The first time I met Dr. David Feinberg, the Geisinger CEO turned Google healthcare leader, was a little over a year ago. We were on opposing sides of a nationally broadcast debate about whether “The U.S. Healthcare System Is Terminally Broken.”
Dr. Feinberg argued, convincingly, that the system was salvageable, but cautioned that solutions wouldn’t come from elected officials on Capitol Hill.
“Healthcare reform does not start in Washington, D.C.,” he told listeners. “It starts in communities that are committed to the people living there, that understand the problems and engage in creative, innovative solutions to make things better, so that every patient gets care that’s compassionate, safe, dignified and low cost.”
Last month, he and I spoke again. This time, he was a guest on my show “Fixing Healthcare,” a monthly podcast that asks leaders to present and defend a cohesive plan to solve American healthcare’s biggest challenges.
At the time, Dr. Feinberg was four years into his tenure as CEO of Geisinger, a sprawling Pennsylvania-based healthcare system comprised of hospital campuses, research centers, a school of medicine, and a health plan serving 600,000 members.
Because Geisinger also insures the patients it serves, there’s a built-in financial incentive to keep people healthy and out of the hospital. Dr. Feinberg took that notion one step further in his opening remarks: “I run a health system and we have about 13 or so hospitals, and I think my job is to close every one of them.”
The alternative? As he told it, bring healthcare to the people instead of bringing people to care providers.
“I think a lot of patients could be managed better at home,” he said. “We look at our highest utilizers, our sickest patients (and) we show up at their house in two cars, because we can’t all fit in one car. We got a nurse, a palliative care nurse, a community health worker, a pharmacist, a doc. We say, hi sir or ma’am, we’re here to take care of you, and our goal is that you never go in the hospital again and we know you’ve been hospitalized 12 times in the last year. Let’s clean out the medicine cabinet. Let’s make sure the house is safe. Oh, you have a bunch of appointments that are hard for you to get to? We’ll do them through telemedicine right now at the kitchen table. We just completely eliminate the need for those folks to ever go in the hospital again.”
Because the goal of medicine should be to provide healthcare, not only sick care, I concur with Dr. Feinberg’s view that the United States has a glut of hospitals. I second his commitment to offering remote monitoring services to achieve superior outcomes at lower costs. These strategies help make care more continuous, timely and personal. However, I would have added to his prescription a dose of realism: Hospitals are filled partly because of ongoing failures to (a) provide effective prevention, (b) help people manage chronic diseases and (c) avoid medical errors. Effectively addressing these problems in outpatient settings can keep people out of inpatient facilities and, of course, that will require a different medical culture than we have today.
I then asked Dr. Feinberg a question I knew would be on the mind of many listeners. What would he suggest we do with the hundreds of thousands of employees who work inside America’s 5,500+ hospitals?
“We need to repurpose those people out in the community to keep people healthy and out of hospitals. Then we have to figure out what to do with the bricks and mortars. I would say to those of us in this business who think we need to hang onto those bricks and mortars that we’re going to start looking like Blockbuster Video. Netflix is coming. I think the bricks and mortars are an asset that we need to get rid of as quickly as possible.”
I was enthralled by the idea of using former hospital employees to address the root causes of poor health and mortality, rather than employing them to intervene when it’s too late. It was then that I began to think he and I were getting to the same place from different angles.
“The problem is we’ve been looking at the wrong problem,” he said. “Twenty percent of whether we live or die (is) based on going to good doctors and good hospitals. We’re going to put all of our efforts in my plan on the stuff that really matters: your genetic code, your zip code, your social environment, your access to clean food, your access to transportation, how much loneliness you have or don’t have.”
Here, Dr. Feinberg is referencing research concluding that medical care has a very small impact on our nation’s overall health and wellbeing. I knew some podcast listeners would find it surprising to hear this coming from a physician and CEO of a health system, so I pushed him to explain.
Dr. Feinberg offered an example of how to address social determinants of health. He explained that Geisinger recently started to recognize how many patients were (a) living with type-two diabetes, a lifestyle disorder closely associated with obesity, and (b) food insecure, meaning they were unable to purchase nutritious foods. Geisinger responded by introducing its Fresh Food Pharmacy program.
“We said to those folks, come on in. We want to give you some diabetic education and here’s healthy food for you and your family. You come in every week and you’ll always get seven fresh fruits and seven fresh vegetables to choose from. Lean meats, whole grains, just good stuff.”
Dr. Feinberg said that within three months, average hemoglobin A1Cs dropped from 13 to seven. Blood sugars improved across the board. And, importantly, average medical costs for patients (with both type-two diabetes and food insecurity) dropped from $200,000 per year to around $40,000.
“In my plan, we once and for all solve the problem of people not having access to healthy food, solve the problem around transportation, solve the problem around homelessness and housing, and we would see a dramatic decrease, not only in healthcare costs, but we would see an improvement in poverty, which would drive our economy.”
As a former CEO in Kaiser Permanent, I understood exactly what Dr. Feinberg was saying. Having tried similar approaches, I knew the incredible impact they could have for individuals and families. At the same time, experience has taught me that implementing these solutions was not always straightforward or successful. Yes, I too had seen patients make the lifestyle changes needed to improve their health when given the opportunity. I have also seen patients who could not overcome their circumstances and, as a result, slide back into the same chronic disease states that plagued them before.
Effective implementation of such a program nationwide would be difficult, but doable. As a nation, we would expect some resistance from healthcare’s biggest legacy players (hospitals, specialty societies and health plans, among others). But, if successful, it would no doubt prove economically cost effective, thereby reducing national health expenditures (NHE).
On the other hand, if the approach Dr. Feinberg suggests works for some patients but not all, then the investments required would exceed the returns. Often the people best suited to help patients make lifestyle changes are not doctors or nurses, but community health workers. Replacing the costly former with the lower-paid latter could balance healthcare’s finances, but doing so would also create job loss and/or widespread income reduction.
Disruptive innovation is mightily painful. And no industry has been more effective in preventing it than U.S. healthcare.
Policy experts note that when we combine the cost of NHE with social-health programs, the United States spends about the same as other nations. What’s different is that we spend much more on the former, and much less on the later than others. As a result, we rank last in most measures of health outcomes.
End-of-life chemo, PET scanners and proton-beam radiation therapies are much more expensive, and far less impactful on national health, than guaranteeing adequate childhood nutrition, ensuring sanitary living conditions, and providing high quality pre-kindergarten education. So, why not just reverse the ratios of spending in the United States? The answer, perhaps not surprisingly, is money. It’s not the total cost, but the economic impact on millions of healthcare workers who will suddenly have no job or will, at best, find themselves in jobs that pay much less.
Dr. Feinberg and I agree that our nation’s current approach to healthcare is broken and unlikely to improve on its own. We both recognize the terrible price our nation pays for ignoring so many social determinants of health. Ultimately, I believe that change will need to come from both inside and outside of traditional medical practice and that won’t happen because of a new million-dollar-a-year drug or machine. To that end, his comments and my views are well aligned.
Over the next few months, Fixing Healthcare will host a number of exceptional leaders in healthcare. Tune into the latest episode with health-tech expert and bestselling author Dr. Eric Topol and stay tuned for the former president and CEO of the Institute for Healthcare Improvement (IHI) Dr. Donald Berwick, along with healthcare futurist and author Dr. Ian Morrison.
Fixing Healthcare is a part of the New Books Network (NBN) and a co-production of Dr. Robert Pearl and Jeremy Corr. Subscribe to the show via iTunes or wherever you find podcasts. Join the conversation or refer a potential candidate by following the show on Twitter @fixingHCpodcast, liking the show on Facebook or visiting the LinkedIn page.