In the Bubble with Andy Slavitt: Our Shot

Omicron and the Changing Health Care Landscape

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Andy begins with a can’t-miss breakdown of the latest information on Omicron. Then, he’s joined by two physicians who are helping create the future of what health care will look like for you: Sree Chaguturu of CVS Health and Toyin Ajayi of Cityblock Health. The three of them discuss the ways COVID changed how we access health care, how to ensure these changes don’t further exacerbate health disparities, and when this will be a reality for most of us.

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

Follow Sree Chaguturu @chaguturu and Toyin Ajayi @toyinajayidoc on Twitter.

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Andy Slavitt, Toyin Ajayi, Sree Chaguturu

Andy Slavitt  00:18

Welcome to IN THE BUBBLE. This is your host, Andy Slavitt. All the world’s talking about Omicron. So we are too, hope you’re doing okay. Let’s just start with kind of where we are. So we are either in the calm before the storm, or we’re in the storm. Or maybe we are in a just kind of a normal riding wave. Or maybe just maybe the end is in sight. We don’t know, we don’t know which cliche or metaphor we’re trapped in. And it’s kind of amusing, in that, in hindsight, I think it will all look very clear. We will say, of course, we should have known in December, that we were on the path to A, B, or C. But more so than ever, I think most of them at any point in the pandemic, every outcome is possible, including a very, very good one. And including some very, very not so good ones. And I’ve got to be honest with you, anybody who is pretending to be confident at this point in time, are people I would probably spend less time listening to than people who are really tracking this closely. But let me explain what I mean. Let’s fi rst take the bear case, the down scenario. And what would that look like with omachron? Well, it would mean that in addition to what we know, about Omicron, that people with prior infections don’t have much if any protection would also mean that vaccines are less effective than they are with Delta, which is, again, if you’ve been listening to this show, it’s not a tragedy, we have the ability to update those vaccines. But it will also mean that we need to work very hard to get more people boosted. But given the state of affairs, that we have a lot of people in this country that aren’t really using the vaccines and boosters that we have available.

Andy Slavitt  02:12

And that we have many, many people that are relying on prior infection to prevent them from getting Omicron and that that’s not effective, that we see a wave both here in the US and in Europe. For that to be true, that would mean that Omicron competes against Delta. What do I mean by that, it means that even in environments where Delta is strong, Omicronn can also be strong, that can happen in one of two ways that can happen with omachron existing alongside delta. And that would mean that it only really grows in places where people have had prior infections, but are unvaccinated and that it doesn’t grow a lot in vaccinated communities. Or it could mean that it overtakes Delta. And it really becomes the dominant variant that we deal with, you know, by February or March. So that is one scenario. It’s a scenario that’s similar to scenarios we’ve seen before. And it could do a lot of damage, it could fill up our hospitals in certain parts of the country if we’re not careful. And it could mean the winter could be challenging. So I don’t want to pretend that that doesn’t exist. But we also know that we have the tools to mitigate that. But what is this good scenario I speak of I say that this could mean that we are glad at the end of the tunnel. You know, there are people out there who believe there’s a possibility, and I would say, nobody’s confident. But many people have seen this possibility in the data, that what you might have with Omicron is a less virulent strain of COVID-19 more contagious, but less virulent. So what would that look like? That would look like you end up with lots of people who are catching Omicron and Omicron replaces Delta, but they’re not getting very sick.

Andy Slavitt  04:07

They’re not ending up in the hospital or they’re not in the hospital needing assisted oxygen, or any of the things that we’re used to. Now, what would that look like that would mean that you know, this is spreading pretty far and wide and it wipes out Delta? But it means that it is wiping it out with something that looks more and more like the other Coronavirus we know so well, the common cold. And that sort of common cold thesis, that eventually delta will be replaced by something much more mild, is one of the ways that people see out of the pandemic. Now, do we know enough from existing data to say that that scenario is a possibility? Well, I think we know enough to say that it’s a possibility. I don’t think we know enough to say that it’s a likelihood. And, you know, I think it’s wise to be conservative and say that that is not necessarily what’s happening. But some data on the ground in South Africa is pretty interesting. And what it shows is that while hospitalizations are indeed up from Omicron, they’re often up in people that are in the hospital for other reasons. And we are detecting that they have Omicron. And they don’t even know it. That is interesting, because what it says is, is spreading very fast. But it’s not creating a lot of symptoms. And if that stays the case, that could be promising. Now, one of the reasons why it wouldn’t stay the case is because it’s still early, the South Africans did a good job of discovering Omicron fast. So we’re only at this for less than a month. And as we know, the severe cases don’t really start to stack up until a little bit later.

Andy Slavitt 

So one can hope, but one shouldn’t plan around that hope. But truly, as we sit here today, in early December of 2021, this could go any direction, it could go the predictable direction we’ve been on, it could go a direction where this is even worse than what we’ve been experiencing. But it could also go direction where this is actually better than what we’ve experienced and moving us towards a better place. The Biden Administration released as many of you may have seen its response, not just to Omicron, but to what’s been going on, and what we anticipate happening over the course of the winter, they got some praise, they got some criticism, I think the aim is to be pretty comprehensive. And I think it was pretty comprehensive, make rapid test much more available, rapid test, they put about $3 billion into rapid tests over the course of the late summer. And they should see a fourfold increase in rapid testing a lot of people who say they can’t find rapid tests, so that has to improve, they’ve also are going to put 50 million rapid tests for free in community health centers. That’s a good thing. Because right now, I think the well to do are rapid testing, and the people who look at that and say I can’t afford $10 every time I want to know if I hope COVID are not testing.

Andy Slavitt

And they’re requiring insurance companies to cover the cost of test for everyone who’s insured, which is aiming to hit the 150 million Americans that maybe not using the test well enough. Now, some people love that proposal. And some people don’t. Some people say why do you need to get insurance companies in the middle and I’ve been on TV talking about that quite a bit, I’ll tell you that if I were in the White House right now, I would be calling all the insurance companies and convincing them to buy these things in bulk, and sending them to people’s homes directly to try to eliminate the hassle. But look, over time, they’re gonna have to get their you know, they’re gonna prove get better and better get better and better policies, getting people boosted. Critical, critical. I think whatever happens with the vaccines, I think we know that the boosts are essential. One day last week, they sent about 9 million doses to Africa, of the vaccine, which is great. You know, I have had conversations with the White House about that. And it is great to see them stepping that up. They’ve committed to send 200 million more vaccines overseas in the next 100 days. I think that is a good pace, very important. And they’ve spent a quarter of a billion dollars on the ground in Africa through USAID trying to implement more vaccines.

Andy Slavitt  08:29

So again, a comprehensive approach, easy for folks on the outside to point to things that they want more of or could see better. And policymaking is never perfect, but I liked the fact that they acted fast and acted comprehensively. So, that is what you can expect from a policy response. On the show today. We’ve got a great episode that we just recorded with Toyin Ajayi, who is the president of city block health and with Sree Chaguturu, who’s the Chief Medical Officer at CVS Caremark, this is a very interesting episode, very timely episode. And it’s really about how Omicron and COVID are changing the way we have to deliver care to people in every community, in the communities that CVS serves. And in the very special communities served by city block health, which are really the 120 million Americans who are on low and fixed incomes, and don’t have access to the best care anyway. And fascinating, as I think you’ll hear in this episode, that COVID kind of gave a kick in the butt to some changes that were long overdue in health care. And hopefully, it’s going to make things different for all of us, namely, is it going to allow us to get care in more convenient ways because we’re trying, all the efforts we made to try to avoid getting people sick with COVID, should we be able to get care virtually? Should we be able to get care at home? That’s a lot of the stuff we’re gonna explore with Toyin and Sree, and I think you’re gonna really gonna enjoy this episode. You know, they’re, they’re amazing. And I think you’re gonna love to hear what they’re doing

Andy Slavitt  10:20

All right, well, this is gonna be fun. And it really, this is a fun, upbeat episode because it will get to talk a little bit about the world where the world’s going with two people who know where the world’s going, because they’re making it happen. I love my first guest so much Toyin Ajayi, she is the Chief Medical Officer at Citi, black health, all you really didn’t know is they are reinventing the way care is delivered to disadvantaged communities that haven’t had access to good care. And it’s amazing. So we’re going to talk about things with her. And then of course, one of the biggest health care providers in the country is CVS, and Shri is the Chief Medical Officer, Shree Chagga. Tour. So what better place to talk about how things are changing, but first, I’ve got a very important question. Are you both a Omicron person or not an Omicron person or an Omicron person. Sree, what’s your favorite pronunciation?

Sree Chaguturu 

Yeah, I’ve also heard Ohmicron. So you know, I think we’ll see where the English language takes.

Andy Slavitt

You’re an Ohmicron guy. Okay. Top that Toyin.

Toyin Ajayi 

Definitely not Omnicron. How’s that? I’m going hard for Omicron.

Andy Slavitt 

I’m trying to stick to the hard O.

Sree Chaguturu 

The hard o is where we’re gonna land.

Andy Slavitt 

What are you doing to prepare over at CVS, Sree?

Sree Chaguturu 

You know, CVS health has continued to provide vaccination and testing services, as well as access to treatments that we continue to monitor across Omicron. And you know, what will be the implications for vaccinations, for testing for treatments, I think we have a lot yet to understand about what the impact will be of these variants. So for right now, it’s stay the course. But we’re ready to pivot as needed across all of these categories of treatments, and vaccinations.

Andy Slavitt  12:13

I’d be remiss if I didn’t ask you, people seem pretty desperate to find more at home tests. And probably will will continue to be the case with a new variant here. We actually are doing an episode on the supply chain, that’s gonna air soon after this one. So we, you know, understanding their challenges. What’s the current status of the availability of these tests at CVS and other places, as far as you can see?

Sree Chaguturu 

They’re available, obviously, there’s continued demand. And it ebbs and flows as the virus continues to spread throughout the country, we see regional variation in terms of demand, we work with manufacturers on supply chain to make sure that we have access in our store. So at times the stores you might not see access to at home test. But broadly, they continue to be available across the country in our stores, as well as on site PCR testing through our drive through pharmacies, across 1000s of locations for PCR testing.

Andy Slavitt 

Can people go on to the CVS website, and locate which stores might have a test so they don’t need to drive around.

Sree Chaguturu

That’s right. So on, you have the ability to look at based on your zip code, what sites are available for drive thru testing. And then availability of rapid test is in the stores. And so you’d have to visit one of our stores. We don’t have that available real time on a website. But as I had mentioned, they’re broadly available and generally will be there when you walk into a store for rapid tests as well.

Andy Slavitt 

Recommendation for your web product development roadmap, you heard it here. Toyin, as you think about it, I know you’ve started to how variants affect care of the communities that you serve. And feel free to start by giving a little bit of background on the communities that you think about every day there was focused on how does, how do you think about how Omicron will hit these communities?

Toyin Ajayi  14:18

Yeah, so at City Block Health. And as you know, we serve some of the most marginalized communities across a number of cities and states in the country. And we’re focused on individuals who have the most complex physical health, social health and behavioral health needs in our society. These are folks primarily who received their health insurance through Medicaid or through Medicare or through a combination of the both. And so very, very significant proportion of the folks that we care for are the highest risk and they’re the highest risk because they have underlying comorbidities. We talked about sort of, you know, pre-existing conditions as risk factors but they’re also highest risk because they don’t have the luxury and the benefit of paying $25 for an over the counter rapid test as an example, or of socially isolating when their day to day existence depends on them to taking public transportation and going out and encountering the public in order to make ends meet. And they’re also at highest risk because they’re over representative of people of color. And we know that this sort of historical sort of systemic racism and the ways that that plays into the pandemic has reflected in just a much, much, much higher burden of disease, and much worse outcomes for these populations.

Toyin Ajayi 

And so anytime something happens, be it a big flu season, be it again, another variant of a very highly transmissible and lethal disease, we know our folks are going to get hit the hardest. And so we have to be extra prepared to serve and care for our populations. And we do basically all the things that we should, from a public health perspective, there’s no sort of magic formula, we’ve got to find our members, we’ve got to be close and connected with them, we have to help them parse through all of the noise of the news and the media, and the fake news and the fake media to really understand what their personal risks are, to help them make choices that help reduce the risks. And in this instance, for us, it’s about vaccinations. And it’s about boosters. We know that works. And we know that our communities are particularly likely to benefit from access. So we’ve got to help people make the choice. And then we’ve got to make sure that we can carry through, deliver those shots and arms for people when they choose to do so. And then down the road, it’s about being prepared to bring care into the home. I think one of the things we saw more broadly, in the early days of the pandemic last year was a drop off of access to primary care and mental health services, particularly in lower income communities, particularly for folks who didn’t have smartphones and unlimited data access, and the ability to use some of the newer technology coming out. And so we have to fill that gap for them. So I think similar to what Sree said, it’s more of the same. But it’s with an intensified focus on the folks who are most likely to stress suffer when things like another variant sort of hit the same scene for them.

Andy Slavitt  17:01

You know, what I, what I appreciate listening to you is, you remind me of all of the things that I take for granted, that just seem to be available to someone like me as part of the healthcare system, you’re being able to afford something that cost $20, being able to get someplace and assume that and then make the wrong assumption that everybody can.

Andy Slavitt

So as we get into this conversation, and I think the theme of the what I want to talk to you both about is there’s a lot of things that changed as a result of the pandemic, many of them bad, we lost a lot of schooling. We’ve got supply chain problems. We have very tired worn out healthcare workforce. We’re all a little bit shaken. If we’re, unless we’re, you know, superhuman, super Omnicron human. But, but there’s also been some changes that have been positive. One of them I want to talk specifically about is how and where people can get access to care. We saw the rest of the economy get digitized over the last couple of decades, but not really so much health care. So I’m wondering, Sree, if you could talk to us about what happened when you know, care, which we’re used to seeing, thinking about as a physical act, go see a doctor, go to an emergency room, go to a hospital, what’s changing?

Sree Chaguturu  19:08

So, out of necessity, we’ve changed substantially across healthcare in terms of access to provision of care, right. So as the economy shut down in that March, April time period, people still needed to see their provider so consumers, patients changed their way that they access their care. They started to use telehealth virtual care. And providers started to adopt a number of new technologies or use old technologies and new ways to be able to connect with their patients. And so what we saw..

Andy Slavitt 

Wait a minute, did you say doctors changed? Doctors adapted technology? I’m sorry. I think there’s a some static on the line here, Sree.

Sree Chaguturu 

Yeah, no, you heard correctly. And I think we’ve all had and you started out the question with how have we changed as healthcare and I think unfortunately took COVID. But COVID did accelerate a lot of change in terms of adoption of digital technologies, right? So consumers, patients now know that you can get care virtually, providers are now offering care virtually, those are the two major changes. Now the question is and, Toyin will, it will be great to hear your thoughts on this, too is how adorable are these changes? Are they the product of the pandemic? And will they be durable as we get to the other side of the pandemic? So look forward to having that discussion. But yes, a lot of changes that have happened.

Andy Slavitt  20:39

Would you say it’s half, it went to half and half, it went to 90/10, it went to 80/20, it went to 20/80. It went up by 2%. How big a change did we see during the peak of the pandemic?

Sree Chaguturu 

So, at CVS Health, as we look at our Aetna medical claims data, what we see is that in 2020, so over the last year, about 13% of primary care visits went virtual 6% of specialty visits went virtual, but we look at behavioral health, and we saw a staggering 38% of visits that went virtual. So it really depends on the type of care that you’re offering, how critical is testing and physical diagnosis, as part of that care, or operations needed so we start to see specialty care being lower as a percentage of overall virtual care, but behavioral health where a lot of that care can be delivered through a connection to the patient establishing that care, you see much higher usage of telehealth so really, Andy, to your question, it varies by specialty, anywhere between 6% to 40% by specialty.

Andy Slavitt

If we’re gonna have to do my own heart surgery. Just tell me that now. It’s someone gonna walk me through my own heart surgery online?

Sree Chaguturu 

Not quite yet.

Andy Slavitt 

Okay. All right. Few, that the other thing that happens Toyin, as you remind us is, it’s not just the things improve, or get worse. It’s often that things improve for people who already have it pretty good. And things don’t get much better at all. For people who have it not as good to kind of populations, you’ve been talking about Medicare, Medicaid populations, people with lower incomes, people on fixed incomes, older, etc. So I fear every time that there is a positive change, whether it’s the internet or anything else, that it just widens the gap, is that happening here? Or is there a hope that this can actually be an equalizer of sorts?

Toyin Ajayi  22:35

I think there is a hope. I think that there was a couple things happened last year that are just were unprecedented. So of course, there’s the pandemic, and we’ve talked about that. But also, we entered into a national discussion about health disparities, and specifically about the drivers behind health disparities. And the ways in which historically, the same thing you described as occurred were the 1% those of us with resources and supports and education and access to tools, things get better and easier. technology and tools get applied to making our lives that much better, and everyone else gets left behind. And I really think the convergence of those two conversations has shifted the ways in which what could otherwise have been simply yet another example of, of the sort of the top floating up and the bottom being left behind if you will. I don’t see that happening quite as much. There’s still gaps for sure. But let me give you some examples. So early in the pandemic, and when we saw this sort of widespread adoption of telehealth, folks we’re seeing, you know, 8000%-9,000%, week on week conversion of visits to telehealth, very early on, we saw that there was disparity there that predominantly commercially insured folks we’re seeing widespread adoption.

Andy Slavitt 

So people who get their insurance through their job?

Toyin Ajayi 

Through their job and those yeah, that’s right. So folks who get insurance through their jobs, people who tend to have access to doctors and other health facilities that are higher reimbursed, so they have just more frankly, more resources to spend.

Andy Slavitt  24:04

So they went first?

Toyin Ajayi 

Yeah, they went first. They went first. And folks, and those those patients are people who have smartphones and have lots of data that’s relatively cheap for them relative to  their incomes. And they were able to really adopt those tools. And frankly, they had a lot of trust, because we’re banking online, us are using our smartphones, we’re talking to our families using our smartphones. The idea that you would log your blood pressure and talk to your doctor didn’t seem not that big of a leap to jump through. On the other hand, physicians and community health centers who were already operating in thin margin environments, not a ton of resources, much lower reimbursement, serving a population of folks who did not have tech savvy necessarily, certainly don’t have unlimited data packages that they can easily leverage even if they have smartphones. Perhaps they’re not as trusting of the digital space is a place to get their health care. They really struggled. And what we saw was that early on telehealth for lower income patients really meant a phone call. And you can do a lot. In a relationship, if it’s a primary care doctor who knows the patient is known the family really well on the phone for an urgent need. But there’s a lot you can’t do. You can’t lay eyes on a person, you can’t put your hands on them.

Toyin Ajayi 

If they’re telling you they’re having trouble breathing, it’s very hard to assess what that means. And so the quality of that experience for a lot of lower income folks, was not the same as as for folks who were downloading our designed app on their phone and and having a virtual video visit. But what we found at city block was that there are ways specifically to start to overcome that gap, to say, what’s the bar? What’s the gold standard for us for virtual care? And how do we ensure that we’re helping our members get access to that, and we saw a lot of other providers doing the same thing. Partly, I think, driven by this recognition that if we do nothing, we’re gonna see the gaps expand. And so we started to see much more focus on getting into the patient’s home into the member’s home, in addition to virtual care, thinking about meeting people where they are virtually so using tools that actually work for individuals, instead of saying the only way to access virtual care in at City Block, as an example is through an app that you have to download from the App Store, you’ve got a two factor authenticate your way into it, you probably need a whole lot more data than you can afford on a monthly basis. What we say is you can text us and if texting works for you let’s do that. And we’ll convert to a phone call if that’s necessary. And if we need to lay eyes on you, we’ll send someone to your house who’s clinically trained to get you on video with a doctor who can get vital science who can really could put it do diagnostics, get labs in real time to inform the visit. You need to do that’s what equity looks like, right? You do provide more to the people who need it, to ensure that they actually getting what they need.

Andy Slavitt  26:52

Wait a minute, I want this. You’re telling me you’re telling me, okay, that the doctor who I’ve got to go drive over to where they are, wait in the waiting room? Well past the time when they’re supposed to see me often, then get in. And I can only get in and see them, you know, pretty briefly did they can come to my house, do they can come to my mom’s apartment?

Toyin Ajayi 

Totally. I mean, it’s baloney. When you’re like this, take a second and think about it, like forget the pandemic for a second, pre-pandemic, the idea that if for most people in this country, if you had a medical problem, it could be I’ve got this weird mold that’s been bothering me for a while or it could be I’m having palpitations, and I don’t know what’s going on, you got to pick up the phone, sit on hold, typically make an appointment. If you’re lucky, it’ll be a couple of days in the future. For most lower income folks accessing oversubscribe community centers, it could be six weeks in advance, you take time off work, find somebody to watch your kids pay for transportation or get a ride over there, you sit in a room with a whole bunch of other sick people waiting on the order of 45 minutes to an hour. And after all that you get 10 minutes of FaceTime with a human who’s asking you a whole bunch of questions that you already answered before. And then you go that was that that was healthcare. That was healthcare for all of us, really, prior to the pandemic. It’s bonkers. And so the idea that we had, we were taking advantage of this moment to further catalyze something that had to be transformed, had to be broken apart, had to be redesigned, is like to me when I think about the silver linings of this moment in time, like this is one of them like that, that shouldn’t have existed anymore, given what we know and what we can do. But certainly now it should not exist. And for the people who we need to serve, they need something different.

Andy Slavitt  28:45

So I sent us both of you this question. Are medical professionals willing to do this are doctors nurses, you know, I guess EMTs do that kind of thing already. But is that something we could expect? Certainly CVS stores are convenient. There’s lots of them, but my house is pretty darn convenient. My phone is pretty darn convenient is that a future that going back to you for a second, Sree, that you see as well?

Sree Chaguturu

Yeah, I mean  painted a vision of the future that we wholeheartedly agree with at CVS health patients, consumers want to access their providers in multiple different ways, whether it’s in the home, whether it’s in a clinic, or in a virtual setting. The fancy business term is Omni channel but you know, fundamentally… But anyways, you know, fancy terms aside, you know, ultimately it’s helping patients receive the care in a way that they want to receive their care. We also know that any one of those opportunities whether it’s the home in the clinic or virtual is insufficient alone, like it has to be the combination of those three, when we think about that opportunity at CVS health, we see the opportunity to provide a virtual front door, an opportunity where you have one place to go to start your care and to be assessed. And if you need to be seen by  a clinician, for hands on care, you can go to one of our minute clinics across the nation. But it’s not a disjointed experience, it is connected to that virtual care that you received. And so that combination of virtual and physical hybrid care is what we believe is the future of healthcare. And it’s going to be rooted in longitudinal primary care relationships, not disjointed, segmented relationships with different providers working in different spaces. So we’re really excited about that vision toy. And I think we’re fully aligned with how you’re painting the future as well.

Andy Slavitt 

When I think about the person out there listening to this episode, that none of us would be surprised if they were thinking that doesn’t exactly describe my reality today. Maybe I experienced virtual care, during the pandemic, maybe it felt like a new experience. But for many people, it didn’t replace things in this omni channel thing, which I teased you about this idea that I can go get care wherever I wanted, or care can come to me, wherever I most needed, when is it going to be a reality for lots and lots of people? And, you know, Toyin, I’m enough of an idealist and you’ve known me, for enough time to know that I kind of put my head in the clouds sometimes. But like, I’d like to think that if we do it right, it happens first for the people who lack the basics, and that they could be the first people to have this kind of new type of experience. Am I dreaming? Is it possible? How and when does this become something that most people out here listening would say yeah, that’s now my experience with the healthcare system.

Toyin Ajayi  32:08

Well, someone I really admire once said to me, that building a startup, particularly in healthcare is like entering into a shared delusion, with as many people as you can get into, to buy into this. And so the idea that you’re if you’re dreaming, I’m dreaming, too. And so let’s dream, let’s read this together. Because I believe it’s possible. And I particularly believe it’s possible that we can start, as you described with folks who needed the most, who have the most to lose, and the most to gain by us getting this right, and who have otherwise and would otherwise be left behind by the sort of wave of innovation. And so I believe it’s possible, I think that there’s a couple of ingredients here. One is, of course, is sort of building the model store, if you will, like you got to build the thing to show people what it looks like and feels like. And I sort of my analogy for myself has been when I think about, you know, the smartphone and the iPhone, and what it means to me today. You know, 10 years ago, 20 years ago, if you’d asked me what I wanted from a new phone, it would be like a slightly nicer flip phone, right, I was really into their like red flip phone. But the idea that like until I saw that I could even demand of my phone, that I can surf the web, I can FaceTime with my nieces and nephew, I can pay my bills, I could do Tiktik that would never occur to me to even ask for it. And now I would never go back to buy a phone and not have those things that I take for granted as part of it. And I think part of this is like, you got to show people that we can actually deliver health care differently and better at scale. And then they will start to demand something different. And the thing that gets me so jazz is the notion that our population the members whom we serve, will eventually become so accustomed to the type of care that we and many others we’re not the only in this space for sure that we and many others are trying to sort of design for and around their needs, that they would never go back to that old rigmarole I just described and consider that to be a healthcare because we have to shift the paradigm entirely.

Andy Slavitt  34:05

Someone I know who I’m married to, misses her BlackBerry’s still just saying.

Andy Slavitt

Toyin, to just to make it real for us. Is there a place in the country right now, where this is happening in communities that City Black serves there and can you just describe maybe just give us a real vivid representation of what it feels like to an individual like maybe an actual actual story just to help me see is this really real today? Or is it still, as you ensure we’re talking about a great vision for the future only?

Toyin Ajayi

Oh, no, it’s real. It happens today. So we at city block we serve members, as I mentioned across a number of states, all of whom are folks with struggling with the confluence of social behavioral and physical health needs. And what it looks like and feels like for our members today. Is is taken individual who same has been struggling with  being marginally housed, not living on the street exactly, but doesn’t have a regular address to go home to every day. And in the middle of the pandemic was, of course, high risk for catching COVID. And, and was also really pretty disengaged from typical primary care services struggles to it’s hard to make an appointment at at a predictable time when you’re taking a couple buses to get to the appointment or when you’re having to navigate just the the day to day experiences that you’re having. And the inconsistencies that you’re having. That person is a city block member would would have the ability to say, I can text my care team, and have triage. So if there’s something urgent going on, we’ll tell you where to go what to do, we can come to you and in this instance, we we would deploy a paramedic or an EMT to your home or to the place you call home. So it could be if you’re staying on a friend’s couch, we’ll go there.

Andy Slavitt  36:23

Just because they sent a text. And that’s how they can access it?

Toyin Ajayi

They can text us, they can call us we have an app that they can use well however you want it to the omni channel point, however you want to reach us, okay, we’ll be reached. We’ve we have people who you know they they spend the day in the library, because that’s pre pandemic, that’s a very common place for people who don’t have a safe and warm place to be to spend the day and they email on the on the computer, the library, and we’ll pick up the email and connect with our members that way. However they want to connect with us. And as I said, we’ll send a care team to you. So we’ve teams and EMTs and paramedics every single day. And all of the communities that we serve who are able to go to people’s homes or to the place they call home, we’ve met a member by the side of the freeway, because he was a long distance bus driver. And that was the place that he could access his care. Well take vital signs we can get labs done, well link in with your medical record, video, real time video with a physician or an advanced practice clinicians. So they’re directing the care if you need treatments. So you’ve got an infection, and you need an antibiotic dose, we can provide that to you there and then in your home. But they can also do things like open the fridge and say, gosh, I wonder if the reason why you know your grandma’s been struggling with low blood sugars is that there’s not a lot of food to eat here. How can we help you figure out groceries?

Toyin Ajayi 

And we had a lot of members who had social needs that sort of got went on that during the pandemic in particular, or, you know, I’m going to pull out the med cab, the meds from the med cabinet. And goodness, there’s things that have expired two years ago, can we get rid of those? Let’s talk about making sure we organize them and pillbox, right, let’s go to CVS and make sure we get your meds done, right. We can provide folks with a level of sort of triage and care for all of their needs in the home. And they can also come to us. And so we’ve had members who come into our physical hubs to trace point it’s not a one size fits all. CVS is a wonderful example of a ubiquitous presence in so many communities. And so the ability to walk in and say, hey, something’s going on. And I need to talk to somebody, we had a member who came in and said, I’m not feeling well, you know, didn’t have to make an appointment. I’m not feeling well, we diagnosed them with what was going on for them and manage next steps of their care. It’s truly, truly the ability to be sort of ubiquitously present in the communities. And it is happening today. And when what we’re hoping to do is to continue to scale that to start to catalyze the sense that it is possible to do this at scale, so that we can shift the paradigm.

Andy Slavitt  38:46

Sree and I are both wondering how we could become city block members. So maybe you can tell us. Shree, I want to ask you a question. I don’t couldn’t go down a line I don’t normally do on the show, which is talk a little bit about business strategy. Because I think that how what you’re talking about clinically, it plays out based on what you know, CVS is trying to do. So CVS, most of us think of CVS, by the brand we see when we walk down the street or drive by a CVS store, it’s as a pharmacy place we can go talk to a pharmacist, but also by over the counter medications and anything else that might be in the store. Now, you referenced another name, the name you referred to was Aetna, which I think people know is an insurance company. And many people might not know that CVS bought Aetna a couple years ago. Now, people generally I think, like drugstores. They like CVS, I imagine because people go and get the problem solved. I have not seen data on this, but I know people they trust pharmacists. Yes, I think people justify with this. Now, I don’t think people like insurance companies very much. I think insurance companies are you know They’re kind of not always solving problems for people and people perception. Sometimes they even create problems for people. Yet. CVS decided in your wisdom that it made sense to buy an insurance company like Aetna or whatever you could talk about why that is and what promise that might create for people.

Sree Chaguturu  40:23

Yeah, Andy, if we kind of step back and just describe for the audience, what is CVS Health, it’s essentially three different businesses, you have pharmacy benefits, which is the coverage of medications, you can think about it as insurance for medications. And at CVS Caremark you have Aetna, which has health benefits, so your medical insurance and in CVS pharmacy, and that’s what people know, in their communities with 9000 locations across the country, in close proximity within five miles of close to 90% of the American population. So you know, to answer that question that you have about what is our business strategy first, starting with who is CVS Health, as we think about the evolution of CVS Health, starting from pharmacy services, we’ve extended into health insurance and pharmacy ensure insurance but also the provision of care, then we saw that in spades with providing 40 million plus test 40 million plus vaccinations, we’ve historically been providing acute episodic care through Minute Clinic. And in addition to that, MinuteClinic has been evolving over the past couple of years, quietly, but importantly, into primary care services. What I mean by that we provide preventative services that you wouldn’t traditionally think of it as acute care, such as getting your vaccination services, or diabetic screening, or providing chronic disease management. If you’ve been screened positive for diabetes, we can help you with managing your diabetes.

Sree Chaguturu 

What we haven’t done today is own a longitudinal relationship, primary care, longitudinal relationship. And as our CEO, Karen Lynch has discussed recently, we will be more actively getting into primary care. Now pull this all together. If you think about the provision of health care services, it starts with insurance and ability to pay for that care, and then locations to receive that care and making sure that both sides, the insurance side, as well as the provision of care are talking to each other so that patients understand what services are available and where to get those services. And that it’s convenient. So Andy look at CVS Health to date, it has been pulling together the different parts of a broken healthcare system. And we look forward to what CVS Health will be. It is about providing solutions to complex problems most significantly, the next problem, we’ll be helping to solve primary care across this country, and primary care services. So really excited about where we’re at.

Andy Slavitt  43:04

Got it. So primary care, my prescriptions, you mentioned, briefly a PBM, which for those who aren’t familiar, the places that really negotiate with the pharmaceutical companies to get to lower prescription drug prices. So it’s kind of a middleman, you don’t really see. But you’re talking about giving someone insurance and providing their primary care and giving them medication. What’s the benefit to me as an individual? Am I going to pay less? Am I going to have a more connected experience where people don’t forget me? What happens when I go outside of CVS to another doctor or to Walgreens or to another hospital or something? Is that going to be a no no? How does all that kind of work in your business strategy,

Sree Chaguturu

It’s across all of the things that we’re all trying to improve in healthcare, lower costs, improve quality, increase access to improve the experience of health care. And so as we continue to build this out, you know, making sure that we’re lowering costs, improving the quality and access to care and making that a more connected experience, I think we would all agree that the current system is unsustainable. And what we’re putting forth is a combined experience that we believe will be better than the current system and Toyin, you describe this. Well, we need to have that shared delusion, we have to build it. We’re really excited about what we’re building here at CVS health.

Andy Slavitt  44:32

So some people, may listeners may not but some you guys might know that I used to work in the health care system, both on the company side private sector side as well as for the government. So I’ll offer an opinion here. I’m going to go out on a limb, CVS as a business understands individuals and how to serve them one at a time in a very much the same way a Walmart or an Amazon or a consumer company would. Aetna understands how to manage large populations. Because ultimately, when you put us together the sum of who we are, and how you make decisions about who needs what is an important lever, the magic in health care will be if people start getting good at the first, and if that culture can pervade over to the insurance people by I think people would find that a positive thing. Because insurance companies, generally speaking, what they’re good at populations, not so good. Individual, I think I say no sound fair, a lot of contradiction. So to me, the question is which culture wins? If you pour it over the ethnic culture into into the way to your stores, and your CVs culture to the insurance companies, I think that’s probably going to be a mistake. But if you could port, the CVS culture into the way you deal with individuals, and this notion of longitudinal population management, over throughout the enterprise, that would probably be better. So I suspect, like a lot of corporate things. There’s a lot of cultural energies at play between those things, to make the challenging, but it feels to me like, if I were going to offer you one bit of highly expensive advice, that’s what it would be.

Sree Chaguturu  46:20

Yeah, Andy, one of the biggest surprises for me when I came over, I used to work in a large health system. And we talked about patients. And when I came to CVS health, we talk about consumers. And it really is understanding what does an individual want when they’re trying to access care and thinking about health care from a consumer land? So to y our point, that is front and center and how we think about redesigning healthcare? How do we make this more consumer centric, so that when you become a patient, you can get the care that you want? And so I just offer that that’s been a big lesson for me coming into CVS Health.

Andy Slavitt

I think the problem we have is that insurance companies talk about neither consumers, nor patients, they talk about members talking about insurance, and so forth. And I think that culture, is why people often feel mistreated by the healthcare system. But look, I think this is discussed back to the question of Toyin  you describe this well, like is information and technology, a substitute or a means to help us know people better, and treat them more individually? And better? You know, I suppose from a business standpoint, your disadvantage is you’re brand new, and your advantage is that you’re brand new, and you’re starting from from scratch, and conceiving of things, you know, brand new, I guess I just asked you how you see all of these forces playing out in City Blocks world?

Toyin Ajayi 

Yeah, absolutely. I mean, I think the discussion about sort of the consumerization of health care and what it means to us to treat people as individuals and to build and design experiences around them, and how that if we do it right, under the right set of incentives, and the right sort of alignment around incentives, how that translates into better outcomes for the population as a whole, is a really important one. And I think the place where historically this sort of like the benefit of being brand, brand new on the scene as you get to like, you know, point and criticize all those who have come before, right. And so I think the thing we’ve missed in the past is recognizing that when you think about sort of a true consumer marketplace, if you will, what do you need, you need people need to have agency in some form of sort of buying power, they need to have an ability to value the thing that they’re purchasing, and the ability to then translate that and hold accountable the system, either by not purchasing again, when it doesn’t meet their needs. And so what is the construct look like in healthcare, particularly in the space that we’re in? And how do you apply the same principles into this space. So when I think about the folks we serve, who often don’t pay co-pays as an example, for healthcare, so they’re not consumers in that they’re making a transaction out of their pocket, but they’re certainly making a payment, they’re giving us their time.

Toyin Ajayi  49:08

And when you are one of my members, your time and your attention is in many instances, your most valuable asset and so that, you know, the rigmarole that we talked about of you know, what we ask people to do access care like that is meaningful to a person. And so if I’m asking someone to spend their time with me, or with a community health partner on my team, or with a nurse on my team, or with any other person within the City Block continuum, what do they perceive as the value that they’re getting from us and how do I ensure that that value meets their needs, and when we have a system of healthcare, that where the connection between value and real health outcomes is really opaque, super opaque, where we know that people decide, you know, whether they like doctors based on whether they you know, treat them right and don’t keep them waiting, but we have no transparency on whether this person is less likely, this person’s care is more likely to translate into me living longer as an example, we’ve got to figure out a way to really, really educate the people whom we care for. So they can be truly discerning consumers of health care. And some of that is around experience. So start there, like, we should make sure that we are oriented around ensuring that every single person we care for leaves every encounter with a system that we deploy, that we deliver, that we’re accountable for feeling valued, feeling respected, feeling dignified feeling heard, and that there’s not a whole list of things in the back of their mind that they wanted to bring up. But they didn’t bring up because they didn’t have a trusted and safe relationship, we can solve for that, step one.

Toyin Ajayi  50:39

Step two is we’ve got to be accountable for ensuring that the way that we deliver care is tailored to actually helping them achieve their goals. And those goals could be, you know, let’s close the life expectancy gap between people with serious mental illness and those who do not. Let’s close the life expectancy gap between people who live in my zip code 11216, and people who live in upper Manhattan, let’s actually start to address the fundamental issues, let’s be transparent about how we’re doing against those goals. So people can choose us or choose something else. And that then I think translates into that. And what we’re looking for, which is overarchingly better outcomes for the population as a whole.

Andy Slavitt

Well, this is exciting to think that we’ve got people like yourselves, and people with quite frankly, the resources that you all bring in the energy that you’ll bring, that could help us over time start to create a better health care system for people people been talking about it a long time. I agree with what both of you said that we’ve actually started during the pandemic actually see some progress against this, we’ve got final couple questions. US of care, which is this nonprofit health care group that I founded with my co founder, Natalie Davis, they just did some really interesting research. And they really went at the what the five commonalities of everybody in this country, think about what they want in the healthcare system, and I’m not going to go through all five of them, they’re gonna release this information. It’s pretty exciting stuff. But what really struck me was the number one item that across political affiliation identification across rural and urban and across income levels, that people are concerned about is something we haven’t yet talked about. And I’m curious whether you both have a reflection on this. And that is support for caregivers. The number one issue people have today is how they managed situations where they’re taking care of parents, kids, or they have caregivers that are taking care of their of people in their families. And it feels like people are saying, in a different way, a lot of pulling a lot of threads together. Some of maybe fear of nursing homes and what went on there, the desire for people, as you both said to be treated at home, and at work community locations. But it really struck me that above cost above predictability, above quality above the things that we talk about all the time as the kind of higher aims in the healthcare system that this has emerged. It’s a top issue. So assuming that that’s would be true, at least some of the audience maybe as we wind down could ask you, Sree to reflect on how, what you’re doing today and what you see ongoing, will address that need.

Sree Chaguturu

Yeah, we’ve seen the same thing. So with our relationships with our customers, and so, Andy, we talked a little bit about what is CVS Health and Aetna and Caremark who are providing health benefits. So critical to that relationship is a relationship with to companies. And so we work with companies to provide health insurance or pharmacy insurance. And when we are working with them, we’re working in a consultative manner to understand what are their needs for their employees. And caregiver support comes up routinely in these conversations. And we cover 100 million lives in either with Aetna or Caremark. So 1 in 3 Americans. And so we have developed out offerings to provide caregiver support. With our pharmacy benefit with CVS Caremark, what we have found is that there are a lot of digital health solutions that can provide support to caregivers, but it’s hard to find a way to identify which ones matter and how to pay for it. So with CVS Caremark, we’ve provided access through our point solutions management to caregiver digital support tools. And with Aetna, we have our employee assistance program. So we work with employers providing EAP to employees to have give them that caregiver support in addition to these specific point solution tools but to provide that longitudinal support for caregivers, and employers are really interested in providing these tools to employees, because they know how much stress people are going through with the pandemic. First off, just trying to get through the activities of daily living. But add on top of that the stress of having to care for a sick loved one, not having the tools if an employer can do that they’re doing right by their employees. And that’s why they’re talking to us either with our relationship at Aetna or CVS Caremark on what can we do to help support? So I just laid out a few of those tools that we’re providing. But it is definitely something that we hear from employers across the country. And we’re trying to do our part in providing those tools.

Andy Slavitt

Toyin, is this also an issue in the populations that City Block Health serves?

Toyin Ajayi

Absolutely. For all of the same reasons we described, this is a huge, huge issue. When we think about our aging population across the country, we think about the proportion of folks who are aging in poverty, we think about parents bring babies into this country where we don’t have a universal paid childcare and and family leave policies. I mean, it’s huge. And I think the the solution is is twofold. I think the things that Sree and other private employers and companies are doing on the private sector, to recognize that there’s economic value to supporting employees and families is really important. But this is a place where we as a society have to decide what we care about. And so I think the thing, there’s many things I admire about your career, Andy, but the way that you’ve sort of gone between, you know, public sector, government, work and private sector, I think it could be a model for many of us, because the conversation we’re having now at the federal level, through the Build Back Better act, thinking about like really investing in a ton of supports that really the underpinnings of what a healthy society can look like, have to be connected to what we’re learning and what our experiences are on the frontlines of caring for families, for the most marginalized families and patients in our society. And the role that I think that we can play in the private sector, in informing and sometimes in being sort of, I think, my job is often just a megaphone for the experiences for the patients whom we serve and the community we serve. So we can elevate these issues and start to think about policy solutions, in addition to private sector solutions. This is a perfect example where we need both. And so I’m hopeful again, that we’re actually in a moment in time when we’re going to start to see some of this come together when we as a society have to reckon with how we want to live, how we care for each other, what matters for healthy communities and for profitable communities. And how do we really, really start to thread the needle across all of these different sectors to build better infrastructure across the board?

Andy Slavitt 

Well, Toyin, I think when you get through realizing this big vision that you’re creating, you should actually consider going and doing something like running the Medicare medicaid program at the federal government or running Health and Human Services, or something else like that. You’ve heard it here first, folks. I don’t know if we get your endorsement for that. But I think ours you I think you need to complete the job that you laid out City Block first, but the public would be so well served. Thank you so much for coming on. It really getting us to think about things that could be different, things to be better. Thank you both for coming IN THE BUBBLE.

Andy Slavitt  58:16

On Wednesday, we have Scott Gottlieb, and we’re gonna dig in to what we’re getting right and wrong about omachron. And what we know so it’s gonna be more of the same on that. Following week, Trevor Bedford, one of the smartest people around who’s got a MacArthur Genius Grant for his work tracking the understanding of SARS-CoV-2, and the origin of Omicron and how it’s playing out. And then we’ve got a upcoming episode on critical items affecting all of us in the US, our supply chain, inflation, what’s happening with the economy and how the economy is changing from the pandemic. Look forward to talking to you Wednesday.


Thanks for listening to IN THE BUBBLE. Hope you rate us highly. We’re a production of Lemonada Media. Kryssy Pease and Alex McOwen produced the show. Our mix is by Ivan Kuraev and Veronica Rodriguez. Jessica Cordova Kramer and Stephanie Wittels Wachs are the executive producers of the show, we love them dearly. Our theme was composed by Dan Molad and Oliver Hill, and additional music by Ivan Kuraev. You can find out more about our show on social media at @LemonadaMedia. And you can find me at @ASlavitt on Twitter or at @AndySlavitt on Instagram. If you like what you heard today, please tell your friends and please stay safe, share some joy and we will definitely get through this together.

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