Connected communities

Welcome everyone to today's webinar, Connected Communities Advancing Population Health Through Data and Emerging Technologies. I'm Riz Hatton with Becker's Healthcare. Thank you for joining us today. Before we meet today's moderator and panelists, I'll go over a few quick housekeeping details. We'll begin today's webinar with a panel discussion and we'll have time at the end of the hour for a question and answer session. You can submit any questions you have throughout the webinar by typing them into the Q&A box you see on your screen. Today's session is being recorded and will be available after the event. You can use the same link you used to log into today's webinar to access the recording. If at any time you are having trouble with the audio, try refreshing your browser. You can also submit any technical questions into the Q&A box as we are here to help. With that, I'm pleased to welcome today's moderator, Miriam Sznycer-Taub. Miriam is the managing director of Cross-Industry Research at Advisory Board. Miriam, thank you so much for being here today. I'll turn the floor over to you to kick things off.

Thank you, Riz. It's a real pleasure to be here. I'm sure many of you on the line, I've been so closely following this topic of how the digitization of healthcare data combined with all of the new technologies that are emerging is causing really a data explosion in healthcare. And at the same time, there's this incredible pressure on healthcare organizations to manage these growing data sets more and more carefully. This is a huge topic, we could spend all day, probably multiple days discussing it. So our focus and our hope for the next just under an hour is to examine how connected communities can really use data-driven virtual and automated technologies to advance and refine population health strategies. And I'm thrilled to be joined by this incredible panel who's going to help us through this discussion today, so let me introduce them. Mylynn Tufte is a partner at Optum Advisory Services and the Population Health Practice lead.

Erik Johnson is a senior vice president at Optum Advisory Services and the Value-Based Care Practice Lead. And Jaime Murillo is a senior Vice president and chief medical officer within United Health Group's Enterprise Strategy and Innovation. So truly a great group of people to help us talk through this topic. We're going to get started and jump right into the conversation. As Riz mentioned, if you have questions throughout, please enter them into the question panel. We'll get to as many of them as we can at the end of the conversation today. So Mylynn, let's start the conversation with you if we can. Tell us a little bit about which populations are a priority for connected care and why?

Thanks, Miriam. And thanks for everyone for joining us today. You're right, we have a great panel, and a really exciting topic to talk about. Connected communities are communities that are collaborative and allow people to be engaged, and both engaged on a digital level as well as engaged with that ability to be networked. We know we have to prioritize the work that we're doing because of workforce issues as well as those workforce constraints, as well as understanding certain populations have higher risk factors around chronic illness as well as mental health issues. Some of the populations that we're most concerned with and working with our clients around our rural health populations, they tend to be more isolated and have social issues related to transportation and access issues related to getting to providers.

Other populations that we're concerned around are individuals with disabilities. You may know that populations that have disabilities are over 25% of the population. Those are individuals with disabilities that are seen and unseen, and those with physical limitations are more vulnerable to health complications. And across the nation, we have seen higher rates of mortality and morbidity for pregnant women, and those women are of a focus for us when we think about population health. Another area that is of concern for us, our LGBTQ+ population, they faced higher discrimination and stigma and that impacts their mental health and frankly, overall trust for the healthcare system just to name a few of the populations that we're concerned about.

Yeah. I agree with everything that Mylynn just said. This is Erik, by the way. Another group that we're being, I think increasingly thoughtful about are the frail elderly because of the mix of healthcare as well as social needs that they face and the community ideally that surrounds them in delivering those needs. But in general, it's individuals who have these predictable, consistent needs that may be unpredictably emergent in certain circumstances who really benefit, I think, from these connected communities. And it doesn't necessarily just have to be a geographic issue when we talk about access, it could be access to transportation, and that can be just as an acutely felt need in an urban environment that lacks sufficient mass transit as it is in a rural setting. So when you take into account those types of factors, the connected communities need to start to address a much broader set of conditions and circumstances than we would normally find in a normal electronic medical record.

Yeah. It seems, just from the answers that two gave, there's no shortage of people who could really benefit from connected care and thinking about these connected communities. So we have to talk, how can we support them? And obviously one of the ways that we think about is through technology. So what are some of these new technologies really that are placing these individuals at the center of a connected ecosystem and thinking about how to refine population health strategies? Jaime, maybe we can start with you here.

Sure. Thank you. So I think those two words, community and technology definitely are going to be with us for years to come, and that's a dissociation we had made in the past. One, because the technology was not ready to, because we're only now starting to reach out to communities. So think about the concept, let's start with the concept of how we provide healthcare today. We wait for people to come to us in a brick and mortar space, office, ER, hospitals. Now, we're virtually available, but that's still waiting for people to come to us, so what if we actually go to the community? And so that's a starting principle for how we can actually simplify healthcare. We talk a lot about redesign, we talk about innovation, we talk about re imagining. The reality is we make healthcare so complex that all we have to do is just simplify it, and a way to simplify is going to the community.

So think about the technology piece, how important it is because one analogy that I always think about, we tend to dissociate poverty and disparities from technology. We think that, "Well, technology, great to use it, but people don't know how to use it. They don't have the broadband, they don't have the means." Well, technology has reached a point where it should be widely available. Think about Africa. In Africa, they completely bypass the phone at home and they're just conducting a lot of business using their mobile technology, so the more so we should use that technology. So we use, for instance, we went to a community in Detroit that was medically disadvantaged, 99.5% black population, and we went out to the community to screen for elevated blood pressures. Interestingly enough, we found that 60% of the population had elevated blood pressure out of control, and if you look at the statistics, 37% in the US have uncontrolled. So that's 60% higher that.

So that's the first thought that come to your mind is, what if instead of waiting for people, we go to the community? We'll find more disease, we'll go upstream, we'll be able to intervene before they actually had bad outcomes. So now as it comes to the technology piece is, "Okay, we found them. Should we wait for them to come to us?" The answer is no. Let's just use technology and just control that remotely. So we did that remote control, they didn't have to have any technology. We just gave them a blood pressure cuff that was steadily activated so they would just take the blood pressure, will come to us to our platform, and then we'll take it from there. They didn't have to download any apps. They didn't have to call anybody, connect, go to the website and so on. So that also solves for the SDOHPs that we'll touch on later, but that's an example of how going from 14% control among African-Americans, we went to 88% using that delivery method, going to the community and just using technology to alleviate that work and make it more efficient as well.

Such a great example. I love the idea of going directly to the community, thinking about how we can engage folks in their health and be sure that we're addressing disease earlier on. One thing that always strikes me when we think about working in the community, taking healthcare more into the community is we sometimes take a narrow view of the stakeholders engaged. We think about the patients, and we might think about the clinicians, and I think this gets a little bit more tricky when we're in these connected communities. So Erik, I know you've thought about this a bit. What are some of the other people involved in the care taking sphere that are embracing some of these tools to better support our patients?

Sure. At the risk of sounding too much like a consultant, I think one of the things that we believe needs to happen to make these connected communities work is to really do a stakeholder analysis around the patient and the community in which they live. Because it is more than just a doctor patient relationship, and it should be particularly with some of the more at risk populations that really would benefit from this. I really love what Dr. Mylynn was talking about earlier, because I think there's a tendency to over-engineer the solution and really rely heavily on technology without actually sitting down and doing a use case analysis of what do these people actually need? How do they receive information and from whom do they receive care? That type of use case and stakeholder analysis gives us a much broader parameters in which to think about who needs to be connected.

Certainly the primary care physician and the patient sit at the center of that circle, but depending on the population, you're going to start to extend that out into family caregivers, what we would consider to be the unpaid caregivers who are doing a lot of the heavy lifting, for frail elderly parents, for example. But also when you start to think about some of the social determinants that start to affect an individual's ability to affect care, you start to look at different types of caregivers, clinical social workers, community health workers, occupational therapists, certainly everybody in the behavioral world.

They don't all need all of the information all of the time through the most sophisticated technologies, but they should be informed about what is going on with that patient, what is going on in that patient's home, and given some consideration and some advice about how to mitigate some of those risks. So it becomes a very large cast of characters when we start to think about who needs to be connected, and then we have to be really careful about how we're connecting them and with what information, and that's something that I think really represents the art of great population health these days, really cutting edge stuff.

Yeah. I think we've set the stage now. We've talked about the patients, we've talked about the technology, we've talked about the stakeholders engaged. Clearly this is a big topic that involves a lot of people, a lot of technology. But let's talk about the other part of this, which is the data itself. There's all kinds of data that can be included in these initiatives, but I'd love to chat a little bit about when race, ethnicity, sexual orientation language, and social determinants of health data should be included. I know you all have thoughts on this question, so I would love to hear from everyone. Erik, maybe you can start us off.

Sure. I think the general rule probably should be to include as much of that data as you can to understand the environment in which these individuals are managing their health or not managing their health, and how some of those unmanaged complexities can start to be addressed. Certainly ethnicity and race become critical factors in understanding how patients consume healthcare, how they access healthcare, and whether they feel comfortable in accessing healthcare. A lot of times, individuals are going to skip over some of the care that they should actually be getting because it's either too hard to receive that care. I'll talk about that in a second, or it's not culturally competent-

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...second, or it's not a culturally competent setting for them to get that care. And that can be a disincentive to actually walk into a clinic or call a physician for an appointment. One of the things that we've seen is that inconvenient access. It's something that I think we've missed for a number of years, and I give the industry a lot of credit over the last maybe 24 months in thinking about transportation as something that really is a missing link for a lot of individuals who are most at risk. That lack of access to a car to a bus system or to a bus schedule starts to really impede the way individuals can access the physician office or the pharmacy for the pharmaceutical refill.

These are huge barriers for a lot of folks, and I think mitigating those barriers does fall on both the payer as well as the provider, making sure that we understand what those challenges are, what those barriers might look like, and adapting our practices, our policies, and our products in order to integrate easier access to it. But I'd ask my colleagues on the panel, they've spent an enormous amount of time thinking about this as well.

Eric, I'll add, and at the same time, challenge some of those concepts. So one is we have a change in the demographics of the country over the past 10, 15 years. And if you look at after a 50-year decline in cardiovascular mortality, for instance, we're now going [inaudible 00:15:34] in our increased cardiovascular mortality the past 12 years. Why is that? We actually looked at 36 million encounters in our database and found that the heart attacks are actually increasing among the Black population. And that unfortunately, even in the younger population, 35 to 64. So that idea that we have in our minds that heart attacks only are, for the most part, occur in elderly white males, is no longer the case. And that's probably a reflection of increasing morbidity, [inaudible 00:16:05], obesity or increasing diabetes, metabolic disorders, and even in smoking, uncontrolled blood pressure, diabetes and so on.

So there are many reasons why we need to start thinking how can we reach out to those populations that are being affected the most? And that's why talking about social determinants of health is so critical because that's where we can have the most impact. But part of the idea is what are we trying to really solve for? This is the challenge. If we think about solving for transportation, how about if we actually use technology instead of asking people to come to those brick and mortar spaces, we actually treat them remotely. And by the way, we can do it more efficient and not have to worry about transportation. Granted, that's a solution for 60 to 70% of the people, but nonetheless, huge amazing amount of people. What about instead of focusing so much on how can we make the lives of the doctors easier by putting pop-up windows in their electronic health records to remind them to prescribe medications, which is a lot of the work that we are doing today.

We actually put those repetitive and [inaudible 00:17:12] tasks using technology again, in the hands of someone who can execute under their supervision so they don't have to bring a patient for 15 minutes, write a note in 10 of those 15 minutes in order to be able to bill for that and just rather have the time to review those recommendations in a platform and say, "Yeah, I agree." And then someone else would execute on those repetitive tasks. So there is a lot of ideas that we have about how we can use technology and how we can really impact those communities that are in most need. And then how we can bypass some of those needs that the communities have by just going straight to them.

Miriam. I'd lean in a little bit further there and say that there are regulatory drivers for the collection of data on [inaudible 00:18:01] and [inaudible 00:18:03]. Whether it be federal, state, or local, to help us do this in a way that is within legal constraints as well as making sure that we have good data governance and we're doing it in a sensitive, secure, and private way. So those are all considerations that we need to be aware of. It's required in some areas and something that we need to be aware of when we're training people to collect this data and how we're storing it and making sure that we're transparent in how we're using race, ethnicity, and language data so that the people that are being impacted have trust with us in the system and the data.

One thing that's clear is there's so much data out there and the amount of data is just growing. All my conversations with stakeholders across healthcare, one thing becomes clear just having the data isn't enough. Once you have the data, we have to know what to do with it. So [inaudible 00:19:24] maybe you can talk a little more about some of the strategies you've seen for taking that data and building the whole health view that really supports a more proactive approach.

I'm really excited about some of the work that we're doing with a Medicare administrative contractor in the southeast and a social care provider. We've been able to implement some technology that allows us to go out to healthcare providers in rural areas and connect them with the social care technology and a social care network so that they can get individuals and providers connected to a social care network. And one of the things that we know CMS is very much interested in is understanding the actual need around social determinants of health and a collection of Z codes. And so that's one of the things that we're doing under an innovation grant through CMS. So that work is part of a three-year project and we're making some strides.

And it is one of the things we have seen within this project is that network for CBOs within the rural area is really not very robust. And in order for us to support rural care providers and individuals that live in rural areas that have social needs, we have to be able to quantify what those are. And so we're in the midst of really trying to understand that and more work needs to happen in this area.

I would agree with [inaudible 00:21:26] around the work that is going on. And there's a lot that we still don't know. The SDOH is a perfect example. Today we're saying we need to collect more data about people, but we don't know what to do with it. Do we know what are the top two or three social determinants or behavioral factors that are more critical? Something that most people may know or may not is that 80% of the clinical outcomes have nothing to do with clinical [inaudible 00:21:56]. In other words, is the behavioral, social context that really makes a difference? And that's where I think we're putting together the data, we'll be able to discern what are the areas that we need to focus on that are going to have the most impact. And you can probably in a couple of years from now, we'll be able to say, these are the two or three social determinants, the two or three behavioral, the other aspects of education and so on that we can focus on that are the most critical and that's where we are going to put our resources.

And then the other concept I will make emphasis on that [inaudible 00:22:32] just touched on collecting the data is not beyond the responsible use, which I think is critical, is how we can actually do personalized care down the road. Because as we accumulate data points, we'll be able to discern patterns and then we'll be able to say, "This is the care that Ms. Smith needs and this is the care for Mr. Parker." That's when we truly talk about equity. Right now we're in the stage of equity for Blacks, for Latinos, for LGBTQ. I think eventually equity means providing the care that every single person needs and deserves.

We've touched on this throughout the conversation, the amount of data, the new technology, and one of the things that I think is becoming so critical is the ability to use and integrate this data. And it's coming from so many different types of sources now. And so I think that another question that all of you maybe can touch on is how do healthcare organizations link clinical, financial social data from all of these disparate unique sources and bring them together in a way that helps them move forward? Eric, why don't you answer this first and then I'm sure others have thoughts as well.

Sure. I've heard the phrase responsible use mentioned a couple of times, and it reminds me of the phrase meaningful use. For those of you who remember the meaningful use program that drove the adoption of EHRs. There's a lot that we can learn from that experience. One is that providers and plans aren't going to do this unless there's money on the barrel. And I think what we have found, what we've seen in the healthcare industry for as long as I've been in it, and I've been in it longer than I care to admit to, is that people do respond to financial incentives. They will start collecting and using this data if they have the right incentives placed in front of them. The question then becomes are they going to use it in the right way? And I think that's where, as an industry from both a payer and a provider standpoint, I think we need to be kind of creative and maybe indirect in the way we encourage the linking and the usage of this data going forward.

I think what we have seen in the early versions of what CMS required for quality reporting from providers is it didn't really move the needle on quality because it was a checklist of things to do. Whether you did this at the right time, it didn't really track results. And I think to CMS credit, they've learned from that and they're moving toward more outcomes-based measures or outcomes-based philosophies of the case. And I think what we're seeing now, particularly, for example, in a MA, is a shifting toward CAHPS as a measurement of consumer satisfaction, which in and of itself isn't a health equity or connected community initiative. But what it's forced the plans to do is think about how do our members engage with their benefits? Are they engaging with those benefits in a way that helps drive better outcomes? And do we make it easy for them to engage with their benefits?

So the ability to collect some of the data, that [inaudible 00:25:52] and Jaime were just talking about, will give those plans some insight into whether individuals are able to engage with those benefits. And if they're not, a couple of things are going to happen to those plans. They're going to have lower CAHPS scores, which will inflect their reimbursement and their members are going to have worse outcomes because they're not engaging with their benefits in ways that that would help them maintain their health. So I think there's got to be money on the table. There's got to be relatively creative and effective ways for folks to use the data once it's integrated and learn from it so they can structure networks and they can structure benefit design and products in such a way that it makes it easy for members to engage with those products in a way that makes sense for them culturally, ethnically, and from a health perspective.

I would take it from the angle of interoperability. And from every client that we talk to, the workforce is an issue. And when I mentioned the work that we're doing in the southeast with social determinants of health innovation, workflow is an issue and workforce is an issue. And if we can have that interoperability around making sure that when we ask the questions and have that closed loop referral for social determinants of health screening built into the electronic medical record, that is where we need to go. Also, I saw this within the public health workforce, if we can do electronic case reporting and share data amongst the public health workforce and the provider workforce, I think that that is another area that we need to continue to invest in. So understanding those workforce constraints and...

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So, understanding those workforce constraints and continuing to invest in interoperability is something that in order for us to have those connected communities, we need to continue to work on.

So, Eric, you truly sounded like a consultant, but you're so right. You're right on the money, pun intended. And so, let me tell you those two concepts. What incentivized people to work one way or the other, especially on the provider side and what Mylin just referred to as the workforce.

So, the fee-for-service system was probably one of the most perverse incentives for us to do what we're doing today. And that has actually led to a lot of work done by the physicians that they don't necessarily have to do, that someone else could do. And that has led to a lot of burnouts. COVID certainly worsened that scenario.

So, now is, we are in a situation where, as Mylin said, what can we do with the workforce? The reality is we will never catch up, we can guarantee you that, because we don't have enough people to take care of the population that we have. Because the number of comorbidities continues to go up, because now the expanded care beyond the clinical scenarios, including the factors that we just mentioned, make care more complex.

So, what can we do about that? So, one is, we need to make it easier for our providers because they're leaving and they're leaving for a reason, because they're tired, they're burned out. So, can we find a way to, number one, extend their ability to do that work through extended care teams? And Eric mentioned at the beginning, all the stakeholders. In Detroit, we use the community health workers as a way to screen and engage and enroll people for that reason, and because trust is always another component, especially when it comes to minorities.

Then the other one is, how can we have ancillary teams doing repetitive tasks? No doctor went to school for 10 years just to increase a medication from 5 to 10 milligrams. They will tell you that. So, can we have someone under their supervision do that for them so they don't have to spend, as I mentioned, X amount of time just doing that? Can we actually do a lot of repetitive ... This signals that we use through technology to get immediate feedback? Instead of handing out prescription and hoping that in four weeks you'll have access. You can just say, "Here's the prescription. We'll wait for the signals coming from your home." Whether it's a blood pressure cuff, whether it's technology looking at your face and looking at your mood, whether you have depression. Or, actually, soon we'll have readings of temperature and blood pressures and heart rates, and so on.

So, there's a lot of technology that's coming in the market that will allows for us to get those signals, whether active or passive way from home. Sleep is another area where there's a lot of progress. And then, that data can be then analyzed using technology and then have ancillary teams reporting what the doctor needs to supervise and approve or not approve.

So, think about all the care that we can actually really provide remotely. We need to change that math, the one provider per patient, to one provider supervising the work done for thousands of patients. So, the opportunity is massive for us, will really change the way we provide care and optimize work. So, the vision is, imagine a doctor in an office saying, "I'm going to use two days to take care of the patients that need to come to my office that are complex, that really require my expertise. I can spend more time with them. And then the rest of the time, I can just supervise the work that many others are doing on my behalf because we have access to the technology to be able to do this and do so."

First of all, I plead guilty to being a consultant. I mean, that's fine. But I really like what you just said because it recenters the patient-provider relationship and getting the physicians to focus really on the patients that need the most care. And the ability to give them the data, whether that's EHR data, or social determinant data, race and ethnicity data, to give them the ability to, instead of taking advantage of the fee-for-service system and just scheduling as many appointments as possible, giving them the data so they know who they should be scheduling for on that particular day or in that particular month. Because they don't need to see everybody.

Payment models need to follow in order to support that type of behavior, but really giving them the ability to improve their own productivity is something that I think is really the value in getting this data together and pulling it in from the different parts of the community.

Yeah. Thank you, Eric, for pointing those two things. One is the concept of what is the payment model? And if anything, this scenario will actually incentivize people to move more toward the value-based care, which I think is definitely the right direction for us to go through.

And then the second aspect is that concept of, "Well, if I don't have the patient in my office, am I going to lose their trust?" Interestingly enough, because you have a ancillary team, let's say in Detroit, we use an navigator to make the constant contact. What you're actually creating is a representation of the office or the provider to the patient. So, we've seen that even though they could see the patients, let's say for blood pressure control, 2.6 times less per year, the NPS goes up, that's a net promoter score, an indication of how satisfied the people are, 17 points, just because they felt more connected to the doctors because they had the constant interaction of this navigator, or this community health worker, or the social worker, or the pharmacist acting on their behalf. So, that people feel like now their questions can be answered more quickly, their care is actually more efficient.

And going back to Detroit again, we control blood pressure in 88% in less than 12 weeks. Most of them, 22 days, because we have this repetitive, iterative system where we could do that. So, the satisfaction on both ends. And for the physician as well, the idea of, "Hey, this is the value that I can provide and I don't have to kill myself working 14 hours a day just to be able to see every single patient. And I'm going to get paid because it's a value-based care and there's less incentive to do a lot of unnecessary testing, procedures and care."

So, I think this is definitely a win-win, and that's where we can definitely ... That's the simplification of care, it is done for the patient in a way that is convenient to them. They don't have to lose time off work, pay copays, hoping, cross their fingers, wait for weeks and months to be seen. So, I think through this panel, we have really come out around the idea of, how can we connect those communities, how we can use the data, how we can use technology, how we can engage people in their own care and utilize those signals and then amplify the amount of information we get from them in order to provide a more personalized care.

Such a powerful vision that you just shared with us, right? Of really thinking about creating these communities, helping providers practice in a smarter way that really takes advantage of the tools that we have to offer today, with the technology and the data that's available.

We're going to shift to take some questions from you all. Again, if you have questions, feel free to put them in the question panel. We'll start with the ones that we have, but please keep on putting them in. We'll start with this one, which is this idea of integration. Right? We have talked about the disparate sources, we've talked about the number of stakeholders, but what are the ways that you can minimize integration challenges as organizations are adding new sources, new structures of data, and really new stakeholders into the puzzle of creating these connected communities?

I'll jump in first and say, it is challenging, but if you have a good partner, it does help to minimize those integration challenges, understanding that you need good data governance around your processes around data sharing. So, good partnerships, good data governance, and understanding that you need to have good processes, I think are important.

I just want to go back a little bit and say, I really liked the discussion that was happening, and I like the extension into the community with community health workers. And want to just say that we need to also recognize in these connected communities, the public-private partnerships that need to exist. And I think that we talked a little bit around the edges of it, but just to make sure that we are recognizing that those public-private partnerships are so important at a local level. We talked about it with the social determinants of health and a little bit on the community benefit organizations, but I want to make sure that that comes clear as we are extending into the communities that those community benefit organizations work with, state local organizations, comes clear for everyone.

Yeah. On the integration challenges, I mean, meaningful use passed, what? 14 years ago, I think. And we're still struggling with it, although we've made a lot of progress. I think the prime mover, and this is going to be a policy framework that I think we've largely gotten to at this point with the fire standards. It has at least made it clear what the rules of the road are for that integration.

But I want to go back to something Mylin just mentioned, which is, we're really talking about communities. We're really talking about a locality, right? A geographic place in time. And I think it's important for those partnerships to start with realistic goals. Do not over-engineer how much integration they want to take on from day one. Let's identify some real root cause problems that we think can be addressed by the integration and sharing of data between a payer and a provider, or between a hospital system and the FQHC or the community health workers, and let's see if that solves the problem and build from there.

I don't want to sound like too much of an incrementalist here, but I think sometimes ambitions have swamped good intentions here. And we should really be anchored on what are the problems that the communities face and let's figure out whether there are a couple data elements and a couple integration pipes that we need to build, and just those pipes, that can solve that. So again, I think from a policy perspective, we've come a long way in the last decade and a half, but from a actual implementation and finding results, we probably still need to be very practical in how we do this.

Yeah. Thanks both of you for those comments. I think the power of starting with the community and thinking about what the community needs has definitely come through, I think, in the conversation today. And so, I appreciate you both bringing it up that we can't just jump into thinking about integration without making sure that what we're doing is truly benefiting the community and the connected communities that we're trying to build.

Gotten a lot of great questions here. So, let's maybe tackle this one. I think this is on the ... Everyone's thoughts is with all of the connectivity and data, what should people be thinking about when it comes to security risks or ensuring quality of data?

They should be terrified, but I'm going to defer to [inaudible 00:41:02] on this one. It is an existential threat, but I'll defer.

Yeah. No, I think the data, we have a lot of opportunities, it's just a matter of how we use it. And let me just create, not the analogies, not the right word, but when EHRs came on board, the idea was, well, now you're going to have data in front of your fingers in a computer. Now you don't have to try to figure out what your partners said in the chart, trying to read. We know what doctor's writing looks like. So, that you'll have that information in front of you.

And then, the concept was great, but the way EHRs were utilized, more for billing purposes, for personnel, cost avoidance and so on, ended up being a significant burden on the providers. And every one of us has PTSD about EHRs-

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And every one of us has PTSD about EHRs because we found out that we could see at least 30% less people because we have EHR even though it was supposed to be the other way around. I think we learned that lesson. And now with the new data, what we can do is, number one, we should have data in a way that now we don't have to type and read every single document so that we replace the inability to read our partner's handwriting. Now, with the inability to read every single thing that is in front of us, can we get to the point where we have technology and we actually will have that. It's already been piloted where you can ask a question and then you'll have the answer right in front of you. What is the relevant information?

There's a significant finding there. What is tied to that significant finding that you don't have to just scroll through hundreds of pages including both structure and structured data. So I think there's a lot of opportunity. And then the other one is someone in the question talk about quality. There's high quality providers, there are providers that are not so quality. There are two things about that. Number one is as we move from a more value-based care, we should think about that value being placed on the outcomes. And Eric mentioned this previously is not on just a simple metrics, but is the pacing better? Are the patient's quality of life better? Are the outcomes improving? Are we preventing adverse outcomes? That's where the true financial incentives should be placed on. And that will, to some extent, force people to do a better job because now it's not about... Think about, go back to the blood pressure issue. It's actually more convenient for a provider to have an uncontrolled blood pressure person in the office because they can bill for a higher complex visit than have someone... And it sounds like what? What are we doing?

And certainly there's no provider that will be incentivized to keep the blood pressure not controlled for that reason. But what I'm saying is there's not an incentive to say, "I want to make sure your blood pressure is truly absolutely controlled and I don't care how many times we have to be in touch with you." So that's number one. The other one with the data is that will allow us to see patterns [inaudible 00:44:16] of what is happening with this certain populations over time and what is the type of the care that has been provided over time. And then figure out which types of care associated with better outcomes. And that will allow us to create more systematic and standardized care that then we can put to the use of future patients. As we come up with that type of data insights.

We touched a little bit on value-based care throughout the conversation as we think about the stakeholders that are involved in creating these connected communities, if any of you have thoughts on organizations that specialize in value-based care, how are they thinking about connected communities or being a part of this discussion, these kind of value-based care companies, we might call them?

As the value-based care guy in OAS, I have a lot of thoughts and I will not drain the rest of the time that we have together. I'll give a couple of examples though. Some provider clients that we've had in the past and how they've thought about these connected communities. And I don't think that they would phrase it that way. These are safety net providers that I'm talking about.

For them, this is a financial imperative to address the communities where those communities live and where they get care. Because if they don't, their emergency rooms are going to get overrun and they're going to get run out of business. So for them, these are just good business practices, collecting as much data as they can through the FQHCs with whom they've partnered back to [inaudible 00:45:58]'s point about the community partnerships, getting as much data out of the EHR, sitting down and analyzing the patterns of care and the patterns of non-care and then developing care teams through community health worker organizations and the like and getting out there with foot soldiers and addressing the transportation needs and the medication refill needs and the like.

Because if they don't, those folks are going to end up in the front door of the emergency room and it's going to cost the system a whole lot of money. And again, I realize that makes me sound like a cold black-hearted consultant, but that is what's motivating really good behaviors. It is motivating them to collect data and get resources out into the communities in order to run a sustainable business. So to the degree that they can contract for that value with their payers, they'll win. They'll do really well. And my opinion, the really nice thing about value-based care contracting mechanisms is it aligns all of the stakeholders in a community to drive the best outcomes. Payers benefit from that, providers should benefit from it, and individuals have better health. It sounds trite, but it really is what the quadruple aim is supposed to be getting at.

And I would add on that I have seen states doing risk adjustment with their MCOs based on their expectations of the MCOs taking care of those social needs for their members.

One of the things we've touched on throughout this conversation is how does this look different from maybe the healthcare system that we have been accustomed to that we are used to? And so I think it begs the question, how do we know if it's working? So how do we measure success of these connected communities? Do we look at historical outcomes, customer satisfaction, physician satisfaction, all of the above, something else? And I guess with the ultimate question of how do we link all of this, improved outcomes, lower costs? So I'm curious how you all think about measuring success of these connected communities.

Great examples out of Detroit. I'd love to hear more about that experience.

Thank you, Eric. So I think there are many ways. You already mentioned some of those, Miriam. So number one is how efficient is care being provider? And it doesn't have to be in that order, but think about what we do today. We don't have a timeframe for how long it's going to take us to control the condition, diabetes, COPD, rheumatoid arthritis, hypertension and so on. We just do our job. But there's no concept of should be done in a matter of weeks, days, months. I think the expectation now should be, has to be as fast as possible because every day count, every second count. When you look at the statistics with the CDC, every 34 second woman dies of a hypertension related condition in this country. Every 40 seconds someone has a heart attack or a stroke.

So time is precious and we need to be mindful that controlling conditions, especially a chronic space, remember 90% of the healthcare is spent in the United States, 4.3 trillion dollars is spent in chronic disease management. So that's an area alone where we can make a huge impact. So is the outcomes piece of it, is the utilization. To Eric's point, are they going more to the ER or less because now we're be more efficient in controlling them? Hospitalizations, do they have a better functional life? So we have what we call the patient reported outcomes, so PROs, that's important. And because it's not just about the disease itself, is about the person. Is the person having a better quality of life? Think about what other industries have done. Banking industry is a perfect example. 10, 15 years ago used to go to the bank for every single transaction.

Now you can conduct as many transactions as you want from the palm of your hand. Why should healthcare be different? Is not different. So we can do a lot of tasks, move them out of the traditional space and then reserve that space for those who truly need it. Like hospitalization for instance is a perfect example. And then along with those outcomes, which are clinical outcomes, the patient reported outcomes, then there's also the financial value attached to it. So is the total cost of care. Unit cost probably will go lower just because if we move more toward the value-based care, then is the total cost of utilization. As you engage with a person, then we can provide a more comprehensive care. And that's where I think the total cost of care will go down. It's not just the cost of a specific condition. And then eventually we'll move from, it's not about a condition, it is about the person.

So it's not about treating the diabetes. What is the lifestyle associated with that diabetes? Then we can provide more comprehensive interventions. And now you heard people talking about diabetes regression before it was diabetes control. Now it's actually regression because we have demonstrated since the '90s that lifestyle intervention is more powerful than medications. And if we move in that direction, now we're talking about maybe we don't need to spend that much on pharmaceutical solutions or devices or procedures because now we're using data. I'm going to put data again in the map, data to feed back the patients or the people and tell them, "This is what you're doing that's affecting your health and this is what you can do to modify that behavior."

I agree with all of that. And as a Consultant, I would normally say that the financial metrics are the ones that we should be paying attention to, and I think that they are. Simply put, let's look at lifespan. Lifespan has shrunk in the United States in the last three years. I'm not sure that's ever happened before in this country. And does a connected community solve that? Is that the silver bullet? Probably not by itself, but certainly it would help if we were able to connect these communities that really do need a lot of behavioral, social, and medical care integrated in such a way that we can treat the whole person, to Jaime's point. Our failure to do that is a big reason that lifespan has shrunk in the United States. And so I think that's a fairly meta measure for whether we're succeeding or not, but it's something I don't think we can ignore.

I was going to go even more aspirational and say we wanted to give back to achieving that quadruple aim or that quintuple aim that is inclusive of achieving health equity. We talked at the beginning of this, what does it mean to be a connected community? And that connected community is inclusive of communication and collaboration and really being engaged and having those outcomes. So I think that that's success.

The amazing vision that all three of you just painted. I think the power that these connected communities can have in improving health, in achieving the quadruple, quintuple aim, all of these things that we can do in this era of data and technology and really the will to bring it all together. My hope is everyone joining us today can take away something that they can do, something that their organization can do to advance connected communities, to think about how we bring care to people, and really start to leverage the tools at our disposal.

Mylan, Jaime, Eric, thank you all so much for such an exciting, interesting conversation. I certainly learned a lot listening to the three of you. Hopefully our audience did as well. Thank you to everyone for joining and for submitting such thoughtful questions into the chat. I think we got to most of them. I hope we did. With that, I will turn it back over to Riz to close us out today. Thank you all again for joining us.

That is all we have time for today. I want to thank Miriam for moderating a fantastic panel. And Mylan, Eric and Jaime for sharing their insights. I also want to thank Optum for sponsoring today's webinar. To learn more about the content presented today, please fill out the post-webinar survey. Thank you for joining us today and we hope you have a wonderful afternoon.

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