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The pandemic changed health care forever. In a special live episode taped with a virtual panel of expert listeners, Dr. Ezekiel Emanuel lays out some of the biggest and most radical changes we will face over the next few years. From how and where we access our coverage to who owns the hospitals and how we will pay for care, nothing will ever be the same. Dr. Emanuel explains why and answers questions from our panelists about a couple of unique and personal topics.

Keep up with Andy on Post and Twitter and Post @ASlavitt.

Follow @ZekeEmanuel on Twitter.

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Check out these resources from today’s episode: 

• Read Dr. Zeke Emanuel’s “Nine Health Care Megatrends” that inspired this conversation
• Find vaccines, masks, testing, treatments, and other resources in your community: https://www.covid.gov/
• Order Andy’s book, “Preventable: The Inside Story of How Leadership Failures, Politics, and Selfishness Doomed the U.S. Coronavirus Response”: https://us.macmillan.com/books/9781250770165

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For additional resources, information, and a transcript of the episode, visit lemonadamedia.com/show/inthebubble.

Transcript

SPEAKERS

Andy Slavitt, Dr. Nzinga Harrison, Andrew McCabe, Tom, Dr. Ezekiel Emanuel, Steve, Andrew

Andy Slavitt 

Welcome in the bubble, this is Andy Slavitt. The healthcare system is one of the most important parts of our society. It’s complex, and it’s super dynamic. When it changes, it changes in a way that impacts all of us. And so we’re all deeply concerned. It’s also true that it’s very hard to change. If you think of some of the major changes over your lifetime, they’ve largely been the result of government action, some form of Obamacare, ensured millions more people. And before that the Children’s Health Insurance legislation in late 90s. And before that, well right around that time, a little after that prescription drug coverage for seniors before that the roots of Medicare and Medicaid, which covered 10s of millions of people who are low income or on fixed incomes. And before that the rise of employer based coverage in the US. In fact, when you look at it and compare it to predictions that people are often making about the health care system, these changes tend to come pretty slowly. And it seems like for me that’s why when a very smart person is willing to go out on a limb. It makes some predictions. I’m interested. So Zeke Emanuel has done such a thing, releasing what he calls the nine changes tonight megatrends that he anticipates coming to the healthcare system. Who is Zeke Emanuel? I’ve often wondered that myself. Sikh is a professor, a physician, a former policy official in the Obama administration, a former bio ethicist at the NIH. He’s also the author of many books. And he’s been a friend for more than a decade. Now. I think that’s right, because he can verify that I’ve always been able to count out and seek for his edgy and opinionated commentary, he may have an opinion about that, while many others are still being more careful, or trying to collect more data, Zeke is often the first one out there with a point of view. Something else that’s different about today’s show, and I want to tell you that we’re experimenting with a new and unusual format, we’ve invited a panel of some 30 of the leading healthcare innovators in the country, to ask questions, to poke holes if they can, and to provide a little bit of their own point of view. So we’re going to spend the first two segments of the show covering those predictions that takers made in the final segment, taking questions from this panel. And I will introduce the panelists as they speak. And hopefully this will make for a lively conversation. And of course, as follows our first live episode, which was a huge success we did in Aspen, Colorado, with Dr. Amrita Cemani. So you can listen to that if you want to talk about real change, talk about that with the person who was actually negotiating to bring down the cost of prescription drugs. So we may talk about that with my friend, and pendant and doctor and everything else. Zeke Emanuel, welcome to the bubble.

Dr. Ezekiel Emanuel 

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

Andy Slavitt 

Is it true? We’ve been friends for a decade that about right?

Dr. Ezekiel Emanuel 

It’s actually a little more than a decade? Yes, that is true. And I can tell you who first introduced us.

Andy Slavitt 

Okay, well, maybe maybe we’ll get to that. But let’s go. Let’s go back a little bit further and seek and just to learn a little bit about you, you can come across as a curious and fearless person, someone who delves into tough topics, someone who sticks out a point of view. What about the way you grew up gives you the confidence to be the type of person or do I have it wrong, and you’re just a ball of worries like everybody else that you just put on a good show?

Dr. Ezekiel Emanuel 

Probably a combination. For one thing, you know, I had the good fortune of having parents who asked us our opinion, didn’t mean they always respected our opinion or took it. But they did want us to have an opinion, when we went into school, and sometimes presented our opinion. And it didn’t necessarily go well with the teacher, my mother would come to school and defend us and defend our right to have an opinion. So I will just tell a story I was in, I think it was a third or fourth grade gym class. And we were bumped to rambunctious kids and the gym teacher, you know, just blew his top lined us up and said, You know, I expect you to behave. And I expect you to call me sir. And anyone who doesn’t think I should be called Sir, please step out of line. So I stepped out of line. And he sent me down to the principal’s office mom was called. And I explained, you know, I think big called service, something you earn. It’s not something you can command students to do. And how old were you when this happened? This is like third or fourth grade, so eight or nine years old.

Andy Slavitt 

So eight or nine years old, you had the temerity to the teachers had to call user to decide you weren’t going to do that. That’s right.

Dr. Ezekiel Emanuel 

And mom came down and defended me and said, You know, I think that’s a pretty reasonable view of teacher has to earn that respect. He wasn’t earning those respect, he was just yelling and commanding. And they weren’t doing anything violent. It’s not like we were doing something terrible. We were just, you know, being kids. So we had an experience of, you know, you formulate a view, it doesn’t have to be popular, go out there and express it. We also had a view that, you know, learn, you may create a view that doesn’t have all the facts, doesn’t have all the information, listen to other people engage in debate. And, you know, I’m happy to say there are many things I’ve changed my opinion on, because other people have educated me. So while I express my opinions very strongly, I also, you know, respect to other people to have different opinions. And, you know, I think when I’ve run departments and groups, you know, I encourage people to not necessarily agree with me, and no one gets penalized for disagreeing me and saying that I’m wrong or stupid, including the youngest people on the team.

Andy Slavitt 

I think people do mistake, competent people, for people who won’t listen. And sometimes I think people are, are less inclined to want to disagree with someone who comes across very confident.

Dr. Ezekiel Emanuel 

I think you’re 100%. Right. That’s certainly an experience that I’ve had people somehow feel intimidated, or they think that oh, he’s never going to listen to me. And in fact, I’ve read it. I’ve regularly had younger people, my students, research assistants, tell me, No, they don’t agree. And here’s why. And convince me that I need to change my opinion. So I’ll just give you an example. I, early on when I was at the NIH in the late 90s, I thought that paying research participants to participate in clinical trials was unethical. We had a guy right out of Dartmouth College, I want to say and he had a different view, he wrote up a paper, and he persuaded me, you know, he had to be 21 years old, you know, half my age. But he had very good arguments, and I listened to those arguments. Okay,

Andy Slavitt 

Let’s talk about the health care system. And I want to take it into a few pieces. And I really want to paint a picture for Americans listening in. And I think our guests in the audience and he will help us down the road. I want to talk about first, some of the things going to impact people’s care how long they live and how well they live. And let’s start with some of the newest, how we should think about some of the newest treatments. Now, you know, this year, you know, the big story, of course, is ozempic. A promising drug for people with diabetes a promising drug potentially for people with a lot of weight loss needs, but we also have a set of things that are here or coming better diagnostics, for cancer for earlier detection, better treatments for cancer. There’s hope Even with Alzheimer’s, that, you know, we’ll be talking about Alzheimer’s in a very different way in 10 or 20 years. Tell us what you expect here. radical change improvements. What’s going on?

Dr. Ezekiel Emanuel 

Oh, yeah. Oh, yeah. So I’m an oncologist. I don’t know that you mentioned that. And I do follow the cancer space reasonably well. This is heyday for cancer. And we’ve had lots and lots of innovation over the last, I would say decade, real important breakthroughs. And, you know, when I was training, we have chronic myelogenous leukemia. And basically, we would have patients perk along and then they do something we call blast off, they transform into acute leukemia, we couldn’t do anything and they die. Invariably, within six months, no matter what we did, Gleevec came along, made it a chronic illness and made these people live normal lives. Talk about transformation, we’ve had car T therapy pioneered by my colleague, Carl June at the University of Pennsylvania, take people who failed every regimen, and resurrects them. It’s really an amazing, amazing story. And we’re just going to get more and more of these. Because I think we have figured out, you know, where the genetic defects what the targets are, and we just have a better game plan for doing that. As you say, you know, we’ve gotten out drugs that affect weight loss, I have to say I’m of two minds about that. Hurray, fantastic. And I guess the latest data literally out yesterday about 24% body weight loss with this new Eli Lilly drug that’s not quite approved. But I’m a little worried that’s gonna, you know, it’s gonna sort of, we’ve had this enormous increase in body mass index, in the last call it 50 years. And it’s not due to, you know, genetic changes, it’s due to behavioral changes and the social environment in terms of food, and we’re gonna now medicalize it, people are going to still get heavy kids are going to get have a high body mass index get obese, and then we’re going to treat it later with a drug. That is the wrong model. That is the wrong therapeutic intervention. And it means that we won’t feel any compulsion to change the underlying cause. And I think that’s a huge mistake.

Andy Slavitt 

Zeke. Isn’t there isn’t have we also learned that this notion that it’s all about willpower, in terms of being able to lose weight, is that wrong notion? Yeah, that there are physiological things. There are certainly psychological things.

Dr. Ezekiel Emanuel 

And there are social thought that’s the environment. There’s McDonald’s and Coke and Pepsi. I totally agree.

Andy Slavitt 

All that and then in those things, very cravings, social political things. And so I guess, I guess I’m Andy,

Dr. Ezekiel Emanuel 

I would totally agree with you it. That’s why I said I’m of two minds, I think this is fantastic. For people, what I worry about is that the underlying problems not going to be addressed. And we’re going to actually perpetuate the underlying problem. Because we have this magic bullet, instead of addressing the whole food system, and how we provide nutrition to people.

Andy Slavitt 

There’s no doubt we’ll take the easy way out when we can no doubt about it. And that’s a really bad thing. Okay, but writ large, if people step back and say, the kind of the treatments that are out there for whether it’s making cancer, more of a chronic illness, whether it’s diagnosing cancers early, whether it’s things that lead to diabetes, and heart disease and weight loss, that they’re going to be more readily available. But what about the cost impact of all this? I mean, you know, if theoretically, you can screen every buddy in the country for colon cancer, but it cost $500. But you could detect it super early in a blood test. We, you know, we can’t afford to screen every we can’t afford to screen every senior. And that’s just one example. You know, all of these new things are going to have to be paid for somehow, how should we think about what’s going to happen there?

Dr. Ezekiel Emanuel 

We don’t have a model for that. We have not worked out as a society, how we’re going to think about it now. Other countries have worked out. Whether it’s Britain or Norway, or Israel, Germany, they thought about pricing of these interventions and how they ought to be priced. They use cost effectiveness, how much is this health improvement worth in terms of our willingness to pay? And I, you know, it’s cost effective, this the be all and end all solve all the problems? No, but it does give you a rigorous way of thinking about how you want to pay. One of the things I would say that we have to actually get to is paying for health improvement. And by the way, that’s not just for drugs. I think it should be for all of our interventions, whether it’s surgery, or what doctors do in their office. So how much is this, what you’re doing going to result in health improvement? And if we did that, I think we would have a more rational way of not only using drugs, using surgical procedures, but also using those adjunctive things we call them, right, whether it’s, you know, transportation to get to the doctor, its nutrition, just a report out today about the impact of giving people nutrition after hospital admission, decreasing their hospital readmission and decreasing their mortality. Whoa, food as food is medicine right there. So I think one of our problems in confronting this issue of how are we going to pay for all of this is, we have been reluctant to say, All right, we should pay in conjunction with the Health Improvement we’re gonna get. And those interventions that don’t give us health improvement, maybe we should pay a lot less for them. And we should be consistent about that. What I worry about is the move that’s happening now both on the left and on the right to say, oh, when the government negotiates with drug companies about prices, they shouldn’t take into account cost effectiveness analysis. I don’t understand. That does seem to me the answer, an important element to how we consider it.

Andy Slavitt 

Sure. clinical improvement at what costs well, let me take a quick break. We’re gonna do commercial, we’re gonna come right back, we’re gonna talk about some very fun things. Like how is AI affecting health care system, mental health care, health care delivery itself was gonna work we’ll be right back. We’re back with the would think we were talking about some of the treatment changes. But let’s let’s talk about patient care itself. You know, it feels like, you know, at one point we had a system around a doctor and a patient we’re talking about decades ago, you know, and then we would go to see a doctor when they’re sick, maybe they pay a house call was all reasonably affordable for many people. And then we came into a system, which I think healthcare kind of industrialized, big hospitals, big corporations, big programs, costs went up. And it was a very institutional experience. So we kind of lost some of the personal feel in healthcare for all the gains that there may have been, nobody feels like they had a particularly great experience, with the exception of maybe wealthy people who do concierge medicine. And now people are saying that the new horizon is the home, that through technology, or patient monitoring, the fact that as you write about, you know, hospitals are closing, there’s more things can be taken care of in the home. Is that one of the transitions, we’re going to see how and where we see care.

Dr. Ezekiel Emanuel 

Absolutely. And I think we have seen that, thanks to COVID. You know, let me just give you a concrete example. That was in my Health Affairs article that happened at Penn. Right? We had, like everyone else shut down most of the delivery system shifting to focus on COVID, except for emergencies, right? I’m an oncologist, what do you do with cancer patients who are in the middle of chemotherapy, you have to continue? So we began doing chemotherapy at home. Now, when I trained with all these 30 years ago, if someone had told me, Oh, you’re going to be doing chemotherapy at home, I would have said, Are you kidding? What hospital? What drugs are you on? But now we’re there. And, you know, it’s like crazy, that we’re able to do that. And if you look at also hospital admissions, Andy, I’m sure you’ve done this in your prior lives, you know, hospital admissions in America on both an absolute and per capita basis peaked in 1981, we have been declining in hospital admissions over time, because, you know, we’re doing more outpatient, you know, hip replacement, knee replacement, and an ambulatory surgery center, I mean, all of these changes. Now, with greater technology, you can do an ultrasound at home, when you couldn’t do that before, all of these changes are going to expand, certainly, with the advent of better sensors, better monitoring, in terms of AI being able to ferret the signal from the noise. And we’re going to be able to not only monitor it home, but intervene at home virtually, and for serious cases, send people to the house, and you see this in all sorts of areas, chemotherapy, just one. But you know, for decades, we did not do dialysis at home, right? We prefer dialysis and paid more for dialysis and facilities, well, that’s going to switch, we’re going to be doing a lot more dialysis at home. And that these are just examples of how we’re evolving, it’s going to be less expensive. And I think it’s going to be much better for patients in the sense that when you’re addressing chronic conditions, doing it at home, as opposed to coming into a bricks and mortar facility, is just going to be a lot better. And that’s critical. Because I think, again, we often don’t fully appreciate 85 cents of every dollar now is spent on chronic illness, and that’s spent on acute interventions. And so being able to do interventions more continuously at home, virtually, but also if someone has to visit, that’s the way to the future.

Andy Slavitt 

You know, it, it’s it strikes me that anybody who’s ever been to a hospital and seen a hospital bill knows that it’s incredibly hospital, you walk in the door, and for some reason, you’re gonna get four bills, and each of those is gonna be $1,000. And you don’t know what to expect. And as much as we’ve known about this problem for the last number of decades, it’s only gotten more and more and more expensive. And there’s reasons why, you know, we’ve had to pay nurses more, there are challenges to how having to cover people who don’t get insurance. There’s there’s a whole bunch of reasons, hospitals aren’t all that efficient. But it seems like the answer is to say rather than being able to reduce that costs, which we haven’t been able to, what you’re talking about is just maybe there’s a lot of things that we go to the hospital for, or to a doctor for even or get a test for whatever that we don’t need to and if there’s a future that you’re laying out here I wear a lot of the things used to go in places for. I’m getting virtual PT at home right now. And by the way, I love it physical therapy for my for my Achilles. People are obviously getting behavioral health therapy sessions at home. How far will this go? And when you look at like a combination of the phone and some of the other tools you talked about in the home? Will it be a transformation akin to the kind of transformation that we’ve talked about that have gotten us this far?

Dr. Ezekiel Emanuel 

Absolutely, I think we have no idea how far this is going to go at this moment. One of the things I think we can say is, sensors are going to get a whole lot better, the AI is going to get a whole lot better. And I think from the diagnostic and outside of taking blood, I think we’re going to be able to do a whole lot more at home. I think the real challenge is how much of the therapy can we do? Not just virtually, but without human intervention, like there’s a lot of the PT that you could probably do without having someone a physical therapist at the other end. And that’s true for occupational therapy for speech therapy, maybe even for mental health, as well as other things. And I think that we just don’t know, we we can confidently say that’s going to expand what the limits of that expansion are. I think it goes beyond crystal balls at this point. Because it’s, you know, it’s a 10 year 15 year phenomena.

Andy Slavitt 

What’s your view of AI?

Dr. Ezekiel Emanuel 

Bright and rosy.

Andy Slavitt 

I think that the community will bright and rosy guy. I love it.

Dr. Ezekiel Emanuel 

I’m an optimist. First of all, I think in terms of drug discovery, you’re going to see its impact very, very soon. I think probably in medicine, you’re gonna see its impact in two places, quickly. One is administrative functions. And there’s going to be an incentive to use it because of the labor shortage and administrative nonsense that we have that I some of which I document in our, in the paper.

Andy Slavitt 

Will that part make people’s lives easier? Will it be easier to get the treatment you need? Or will they? Or will it be easier for them to say no to you?

Dr. Ezekiel Emanuel 

I think one of the worries I have is that both could be true. And it could be a war Mutually Assured annoyance. But there is a way of of solving that I think, but that’s going to take some payment reform. The other place I think you’re gonna see it is in decision supports where you’re going to see a lot of AI go in and tell doctors, you know, here’s what we’d recommend. But it will ultimately be the doctor’s choice, because we’re not going to be sufficiently confident. And I’ve been working with a company that looks at medications and people’s past medical history, and will predict who’s had high risk of getting a complication in the next four months. And Rakhat, making recommendations about switching the medications to forestall that and prevent hospitalization, not that’s the kind of thing that I think you’re just going to see a lot more of that has high fidelity picks out high at risk patients and picks out recommendations on how the physician should intervene. Because they’re not perfect yet, they’re still going to have a lot of still, fortunately going to have a lot of physician judgment on top of it. But the better they get the better care, we’re going to get and forestall and complications and adverse events from drug drugs, interaction, that’s great. That’ll save money. And it also mean people won’t suffer.

Andy Slavitt 

So you’re describing a world of way more good than bad. There are people who did talk about AI, our executive producer, Kelsey Lee believes it’s going to be the ultimate end of us.

Dr. Ezekiel Emanuel 

But that’s a different I think that’s true. I am not a big fan of things like social media and other parts of, of the technology world in other realms. I totally agree with that. I actually worried that unless we figure out a way to check it social media could undermine democracy. Big time. And that worries the anatomy, frankly, you know, that would be the worst thing.

Andy Slavitt 

Yeah. I mean, we used to grow up worrying about nuclear weapons. I think this is social media, maybe maybe worse than the nuclear weapons. Yeah. In terms of the impact it can have. Yeah, I want to switch to talking about mental health. attitudes are changing, no doubt in a healthy way we’re able to talk about mental health, we’re able to talk about mental illness in a way that feels safer. I think some of this is driven by the new generation. Some of it’s just out of necessity, yet we have problems. One big problem we have is we don’t have nearly the number of mental health professionals that we need. Secondly, they’re not always in the right place. And the system is very confusing. And if we think it’s confusing to know where to start when you’ve got a physical health ailment, that’s what it’s confirmed. You need to know where to start when there’s a mental health ailment, it can be really, really concerning and befuddling. Yet we come from a system that was based on isolating people with mental illness from society. We’re now in some state where we’re going to change that, I think, what do you see happening there?

Dr. Ezekiel Emanuel 

I totally agree with you. And I just tell a little anecdote that’s in my book about which country has the world’s best health care, we went to Switzerland. And we’re asking them, we had a seven standard questions about mental health. And the guy in Geneva, pointed out the window. And he said, Yes, our mental health, we have a hospital there. It’s near the prison on the border with France, it told you everything you need to know about their attitude towards mental health, right? It’s near a prison. And we’re pushing it into another country, particularly the French. Anyway, I agree with you attitudes have totally changed. And I’ve been pounding on mental health, I became a convert, I think, in 2014, about how important mental health was to getting costs under control to getting patients better treatment to making them live longer. And I think it’s here, in part because COVID Expose so many people, two stresses of isolation and increased anxiety, increased depression, increased loneliness, and we don’t have enough people as you’re right. 500,000 mental health providers, when you get psychiatrists and social workers and nurse practitioners and psychologists, that’s nowhere near enough for 330 million Americans. But I do think we’ve got getting parity. We’ve got the big insurers like united and Humana and CVS saying we’re going to put this forward because it’s good for cost control. And then I think figuring out how we’re going to get all the people routinely screened when they come to the engage with the healthcare system for anxiety and depression. And then being able to hook them up with some most likely going to be virtual therapy. And the crazy thing is, I think a lot of this is going to be machine based. B, it turns out that the original AI was actually a therapist, Joseph, I think whites and bam at MIT created a therapist, very simple program, and people actually liked it. And he was shocked and horrified. The one thing I will say also, that’s changing Andy, that I predict is the normalization of psychedelics. What do you think about that? I’ve been involved in some research on it. And I have to say, wildly impressed at the study we’ve done. And we were just about to submit another is, first of all, these are cancer patients with depression, within one week, you can assess them, and they get benefit that all of them, you know, but we’re talking about 70%, which is better than most medications.

Andy Slavitt 

Much better than what, which drug specific?

Dr. Ezekiel Emanuel 

Psilocybin. And then you see, the first study we did followed up them out to eight weeks, fine. Now, we’re out to 18 months, we haven’t published this yet. So 18 months, and 50% of them are still fine. That changes the game, I think, and I I think makes it very, very big difference. And so I think, again, you’re gonna have to have providers who can who are trained, who can administer this, we have to make it more efficient. You can’t have one person for one patient. But I do think, in the next five years, completely different attitude on these things. And they’re going to be normalized.

Andy Slavitt 

Well, I hope we get some questions from from folks, when we get to the question and answer portion, I want to take a big topic and try to mush it together into one thing. It’s a it’s something that people who are inside the healthcare industry, like our experts today, understand very well. It’s something that the general public has not been kept well informed of. And that is this idea of the rolls in the way the payments and health care work in may be changing by roles. We’re talking about the fact that your friendly hospital, may now own or be owned by an insurance company. They may be buying physician practices, they may own lots of other things. They’re more of a corporation, and insurance companies. Likewise, many of them now are not just your insurance company anymore. They own doctors practices, they own chronic disease management, businesses, they own all those sorts of things. There used to be very clean lines, my insurance company and I like to say to remind insurance companies that the one thing consumers expect for them to pay my damn claim that you get a don’t engage me and all this other nonsense until you pay my damn claim. But they’re increasingly taking on a bigger role. And then the payment piece which is something that is driving a lot of change in healthcare, maybe some of the good maybe some of it not, you’ll have to tell us. But the idea that we should, as you talked about earlier with prescription drugs, be rewarding the healthcare system, when they take better care of us, keep us healthier, keep us out of the hospital when we don’t need to be there and penalize us penalize the system, when it doesn’t do those things. That has adopted a moniker that everyone on this call is very familiar with called value based care. So help us make sense of what you see happening in these two very related areas.

Dr. Ezekiel Emanuel 

Right. So I think it’s really important in the old days, the days my father, a practice that right, we had 100% fee for service, that is you got paid for doing things and the things you did, you got paid for. And if they didn’t pay for doing something get into it, and that incentivize doing more doing often unnecessary things, more tests, more treatments, it wasn’t a very by how, what the quality of carrots wasn’t very by how much it improved your health. And that lead to, you know, just more money without more health. Value Based Payment is an attempt to change that, to incentivize doctors in the health system to keep people healthy, keep them out of the clutches of the system, avoid complications. And it’s done through incentives, like a lump sum payment, with greater payment for things that are higher quality, or are more efficient and lower costs, keeping your disease under control out of the hospital, and following the guidelines that are experts that have said are the best way to treat patients. that evolution has been slow to go many, many reasons, one hesitation, that it was just a way of taking money away from doctors, so they were nervous. You have to contract. So it’s subject to contracting and sort of, you know, those intricacies. And we’ve also learned a lot about what doesn’t work, we’re getting to lift off with Value Based Payment simultaneously. As you point out, we’re going to integration, I predicted that in 2014, the Kaiser reification of American healthcare. Remember, Kaiser is the model of this integration where you have an insurer, with a provider, with hospitals with doctors all in one rubric, and they’re responsible for your care, given a fixed amount of money. And Kaiser ranks very, very well in general, and patient satisfaction, keeping costs under control, etc. There’s more they could do I know that. And that’s the direction we’re going when you go that direction, this value based payment makes sense. Paying for keeping people healthy, makes a lot of sense.

Andy Slavitt 

We do. People don’t know how to evaluate quality all the time, but they really know how to evaluate simplicity. And they know how to value ease and know how to evaluate access. And we’re at a point in this healthcare system. And we’re going to come back and start to take questions after this break. But maybe we’ll kick off by talking about how some of these attitudes that people have about what they really want, are often ignored in conversations like this. And that many of these payment models that people are supposedly a party to IE, you are in an accountable care organization. I don’t know what that is, and no one ever told me about it. So let’s come back. Let’s do one final break. And then I hope that the expert innovators out there are ready to ask questions, because we’re going to launch into those when we come back. Okay, we’re back with Dr. Zeke Emanuel. And we’re about to get to the experimental portion of our show, which is where we have an expert panel of innovators that I’m going to call on in a second. And, Zeke, they’re going to either challenge you or ask you to go deeper than I was able to do. Let me start with Andrew Clifton. Andrew, why don’t you introduce yourself? Keep a sentence on what company you come from, and then fire away at seek.

Andrew 

Oh, thank you. So my Andrew Clift, I’m the CEO of a company called zing health where Medicare Advantage company focused on serving underserved populations, minority populations and chronic snip populations.

Andy Slavitt 

Do the gig note no acronyms. Andrew, can you tell us what those acronyms stand for?

Andrew McCabe 

Oh, sorry, Chronic Special Needs Plans. So plans that are built for people with certain conditions in the Medicare space of folks disabled are generally over 65. So you know, it Medicare Advantage is interesting, because it’s at the forefront because of where the premium dollars are, meaning there’s a high amount of spending in Medicare. So a lot of what we’re talking about with managed care, the value based care is obviously very focused on question I want to ask you, we were talking earlier about the changes of the hospital systems and hospital systems kind of being the center of the ecosystem and new advancements with technology, new advancements in home care, you know, the care has been moving away from hospital systems for a while, but hospital systems have acquired or integrated, you know, going forward. I was just curious on your thoughts on how some of these advancements with home based care, virtual care could impact the finances of hospital systems. And then what you see as the role of hospital systems going forward, you know, if you go 1015 20 years down the road with some of these changes?

Dr. Ezekiel Emanuel 

Great question. First of all, I do think hospitals have acquired the mass of delivery platforms, including outpatient facilities, physician practices, and home care. And that’s because, again, you know, a lot of hospital systems, most of the revenue now, over 50% of the revenue is coming from the outpatient, not the inpatient, and the smart ones who have seen the writing on the wall and are trying to get those other assets and delivering care in different locales. And I think that’s probably a good and important thing. You don’t need to come into the center of Philadelphia to the University of Pennsylvania to get a routine colonoscopy, or routine echo. And we should be thinking about doing these interventions in other places that are both lower costs, and more efficient. What I worry about is that that’s often a burden driven by this financial incentive for Medicare, that once you become part of a hospital, you can charge more, and there’s no added advantage, and All there is is higher costs. And that seems to me to be the wrong direction to go. I do think you’ll, as I said, I think we’re going to see a lot of shift in the site of care. And my suspicion is, hospitals are not necessarily going to be or health systems are not necessarily going to be the main providers of this care at home, or in other settings, because they are going to be more expensive, they’re not going to be as agile. And we aren’t going to go to a more asset light delivery system where the bricks and mortars of these facilities are going to count less and less. And so I’m, I’m gung ho on the outpatient delivery of more complex care, not that gung ho on health systems, being the leading survivors in that going forward. Well run healthcare systems, probably, but I think a lot of startups are going to most likely do it more efficiently.

Andy Slavitt 

Okay. Let’s go to the next question. Dr. Nzinga Harrison, please introduce yourself. And let your question.

Dr. Nzinga Harrison 

Thanks, Andy. Good to be here. Dr. Nzinga Harrison, Co-founder and Chief Medical Officer of Eleanor health. We do population health management for communities and individuals with substance use disorder. I’m a psychiatrist and addiction medicine doctor. So I really really appreciated your comments on creating space for people to disagree with you even when you have a very definitive voice. And the vignette that you shared with us about changing your thinking about the ethics of paying people for clinical trials, and so I wanted to click one level deeper in that like I truly believe transformational Lee jurors are not only skilled at listening and hearing other opinions, but proactively seek to challenge their own deeply held beliefs and ethical values. And so if you had to think through a deeply held core belief, or a deeply held ethical beliefs that you had that is now different. What is that? And what drove the evolution to where you are now?

Dr. Ezekiel Emanuel 

You’re getting really personal. It’s a good question of, well, I’ll tell you one. So when I left government, I did not do any for profits, and I wasn’t doing any companies. And I said no to lots of opportunities, and went back to my academic work. And then 2017, I joined a venture firm. And the major change, actually, this will probably be interesting, was provoked by Bill Gates. We were talking about ideas we had for how to change physician behavior, and how to get make the system more efficient. And he was very insistent that it had to be a company and had to be company because you couldn’t scale things for not for profits. And so that actually was a really important insight of scaling really doesn’t not for profits don’t do that. You know, what’s my incentive, as an academic get it published in the New England Journal, or Jama or Lancet? But how many people take it up? How many people get affected by that? That my interest, right, no impact that way? My impact that I get evaluated on is, you know, do I get published in good places? Do I get more money to support my research, and the idea that it’s really important to scale. And that scaling happens by for profit startups, I changed my view, I’ll give you a now I’m really gonna roll the the importance of automation, for standardization of practices, and reducing the costs. Again, that came to me through a collaboration with this company called Solaris, which is trying to produce cells for car T therapy that I work with. And the whole point of the automation is to take out the variability in quality and to standardize it through robotic procedures. And that also turns out to reduce costs substantially 50 plus percent on preparation of those cells for transplantation. Well, if you had asked me before, a deeply held view, would I have thought that automation was going to be that important in medical care, I probably would have been very skeptical. So there you’ve got to changes of my views in addition to the ones and there are plenty more, plenty more.

Andy Slavitt 

Let me go to the next question for Zeke Emanuel, Dr […]. Can we have her ask the next question?

Speaker 5 

Great. Thank you. Andy Munar Amani partner with townhall ventures, we’re an investment firm focused on healthcare solutions for underserved populations. My question is this. I’m happy to hear you say the future of AI in healthcare is Brian rosy. But what if anything is terrifying about the future of AI and healthcare to you and more importantly, what’s to be done about it?

Dr. Ezekiel Emanuel 

Well, I am not an AI person, I’ve assembled an AI and machine learning team to do certain things like help with risk adjustment, try to fix the Medicare risk adjustment model. What concerns me is people with bad intentions, or even where their intentions are not necessarily bad, but their intentions lead them to do things that are orthogonal towards to improving people’s health. You see this with, you know, Facebook and Twitter where what they want are eyeballs that stay on their platform for a long time. And what they end up doing is keeping people in bubbles, rather than exposing them to alternative views. And that kind of bad, either bad motivation or motivation that isn’t directed at health and improving people’s health is what worries me about AI that’s not so much that the AI itself is going to overtake us, but that the people are going to use it in ways that are directed at improving health. And I think that’s that’s always what happens or that’s the worry, right? One of the things you know, early days Google was you know, do no harm, whatever. All of these things end up going off the rails because either bad people take them over and they have nefarious goals or even they get perverted to it’s just in the money will do whatever it takes for the money and that’s too easy to have In general, and so if you ask me where is not just AI, but all sorts of automation things going to go off the rails, those are the two places. I see it. The downside, you know, to go back to the previous question, the downside of startups is they end up doing bad things in the pursuit of money. And that I think, is what is, you know, that’s the the flip side, the good thing is they want to grow, and they want to spread their innovation. The bad side is that they will often compromise things and goals for the goal of making dollars and making profits and getting people whose core mission is we are going to do the right thing, no matter what the dollars, even if it means less dollars. I think that’s really important.

Andy Slavitt 

Yeah, you know, people, people really want incentives to fix everything in healthcare. But the reality is incentives can’t turn real patients, people in the good people better said than I did, yes, you’re right. Let’s go to Steve Schulman who has a question. And I think we’ve got time for maybe a couple more. Steve.

Steve 

Hey, guys, Steve Schulman I run my own family office and been banging around healthcare for 50 years running hospitals and and payer systems starting at Kaiser and Zeke, we’re both old enough to appreciate this isn’t the first time we’re going at this. I would say generation one of managed care broadly was phos, physician hospital organizations. And then the market got excited about ppm physician practice management companies that all went public, and they flamed out. So value based care, in my opinion, is again, the third time we’re at this, do you think it’s going to work? And if so, why is it going to work this time?

Dr. Ezekiel Emanuel 

Yes, I am optimistic, Steve. And yes, history is littered with problems. And you know, probably a fair number of people listening to this podcast will remember the 90s When everyone was talking about managed care, and that blew up. Why is this time different? Well, one thing that is different is we have a lot more information, not just data about what works and what doesn’t. We also have guidelines, we also have the ability to monitor and give physicians and health systems feedback on their performance. And I think that makes a huge difference. The second thing is we’re also I think, appreciating the importance of management, in getting good health outcomes. You know, we now, as I said, 85 cents of every dollar is for chronic illness. And the big part of the problem is people with multiple chronic illnesses, both physical and mental. In those people, you cannot improve their health situation, just by giving them a drug. It’s a management problem. And it’s a management problem that requires continuous interventions, someone has to actually change their life and be committed to doing things that are going to make them healthy. And part of the purpose of the healthcare system in those circumstances is to go with them, encourage them be proactive, right? In the old days, we were reactive. In the future, we’re going to have to be proactive. And the best groups out there, the best primary care doctor, don’t wait for patients come in, they reach out to patients, they help patients, they educate patients. And we’re going to have to have more of that. You can’t have that in a fee for service standalone doctor, you need managed care, where doctors and their practices not just the individual, but the care manager, the mental health providers, and others are actually helping patients and reaching out to them on a regular basis.

Andy Slavitt 

Let me take one more question. And then I’m going to finish with one of my own little time men. Oh, Tom, introduce yourself and question.

Tom 

Yeah, hey, this is Tom. I’m from hopscotch health, a primary care company that’s focused on serving rural and underserved communities. I’m curious, from your perspective, what what needs to happen to enable better access to care and better patient outcomes in rural communities?

Dr. Ezekiel Emanuel 

Well, first of all, I think they’re, it’s a very tough situation, because you’re not going to get backers by and large to move to rural communities. Every country and this isn’t just true in the United States, where souI generous somehow, whether it’s Norway or Canada or Australia that’s tried to get docks to move into rural communities, especially specialists just not happening. So we need to create a network where you have nurse practitioners, other providers in rural communities to convert those hospitals into multi physician practices and urgent care practices, but linked up to central hubs that help them for more complicated care provision. And you know, other Every kind of specialist that people need, I think that’s actually one of the promising things about telemedicine and virtual medicine and getting more specialists and specialty care out to rural communities and have the connection of primary care out there not necessarily through doctors. I think that’s where we’re going. Are we getting there fast? Absolutely not. Does that require changes so that we can practice across state lines, etc? Absolutely. All of that is going to be important and what one of the strange things I see is, you know, you would think that all the senators and politicians representing rural states, with big rural communities would be gung ho, in changing the rules around payment, and consultations by via telemedicine and across state lines. I just don’t see that. And I don’t see them leading the charge enough. And I’m perplexed by that, because how do you think you’re going to get all those patients the right kind of care? I remember 20 years ago, I was doing a bunch of surveys of oncologists for various things. And, you know, notice that there were like three oncologists in North Dakota. And I noticed that because I called one of them who was about to get on a plane and pilot herself across the state to provide cancer care. You know, you kind of situation like that it, you’re gonna have to use telemedicine just a lot more. That’s the only answer.

Andy Slavitt 

Yeah. It’s very interesting. Zeke. You know, hopscotch is a great example of someone trying to solve this problem. But I also see that, you know, businesses today that are trying to be innovative and serve healthcare, the number one question they used to have to answer is, how are you going to acquire a new patient or new customer? Today? The number one question they had was, how are you going to acquire the clinical resources you need? Because there’s so few, I have one final question. I want to reuse the wrap up. So you can it really is, to me the ultimate question. In the United States for the first time ever. Over the last few years, we’ve seen life expectancy decrease. This is even before the pandemic started, the pandemic exacerbated those numbers. But that’s not the simple cause. Understanding the simple cause will certainly help us solve it. But it is incredibly pessimistic idea that for all of the medical advances we’ve been talking about, for all of the investment and money we spend, in healthcare, we are losing. And we are losing in a pretty profound way. Ultimately, life expectancy and the quality of those years are what the healthcare system should be able to impart deliver for us. There’s other elements as well. So I really want to know, are we going to solve this? Are we going to turn it around, convinced me if the answer if your answer is yes. Tell me what we need to do differently? If your answer is it doesn’t really look like it.

Dr. Ezekiel Emanuel 

I do think we’ll turn it around, but I don’t think it’s going to be evenly distributed, which is the thing that really bothers me. You know, I don’t know your listenership, but I’m estimating that if they’re listening to you and the your listenership is the people who are going to live a long time they’re doing the five things of wellness that I mentioned, or at least are doing four out of the five. And they’re going to just by dint of doing that, unless something on lucky happens to them going to live a long time and beyond the median. The problem with the decrease is that we have a huge swath of people where, you know, they, their future is not so good. So we’ve got suicide, we’ve got gun violence, we’ve got accidents increasing. And we have people who aren’t necessarily able to or know enough to take care of their incipient illnesses over time. We have to make better interventions. And it’s not necessarily through the healthcare system. I think the main interventions, you know, obviously, the opioid crisis, we have a set of actually pretty good interventions there. We have to get them standardized and given to people regularly wherever they are, we have to get mental health of people better, we have to have them so that they have hope in living better and not in being depressed or anxious and ending their life that is going to take lots of changes. It’s going to take changes of social media, as well as other, you know, more outreach. And by the way, I would highlight in that group, the ones who are most concerned to adolescence, we tend to overlook adolescence. We talk about young kids, we talk about adults, adolescents are in real crisis, I think mentally and I think we need to do more there. The other thing I would do from where the healthcare system needs to make a major commitment is in hypertension. 100 and 10 million Americans are hypertensive, high blood pressure. And we do a crummy job of managing it, despite the fact that we have no, the single biggest thing we did in the last 60 years to improve lifespan, not smoking cessation, not seatbelts, controlling blood pressure, it is outrageous, that we haven’t committed and if I were Mandy Cohen, at the CDC, this would be my initiative, you will make a bigger impact on healthcare first. Second, you will actually reduce disparities because it’s disproportionately a disease of minorities, and particularly black Americans. And so it’s like the sweet spot, we know how to do it. We’ve got the diagnostic as well as therapeutic regimens and they’re cheap, it will improve disparities and improve survival. So that I think ought to be you should be laser focused.

Andy Slavitt 

And that will last a bit less that Mandy, when she comes on in the next week, and she’s gonna do her first kind of broadcast for what she’s seeing inside the CB see here and in the bubble. Zeke, I want to I want to thank you. I want to thank the expert innovators who tuned in and who asked questions. And if you’ve got more questions, send them over. But everybody can look at Zeke’s nine, transit, which he talked about almost all of them here on our show notes. Thank you so much for joining Tune in next week for a show that will help to be just as good as this one.

Dr. Ezekiel Emanuel 

Thank you, Andy.

Andy Slavitt 

Thank you for listening IN THE BUBBLE. If you like what you heard, rate and review and most importantly, tell a friend about the show. tell anyone about the show. We’re a production of Lemonada Media. Kyle Shiely is the Senior Producer of our show. He’s the main guy, and he rocks it with me every week. The mix is by Noah Smith. He’s a wizard. He does all the technical stuff and he’s a cool guy. Steve Nelson is the vice president of weekly content. He’s well above average. And of course, the ultimate big bosses are Jessica Cordova Kramer and Stephanie Wittels Wachs. They are wonderful, inspiring, and they put the sugar in the lemonade. They executive produced the show along with me. Our theme was composed by Dan Molad and Oliver Hill, and additional music is by Ivan Kuraev. You can find out more about our show on social media at @LemonadMedia where you can also get a transcript of the show and buy some in the bubble gear. Email me directly at andy@lemonadamedia.com. You can find my Twitter feed at @Slavitt and you can download in the bubble wherever you get your podcasts or listen ad free on Amazon music. It’s a prime membership. Thank you for listening.