Disruption and risk in health care

Ed Prewitt:

Thanks, Tom. We're here today with a special guest, Dr. Wyatt Decker, the CEO of Optum Health.

Wyatt Decker:

Great to be here. Ed. Excited for the conversation.

Ed Prewitt:

As am I. We are here today to talk about the upside of disruption, which is innovation. So to begin with, the themes of today's event are risk and disruption in healthcare. How do you view these concepts for clinicians and for patients today?

Wyatt Decker:

Yeah, and I think this is a great and timely topic for all of us. Everybody recognizes that healthcare in the US is both excellent and terrible at the same time. And how could we say that? How could I utter that juxtaposition? We have fantastic universities and medical centers, we've got well-trained physicians and nurses, but at the same time, we've got a system that is exhausting everybody, patients, providers. Burnout is at an all time high.

And so, what are we going to do about this? And to me, the notion of disruption, and I like the up in disruption, how are we going to make things better by changing the status quo is really important. And when we talk about risk, I would say I divide risk into a couple of buckets. There's obviously clinical risk. You do a procedure, there's some risk to how it turns out. We all understand that.

There's also risk to actions and inactions more broadly, as leaders of medical practices and medical systems. But remember, there's risk to inaction too. Risk to actions, risk to inaction. So we have to calculate both and have at least our best estimates of how to chart the best course for our organizations or the health system at large.

And then of course, there's a financial term that risk is often applied to, meaning who bears the financial burden for paying for patients' care? And we'll get into that when we talk about value-based care, because that's a really important part of risk.

Ed Prewitt:

Health systems showed during the pandemic that they can move fast when the situation is urgent and when they're allowed to. So now, post-pandemic, how can they maintain that agility and that resilience?

Wyatt Decker:

Yeah, and I think that so many of us found out what our organizations are capable of during the pandemic. I remember us, in our organization, standing up 16,000 providers in a matter of about eight weeks on telehealth solutions. That normally might've taken years to get done, and it showed us what we're capable of as organizations, as people, when the situation demands it.

And so, what I've been telling my teams and share with all of our viewers today is let's not lose that sense of urgency and that can-do spirit that the pandemic kind of forced us all into. And I saw across the health system, across different sectors of the health system, there was a rolling up your sleeves, there was a let's get this done attitude. And that's super valuable.

Yes, we're in a more regulated, more sustained environmental milieu today. So that doesn't mean we hang up our cleats and just coast. It means we have to push and innovate and try things and hold ourselves accountable to timelines that historically we didn't think were possible.

Ed Prewitt:

So you talked about the risk of inaction, and I'd like to dig into that a little bit. What are the risks if we can't create a health system that works? And again, for providers and patients?

Wyatt Decker:

Yeah. Well, they're substantial. And as we all talk about, the US spends more per capita on healthcare than virtually any other industrialized nation on earth, and observes, frankly, pretty sorry results as a population. Yet we also know there's pockets of excellence and pockets of good outcomes, and so it isn't all bad news. But when you look at it at large, you say, "How could we do better?"

And I think there is significant risk. At some point, the US healthcare system just gets too expensive. Employers and government and, frankly, people, healthcare is the number one cause of personal bankruptcy in the United States. Are we okay with that? It's kind of mind-blowing when you think about it. I'm not okay with that.

So I think the question for us is, okay, we have terrific physicians, nurses, and a great workforce in healthcare. Now how do we harness what we've got in the US? I would also argue we have among the most innovative physicians and scientists in the world. So how do we harness that in a way to help make our system itself better?

And I think we can talk about the regulatory environment, the clerical burden, the tort system. These are all influences that get pointed to as making healthcare difficult, and that's why we need to think about it. But I actually think one of the most challenging parts of the US healthcare system is how it's structured financially, which is we historically have always rewarded volume, not quality and value. And that's what the fee for service system currently does. It pays for volume, not quality.

Ed Prewitt:

So the flip side of disruption is innovation.

Wyatt Decker:

Right.

Ed Prewitt:

How can care delivery organizations innovate in the ways that are needed to create this vision of a better healthcare ecosystem? Because it's hard for individual health systems to move monolith.

Wyatt Decker:

Yeah. It's true. And we've been talking about value-based care in the US for decades. So first, let me just quickly talk about why I view innovation around value-based care is so important.

So when we think about value-based care, think about care where the providers are rewarded and responsible for the healthcare spend of the population they're serving. When that happens, it changes the dynamic. Instead of paying for procedures and doing things, we begin paying the provider system, the team, for keeping people healthy and well. And that's a super important shift.

But to do this, we have to innovate in all kinds of ways. And what's exciting about a value-based care construct is that providers historically have been limited in what they can innovate in because we're limited in what we can code for and bill for as providers in a fee for service system. As you move to various risk structures, but particularly full accountability, full capitation for an individual's healthcare spend, you can now start to get at things that historically were viewed as out of reach of the provider community.

What do I mean by that, Ed? I'm talking about things like social determinants. We've come to recognize that we'll often be serving individuals that have significant food insecurity, housing insecurity, difficulty with transportation. And again, for the typical fee for service primary care practice, that's sort of out of scope for them to try to figure those pieces and parts out.

But when you're fully responsible for somebody's healthcare journey and outcome, you become actually quite interested, as we are at Optum, but so are others in this space, around how do we solve for social determinant needs that are creating barriers to obtaining good health outcomes? So we'll send a medical vehicle to a person's home to bring them to a clinic. We'll provide food and housing security as appropriate. Or maybe we'll bring a practitioner into that home so that the individual doesn't need to go into a clinic. And all of those things are historically kind of outside the norm. And it opens up a whole bucket of opportunities for innovation around care delivery that, again, were historically not part of the picture.

Ed Prewitt:

I'd like to continue on this topic and ask specifically about technology, which is sometimes described as a silver bullet. Of course, it hasn't turned out to be. How do you view the role of technology innovation in healthcare to make things better?

Wyatt Decker:

Yeah. Well, and I think it's important to acknowledge that we have reached a point where technologies are ubiquitous and we're in the hype right now of LLM or large language models that can generate various letters and forms and emails and chats to our patients or to people who are in need of communication. That's great.

But I always like to take a step back and say, technologies are simply tools. It's where the words derive from. These are tools to help us solve problems. So instead of falling in love with cool technologies, it's very important, and if I have any CIOs and tech members on the team, I always say, "Hey, think about what problem we're trying to solve and then look at your palette of options and solutions and help us, as a technology expert in healthcare, figure out what is going to apply." Doesn't really matter to me whether we're using AI, ML, or some other digital technology, it matters to me that we're solving problems. And that's, I think, where healthcare leaders and technology experts need to work more closely together.

And we actually have a team that goes deep into the clinic environment. So when we're developing next generation decision support, we're actually embedded and iterating with frontline practitioners because we need that feedback. Are we really solving your problems or are we just doing an interesting science project? Or are we doing something that seems cool but doesn't solve a problem?

Ed Prewitt:

I love that characterization. So the NEJM Catalyst audience is clinicians, healthcare leaders. And to the many clinicians and leaders listening today, what would you say about the opportunities for them when they think about innovation, when they think about disruption, pros and cons?

Wyatt Decker:

Yeah. Well, and I think there's a lot of opportunities. And having spent 22 years as a practicing emergency physician, for the clinicians who have joined us, I would share, think about the environment that you are in and how do you make it better? It's a little bit like the expression we all know. Think globally, act locally. Figure out what is in your sphere of influence and start to make it better.

Maybe it's wait times, maybe it's helping to get rid of a couple of irritants in your daily practice, maybe for you and your other physician or nursing colleagues. To me, don't underestimate the impact all of us can have by taking problems, breaking them down and solving even a part of them. And then as you look in different spheres, when I think about those of you that lead health systems, again, large, medium, small, think about how do you get to a place where we're beginning to provide what people really want from their healthcare system?

And having spent a career both caring for patients and talking to people about what they wish their healthcare system had, most people wish that they had a healthcare system that had their back and helped keep them healthy and well, but was there for them if they had something serious.

As you know, and often we find ourselves, as patients or people on our healthcare journeys, suddenly wondering, "Oh no, I've got a bump or an injury. I don't need to go to the emergency department, but who do I see? How do I find them? How do I know if they're good? How much is it going to cost?"

All these things are things that health systems can solve for. But it's hard to do on your own. And we increasingly, ourselves, and we're a large organization, but we increasingly partner with others. We're partnering with hospital systems today to say, "How do we accelerate our and your journey to value-based care?" Because it takes a different skillset than has been honed over the decades in fee for service care. And it's very, very important that we work together through these kinds of partnerships to advance value-based care as we move forward.

Ed Prewitt:

And when we talk to individual leaders of organizations about how they embrace the risk-bearing model, it's very difficult for a lot of systems. It requires a lot of negotiation. What would you say to them on how to move forward, how to make progress?

Wyatt Decker:

Yeah. Well, one is it takes a certain amount of courage because all of our systems are perfectly designed to create the results we observe, right? That's a paraphrase of Peter Drucker. But our systems create the results we observe. So our systems today are creating healthcare that's overpriced, focuses on volume, and doesn't always deliver the comprehensive care that people wish they had access to.

So then I'd say, let's take a step back and say, "Okay, how do we get to that place?" And I believe, and I think the principles underpinning value-based care, particularly fully capitated care, provide the construct. And then to your question, Ed, "Okay, but it's hard. How do we get there?" And that's where, we talked about partnerships, finding the right partner, if it's a new space for you. And there's also ways to begin to get into it. As you know, there's advanced care organization and Medicare shared savings programs that are a key part of beginning the journey to value-based care, so that you don't have to take, back to risk, full upside and downside financial risk, all right out of the gate when you're not sure what that's going to mean for the financial health of your organization.

And at the end of the day, aren't we all here to take better care of patients? And major academic medical centers where we crank out incredible innovations, scientific advances all the time, are we willing to actually not just disrupt a piece of care, like the next generation heart valve or genomic advance, which actually we're fantastic at, but are we willing to challenge ourselves to say, "How do we think differently about how we deliver care in a way that's more holistic and focuses on keeping people healthy and well?"

And frankly, that's my challenge to all of our listeners today. What are you doing to help keep people healthy and well? Because that's powerful. And frankly, that's what most people want. Now, they also want to know we've got their back when they have something serious or rare or complicated, and that's super important too. And so, I think balancing those is critical as we go forward.

Ed Prewitt:

Well, thank you, Wyatt. Terrific conversation. Really appreciate you sharing your insights.

Wyatt Decker:

Well, great to be here, Ed. As you can tell, I'm super passionate about this topic. And if I can do any more, if any of your viewers have questions, I'd love to follow up. Thanks so much.

Ed Prewitt:

I'd now like to introduce Sara Vaezy, who's the Chief Strategy and Digital Officer for Providence Health, for the next segment of our program.