In the Bubble with Andy Slavitt: Our Shot

How the Pandemic Changed Health Care (with Dr. Alan Lotvin)

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What if we could take the best of what we learned from the pandemic to build a better and more equitable health care system? What would it look like? That question is at the center of Andy’s conversation with CVS Health’s Executive Vice President Alan Lotvin. Alan envisions a future where the expertise of pharmacists and nurse practitioners is better utilized to help aid the labor shortage. And he believes wearable health technology could become as essential as your wallet, leading to fast, convenient, and personalized health care without stepping into a doctor’s office.

Keep up with Andy on Twitter @ASlavitt and Instagram @andyslavitt.

Follow Alan Lotvin on Twitter @AlanLotvinMD.

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Andy Slavitt, Curtis Lane, Alan Lotvin

Andy Slavitt  00:00

Welcome to IN THE BUBBLE. This is your host, Andy Slavitt. That, of course, was the latest from the Ukraine where I’m saddened to report that our friend my friend, Chef Jose Andres, has suffered a bombing at their kitchen in Kharkiv. From what I hear, there are folks that are injured are going to be fine. But our hearts go out to the real heroes that are there cooking meals for people healing people. And that’s the way we’re going to start the show today, we’re going to get to a conversation about the healthcare system here in the US. But I do want to first bring you a conversation with someone who has been over spending the last week on the border with refugees. He recorded some of his conversations over there. And I really wanted to give people a sense of the dialogue. So we’re gonna talk in a second to my friend Curtis lane. And then after that, the major part of the show, I think, asks a fascinating question. And it’s a what if question, what if we could really rally this country to learn the lessons of the pandemic and get to a better health care system that had the kinds of things in it that we saw a little of during the pandemic, some of it is more virtual care, more wearables and devices, a more equitable system, a system that people didn’t have to worry about paying for, and have on the show Alan Lotvin, for a really fascinating conversation about that. But first, let’s talk to my friend Curtis, who just got back from a trip to Poland, where you spent the week with refugees.

Andy Slavitt  02:34

Welcome to the bubble, Curtis.

Curtis Lane

Thanks for having me.

Andy Slavitt 

So you just took a trip to the border in Poland, where you get to interact with many that people crossing the border. Can you describe what it is you saw and tell us a little bit about what you saw the migrants experiencing?

Curtis Lane 

It was an amazing trip in terms of really seeing directly. It’s different than watching TV. And which tends to make things kind of not real, but this was very much real. So I went over Saturday night and Sunday afternoon, Sunday night, we met with a lot of refugees. And the next morning, we went to the border, and actually spent half the day there and watching the actual process by which refugees cross the border, get greeted by relief organizations, then go to a center kind of replace Costco or a Kia type store where there’s lots of relief organizations set up there to help people figure out where they go from there. And then go went to Warsaw to see the hotels that many of them stay at because one of the relief organizations took big books of rooms, including the hotels, in a variety of places all across Poland, and Romania, and I think any other countries that are there, and watches the people then were helped to go meet their family, etc. And, you know, it was, you know, watching number one to see what the polls and these relief organizations have done to be able to handle over 4 million people in basically six weeks is nothing short of phenomenal. It was incredible to see how well that was working. Because it’s only women, children, the elderly. That’s the thing that strikes you first, there are no men because the men are obviously staying to fight. So you’ve got these people that really had to leave in a nanosecond with everything they own. Basically, sometimes in a shopping cart, sometimes it’s in a bag sometimes in a roller bag. And that’s everything they own walking with multiple kids and going across the border. And you just struck by how quickly their lives were just changed so dramatically.

Andy Slavitt  04:45

Did you get to interact with some of the women in some of the families directly and what kind of things were you hearing and really stood out what surprised you?

Curtis Lane 

I did spend a lot of time with them in various settings. But where I got to know them the most was actually waiting to check in to a plane with 141 of them that we were flying them to Israel on behalf of an organization that I work with. And as a part of that, I went on the bus with them to the airport and then checking in was a three-hour process that was a mess. But we waited literally on line with them. And you know, you think about it back to being women and children. They’re there with big bags at this point, how did they get there? So you ended up helping them and I hung out with basically two or three families for quite a while and for the people that were around us, and then you did get to know them. And they’re just scared out of their minds.

Andy Slavitt 

Were they in touch with their husbands and brothers and fathers? Did they know where they were, were they updated? Or were they completely in the dark?

Curtis Lane

I think at times they were they were in contact. I know we spoke to one woman who quite a bit was explaining to us that they do speak by cell phones, and you’re there texting with them. But there are times where that’s not the case. And one young woman told us about how she went 24 hours without having any contact with her boyfriend. So when you go from having a lot of contact, and you’re texting and you’re in touch with them, and then he disappears for 24 hours, she explained to us obviously, how scared she was and how she obviously thought about the worst.

Andy Slavitt  06:19

So I want to go back and talk about some of the more political and policy dimensions of, of the implications of what you saw. But I want to play some tape that you brought back. It’s part of the organization that you were over there with one woman’s story. So if you could give us the audience who says to be able to see through your eyes. You know what else can you tell us about this experience that comes through in the story we just heard.

Curtis Lane 

Well, that was pretty consistent story across the board is that one minute they were living their lives, and the next minute, their lives were completely overturned. That young woman I think she’s around 19-20. So she hid with her grandparents. And, you know, told us more later that in terms of getting water there was that discussion about a well, she actually said that they were drinking water out of, you know, puddles, if you will, during that period, and it was so cold they were freezing for days because it was below zero. So that was you know, a perfect example of people escaping. But then there was someone you could understand relate to a woman who was a cardiovascular surgeon. She was in her office I guess in the burbs in the hospital, she went home, and they were trying to decide what to do. And then all of a sudden there were bombs going off and she got in the car with her two daughters and their dog. That’s one thing that you see consistently. It’s not just the women, children, the elderly, it’s also their dogs and got in the car and they had to skirt various areas in his tiny car to get out of where they work to make it to cross the border and this woman talking about how she had been operating the day before and here she was with her life completely up to her overturned and that they thought they were okay for a second in their homes and then realize that they weren’t very suddenly and had to run with nothing. And they were waiting to figure out where to go, they were probably going to go to Israel. But that a problem because their dog was so big, that wasn’t a cage big enough for it. So therefore, they had to wait.

Andy Slavitt  10:18

Were you impressed with the jobs, that the relief agencies across the board were doing?

Curtis Lane

It’s unbelievable. The thing that struck me there were three things. One was the Polish government. And in terms of how organized and how supportive they were, you know, there was a map, and in the train station in Warsaw, with instructions to the refugees to say, hey, don’t and it was in Ukrainian. And don’t just go up to the big cities, here all these other smaller towns and cities where there’ll be better opportunities for you to have jobs, and, you know, be more comfortable for you to be there. I mean, so they were really figuring out how to do that. So I thought the Polish government was everywhere and very effective. The other thing that just struck me is a number of relief organizations, I have a picture of when you come across the border, you’re basically walking up and I filmed it, a whole walkway for relief organizations. And the things that come out, you know, there’s ones that stuck out there were Sikhs that had a little food truck, there was, you know, ones from Poland, ones from here from all over the world coming to provide some type of relief. But the two things that struck me consistently out of everywhere I went, were actually the Israeli and Jewish relief organizations where a ton of money had been given. But the volunteers that were there, they were everywhere, the first tent, when you cross the border, where we were was an Israeli managed medical tent, where that was the only thing that was right on the border. And the later on, you saw doctors from Israeli hospitals in the refugee center, which was the only medical care that we’re receiving. So it’s them and the thing called the World Food kitchen. And I think, Andy, you’re familiar with that. Yeah, World Central Kitchen. It was amazing to see how active they were and where they were everywhere, and how now they’re even not just around the border, and up there in Ukraine, serving meals in Kyiv, And Lviv, they are actually they’re, you know, wearing flak jackets, etc. But they were everywhere.

Andy Slavitt  12:18

And you know, this show should just remind listeners, because it’s really coming from listeners, that we’ve donated $25,000 to World Central Kitchen, for the work they’re doing on the border, and also to an organization in Yemen, which we’re going to announce shortly for the refugee work there. Finally, Curtis, just want to maybe see if this if you gained any perspective on the military and political situation or solutions there as we speak. You know, the Russian army has been pushed back out of Kyiv. They’re regrouping, they’re moving away from the more challenging urban and forested environments over to the eastern part of the country that are more wide open, where they have more political support, did you get a sense of what solutions the Ukrainians see as real as realistic?

Curtis Lane

I think the people that were, you know, the refugees weren’t focusing aren’t talking about that. But you talk to the volunteers and some of the government officials that we talked to, I think there’s just big uncertainty, they don’t know where it’s going to come out. But, you know, everybody around the world, and you can see it there, too, is shocked at how well the Ukrainian army and the political leadership has done in this environment. I’ve sensed a change in terms of the world prepared to give more and do more for the Ukrainian since the uncovering of all the murders and atrocities in the various towns. And, you know, one of the things that has struck me is all this talk about war crimes, is that, you know, all the politicians want to talk about war crimes. But I don’t know about you, Andy, But do you know of any leaders are any country that has ever been prosecuted for a war crime when they haven’t been defeated, first in battle and war? So I guess my view is and others share it is that I think I’d rather not be talking so much about prosecuting war crimes that will take whatever but preventing tomorrow’s war crimes.

Andy Slavitt  14:14

So your message, after seeing what you’ve seen, observing what you’ve been observing, is we need to help them win the war.

Curtis Lane 

Perhaps there is no solution other than them winning the war to come some type of partition like North Korea, South Korea, things like that, where does that get us? I think, you know, they’ve already had some of it, and that might be some type of, you know, way to get some type of piece done. But you know, they’re fighting a war not just for themselves, but for all of us.

Andy Slavitt 

Well, Curtis, it sounds like an amazing, amazing trip and really appreciate you coming back to relate it all to us.

Curtis Lane 

Now. Thank you, Andy, for having me. I thought it was interesting, someone said something really well. He said if you would have taken all the things that we saw and put it in Black and White pictures rather than color, we would have been watching the newsreels from World War Two.

Andy Slavitt 

Wait, that’s the tough way to look at it. But it’s really true. We haven’t seen this kind of thing in 75 years of war.

Andy Slavitt 

Again, I think this is probably one of the last times I want to ask you, if you want to vote for our show for Webby Award, there’s a link in the show notes to do that, were nominated for two awards. We’re up to 25% in the health and wellness category for best health and wellness podcast. And that puts us in second place. And for best host 15%, in third place. I’m sure you’re sick of me talking about that. But I appreciate you sticking with me. All right, let’s turn to Alan, who is executive vice president at CVS Health, he’s actually someone I’ve known for quite a while. And I think you’re gonna really enjoy this conversation, we go in fairly deeply into the issues in the healthcare system that I spent a lot of time thinking about, that he spends a lot of time thinking about. And it’s almost like you’re listening in to a private conversation where we get into some of the tough topics. Here it is.

Andy Slavitt  16:50

Alan, great to have you on the show. You’ve asked us specifically not to call you Dr. Lotvin. And so we’re gonna call you, Alan, and you call me whatever you like. So we’ve just been through a pretty remarkable period. Just not to suggest we’re done with it. But we’re certainly moving to new a new stage. You have been a practitioner, and a student and a leader in the healthcare system for a long time. How did the healthcare system respond in the US? Compared your expectations?

Alan Lotvin

That’s a very good, very complicated question. I think they’re their absolute bright spots, right? If you think about the ability of the health care system in the US to mobilize an enormous number of people, the repetitive learning on how to treat these critically ill patients, I don’t know if you remember, early in the pandemic, everyone got into this idea of proning, turning the intubated patients upside down, which was something that never heard of when I was in practice, the experimentation, the trying out new therapies that happened very early in the pandemic, you saw the mortality curves come down relatively rapidly, I think the ability of the industry to generate a vaccine and treatments in record time, the ability to test them completely demonstrate they were safe in all sorts of populations, right. So these probably were some of the more diverse trials that were ever done in the country, really sort of spoke to the ability of the healthcare system. Now, that was on the good side, right? On the bad side, we saw the problems of the hyper efficiency of our healthcare system, we don’t have the capacity to handle this many really ill people.

Andy Slavitt  18:45

Let’s pick up on some of the positives to start with. You know, it shouldn’t be lost on us that when this started in China, and in Italy, and in New York, you know, generally speaking, there was because there wasn’t a standard of care, was a novel virus. We had a healthcare system, that, you know, you start to go to hospital, you’d expect to be ventilated, you’d expect to die. Although obviously, many, many people survived. But this idea of a learning healthcare system and a rapidly evolving standard of care, you make this really interesting point about when you talked about proning. Which is to say, you know, when do you put someone on a ventilator? And if so, is there a way to do it and this idea of proning, putting them on their stomach, which is, by the way, much harder than it sounds like a seven-person job evolved, and you know, there’s a there’s an old saying in healthcare that if there’s a new standard of care, in healthcare, it takes about seven years normally to permeate the healthcare system. So new knowledge appeared somewhere. It’s seven years before it’s used everywhere. Yet in this public health crisis, this idea of when to put people on a ventilator and how to do this rapidly save lives. And it seemed like it happened in a matter of, I don’t know, most weeks or months, does that tell you that there’s something in the healthcare system that doesn’t meet the eye? That’s actually more capable than we thought?

Alan Lotvin  20:17

Wow, that’s really the thoughtful observation. So I, you know, I think what was really fascinating about that early experience, right was, you know, there was a, you know, people who wandered into the emergency room with COVID, who had oxygen saturation, a measure of how much oxygen is in the blood of 80%, you would not know before COVID, you’d probably say that’s almost not compatible with life. But these people were asymptomatic. So, you know, I think we learned a lot. Why did we learn so fast? I think a couple things. So one, I think it was it is that sense of emergency and people kind of did what they needed to do. It was that kind of field medicine approach. I think the second part was is it’s a narrow scope, we’re working in 1000s of hospitals, not 10s, or hundreds of 1000s of doctors’ offices, you were working in an environment that was often full of doctors and nurses who self-selected out into these critical care specialties, who were self-selecting into an area that was rapidly evolving. What happened in COVID, you had a bunch of very motivated, relatively small group of people who were communicating constantly because they were learning together, it was the epitome of a learning system.

Andy Slavitt 

This idea of preprints, which was a little scary. And by preprint, I mean, this idea that someone making an observation published something without being peer reviewed, in some sense is scary if you’re not in a crisis, if that’s how propaganda starts. That’s how rumors start. Anybody could self-publish, but it feels like it served us well, more than it did. Am I wrong about that?

Alan Lotvin  22:01

No, I think that’s right. And again, I think it’s, you know, part of peer review is to ensure that there wasn’t even inadvertent bias. I mean, clearly real bias, but even inadvertent bias, but I think, what substituted for peer review in this scenario, and I’m hypothesizing to a certain extent, was personal relationships. I know so and so I trained the so and so I did this. And the very rapid ability to validate yourself that, yes, putting the person onto their belly was seven people made a difference. Yes, you didn’t have to intubate everyone at 85. Or, you know, so if you were able to very quickly know, the other party you got to be careful about is as you got further and further away from those really acute clearly demonstrated outcomes, it gets easier and easier to introduce bias. But yeah, I think that’s a lot of it.

Andy Slavitt

Yeah, it’s, you know, I actually think I gain some trust in people’s ability to curate, right, so, you know, if there was a preprint, which said, you know, we’ve talked to we’ve seen 30 people, and this is how they responded. It felt like people did that by people now, I’m actually talking about clinicians and scientists in the medical community, I’m not talking about, you know, all of the rest of us. But it felt like people, were you contextualize each of these studies. And you will, people will say, well, it’s only one, or that we’re seeing this everywhere, or you know, what, it’s the best information we have. So we use it and it feels like, globally, the medical community was, you know, something happened in South Africa, we’d see something in a lab, it would get published, people would explore it, people didn’t overreact and didn’t underreact generally speaking, the knowledge gap permeated, and in this world, it’s sort of a vote for, you know, it’s a vote for the things that we criticize all the time, the internet, global connectivity, knowledge sharing, you know, pre internet, right? You know, that stuff would have been possible that, that felt like maybe one of the good guys for us.

Alan Lotvin  24:03

But that’s right. I mean, if you think about even what led to the mRNA vaccines was, you know, the virus, which you know, was published in some ridiculously short period of time, but by the Chinese scientists, and that allowed people to go right in and start designing these things. I think the other part, you know, in addition to that rapid feedback, is I don’t think anyone saw any ulterior motive here, like there was no, it was clear, this was a public health emergency, there was no profit motive, there is no self-aggrandizement motive. There was nothing other than we have to figure out how to get in front of these really, really sick people and treat them. It the best of what you could hope for.

Andy Slavitt

It’s funny, that’s exactly where I want to go next. Because you know, what you made me think of Elon is, in some ways, I feel like in a sneaky way. COVID-19 was American’s first experience with single payer health care, and here’s what I mean by that. The government basically said, you know, we’re gonna pay hospitals effectively, eventually, for shortcomings that you have, we’re going to pay the pharmacies for whoever comes in to take a vaccine, or eventually, you know, even tests, and certainly therapies, regardless of their insurance status, and you as a patient, cost is not an issue, there’s no copay to get a vaccine. There’ll be no costs of getting medical treatment. This stuff is hard enough as it is, we’re going to take all the financial stuff off the table. And the one thing up until recently, when we’ve started to deal with Congress, whether they would put more funds together for future needs, up until this point, that just hasn’t been on the table. And you and I both know, when we’ve been in this been around healthcare for a long time, that you can’t, until this point, you can’t have a conversation about health care, without saying, well, what’s the incentive to your point you were just making? And who’s going to do well financially? Do you really trust that and if you’re gonna make this work, you’re going to have to do pay people more, or you’re going to be robbing access of people who are having a tough time, even if they had the funds, they have access issues, as we’ve seen, I thought, I don’t know. Is there something that you learn from that? I mean, this is that what Bernie Sanders had in mind, but it’s very interesting.

Alan Lotvin  26:26

It’s an interesting perspective. And I think one part of me is, says, like, let’s look at all the other healthcare systems that already had single payer systems and say, why didn’t they do quite as well as we did? And I think part of part of that is, in addition to making all of the financial issues go away for individuals, and for any actually anyone in the chain, right? We’re just like, listen, we need you to do this, and we promise we’re gonna pay you. And that’s backed by the full faith and credit of the US government. And we’ll figure it out later on. And by and large, I think that’s sort of worked out. I think it’s also that, you know, we threw an overwhelming amount of money at this. Right. So if you look at the early, early vaccine discussions, I think the some of the other developed countries, in particular, were trying to negotiate price and, and we just said, We’re gonna buy 500 million doses, and it’s almost cost the damned. And so I think the question is, how do we take the best of what we learned from this, because the speed, the other thing that gets lost sometimes is those vaccines were all given under us, which in our current system is like, the only way you’re gonna get them paid for is that the government paid for it. So that can be but how do we get that speed for other critical things? Because there’s so many diseases that kill more people than COVID. Right? But we’ve sort of tolerated that level of morbidity and mortality for years. And how do we sort of think about bringing that seed to bear?

Andy Slavitt  28:03

Yeah, yeah. Well, it’s a great point. I haven’t talked about this in the show, but I’m just so steamed to a White House task force to look at the future of pandemic preparedness, or the current pandemic preparedness or what have you. And I think that’s a really, really important observation you just made, which is, you know, when we got ourselves on, quote, unquote, wartime footing, at least at the FDA, to focus there where you did, they have a different set of rules, to make decisions. And those rules essentially say, you know, you don’t need to have belt and suspenders and be 100%, certain of everything, before you prove something, you really have to prove that the benefits really significantly outweigh the risk for the you know, and for a significant part of the population. And it’s a more practical standard, and it’s one that should apply in more time. And then you have to ask yourself, wait a minute,  should some of this apply in peacetime? And by the way, the FDA operated under those terms, but the CDC, you could argue, really didn’t necessarily move to a different type of footing. Or if they did it, maybe it took them a little bit of time. And likewise, you know, we don’t have a stand at the ready public health system all across the US like you do and parts of the world like Brazil and many, many other countries, we expect our private healthcare system to be both a private healthcare system and our public health care system. So it really begs the question of, what did we see? Either that worked, that we want to keep? Or maybe that didn’t work? And we really know we need to change

Alan Lotvin

There’s a lot in there and I’ll start with the FDA, and I’ll start by saying what the FDA is full of really, really smart people. People who are doing really, really good work. The one thing that’s pandemic demonstrated with the FDA, the FDA has always sort of looks at its risk aversion. How do I avoid a problem and the issue of a therapy not being available for a period of time generally doesn’t fall into the calculus. So that’s the speed problem. And anyone who’s worked with the FDA can share with you kind of stories about, you know, challenges and staff turnover, all sorts of things, it ultimately comes down to incentives and how they’re measured. The FDA when you talk to them most clearly, they are worried about making an affirmative decision that results in something that happening, a non-decision that results in therapies, not hitting market, in general doesn’t fall into their calculus under the pandemic, when you know, when a million people were getting sick a day, it came into the calculus. And so the question becomes, do we need to think what we direct the FDA to do, because I assure you that people, the FDA don’t wake up in the morning go, I don’t like slow down innovation. That’s not what they’re trying to do. Or they’re trying to say, you told me to be safe, I’m trying to be safe. So that’s where I think, you know, that’s one area we can think about. I think the other thing to think about that you brought up earlier, is how do we create a more robust, rapid response to emerging diseases that present new therapeutic challenges. And again, we self-organized, right, the pulmonologist self-organized because this was so fast, and so rapid, like if you said, supposing COVID happened at 1/5, the speed, sort of more like HIV, maybe, I don’t know that we would have learned as much as quickly I don’t know that we would have had the sharing, and so how, if you’re gonna have a robust, resilient system, you got to be able to handle super aggressive like we saw COVID, and maybe not so aggressive as well, we might be harder to get that self-reinforcing experience.

Andy Slavitt  32:38

Let’s put a second on some of the things we learned about the healthcare system that aren’t so flattering, that were revealed. And I want to start with this idea of trust. And what seemed interesting is the very heterogeneous reaction of people in the country to a situation that was clearly going to end up being one of the two or three or four biggest killers that we had, it was going to pray, as we quickly learned, on people who were older, people who were sick already in some form or another, including people who had chronic conditions and like obesity, that were going to leave a lot of people only mildly affected, but they would be impacting others. And that would really hurt communities where people worked by the hour, worked with the public, worked in frontline jobs, much more than people like me who can sit in the comfort of my home and get on Zoom and work. So the diversity reaction including people who I think, very much tried to figure out what the right thing to do was, and it wasn’t always clear, but had clearly enough trust in the process. And in medicine and in science. Men included another group of people who I think, revealed themselves to be quite skeptical of the institutions of this country. Skeptical of government for sure, skeptical of pharmaceutical companies, skeptical of corporations, skeptical of science and expertise. And always be lied, a sense that the even the pace at which the smart people, the scientists, the medical community was moving. There are a lot of people who in this country feel very disconnected, not just from our healthcare system, but I think to just feel disconnected in general. You know, one of the things about you and your organization is you are multi local. You’re not just a national organization, but you are deeply embedded in communities. Did you notice in different regions, different parts of the country, different attitudes towards masking, vaccines, I mean, you must have a lot of data which showed urban, rural, north, south, east, west. Some of the differences that must have been occurring, did you experience the diversity of this country on a microcosm?

Alan Lotvin 

We absolutely did. And again, you know, with close to 10,000 stores, you know, all over the country, I think the statistic and get close, but it’s something like 80% of the population is within 10 miles of one of our stores. So we really do see a microcosm, and depending on which variable you were looking at, you definitely saw definitely saw what’s been reported we saw lower vaccination rates in the southeast, we saw lower vaccination rates in Black communities we saw far less mask, far less demand for testing in no sort of Sunbelt area than we did in the Northeast. And so I think you definitely see it and it tracks, political borderlines, it tracks, socio economic borderlines attracts racial and ethnic borderlines. No question about it.

Andy Slavitt  36:11

Okay. But, you know, there’s another element of this sound as kind of a topic right now, I think people are interested in which President Biden talked about, which is this idea of test to treat? And can you explain what that is?

Alan Lotvin

Yeah. So test and treat is this idea that we have effective antivirals, but they need to be given quickly. So how do you if you just were an industrial process engineer, you’d say, how do I go from, I see the test, I get the positive test to dispensing and administering the drug as quickly as possible. And clearly your most people get their drugs that are at one of the 60,000 plus drugstores in the United States, that’s also a place where a lot of people get their COVID test. So let’s connect the two and ensure that as soon as we see a positive test, they can see a professional with prescribing ability, who can give them the course of antivirals, and just shorten the time because we know the antivirals shorten the time, reduce your risk of dying, reduce risk of hospitalization, shorten the time for recovery. So that was the idea behind test and treat. And, you know, again, the obvious date place to do it is using the existing supply chain and existing workforce you have.

Andy Slavitt

Sounds like we’re simplifying for people to get masks for free, they can go in and get tests, if they get a positive test, they can be right there, get a treatment. So look, it takes us a little while sometimes. But we can do big things, if we all work together. I’m going to go into this slightly more futuristic space a little bit now with you, because just sort of fun to do. Again, we all kind of imagine a better healthcare system in the abstract, but we’re kind of talking a little bit earlier about how we’re going to have this major labor crisis in this country. And I think it’s the way I would put it as we have more nurses, and doctors today than we will probably ever have ever again in this country. And it may not ever get to 70% to 80%, of where we are today ever again. And we’re gonna have to restructure our healthcare system, by necessity, we’re gonna have to make some changes and make some make some choices. And some of that is scary, right? None of us wants to think about not being able to get the care we need. But someone’s kind of potentially as positive. And here’s what I mean. If you think about the number of things that people go to the hospital for today and need to get admitted for that could and should be able to be done at home, in the community, in more comfortable settings. Think about the things that are done in person that maybe we’ve learned could be done virtually, meaning over text, over video, tools that more and more and more and more people have, that by necessity, we might start to see or will we start to see those things as a replacement. This is an area where you’ve done a tremendous amount of thinking over your career on the structure of the healthcare system, where people should get care, where the best place is, and how that redesign works. Could we see this hasten? And what have you observed about virtual care and what can be done there? And what else can be done in lower cost more comfortable settings?

Alan Lotvin 

That’s really that’s really one of my favorite topics, right? So the arc of medical care is moving towards kind of less invasive, more outpatient sort of thing. So if you think about when I was back in when my training, you know, there was a procedure for ulcers, it was a surgical procedure to cure ulcers. And then that little purple pill came along and I doube there is a person, a surgeon left, who can do it, they got an Pyloroplasty. It just doesn’t exist anymore. You went from an inpatient seven, eight days day to be you take a few pills, you know, all the things we talked about for orthopedic surgery becomes same day, next day, outpatient. All of those are moving things out of the hospital, the next step becomes, how do you move even more kind of observational things out of hospitals into other settings, whether it’s home, whether it’s outpatient, and so I think we’re gonna see a healthcare system, a couple of things that you brought up. So one is, we have to make sure that every licensed professional we have is operating at the top of their license, right?

Andy Slavitt  40:40

Explain what that means top of their license?

Alan Lotvin 

I was born certified cardiologist, I used to do angioplasty. But when I was in the office, I would see people with high blood pressure and high cholesterol, you did not need to see a board-certified Interventional Cardiologist to look at your cholesterol go, oh, it’s 240. I want it to be 200. Let’s increase your Atorvastatin. So the top your license means you’re using specialists. So that’s what I mean by that. And I think we can have nurse practitioners and physician’s assistants and pharmacists do so much more, given the amount of training and education they have than we do today. So that’s one way to help with that shortage. I think the second way is to bring more technology into the world. And I think we’re just starting to scratch the surface of what it means when we’re all wearing biometric monitors full time all the time. Your smartwatch is a lot smarter than you think. And it’s only going to continue to get smarter and smarter and smarter.

Andy Slavitt 

Now, for people out there. Should we like that? Should we be worried about it? How should we be thinking about it?

Alan Lotvin 

I think with the right privacy controls, you should love it. And the reason is, I’ll give you a very, very fast example. So imagine that you’re a little bit older, and we’re tracking your steps over the course of two years. Now, it’s every week, the number of steps you take goes down by 10 and your step length narrows, right, and you get a little bit more unsteady on your feet, I want to know that as soon as I can, right? Because it can be an early indicator of all sorts of diseases, it could also be an early indicator of just not doing enough physical therapy and physical work. So that’s an example you can look at your heart rate and the diagnosis of atrial fibrillation, right, which is an unusual heart rhythm, which can lead to stroke, there’s a group that I met that was fascinating just from your heart rate. And we’re able to diagnose or suggest that you might have diabetes. So there’s this whole, you know, the combination of monitoring and AI. And closing that feedback loop is going to create real opportunities for very early diagnosis, the ability to track therapy, etc. So I’m very hopeful for the ability of technology to augment and help us become confidently self-serve for our own health.

Andy Slavitt 

So okay, and you put this benefit in the category of number one, prevention. You can see this technology can help you see things that you otherwise would have to wait to an annual checkup if you even went to an annual checkup. And by the way, your annual checkup been increasingly maybe just a doc spending 30 minutes with you who won’t have those insights. And secondly, I’m hearing that if you have a chronic illness, that, you know, it could help, you know, people who have chronic illnesses, it could help monitor those chronic illnesses to make sure they’re being well managed. So those are two things you feel pretty confident technology can help with?

Alan Lotvin 

Yeah, so and again, it’s also I think it’s one of two things we wouldn’t otherwise do. It’s like you know, the story of the frog that you boil by turning the heater, which I don’t actually think is true. I think the frog jumps out at some point. But in any case, these […]

Andy Slavitt  44:06

The frog jumps out? I’ve spent so much of my life on that story being true. We need a different analogy.

Alan Lotvin 

No one should try. I think the frog jumps out. But you have these subtle changes over time, you just don’t notice. So when you can track them electronically, you can notice them. So I think it’s early diagnosis. I think it’s monitoring response to therapy. If you’re, on a very expensive drug for multiple sclerosis or rheumatoid arthritis, again, if you’re not getting up and moving around, or you’re getting up and moving around less this month than you did last month, well maybe it means you’re not responding to the therapy anymore. So I think those are all opportunities that we can start to think about and then you’ll get some more sort of futuristic ones around monitoring people postoperatively at home and, you know, maybe just being in the hospital for a very short period of time, but having a whole like almost hospital at home get delivered to your house that becomes linked and observed remotely.

Andy Slavitt 

That will give you a big challenge about something that I know you care deeply about. And I care deeply about this to be done in a way, which doesn’t increase that gap in equity that exists in this country, but actually decreases it.

Alan Lotvin 

That’s a fantastic question. And it’s deeply important to me. So we’re doing a project right now, where we looked at people with high blood pressure. And we looked at, usually, when you’re high blood pressure, give them a drug, rarely does the first drug and first dose work, you usually have to sort of play with the recipe, right? Titrate up, change the drug, what you see in in zip codes that are lower socio-economic class, like, we don’t get report of race and ethnicity, but you’d see less titration of drugs now. So the hypothesis is that, that is an access issue, that there’s just not enough doctors, you know, don’t have enough time, people who can’t take time off work. That’s where you know, I have a blood pressure cuff on my house, it’s reliable, I can upload it to my doctor, or remotely via telehealth, I create more access for communities where, you know, if you can’t get off work between 8 and 5, it may be hard to the doctor. But I think we really do have the opportunity to do that. And then also, you know, when you’re not using licensed professionals, and you’re using technology, like, like everything else, it’s a lot cheaper, a lot less expensive, I would argue it’s as if not more effective, right? Because we’re doctors and everyone else, we’re only human, right? Algorithms are much, in some ways, they’re much more reliable. And I have a lot of friends who are doctors who sort of cry and yell at me about cookbook medicine, and usually my tongue in cheek responses. Not all of us are Julia Child, probably better if we use a recipe every now and then.

Andy Slavitt 

Right. Well, I gotta say that your personality is much better than robot, Alan. So, people who want to come in and talk to him. But no, I see your point. I think the thing that I would push us on not just in this conversation. But as a system more broadly, is technology has always had the promise of closing gaps. Sometimes it does stem cell phones and Africa, as is probably the example that people use frequently. But more often than not, either because of trust issues, because of access to technology issues, because broadband isn’t yet a free universal, good for a whole variety of reasons. Technology tend to increase inequities, at least the first more so than the not, and what’s done even I think people who do things in lower income communities tend to have bells and whistles that cost a little more for people so you could get an exercise bike, you use exercise bike alone, but you can’t get a peloton. And when you’re not completely self-actualized I haven’t told until you have a peloton, you’re not really don’t understand what true joy and happiness and harmony is until you have a multi $1,000 bike. But in all seriousness, like I do think it takes more work and what I learned, you know, in the White House vaccination processes, if you just do the job, whether it’s rolling out vaccinations, or anything else, and you don’t pay special attention to it, you send vaccines to Oakland. And guess what, people from San Francisco, get on the BART and go into Oakland and they take all the vaccines, unless you actually say these vaccines are going to these zip codes must be used for people in these communities, then it doesn’t happen. And I think your healthcare system is nothing but 1000s of stories every day, where people who have a more complicated life, but the same medical condition is someone else just get a worse outcome because they have lower access, face bias, and so on. And I think designing technology policy, I’ve gone on a little bit of a soapbox here, but figuring out how to do this is in a way that benefits the people need it the most is pretty complex.

Alan Lotvin 

It is and I completely agree with you. You know, I think that the promise of technology is the promise of democratization of access of, you know, to some extent ass Peter Diamandis says demonetization, right? You sort of it becomes you know, no one carries a camera anymore because it’s on your phone. Right? But I think what was I think about the health care system and, you know, how do we really get to the next level in all communities. It’s taking a systems approach to it saying what’s the problem is not always medical, right? The problem sometimes is you need to be open from 6am to 10pm, at least occasionally, right? You need to be available on weekends, you need to be available at night, you can’t ask people to wait in offices. So it’s what does an individual need? How do you set up a primary care system, a health care system that really is focused on what a patient needs and says, you know, cause a team of people who are taking care of them, we talked about kind of the kind of shifting shift work mentality or shifting the way that doctors work. A good part about that is, let’s work in teams, let’s have everyone at the top of their license, let’s make sure that everyone sees in a workflow system, what has to happen next for a patient, let’s bring that care closer to them. Whether it’s because of the actual physical clinic is closer to them, because we’re doing it virtually, we’re going to their home, where enabling technologies. And again, the technologies don’t have to be permanent. We don’t have to look for people to buy some of these things that we can figure out how to use it on a on a different business model to put it with people for the period of time they need it, because then they not need it for the whole time. You don’t need the blood pressure cuff once you’re on a stable dose. Maybe you get checked every quarter then, we take it back, we give it to someone else. I mean, those are I think there’s a lot of different models that we can conceptualize, but it starts with what does that individual human being need in order to help them sort of actualize the life they want to lead, even if it’s without a peloton.

Andy Slavitt

Well, thank you for this wide-ranging conversation. There’s very few people that I think could go as wide as we did. And it certainly as deep into some of these topics. In diversity as you did Alan, your knowledge and your breath, and your insight and your practical thinking, really, I think is helpful to all of us as we think through we got to do next in healthcare.

Alan Lotvin  52:07

And I appreciate it. I appreciate the opportunity. And I would say that you know, the only, in an interview the questions are arguably more important than the answers because you can only give a good answer to a good question.

Andy Slavitt

Well, that was a really eventful show. And if that wasn’t eventful enough, I probably harder part for me is I want to dedicate this episode to my partner on the show, who is leaving for bluer waters. I actually think there may be greener waters or gray waters. But nevertheless, Kryssy Pease and Alex McOwen, who are the senior producer and the producers of the show, who’ve been with the show, since almost the beginning, 150 episodes or so are moving on. They’re staying within the Lemonada family, they’re still gonna be close. But I wanted to thank Kryssy and Alex, for the partnership. There’s a lot of great stuff we’ve done on the show together, Kryssy is equally responsible, if not more so, for a lot of it, you know, she spent a lot of effort and energy, making me sound better, making me smarter, finding great guests. And you know, she cared about the show as much as anybody could possibly hope for. And, you know, from texting me in the middle of the night about a guest idea to helping to edit out some things that I didn’t do well, or asking me to do stuff again. And just being a funny, regular person putting up with my jokes. So you’re going to hear a different row of the credits. You’ll hear some new names. Some that I think you will absolutely love. I have adored meeting up, new team here at In The Bubble. And they’re going to be on the episode on Monday. I’m going to chat with them a little bit about what’s coming next in the show, because there are some changes in order. These people who’ve come, have come with an agenda. It’s gonna change the show, they’re gonna change me, you’re not gonna recognize it. Well, you’ll recognize it and I’m 55 so how much can you really change me anyway? Anyway, looking forward to that in our next upcoming shows Sir David Pryor, the head of the National Health Service in England, […] who is one of the scientists that has been pioneering work on the mRNA platform about what changes that has in store for us. So more lessons learned and exclusively the FDA commissioner Rob Califf the new FDA commissioner Rob Califf who I’m gonna get to the bottom of quite a few things throb. Look forward to those conversations and hope you have a great rest of the week.


Thanks for listening to IN THE BUBBLE. We’re a production of Lemonada Media. Kathryn Barnes, Jackie Harris and Kyle Shiely produced our show, and they’re great. Our mix is by Noah Smith and James Barber, and they’re great, too. Steve Nelson is the vice president of the weekly content, and he’s okay, too. And of course, the ultimate bosses, Jessica Cordova Kramer and Stephanie Wittels Wachs, they executive produced the show, we love them dearly. Our theme was composed by Dan Molad and Oliver Hill, with additional music by Ivan Kuraev. You can find out more about our show on social media at @LemonadaMedia where you’ll also get the transcript of the show. And you can find me at @ASlavitt on Twitter. If you like what you heard today, why don’t you tell your friends to listen as well, and get them to write a review. Thanks so much, talk to you next time.

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