51

the third time we're at this. Do

50:53

you think it's gonna work? And if so, why is

50:55

it gonna work this time?

50:57

Yes, I am optimistic

50:59

Steve. And yes, history

51:02

is littered with problems and probably

51:04

a fair number of people listening

51:07

to this podcast will remember the 90s when

51:09

everyone was talking about managed care and

51:11

that blew up. Why

51:14

is this time different? Well, one thing

51:16

that is different is we have a lot more

51:19

information, not just data

51:21

about what works and what doesn't. We also

51:23

have guidelines, we also have the

51:25

ability to monitor and give physicians

51:28

and health systems feedback on

51:30

their performance. And

51:32

I think that makes a huge difference.

51:35

The second thing is we're also, I

51:37

think, appreciating the importance of

51:40

management in getting good

51:42

health outcomes. You know, we now,

51:45

as I said, 85 cents of every dollar is

51:47

for chronic illness and the big part

51:50

of the problem is people with multiple chronic

51:52

illnesses, both physical and mental.

51:55

Those people, you cannot improve their health

51:57

situation just by giving

51:59

them a... It's a management problem,

52:02

and it's a management problem that requires

52:04

continuous interventions. Someone

52:07

has to actually change

52:09

their life and be committed to doing things

52:11

that are gonna make them healthy. And

52:14

part of the purpose of the healthcare system

52:16

in those circumstances is to go with them, encourage

52:19

them, be proactive, right? In

52:22

the old days, we were reactive. In

52:25

the future, we're gonna have to be proactive. And

52:27

the best groups out there, the best primary

52:29

care doctor, don't wait for patients to come in.

52:31

They reach out to patients. They

52:34

help patients, they educate patients.

52:36

And we're gonna have to have more of that. You can't have

52:39

that in a fee-for-service, standalone

52:41

doctor. You need managed care, where

52:44

doctors and their practices, not just

52:46

the individual, but the care manager, the mental

52:48

health providers, and others

52:51

are actually helping patients and

52:53

reaching out to them on a regular

52:54

basis. Let me take one more question,

52:57

and then I have one to finish with one of my own. We're

52:59

gonna, Tom, Mano, Tom, introduce yourself

53:02

and ask the question.

53:03

Yeah, hey, this is Tom Mano. I'm

53:05

from Hopscotch Health, a primary

53:08

care company that's focused on serving

53:10

rural and underserved communities.

53:13

I'm curious, from your perspective,

53:16

what needs to happen to enable

53:18

better access to care and

53:20

better patient outcomes in rural communities?

53:25

Well, first of all, I think

53:28

there, it's a very tough

53:30

situation because you're not gonna

53:32

get doctors, by and large, to

53:34

move to rural communities. Every

53:37

country, and this isn't just true in the United States, we're

53:39

sui gener somehow, whether

53:41

it's Norway or Canada or Australia

53:43

that's tried to get docs

53:46

to move into rural communities, especially specialists,

53:48

just not happening. So we

53:50

need to create a network where

53:53

you have nurse practitioners, other

53:55

providers in rural communities to

53:57

convert those hospitals into.

54:00

multi-physician practices and

54:03

urgent care practices, but linked up

54:05

to central hubs that

54:08

help them for more complicated

54:09

care provision and

54:13

every

54:15

kind of specialists that people need. I

54:17

think that's actually one of the promising things

54:19

about telemedicine and virtual

54:21

medicine and getting more specialists

54:23

and specialty care out to rural communities

54:26

and have the connection of

54:28

primary care out there, not necessarily

54:31

through doctors. I think that's where we're going.

54:34

Are we getting there fast? Absolutely not. Does

54:36

that require changes so that we can practice

54:38

across state lines, et cetera? Absolutely.

54:41

All of that is gonna be important. And one of the strange

54:44

things

54:44

I see is, you would

54:47

think that all the

54:48

senators and politicians representing

54:50

rural states, the big

54:53

rural communities, would be gung-ho

54:55

in changing the rules around payment

54:59

and consultations via

55:01

telemedicine and across state lines. I

55:04

just don't see that. And I don't

55:06

see them leading the charge enough.

55:09

And I'm perplexed by that because how

55:11

do you think you're gonna get all

55:13

those patients the right kind of

55:15

care? I remember 20

55:17

years ago, I was doing a bunch of surveys

55:20

of oncologists for various things. And

55:23

notice that there were like three oncologists

55:26

in North Dakota. And I noticed

55:28

that because I called one of them who was about to

55:30

get on a plane and pilot herself across the

55:33

state to provide cancer care.

55:35

You got a situation like

55:37

that. You're gonna have to

55:39

use telemedicine just a lot more.

55:41

That's the only

55:43

answer. It's very interesting,

55:45

Zeke. Hopscotch is a great example

55:47

of someone trying to solve this problem. But

55:49

I also see that

55:52

businesses today that are trying

55:54

to be innovative and serve healthcare, the number one question

55:56

that you have to answer is how are you going

55:58

to acquire a...

55:59

new patient or new customer. Today, the number

56:02

one question I have to answer is how are you going to acquire the

56:04

clinical resources you need because there's so few.

56:06

I have one final question I want to use to wrap up. Zeke,

56:09

and it really is to me the ultimate question.

56:12

In the United States, for the first time

56:15

ever, over the last few years, we've seen

56:17

life expectancy decrease. This

56:19

is even before the pandemic, I

56:22

started the pandemic, exacerbated those

56:24

numbers, but that's not the simple

56:26

cause. Understanding the simple

56:28

cause will certainly help us solve it, but

56:31

it is an incredibly

56:33

pessimistic idea

56:35

that for all of the medical advances we've

56:37

been talking about, for all

56:40

of the investment and money we spend

56:42

in healthcare,

56:45

we are losing, and we

56:47

are losing in a pretty profound way.

56:50

Ultimately, life expectancy and the

56:52

quality of those years are what

56:54

the healthcare system should be

56:56

able to in part deliver for us. There's

56:58

other elements as well. So I

57:01

really want to know, are

57:03

we going to solve this? Are we going to turn it around?

57:05

Convince me if your answer is yes. Tell

57:09

me what we need to do differently if your answer

57:11

is it doesn't really look like it.

57:14

I do think we'll turn it around, but

57:16

I don't think

57:18

it's going to be evenly distributed,

57:20

which is the thing that really bothers me. You

57:22

know,

57:23

I don't know your listenership,

57:26

but I'm estimating that if they're listening

57:28

to you, Andy, your listenership is

57:30

the people who are going to live a long

57:33

time. They're doing the five things of wellness that

57:35

I mentioned, or at least they're doing four out of the five,

57:38

and they're going to just

57:40

by dint of doing that unless something

57:42

unlucky happens to them. Going

57:44

to live a long time and beyond the median. The

57:47

problem with the decrease is that we

57:49

have a huge swath of people

57:52

where their

57:54

future is not so good. So we've got

57:56

suicide, we've got gun violence, we've

57:58

got accidents. increasing

58:02

and we have people who aren't necessarily

58:04

able to or know enough to take care

58:07

of their

58:08

incipient illnesses over time.

58:11

We have to make

58:13

better interventions and it's not necessarily through

58:15

the healthcare system. I think the main interventions,

58:18

you know, obviously the opioid crisis,

58:21

we have a set of actually pretty

58:23

good interventions there. We have to get them standardized

58:26

and given to people regularly,

58:29

wherever they are. We

58:31

have to get mental health of people

58:34

better. We have to have them so that they have

58:36

hope in living better

58:38

and not in being depressed

58:41

or anxious and ending

58:43

their life. That is going to take lots of changes.

58:45

It's going to take changes of social media as

58:47

well as other, you know, more

58:50

outreach. By the way, I would highlight

58:52

in that group the ones that are most concerned

58:55

with adolescents. We tend to overlook adolescents.

58:58

We talk about young kids. We talk about

59:00

adults. Adolescents are in real

59:03

crisis, I think, mentally and I think

59:05

we need to do more there. The other

59:07

thing I would do from where

59:09

the healthcare system needs to make a major

59:12

commitment is in hypertension.

59:15

110 million Americans are hypertensive,

59:18

high blood pressure. And we do

59:20

a crummy job of managing

59:23

it despite the fact that we have known

59:25

the single biggest thing we did in the last 60

59:27

years to improve lifespan,

59:30

not smoking cessation, not seat belts,

59:33

controlling blood pressure. It

59:35

is outrageous that we

59:37

haven't committed. And if I were Mandy Cohen at

59:40

the CDC,

59:41

this would be my initiative. You will make

59:43

a bigger impact on healthcare first. Second,

59:47

you will actually reduce disparities because

59:49

it's disproportionately a disease

59:51

of minorities and particularly

59:53

black Americans. And so it's

59:56

like the sweet spot. We know how to do it.

59:59

diagnostic as well as therapeutic regimens

1:00:02

and they're cheap, it would

1:00:04

improve disparities and improve survival.

1:00:07

So that I think ought to be, you should

1:00:09

be laser focused on that. Well,

1:00:11

we'll ask that of Mandy when she comes

1:00:14

on in the next week and she's going to do her first kind

1:00:16

of broadcast for what she's singing to the CDC

1:00:18

here and in the bubble. Zeke, I want to thank

1:00:21

you. I want to thank

1:00:23

the expert innovators who

1:00:26

tuned in and who asked questions. And

1:00:29

if you've got more

1:00:29

questions, send them over, but

1:00:32

everybody can look at Zeke's nine

1:00:35

trends, which you've talked about almost all of them here

1:00:38

on our show notes. Thank

1:00:41

you so much for joining. Tune in

1:00:43

next week for a show that will

1:00:45

help to make just as good as this one. Thank

1:00:48

you, Andy.

1:00:54

Thank you for listening in the bubble. If

1:00:56

you like what you heard, rate and review,

1:00:59

and most importantly, tell a friend

1:01:01

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1:01:03

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