Tuning Healthcare, Episode 6: Interoperability and Value-based Care in a COVID-19 World

Aneesh Chopra, President, CareJourney

In this latest episode of Tuning Healthcare, Aneesh Chopra discusses how the lack of data transparency and interoperability has crippled the ability for the US to respond to current COVID-19 public health crisis. Aneesh is the president and cofounder of CareJourney, a data and analytics company focused on the move to value-based care, and was also the former first Chief Technology Officer of the United States, serving under President Obama from 2009 to 2012. He also discusses how the move to value-based care may accelerate as a result of this crisis, and how revitalizing our nation’s healthcare IT infrastructure could speed up improvements for providers, payers and consumers.

“We may emerge with a different cost structure in the healthcare delivery system, that’s more asset light. That may be disruptive to organizations that generate the big institutional revenue, but we’re going to work our way through that change. That would have come anyway through value-based care, but this will just accelerate. And then you’d ask the question, “If I can treat this group of patients at home, in a much lower cost setting, with this remote monitoring, with physicians checking in at this time period and we get similar or better outcomes, remind me again why we’re not doing that today?”
– Aneesh Chopra, President of CareJourney and former Chief Technology Officer of the United States

In this episode, Aneesh and Lumeris Senior Vice President Nigel Ohrenstein discuss:

• The lack of data transparency and interoperability in healthcare and its impact during the COVID-19 crisis
• How the move to value-based care may accelerate in the post-pandemic era
• What the new normal of healthcare could look like from a care delivery and infrastructure standpoint
• What a fully informed provider and patient experience could look like
• How data transparency and consumer apps can help speed up interoperability

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• Read Transcript:

  Nigel Ohrenstein: In this episode of Tuning Healthcare, I’m joined by Aneesh Chopra, the President and Cofounder of CareJourney, a data and analytics company focused on the move to value-based care.

  Nigel Ohrenstein: Aneesh was the first Chief Technology Officer of the United States, serving under President Obama from 2009 to 2012. And in 2014, wrote the book, Innovative State: How New Technologies Can Transform Government.

  Nigel Ohrenstein: In this episode of Tuning Healthcare, Aneesh and I talk about how the lack of data transparency and interoperability has crippled the ability for us to respond to the public health crisis, how the move to value-based care will be increased as a result of this crisis and how perhaps a silver lining, as we sit in these dark times of COVID-19, is the fact that there’ll be data transparency and interoperability and consumer apps that will speed up the improvement through our healthcare system. Join Aneesh and I as we tune healthcare.

  Nigel Ohrenstein: Good morning Aneesh. Thanks for joining me. Normally, in normal times, we would conduct these podcasts face-to-face across the table in a cafe, in the way that we would normally sit and chat about healthcare.

  Nigel Ohrenstein: But today, like the rest of the country, we’re social distancing and we’re conducting this podcast via Zoom. Nonetheless, I think we will have a great conversation.

  Nigel Ohrenstein: Before we get to the times we’re in and the impact they have to healthcare and data, I’d love to learn a little bit more about how you developed your interest in technology, your interest in healthcare and really just sort of the intersection of the two.

  Aneesh Chopra: So growing up, a hero of mine, a gentleman named Sam Pitroda was a classmate of my father’s in college in India. His story inspired me about the role of innovation in society.

  Aneesh Chopra: Briefly, he was trained in a modern form of telecommunications, the move towards digital switches, at a time when most of the phone systems around the world were analog. He was successful in the US, like entrepreneurs are, sold a business. But then chose in the early 1980s, to return to India and took a penny a year salary to help the country modernize its telecommunications infrastructure, so every village would have access to phone service.

  Aneesh Chopra: I think at the time the country had 300 million people and had 300,000 phones. Under normal circumstances this would have been a multibillion dollar rollout, but because of his background, he essentially invented or innovated his way through the crisis by recruiting engineers to help design a new model that was dramatically cheaper and leapfrog the analog infrastructure that was so high cost to deploy.

  Aneesh Chopra: Fast forward, my first job out of college, I was at Morgan Stanley in investment banking. I was on the healthcare team. My colleagues in technology took a little old company called Netscape public and that just drew my attention.

  Aneesh Chopra: This internet capability, which was just … we just missed it in college. I didn’t have an internet email. We were just getting going, but I quickly married my passion for healthcare and the capabilities of technology and the philosophy of looking for a new path, borne from Sam’s experience. And that led me on a journey.

  Aneesh Chopra: I spent the next decade researching, studying, going to the Kennedy School, writing my master’s thesis on how internet-based technologies would influence healthcare. And I found myself as Virginia’s Secretary of Technology, where electronic health record policy was a priority of my governor Tim Kaine, and the rest is history.

  Nigel Ohrenstein: Yeah, incredible. So we met, I don’t know if you remember, for the first time, it must have been about eight years ago while you were still the Chief Technology Officer of the United States. Which by the way, any title “of the United States” is pretty cool.

  Aneesh Chopra: Yeah.

  Nigel Ohrenstein: Also, you were the first CTO, right? The position was created … whether it was for you, you were the first. I don’t know if you remember, John Doerr brought you to see Dr. Tom Hastings, who actually was on the last episode of Tuning Healthcare.

  Nigel Ohrenstein: What excited me about that visit, where I was with Tom and John and you in his practice, was the potential for the partnership between the public sector and the private sector to drive better healthcare.

  Nigel Ohrenstein: Roll the clock forward eight years. Is it working? Is the partnership between the public sector and the private sector driving better healthcare?

  Aneesh Chopra: The building blocks are in place, but we’re not quite in sync on what we needed to have happen, which is to say the concurrence of two paths. The first path was that we needed to have the digital infrastructure that would allow practices like Tom’s to thrive.

  Aneesh Chopra: When patients were traveling into the kind of specialist community or the hospitals, to be able to coordinate that care better, Tom obviously would need access to that full patient experience and to be able to coordinate and hopefully get ahead of certain conditions or challenges that may be a protocol that you are deploying with would allow for.

  Aneesh Chopra: So we needed to have the technical path and we’re on a trajectory to get the technical foundation where it needs to be. It’s not where it needs to be yet, but we’re on a path.

  Aneesh Chopra: We also needed the demand signal for that infrastructure to come from the industry. The first chapter of this has been that the government, in anticipation of value-based care, imposed certain requirements that said that the demand signal, say for example, recording blood pressure or vital signs in every encounter. Many physicians said, “Why am I doing this? That doesn’t affect my practice of medicine. I’m a psychiatrist. I don’t really do that.”

  Aneesh Chopra: We anticipated a world of coordinated care, moving from a world of fragmented care, where every clinical touch point would be a signal to make sure that we’re ahead of the condition or challenges of a patient.

  Aneesh Chopra: The VA for example, was a demonstration that, if you collected timely information about blood pressure, you could be more effective in managing hypertensive patients who only had maybe 20 or 30% of them under control. Moved to 70-80% when they did that kind of horizontal policy of everyone should collect and share.

  Aneesh Chopra: So the demand signal, Nigel, we anticipated coming from organizations on the move to value. Once you took risk, you would need the ability to communicate outside of your network. And if we could get more organizations to take risk, then they would speak almost as a proxy for what the government regulators were saying, to tell the broader healthcare IT community, “We need standard-based ways of communicating basic health information, no matter where you go in America, no matter what EHR vendor you’re on, no matter what independent physician you visit or a big integrated network.”

  Aneesh Chopra: That demand signal, Nigel, hasn’t come from the private sector healthcare delivery community yet. It’s still largely a government-mandated approach and we’re hoping that the pace of a value-based care adoption will pick up the demand signal.

  Aneesh Chopra: That would allow market forces to come to play and that’s the disconnect we’ve seen over the last, call it five years. We would have probably anticipated more of a market demand signal from value-based care earlier and that would have filtered down into the IT requirements and that quite hasn’t happened yet.

  Nigel Ohrenstein: Right. Before the coronavirus crisis hit us, I would have told you that, at least what we’re seeing in Lumeris, is that demand signal for value-based care is growing dramatically.

  Nigel Ohrenstein: There’s hardly a health system board that doesn’t talk about, how are we going to react? How are we going to evolve in a value-based care world? Even the great bastions of fee-for-service were beginning to talk about how I needed to begin to educate myself on value-based care.

  Nigel Ohrenstein: How do you think this crisis will impact that move to value-based care? Do you think it will speed it up, slow it down, temporary halt and then speed up again? What’s your perspective?

  Aneesh Chopra: Oh, here’s an interesting take, if I may. First of all, I appreciate you’re at the tip of the spear. So organizations that you work with and many of them are our shared partners, they get it and the leadership structure does suggest that they’re going to see more of this demand coming from boards around the country.

  Aneesh Chopra: The tension right now, and I think the COVID crisis is going to help solve for, if you sat in the room with the CIOs at the very institutions whose boards are embracing value-based care, as they negotiate with the EHR vendors the priority technical updates that are needed in the coming months, where do the value-based care, interoperability and standards requirements rank on the list of IT security, and physician burden, and a whole range of other issues that need to get solved?

  Aneesh Chopra: So when I talk about the demand signal, Nigel, I’m really speaking more explicitly about the demand signal to the EHR community from their main customers, often spoken to by the CIO.

  Aneesh Chopra: The reason I still believe this is a challenge, even though boards are saying, “Let’s go,” is we have a … I’m very involved in a bunch of these volunteers standards bodies and the one that the EHR communities have been most sort of organized around has been the FHIR project called the Argonaut Project, which was born out of the need to comply with the CMS rule, ONC rule around giving patients application access to their data back in 2015.

  Aneesh Chopra: That group has put maybe eight or nine implementation guides, technical guidance that every EHR vendor has endorsed, with engagement over the course of a year or two.

  Aneesh Chopra: The only one of all of those guides that’s in production at scale is the one the government requires, which we can think of as the Apple Health data feed.

  Aneesh Chopra: Everything else is sitting there on a shelf waiting for customers to demand, that I want to be able to collect assessment data in a standardized format, that I want to make bulk access available to my payer partners, my payvider network or any other stakeholder.

  Aneesh Chopra: So if you go down that list, decision support for closing care gaps at the point of care, each of these things has a technical guide that’s been vetted, but the adoption has been slow and it’s in part because of the demand signal.

  Aneesh Chopra: Now, fast forward to COVID. We are seeing in real time the complete and utter failure of this decade of EHR investment informing our public health response.

  Aneesh Chopra: Two quick data points. In mid-March, the Centers for Disease Control published the very first statistics on the case fatality rates essentially, on the 4,000 plus initial COVID patients that were reported to the Centers for Disease Control.

  Aneesh Chopra: Now, you would think we’d package up a ton of health information we’ve been digitizing and so we’d have a ton of knowledge about who these patients are, what their risks are, what happened to them, and what we can learn.

  Aneesh Chopra: Quite the opposite. We learned that a third of those forms didn’t indicate whether the patient was admitted to the hospital or not. More than half of the forms didn’t indicate whether the patient was in the ICU or not. Less than half, but barely, 47%, did not indicate whether the patient died or not. And even something as outrageously simple as the age of the patient that got COVID was missing in 9% of the forms.

  Aneesh Chopra: When you ask people on the ground, “How did you use your EHR to communicate with public health?” and the answer was crickets. It was phone and fax of rapidly completed paper-based sheets that were barely keyed in.

  Aneesh Chopra: This morning, this being April 1st, we’ve seen the most recent publication from the Centers for Disease Control. This time on a base of over 100,000 cases that have been reported. And another sobering judgment, less than 6% of those cases reported to the Centers for Disease Control have any history of the patient’s co-morbidities or chronic condition status.

  Aneesh Chopra: So Nigel, once we realize that the demand signal didn’t force us to use this government-regulated infrastructure, that feeds Apple Health and the Android version and all the other communities out there, we didn’t really organize it to feed public health. We could have. The incremental cost of connecting app one to app two should be near zero, but we didn’t do that last mile work as an industry.

  Aneesh Chopra: We’re going to have a lot of discussion about why and how that fell short. But as a result, we’ve literally dropped the ball and are flying blind during this crisis. It is unacceptable and I hope this will really kick the IT infrastructure in the rear and the benefit will be value-based care on the other side. Because the very same infrastructure that can feed public health should also be able to feed value-based care networks.

  Nigel Ohrenstein: Yeah, sobering, but unfortunately true. So you obviously are an esteemed leader in your own right, you’ve obviously been close to some great leaders. How have you seen them behave and yourself, in times of crisis, and what have you learned from that?

  Aneesh Chopra: Well, this is where serving in the Obama administration for me personally was humbling, sobering and massively educational. In the first few months of my arrival in 2009, was the first cases of the H1N1 virus, if you remember.

  Nigel Ohrenstein: Right. Yeah.

  Aneesh Chopra: The most important thing is we had effectively a general in command that helped drive a set of near-term actions that had to get done. And my swimming lane was to think about, what did we miss on the information side in the immediate crisis, that we can tackle as rapidly as possible in preparation for what we thought was going to be wave two and wave three of H1N1?

  Aneesh Chopra: What I learned is that there is an incredibly important function for a general manager that can call the shots consistently and clearly, to organize and mobilize the very many moving parts that otherwise take place within the government, federal, state and local as well as extending from the government into the private sector.

  Aneesh Chopra: So having President Obama set the tone and put in place that sort of almost military style infrastructure, coordinated command, everyone understands their role, all hands on deck, transparency of where we are, understanding what are the immediate priorities. And then again, being more of this sort of technology innovation role, understanding my swim lane being about the kind of preparation and lessons learned.

  Aneesh Chopra: So, that was a sobering chapter of going through those crises. Whether it be the uncapped oil well, if you remember when the BP spill … looking at those pictures every single day. Having a bit of a crisis mentality to get through that, all the way through many of the international challenges.

  Aneesh Chopra: So Nigel, being a part of that experience was very educational for me personally, and I hope it’s informing some of the activity that I’m trying to do from the private sector in response to this crisis.

  Nigel Ohrenstein: As you said, you were fortunate to be in as part of the Obama administration. And you obviously said, as you just articulated, you have to stay in your lane and figure out, how do you come up with the things that were necessary to prevent wave two and wave three?

  Nigel Ohrenstein: Vice President Pence has come out and called for more data sharing, more transparency. Do you think that will happen this time? Do you think this will be a watershed moment in the transparency of data in healthcare?

  Aneesh Chopra: Yeah. Well, I think what the vice president was reacting to was the fact that we have digitized this information. It exists, Nigel. It’s just not in the hands of the public health community in a manner that would allow them to make really important policy decisions.

  Aneesh Chopra: So, what I think the letter has done is kind of woken up the community about, “Wait a minute, we have all the bits of data here. What’s it take to get it over there?” Phone and fax is unacceptable in today’s environment.

  Aneesh Chopra: So the letter itself, on the surface, suggested for what we need right now, upload a spreadsheet with information that doesn’t involve personal health information, but can be summary statistics and get it to us yesterday.

  Aneesh Chopra: But the mere fact that he has to ask for a spreadsheet, if anything, is making everyone in the industry understand that this is absolutely unacceptable.

  Aneesh Chopra: We’re not inventing a new form of blockchain, we’re not designing some artificial intelligence application. This is literally moving existing bits of data for patients that have COVID into an environment that allows public health to understand the root cause problems and can evaluate whether or not certain hotspots are emerging throughout the United States.

  Aneesh Chopra: Very simple request. And my hope is that, yes, we’re going to be seeing people complete spreadsheets and you’ll see some snark about spreadsheet-itis because maybe the local authorities are asking for a spreadsheet. CDC’s asking for a spreadsheet. FEMA’s asking for a spreadsheet.

  Aneesh Chopra: So there’s sort of a demand for spreadsheets that’s going to be a little annoying, but right on the heels of it, our efforts to say, “Wait a minute, why can’t we find simple standardized mechanisms to transmit this information?”

  Aneesh Chopra: The first area of focus to me is to take the existing pipes from hospitals all over America, that flow into public health, and to squeeze more clinical signal out of those pipes that already have gone through data use agreements and BAAs and security reviews and all of that.

  Aneesh Chopra: We may, in the future, not too distant future, move towards FIHR-based apps and I do hope to get half a dozen or a dozen organizations to kind of demonstrate the future today because they’re ready. And you’ll see some news, I hope, Robert Wood Johnson Foundation may be underwriting some of these projects, others to get off the ground.

  Aneesh Chopra: So we’ll sort of fix the masses through spreadsheets, with some improvement in the existing interfaces. But I think we’re going to see a sentinel network emerge, that can get much further faster and that will be the tip of the spear that hopefully scales these capabilities.

  Aneesh Chopra: Imagine this Nigel, only a month or two before this really hit the US, we had a big policy debate over the interoperability future of America. We basically agreed that we’re going to move towards internet applications, using the FHIR API standards for consumer apps and physician or public health or health plan apps.

  Aneesh Chopra: That future was given a two year to three year delay, meaning there’s an implementation cycle. Imagine if that policy was pulled forward to go into production tomorrow. How would this system work? That’s what I’m hoping the sentinel network will assist us in learning and will be a beacon for what the future will be. Maybe not two to three years, but maybe the country moves a little bit faster to a year, a year and a half.

  Nigel Ohrenstein: Obviously that would be would be excellent. How quickly do you think it will get down to impacting patient care outside of a pandemic?

  Nigel Ohrenstein: So as I mentioned, I’m in New York City. If I went into Mount Sinai for healthcare and then walked across the street and went into a New York Presbyterian facility, both on Epic, it would have no clue about what I had done before, even though they’re on the same EMR. Right?

  Aneesh Chopra: Well, sort of. If they had known, like a clairvoyant, sort of a maestro, to look up your record even when you’re not in their care, they could query for it and find information Epic-to-Epic. That’s one of the more successful HIEs in the country.

  Aneesh Chopra: But I think the spirit of your comment is that this should be a little bit more programmatic, that there’s the ability to assemble a record for a patient and that that assembly can be organized by institutions patients trust.

  Aneesh Chopra: Whether that be applications outside of the healthcare system, which is sort of the consumer apps movement or through trusted contractual agreements. Where for example, that patient that you outlined that walks into the hospital one and then hospital two, if they’re enrolled in a value-based care network, say under the Medicare program, the Medicare program may authorize an organization to stitch that together contractually, unless the patient opts out.

  Aneesh Chopra: So, you could see both worlds emerging, the consumer trusted world, where I opt in to a community that I hope will work to bring that information to life and giving me guidance on the next step of my journey, or through contractual agreements or organizations that I’ve chosen not to opt out of doing this on my behalf.

  Aneesh Chopra: Nigel, both worlds should get better as soon as we complete this COVID infrastructure discussion. They are the underlying, the same technical capabilities of sharing the public health, to sharing with the trusted value-based care network and to a consumer designated app.

  Nigel Ohrenstein: Very helpful, thank you. The Coronavirus Aid Relief and Economic Security Act, known as CARES, obviously historic proportions, right? $2.2 trillion, and even the President joked he hasn’t signed anything with a “T” before. Right?

  Nigel Ohrenstein: What did it get right and what do you think the gaps are that you’d like to see in the next … probably what [will be] inevitably the next aid package post-COVID or during COVID?

  Aneesh Chopra: Yeah, I think it served three purposes. One was to immediately stop the economic bleed. That’s really the lion’s share of the bill. That economic bleed is about small businesses and gig workers and individuals that don’t draw traditional salary.

  Aneesh Chopra: You saw the unemployment figures skyrocket. We needed to have an immediate injection of capital to keep the economy from falling off a cliff. And so that, I think for emergency stability, they hit a number that seems to have stabilized at least market reaction to where we are growing, number one.

  Aneesh Chopra: Number two, hospitals and provider networks, physician groups on the front lines of this crisis are suffering a double whammy, triple whammy. One, they’re putting themselves in harm’s way for obvious reasons, the lack of PPE and thoughtful triage measures that could keep people safe. We’ve got kind of a challenge for healthcare workers, who are at greater risk of the virus.

  Aneesh Chopra: We’ve got an economic shock to hospitals. Canceling of elective surgery is hundreds of millions of dollars of lost revenue per institution and often the most profitable revenue to cross-subsidize much of this sort of medical intervention that we’re seeing with COVID-19.

  Aneesh Chopra: And then a triple risk, which is for again, obvious reasons, the demand for these organizations to make immediate investments with declining revenues, to kind of build triage units and to build more ICU bed capacity and everything else.

  Aneesh Chopra: So there was a $100 billion component of the package to just wire up the delivery system. I do hope that distribution of that funding will be thoughtful towards the frontline primary care physicians that don’t have lobbyists and power structures, but who’ve seen 50, 60, 70% drops in revenue.

  Aneesh Chopra: I don’t know how many primary care doctors can keep their payroll if they’re dropping 50, 60% of their revenue. So, we’ll hopefully see a balance in how that money is distributed.

  Aneesh Chopra: But then the third piece was, there was a place in the bucket, about a half a billion dollars, that went towards the public health surveillance information systems world.

  Aneesh Chopra: I have no clue exactly how the CDC intends to spend that money. But Nigel, I can only hope and pray that that money is built on what we’ve just regulated and standardized as opposed to going in a completely different direction, which would be requiring us to come up with a new interoperability system just for the CDC. That’s a choice the CDC is going to have to make and we’re going to see where we land.

  Aneesh Chopra: But what does that mean? I think once we’ve got the CARES Act deployed and stabilized, we’re going to see the true economic risks. The spillover effects of having no travel industry, which means the hotel industry is effectively bankrupt, which means that large swaths of major corporations just stopping payments to vendors.

  Aneesh Chopra: There’s a litany of trickle down economic effects that we’re going to learn in the next couple of months. And so stimulus part two or part three, depending on how you calculate these things, will likely be very much geared towards the economic recession or potential depression that’s coming, less about COVID public health response.

  Nigel Ohrenstein: Right. Healthcare, as we know, is incredibly complicated. Let’s just focus on the payer, the health system and the frontline physician, the independent physician. Let’s just focus on those three entities for now.

  Nigel Ohrenstein: There’s obviously so much more in healthcare, the government, pharma. I mean, it goes on and on, urgent care centers. We could talk about healthcare all day, but let’s focus on those three.

  Aneesh Chopra: Yep.

  Nigel Ohrenstein: Now, as you just said, it’s fascinating because the frontline physician, the independent practice, the loosely affiliated IPA, they have all but closed down their practice, right?

  Nigel Ohrenstein: We can talk about the overnight adoption of telehealth, which is fascinating, but let’s put that to the side for a second. As you correctly said, they run on the risk of literally having to shut their doors.

  Nigel Ohrenstein: Then you have the health system, which is hemorrhaging money at unprecedented rates. I spoke to a senior leader at a health system just yesterday, who told me they’re losing about $150 million a month.

  Aneesh Chopra: Yep.

  Nigel Ohrenstein: Crazy amounts of money. If that goes on for too long, that’s hitting $1 billion. Not many institutions can handle that.

  Nigel Ohrenstein: So roll the clock for us. Given your experience, do you see some type of seismic change in the healthcare ecosystem or do you see us being able to provide economic support, that we’ll go back to the new normal? Give us some of your insights as to how that might play out.

  Aneesh Chopra: First principles, if we aggressively social distance, shelter in place and take these extreme personal commitments to just contain the spread of the virus over the next month and we get through this chapter, that assumption means that there’ll be a new normal that starts, call it in June, May or June.

  Aneesh Chopra: In that new normal, we’re going to have to have a much more vigilant public health surveillance system, that could identify hotspots with enough early detection, that we can contain, socially isolate in a more precise manner in certain communities.

  Aneesh Chopra: That would mean, Nigel, a faster return to “normalcy”, with elective surgeries and others coming back into the queue, potentially in that next quarter.

  Aneesh Chopra: That is the best case scenario. That we don’t subsidize this period of inactivity, we get back to normalcy with this vigilant public health surveillance construction. So we’re not having to, broadly speaking, stem the crisis, but we can be much more targeted. Get back to contact and trace. All the tools in the toolkit in South Korea, when they identified early the church and what the process was, if we had the infrastructure.

  Aneesh Chopra: Now, I do believe we as a country have the capacity for sure, to weather this storm and to put the resources that are needed, to keep the healthcare delivery system afloat.

  Aneesh Chopra: There are going to be some fundamental changes, Nigel. I do think the ability to deliver more services in the home, that have been maybe culturally or regulatory or technically delayed. We’re going to see, what does an ICU in the home look like?

  Aneesh Chopra: We’ve talked hospital in the home. What are the ways in which we can deliver the needed services, but with minimal harm, that still are generating revenue to the organizations that are hemorrhaging but in a different way? The mix of revenue might change.

  Aneesh Chopra: You made the comment about overnight telehealth. I think some of these barriers were silly. I can’t text message my patient because I have to be HIPAA secure, so I got to pay a third-party vendor to do some kludgy thing, which is some password I don’t remember.

  Aneesh Chopra: The experience to the physician is miserable. And so to the credit of the CMS leadership team, Seema Verma in particular, they said, “Look, use off-the-shelf tools. Okay? In this crisis, use off-the-shelf tools.” And Nigel, we may emerge on the other side with the, “Hey, the harm wasn’t as risky and people we’re not texting sensitive stuff inappropriately. They were doing reasonable judgment and we worked our way through this.” Phone, text, video, you can use FaceTime, you can use Zoom. So we kind of cut through a lot of the clutter.

  Aneesh Chopra: We may emerge with a different cost structure in the healthcare delivery system, that’s more asset light. That may be disruptive to organizations that generate the big institutional revenue, but we’re going to work our way through that change. That would have come anyway through value-based care, but this will just accelerate.

  Aneesh Chopra: And then you’d ask the question, “If I can treat this group of patients at home, in a much lower cost setting, with this remote monitoring, with physicians checking in at this time period and we get similar or better outcomes, remind me again why we’re not doing that today?

  Aneesh Chopra: So Nigel, this may be an economic disruption that is to the betterment of what we envision happening in value-based care. It just might happen faster. And we’ll figure out what the economics of that are going to look like, with respect to health plans and the health systems and the independent physician practices.

  Nigel Ohrenstein: Aneesh, there’s great hope in that message, right? That is obviously somewhere I hope, not just for patient care, but just when you look sort of macro at the cost of US healthcare and think about my children, my grandchildren and how are they going to afford to pay for the rising cost of our healthcare.

  Nigel Ohrenstein: Whatever projection you give it, it’s knocking 20% of GDP in their lifetime and beyond. So, that is perhaps a silver lining of an awful crisis, that hopefully will drive a better healthcare system. Not just in what you just said, but also the things you said about public health and the like.

  Nigel Ohrenstein: I’d like to end with what I call the quick fire round. Just a couple of quick questions. Best advice you were ever given?

  Aneesh Chopra: Spirit of Generosity from David Bradley. The notion that, in a conversation like this, I should lead with making sure you get more value out of this conversation than me and that our spirit should be that that’s the default and that gives us joy. So where possible, giving exceeds the benefit of whatever interaction that comes to me.

  Nigel Ohrenstein: Obviously, you’ve achieved so much. What’d you do to relax or have fun? What’s the number one thing you go to?

  Aneesh Chopra: My kids are a little younger. I got a five, 11 and a 13, and so we’ve built a bit of a daily routine of kind of dad tag. So, I just absolutely love doing something athletic with the kids, and I’m embarrassed that now they’re a little bit faster than me, which really says a lot about that health status of dad. But dad tag is one of my favorite pastimes.

  Nigel Ohrenstein: You might want to patent that during the coronavirus here for people at home. If you could change one thing about healthcare, what would it be?

  Aneesh Chopra: Culture. Culture to me, in the context of what I would call a fiduciary culture. That is to say, in a fragmented system, any individual actor on the stage can do what they think is right, but may not be in the absolute best interest of the patient. Because they could have come into the clinic, but they could have gotten a telehealth consult and gotten a similar outcome. So do I need to bring him in?

  Aneesh Chopra: If every touch point in our fragmented system had the ability to think through, what is the true best next path for the patient and could communicate that information to the patient, I think the system as a whole would work a lot better.

  Aneesh Chopra: So, I’m hopeful Lumeris acts as a proxy, a fiduciary for patients under your care, as I saw when we visited in St. Louis, and that more and more of the healthcare delivery system will build that muscle, that culture of focusing on what’s in the best interest of the patient regardless of the implications for the fragmented actors on the stage.

  Nigel Ohrenstein: Aneesh, thank you for your generosity. I can tell you that I, without doubt, learned more and got more out of this conversation than probably you did, but thank you for that and thank you for joining me today. Stay safe, and we will hopefully all continue to social distance.

  Nigel Ohrenstein: We can do another episode of this, in due course, in person, and see if data sharing, our public health infrastructure has improved in the future. And hopefully this will be a moment as that.

  Aneesh Chopra: We’re all hopeful, Nigel. Thanks for having me.

  Nigel Ohrenstein: Thank you for joining us today. Please subscribe on your favorite streamer and leave a comment as it helps others find the podcast. And don’t forget to rate us. Join us again as we tune healthcare. This is Nigel Ohrenstein in New York.