Ed Clarke MD - Engineering Healthcare

Speaker 0 00:00:07 No Speaker 1 00:00:18 Welcome. I'm Dr. Robert brogues, your host for the groves connection podcast. The groves connection brings you intimate conversations with pundits providers, patients, leaders, and late people all to help us understand the contradiction. How can our healthcare system be both magnificent and yet so deeply flooded. We're going inside healthcare to talk candidly with those who know what they have to say, may delight, surprise frustrate, or at times even anger. But I invite you to get curious and listen to the truth about healthcare and those who want to fix it. Maybe the answers have been there all along. We just need to make the connection Speaker 0 00:01:07 <inaudible> Speaker 1 00:01:15 In this inaugural episode of the groves connection. I'm speaking with Dr. Ed Clark, Dr. Clark is a respected leader in Arizona who is highly skilled at cutting through complexity and combining his experience in private medical practice, as well as it and informatics to identify and implement meaningful measures of physician practice performance. The final step then is getting that information to physicians so that they can make good decisions for patients leading to better care. It does this as well or better than anyone I know, and that's not easy in a complex organization like banner health, comprised of a benign billion dollar integrated delivery system with 28 hospitals across six States and an insurance network of more than 10,000 employed and independent physicians. This is a big job. So without further ado, let's make the connection with Dr. Ed Clark. Speaker 0 00:02:15 Ready? Speaker 1 00:02:36 Welcome Dr. Ed Clark. It's good to see you. It's been a while. It has been. And, uh, we're going to have a conversation today about the pandemic and what's been happening in healthcare in your world, but, but where I want to start is how did you arrive in the position that you now occupy, give us a little bit of background and start wherever you want, but first of all, why a doctor, and then describe your journey to where you sit today. Speaker 2 00:03:04 Be happy to, and thanks for having me. Uh, so why a doctor? Um, that's not a clear path. Uh, that's one that kind of zigged and zagged, uh, growing up. So, you know, going to school, you know, as a kid always did gravitate toward the sciences, um, mathematics, things of that sort. And I grew up in a small town in West Texas, and most of my family and my, uh, aunts and uncles, grandparents were on the other side of the country. So they were kind of around the East coast and the Gulf States around Alabama actually. And so I didn't see them all that often. And I had a physician in the family. My grandfather was one of the old school GPS who did everything, who was a surgeon or an obstetrician and a family doc, everything. And I always heard stories about my grandfather, who we called Papa doc, but didn't see him that often because it was a two days drive for us. And so, Speaker 1 00:04:05 Well, wait a second, pop a doc, really pop a doc. Yeah. I love that you called him Speaker 2 00:04:10 Papa doc. And so that, wasn't just the grandkids that was, you know, my mom and her brothers and sisters and everyone, and she was in a family of five. And so, so I always heard these stories and, you know, just think romanticize this idea of this doc in Alabama, doing everything, you know, then being in a small town where really all there were, were GPS there, there, there weren't specialists. I mean, we had to drive at least an hour to get to, you know, what we would kind of now look at as the specialist community that was in Amarillo. I, you know, Jed kind of just see what impact primary care physicians had in a community. And so, you know, always, um, you know, said that's a good place to be. I can have an impact. And again, I had this idea that I could be Papa doc. Speaker 2 00:05:00 I could be in a community like this and, you know, be successful and really help out a community. So as I approached college, my folks, you know, who were very conservative with pretty much approaching life in every way I recommended I have a backup plan because they understood not everybody gets into medical school and everything. And so my dad was an engineer by training, which is why we're in kind of rural Texas. He had worked in the oil and gas industry. And so, uh, studied engineering and, uh, found that there was a path for bioengineering, which seemed like a great backup for medical school. But again, some zigs and zags and, uh, found myself studying civil engineering. Specifically the environmental path there was getting close to graduation, was applying for jobs. And as I met with recruiters and companies, nothing really just grabbed me and said, Hey, this is the engineering version of Papa doc and said, it's gotta be hard to find. Speaker 2 00:06:03 And so I said, you know what? I do think I need to get back on the path towards medicine. And so finished my degree in engineering, but had to kind of backtrack and get a lot of my prereq's in a long story, short ended up at UT Southwestern for medical school and, um, which I did, you know, that is right. I believe you did your residency there. I think from, yeah, so, um, completed medical school there and, um, you know, still did have this pathway. I wanted to be a primary care physician. And so residency came around and I kind of looked on the coast, wanted to do something a little bit different. Having been kind of landlocked, mainly looked on West coast, East coast on the coast. I wanted to be near water. The greatest irony is though on my way out to the West coast to interview as to what their friend in Tucson fell in love with the desert and was like, wow, I think I need to look at some of the programs here. Speaker 2 00:06:57 So trained at what was called good Samaritan at the time and family medicine, and now called banner university, uh, family medicine, uh, completed a sports medicine fellowship after that at U of a Tucson. Wow. I didn't know that. Yeah. And so I practiced in primary care sports medicine for about three and a half years and had an absolute blast, got to do lots of great things, not only primary care, but was involved with various levels of teams, whether it be high school, collegiate and professional. So I was blessed to be in a practice that really already had some established ties there. One of my attendings, when I was in residency, he was one of the <inaudible> at banner health at the time his name was Greg <inaudible>. Um, he reached out to me, great guy, hadn't talked, talked to Greg for a number of years. He reached out to me and asked me if I would be interested in medical informatics. Speaker 2 00:07:48 And I said, I don't know, but I'm interested in talking to you and learning what the heck that is. So, um, Greg at the time was, uh, helping implement electronic health records at banner health and primarily converting the employed medical group over to an EMR. And as I talked to him and learned what he and his team did, how it wasn't just putting an EHR in someone's office, it was looking at all aspects of medicine and figuring out how can we make this more efficient? How can we build workflows and other things to actually make a physicians practice better? Now, can I interrupt you right there? Speaker 1 00:08:24 Can I, because all of the things that you have said so far resonates so deeply with me, same sort of my dad was a primary care physician in Albany, Georgia, and I idolized that life that he led. And I, I, I got the same impression about the way healthcare was going, particularly when I started practicing. Now, I'm one of those specialists, you know, I, I went through pulmonary and critical care training, but it was the same thing. I felt like I was on a treadmill. I did a fair amount of primary care for particularly patients with COPD, uh, and, and ran into the same roadblocks. I'm going to ask you, before we go on with this journey, how do you think we've done in, uh, the transition to electronic health records? And the reason I asked that is because so many of our colleagues who complain of burnout point their finger directly at the E H R so, so what's your perspective Speaker 2 00:09:23 On that? Yeah, that's a great question. Um, we've still not got it figured out because yes, as I look at articles about physician burnout, which I'm incredibly interested in, I'm not practicing right now and I don't run physician practices, but in my current role, which we'll get to in a little bit, a lot of times it is perceived that the things I and the team are asking folks to do are just extra things. And it is pretty common for us to hear, well, gosh, how come this just can't be in my EMR, you're making me do more stuff. So, right. So I think we've done better for the industry as a whole, because what it's done is it's allowed us to actually have better access to the data, to see who is truly doing what that ultimately can, you know, that we can study to say, Hey, are these activities improving outcomes and other thing, but have we made a practitioners life easier? Speaker 2 00:10:17 I'd say we still have a ways to go. There are a number of things. And of course, as I talked to physician groups who have scribes that has dramatically improved their quality of life, they get home earlier. And you might can even argue that the scribe is many times better able to codify or document those things in the chart that they might have lost track of because of all the other things. So I think we have a ways to go. I haven't been frontline at an implementation of an EMR in quite some time, but as I hear just all the other AIDS, the voice to text technologies and other things, I think we're getting there. But I do think it's a necessary evil right now because it really is the thing that allows us to mind the data truly say, are we having impact other than that, we have to use humans to go in there and look in the chart. And that that's really tough. Speaker 1 00:11:07 Well, thank you for that perspective. I, I, I struggle with that same thing, you know, obviously we can't go backwards. Paper is not useful for sharing information for having population level data. We can't go backwards. We need to move forward. I'm going to put a placeholder there. Maybe we'll come back to that, but let's get back to your journey. So, uh, pick up where you left off and great. Speaker 2 00:11:28 Yeah. So when I joined the medical informatics team, that really was the first time where I said, okay, I do think I can have an impact, not only on these practices that I'm engaging with, but I can be part of us figuring this healthcare thing out to where, um, you know, there has to be a way that we can make this better for physicians and practitioners that really, again, help a broader, because right when we are rolling out EMR, there was a thing called meaningful use that was that everyone had to do. And there were carrots and sticks. And of course we were rolling out EMR as part of a big system. So there was lots of focus on the carrots. And part of it was to build in, uh, or report on performance on some of these clinical quality measures that are endorsed by Hetus since you QA all these entities. Speaker 2 00:12:21 And it, and it started with a handful. And I was fascinated by that because especially working with a large employed medical group saying, wow, um, now that we're collecting this data, what can we do with it? How do we improve this over time? Are we underperforming or overperforming because of issues with the data collection? Is it the clinical practices that the groups have adopted? There were so many questions that I had. So I talked to Greg, my boss at the time and said, Hey, I think we need to build out more than just the two or three that were required for meaningful years. Let's build out a dashboard and literally start to see what we can do to impact, you know, A1C, blood pressures, all these things. And they were largely measured around primary care and the bread and butter things at the time. And so we did that and I was having an absolute blast doing that, working with the analysts and everybody, and just the things we were discovering. Speaker 1 00:13:16 Quick, quick question. Did your engineering background help you with that transition to informatics? Or did you feel like you were starting from scratch there? Speaker 2 00:13:24 You know, I think it did help because, you know, at the time there were not too many programs dedicated to medical informatics at the time. There were some, uh, I think there were some masters programs there wasn't a fellowship at the time. Um, but yeah, I mean, I think just the type of analytic approach that you have just, you know, going through the curriculum to be an engineer and others just, I do think that helped me got it. So, uh, as we were doing those things and building those, I, uh, found myself kind of running the quality committee for the medical group, even though, as I was in informatics, I was kind of the guy who was pulling the strings and had access on there. Speaker 1 00:13:59 And when you say the medical group, you're talking about banner health. Speaker 2 00:14:03 Yes. Banner medical group, so large multi-specialty group and you're talking about here. So I think at that time, Ben, our medical group in aggregate was probably about 1400 physicians across six States. So Speaker 1 00:14:16 Big, big enterprise. Yeah. Speaker 2 00:14:18 Yeah. And, um, and again, as we were building these things at the time for meaningful use, it was pay for reporting. So you didn't have to hit a threshold or anything, but knowing the direction the system wanted to take. Speaker 1 00:14:34 So to clarify, pay for reporting. But what that means practically is that it's a performance based payment, but the performance in this circumstance is simply that you can collect and send information to that regulatory entity in this case, I'm guessing CMS, is that right? Yep. And so the kind of information might be a hemoglobin A1C and you're not held accountable for what that level is yet. You just need to be able to send it to them. Is that right? Speaker 2 00:15:04 That that's it. So, so yeah, as I was looking at this across all of these physicians with banner medical group in multiple States, I was like, aha, this is it okay if we do things collectively not only on the it informatics side, but also partnering with the employed medical group and the quality committee and everything and their leadership, either automate this build workflows or help others on the team, have these diabetics, get their A1C, get their urine micro albumin test and other things really in a broad scale, we can improve the outcome of populations. And, you know, the irony I started with, gosh, I felt like all I do is cut a, find my work and reimbursements, you know, upside down here between a primary care doc and a specialist at times the army was for us, there was no increased reimbursement for doing those things though. Right. So if we did improve the outcome of diabetics, we weren't in a lot of value-based contracts or other things at the time. So, but nonetheless, I was happy. Speaker 1 00:16:01 So, so that was perceived simply as extra work for a practicing physician at the bedside, who said, you know, I need to take care of patients. And here you come telling me that I have to click these few extra boxes. Is that kind of how it was perceived Speaker 2 00:16:17 For some yes. And we were, you know, very aware of that because we had, for many of these practices just recently converted them from paper to an EHR. Right. So everything was more work. Yes, fair enough. And so, uh, and, and yes, you know, we did all we could within the limitations of the EHR we had at the time, automate things, build things in prompt things, you know, you know, we did all those things, but yes, there is nothing in it for them at the time. So, uh, run around that time banner health and its network, which was relatively new, uh, was selected as one of the pioneer ACO hosts at the time. And so I, I think banner was one of the 33 entities that CMS kind of judged had the chops to kind of start this new demonstration model. I didn't really know what was happening with CMS specifically with, uh, these models and everything. But I quickly found out after my boss had the printed out narrative specs for all the quality measures that we were, uh, either on the hook for, or responsible for improving in the pioneer ACO and given what I was doing with a quality committee and everything else, he put it on my desk and said, Hey, you need to figure this out. And, uh, away I went, Speaker 1 00:17:31 So, so, so let me stop you here for just a second so that our listeners can have a little bit better understanding of what, uh, what is an ACO and, uh, how did pioneer work versus Medicare advantage or straight Medicare? Most people don't have to delve that, and this was a novel way of looking at it. And so can you give us a little bit of background on what that means Speaker 2 00:17:55 Be happy to? Um, so an ACO is an accountable care organization, so that's the acronym and it's, it's used quite a bit, but in this context it was defined as a group of healthcare providers. So physicians, PS, and aligned entities, including hospitals and other folks in their network being advanced practice professionals professional. Yes. Speaker 1 00:18:21 Yeah. It could be nurse practitioners or physician assistants, Speaker 2 00:18:24 That's it. Okay. Yep. So it is an organization or collection of those individuals and aligning identities who are, uh, working together to collectively lower the cost of care for a population of patients while improving outcomes and improving the experience of those patients. And so, so the pioneer ACO, we're a collection of about 33 systems nationwide who had a, you know, a critical mass of members or patients that were seeing them. And in this context, they were folks with straight Medicare. So traditional Medicare, they weren't a Medicare advantage or any other plant plans. So who we're seeing providers aligned to those systems. And those systems also had to demonstrate that they had adequate capabilities with electronic health records and integrated delivery systems and other things. Yeah. Speaker 1 00:19:17 And so these, these systems were literally selected by, uh, CMS, and it was the innovation arm of CMS, which was fairly newly created. And so they were selected if they met that, uh, that bar of, uh, having an electronic health record, demonstrating that they could manage a program like that, or at least in the view of CMS. Is that right? Speaker 2 00:19:39 Correct. Yeah. Yes. And so, um, so banner health was luckily one who got picked and I found myself kind of on the informatics team and heavily involved with the quality committee for the medical group in a great position to figure out, okay, how do we make this work? Because making this work could mean, uh, at least for us and where I honed in on this thing, I was like, gosh, okay, this is what I needed when I was practicing primary care. Right? Because the, the idea is if all the folks in your ACO collectively do things that end up lowering total medical costs for those patients assigned to that group, the Delta between what the historic expenditures were for the population or what at least the predicted expenditures were to where you actually came in after you did all these wonderful things to lower cost, those dollars would then be available to be paid to the network and what they call a shared savings payment. Speaker 1 00:20:40 Can I stop you there just for a second? And this is just for the benefit of listeners who may be less familiar than you and I are, uh, uh, with how this works. So, so Medicare advantage will leave on the side for right now, that's, that's a whole program unto itself, and that's where private insurers compete to serve Medicare patients. And there are rules and regulations around all of that. But if it's a Medicare advantage program, the patient knows that they have chosen Medicare advantage. And then before pioneer, there was just straight Medicare, which is broader choice for the individual. They can kind of go to whoever they want to go to. And as long as Medicare pays for it, there's no restriction in the network and correct me if I get this wrong and I'm going to try to describe it. The interesting thing about pioneers, it's kind of convoluted in that, what CMS said, the center for Medicare and Medicaid services said, look, we're not necessarily going to notify any patients that they're in this new model and they're going to behave as if they're straight Medicare. Speaker 1 00:21:44 And then at the end, we're going to look at who they saw, which physicians they visited retrospectively. And based on that assessment figure out who then is responsible for their care primarily. And usually that's a primary care physician, but not always, right. So that's how attribution happens. So it's in retrospect, you don't necessarily know as a doc, what that's going to look like while you're practicing it's in retrospect. And then the shared savings that you're talking about, the bar that you're trying to beat is a predictive model of what it would have cost in straight Medicare for that one year period. So upfront they predict what it would have costs. Uh, and then they work backwards from that and say, what did it cost? And then the difference between those two, you have the opportunity to take advantage of that's the shared savings. If you exceed the costs, there are no shared savings, but there was not much risk, but there was some, if I remember correctly in the pioneer program and it was a five-year program, you had to sign up for, uh, you didn't have to stay for all five years, but that's what you were signing up for. Speaker 1 00:23:00 So it's a very odd creature. And it was an experiment in trying to understand if we leave the fee for service payments in place, as they are. Can we incentivize health systems in this case? Because as you described nicely, it's not just the physicians, it's everybody in the system that's involved. Can we incentivize them to save money without changing anything else? Is that, Speaker 2 00:23:26 Yeah. Okay. That's a great summary. I was excited to see that here is perhaps that chance and it was a demonstration project, right? So figuring out how do we take? And I started with the quality measures that were built in there because it wasn't just, did you lower cost. It was, if you lowered costs, the percentage of those savings you received, uh, were, uh, multiplied by a modifier, which was determined by how well you performed on the quality measures and other outcomes metrics, which did include patient experience. So, and the reason why those are baked in is because, you know, we can lower costs by just withholding care, Speaker 1 00:24:10 Right? Some of us remember the eighties, the original capitation strategy, which was, Hey, here's X number of dollars. And if you save money, then we'll split it with you. But there was no countermeasure. There was no way we didn't have the sophistication then to be, yeah, to be clear, but we weren't measuring quality or experience. And so you can see where that leads. If the incentive is simply to save money, then, uh, you know, the easiest thing to do is not to take care of patients. And patients figured this out very quickly and there's this huge backlash. The difference now is we can collect that information and we do collect that information. So there's a balance you can reduce costs, but you better make darn sure that you're hitting your quality metrics and that you're hitting your experience metrics, or it's going to cost you. Is that Speaker 2 00:24:56 Yes, sir. Yep, absolutely. So we lowered cost. Did we perform well on the quality measures, which are generally tied to a lot of the, uh, chronic illnesses prevention, uh, screening, those sorts of things, just the bread and butter things that, um, primary care physicians and other specialists are trying to do all the time. Did we keep folks out of the hospital? Did we not use utilize the emergency room as much? Did we reduce a use of expensive imaging? Those are some other things in there. And then the classic kind of cap surveys around, uh, how well you rate your provider. Were they available? Do they treat you with courtesy and respect? So combine all that together, you get your quality multiplier and then, uh, multiply that by your shared savings. And there you go. Yeah. So the idea is then, uh, you, these like-minded individuals come together in an ACO and they say, wow, we do have levers and things we can do to generate these shared savings while improving outcomes. Speaker 2 00:25:53 And then there's a reward. So then that a practitioner spending hours upon in trying to control someone's diabetes and obesity and blood pressure, which might only generate a level three or four visit and be reimbursed a hundred bucks can see some reward on the back end because by doing those things, they truly created better outcomes for that patients. And so, so that was the beginning. We built that in. We started to really encourage the rest of the organization to develop processes and other things to make this easier. And my career changed a little bit of right around there. So given I was so involved with lots of things with the medical group, I was asked to be one of their chief medical officers. And so I think my title at the time was a chief medical officer of clinical operations. And so I, in that position was able to continue to help influence and make decisions and other things to help operationalize largely a lot of these things that I just spoke about. Speaker 1 00:26:56 If I remember correctly, just by way of background context, if you will, at the time that you were doing that, uh, you were putting all of those metrics together and making sure that we were able to measure them. I was sitting in a position similar to the one that you're sitting in. Now I have to say that yours has been expanded significantly. You've got a lot more going on than I did at the time, but my perspective was, was essentially your seat right now. And I have not yet thanked you for all of the work you did to make those metrics available because banner performed really well in the pioneer program. I mean, ultimately yeah. Uh, it was, I think the top performer overall, uh, five years combined. And, uh, and, and that's a Testament to the work that, that you and others did to, to make sure that we could measure properly and to continuously improve those measurements over time, which we did indeed. Speaker 2 00:27:48 Yeah. It was, um, yeah, in hindsight, um, it is pretty impressive when you look at an aggregate to say, wow, it all came together. So, so yeah, I kind of pivoted away from informatics and got involved in, you know, kind of helping with the operations of the banner medical group. And I also had oversight of the physicians in the East division. And so was involved in kind of physician management, physician leadership as well. Where's that Speaker 1 00:28:13 Something that you aspired to do or did that just sort of fall in there? Speaker 2 00:28:18 I kind of fell in my lap. You know, I had not been in a leadership role directly ever. Uh, at that point, I mean, you're indirectly a leader when you're a physician in a practice, right. I mean, you're kind of like top of the pyramid and you've got the team there that supports you and everything, but now I had no idea had no idea because going back to, you know, this idea of being a country general practitioner as like Speaker 1 00:28:44 You are so far removed from that yeah. Speaker 2 00:28:46 Involved in one of the largest medical groups in the country with a large non-for-profits system and doing all these, it never dawned on me at all. So, so yes, there were, um, it was a fire hose of how to be a leader very quickly because yeah, I think there were around 800 physicians under me and my division at the time there was not distributed physician leadership. It was me and 800 physicians. And maybe for another podcast, we'll tell stories about that whole thing. But yeah, so I spent a lot of time just creating leadership structure and other things to support doing these things because you quickly realize, um, yeah, we can't have 800 physicians collectively pull together to really do things to lower cost and chains, outcomes without having leaders distributed throughout that infrastructure. It is absolutely because without those peer-to-peer conversations where you're really asking folks to change the way they practice medicine, it's just really tough. So, Speaker 1 00:29:50 I mean, you can think about it as having 800 direct reports. Yeah. Speaker 2 00:29:54 Uh, that's the larger, how w it was built Speaker 1 00:29:57 And who did not see themselves as reporting to anyone. Yeah. I should also add. Speaker 2 00:30:03 Correct. Yeah. And when you find yourself in that situation, the, your email inbox is just unmanageable. Yes. Speaker 1 00:30:11 So, so yeah. Now if I remember correctly, it was shortly that you did a lot of work to, to help put the infrastructure in place that continues to evolve today. And we'll get to that, but you left banner for a while. Talk a little bit about that. What happened there? Speaker 2 00:30:27 I did. Yeah. So after, uh, you know, kind of getting involved in the general practice management aspects of being a CMO for a large medical group, I did find myself wanting to embed more in purely the accountable care part of the world and how do we truly lower costs and improve outcomes. And so there was an opportunity at a competing system in town. The Institute is called Arizona care network. And so that was a joint venture between the dignity, uh, which has hospitals and clinic clinics in the Phoenix area and tenants who also, uh, owned, uh, hospitals, physician groups, and otherwise, uh, they were branded as Abrazo here in this market. So it was a JV between those two entities and that was their accountable care arm. So they were, they were not a pioneer ratio, but, uh, at the time we were a next gen ACO, which was another one of CMS is, uh, experiments in this space and participated in Medicare advantage contracts, a lot of commercial ACO style contracts, and also Medicaid contracts, all, and these were all value-based contracts with a varying degree of either upside only risk or downside risk as well. Speaker 2 00:31:43 And so yes, left the banner organization for just over a year and a half, um, because I wanted to embed in that work. Speaker 1 00:31:51 Let me stop you there for just a second and back up and talk about the upside downside. What does that mean? Well, a value-based contract, typically there is some sort of performance that a group, uh, in this case, an ACO is asked to perform to if you will, and to the extent that they do that there is more reward available to that group. And obviously that includes both improving quality and reducing costs. If you don't reduce costs, then there's no money to share at the end of the day. But some of those contracts, they can be more or less lucrative depending on whether you're willing to accept downside risk. What that means is if you sign that contract and you end up spending more money than, uh, you know, was predicted or your target, then you're to end up paying back money to the entity that sponsored it, and whether that's CMS or a commercial insurer, that downside risk is very real. It means if I don't meet that benchmark and I exceed it, then I'm going to have to give money back typically contracts that have downside risk, give you much more of the percentage on the upside. In other words, you get the opportunity to, uh, make more money, uh, through improving quality measures and reducing costs because you take that downside risk. If there's only, you know, if there's no downside risk, then typically those aren't as lucrative. Is that what your experience? Speaker 2 00:33:17 Yes, absolutely. And so, yes, I found myself in this new role right. In the mix of that. Right. And so, and that was appealing because while I was with banner with banner medical group, we were tasked at the time with how incentives flow when you're in one of these ICO's is critical, and these are relatively new concepts for a lot of systems, right? So really seeing that lowering costs and generating shared savings can be a significant part of your margin and generating revenue. Um, it's really hard or had been historically for systems to forecast that and create a budget and then figure out how we support that infrastructure. And so with the employed medical group at the time, I mean, it was still largely are we generating RV use, which are relative value units, which are a way to monetize a physician's percentage of time, rendering care, which back to the whole thing that we all kind of like didn't enjoy when we were like, when I was a primary care doc, um, by kind of leaving the organization for a little bit and working for an accountable care organization. Speaker 2 00:34:32 And I, not sure if you were in that seat for banner at the time, but, you know, I found myself able to just fully immerse in the world and so learned to learn tons, um, made lots of great friends. And again, just deepen my experience because I had to that point really worked from the informatics side, the employed physician side, to do these things that can result in lower costs and then found myself in the opportunity to help negotiate the contracts, to figure out really, okay, what are the key drivers here of these, and then work with not only employed physicians that were aligned with dignity and tenant, but also independent providers and other entities. So really kind of broaden the horizon there. Speaker 1 00:35:14 So let me just spend a second on that point. And maybe I'm, I'm stopping too frequently to try and explain these things, but, uh, so, uh, employed physicians, uh, they're employed by their dignity or Abrazo, um, I'm assuming in that, uh, in that role, is that right? Or yes. And then independent practices are literally independent practices that for one reason or another are aligned with, uh, that ACO. In other words, they're not beholden to the ACO in any other way than what is specified in the contract that they sign for that ACO contract. So, uh, you have less of a lever to pull with regards to those independent practices because they are independent and they can, uh, they can simply say, no, they typically are inclined towards cooperation only by the opportunity to learn about value-based care and to share in the shared savings if they are successful. Speaker 2 00:36:19 Yes, yes. And so, um, the other thing that is unique about the market here in Phoenix is roughly 80% of the at least primary care physicians are independent employed docs. So these are folks who hung a shingle and started a practice, which is very different than what you'll see in a lot of other markets. So on the coast or in the Midwest, it is perhaps the opposite where 80% of physicians are employed. And so yes, to your point of what levers do you have? It really makes it tough because, uh, yes, it is nice when there are some meaningful incentives that you can pass on to them. If we collectively lowered costs and do all these things, but the lever you don't have, which you do. And you're in an employed medical group as a, you don't have one common EMR or one common set of tools that are helping aggregate and standardize how you do the work. Speaker 2 00:37:17 And so that makes it really tough. And, um, figuring out how to standardize how data and information are pushed out to the network of these independent physicians proactively. So they can identify folks at risk and do outreach, but then more importantly, pull information back to not only, you know, tell folks at the end of the year, yes, we lowered, uh, cost and improve outcomes and other things back to the, uh, the payment that we get. Um, but helping folks, um, kind of, uh, you know, do these PTSA cycles in real time is really tough when you don't have the data in real time. So, uh, so that is one challenge about partnering with independent physicians. However, I'll say on the other side of it though, is, uh, there is a, uh, entrepreneurial spirit with many of these offices because, um, you know, once a practice sees just how significant these shared savings, uh, checks can be. Speaker 2 00:38:23 And in back in the context of how they're just grinding to keep the lights on and crank out all these patients, you really can start to change the dynamic. And so it has been very rewarding, especially now in my current role. Um, the most skilled physicians we have right now in lowering cost and improving outcomes are with some of the independent groups. Uh, and some of them have really kind of, uh, uh, completely changed their model to where they, they, they kind of don't enter into these fee for service only contracts anymore. And so, and there's a spectrum. There's other folks who just are, it might have just implemented an EMR, actually, I think we're, I think we're past those days every now and then the year about a practice who's on paper and you're thinking what, like, Speaker 1 00:39:08 How can that be? But that's really interesting. I mean, that, that independent entrepreneurial spirit, once they get it, they're comparing a fee for service world where, you know, as, as the reimbursement continues to be ratcheted down, because we're spending too much money, the only choices that they have to, you know, keep the lights on, pay their staff, maintain their income, is to see more and more patients. And so the time with each patient gets shorter and shorter, and that is a wheel that is just exhausting and it keeps going faster every year. It seems like. And so what they see on the other side is look, uh, if I'm in a value-based arrangement and the more value-based the more freedom I have to do, what I really think is right. Uh, I don't mean to imply that they're not doing what they think is right on this side. They, they just, they, they don't have time to really think and consider and engage, create relationships, et cetera. So it's incredibly attractive once they understand that they can not only make a living, but be far more satisfied with their day-to-day lives on this value-based care side. And, and the docs that really get that and have the, the pieces in place to collect the data, to look at the data, uh, those docs, get it very quickly and they want to transition to that other world. Speaker 2 00:40:36 Correct? Yes. And so, um, it's been well, gosh, since I have been working with physician practices from when the pioneer ACO started, which is probably, I don't know, eight, nine years ago now to now it has been, um, uh, it's been lots of fun to watch the, the competencies grow and, uh, these independent office and especially the employed office as well. I mean, everybody has upped their game, um, runs it it's and we've demonstrated year over year improvements in cost outcomes and quality scores. And so we saw that not only when I was working at Arizona care care network, um, while I was there, we, uh, enjoyed our first shared savings in the next gen ACO and also in one of our MSSP years. Um, but now banner health network, which is current role as COO of the insurance division and the networks we're seeing year over year improvement in our performance in those contracts as well. Speaker 1 00:41:42 I, you know, uh, uh, I have always admired your ability to play on that informatics side and understand what the necessary steps are to actually get from point a to point B and, and how you have skirted around interoperability challenges. And, and I think you've really done a great job of that, but, but, uh, before we change gears, now I do want to talk a little bit about, uh, the COVID-19 crisis in Arizona. Cause I think people will be fascinated by that, but before we change gears, how did you come back to banner? What, what was, what happened? And, and, uh, and then maybe just briefly, what is your role? What is the CMO of the insurance division? Yeah. Speaker 2 00:42:20 Yeah. So, um, why didn't it come back to banner? So again, I was at a competitor in the market, uh, and doing very similar things. Again, working with employed physicians, independent in a number of value based arrangements. The difference was we only had value-based contracts or ACO contracts in my role at the time with the health insurers and payers where we still were somewhat at their mercy, you can only do, uh, or your rewards or, um, levers that you can pull are somewhat limited by what is in the contract, right? And so, yes, there's many things you can do to lower costs, but the rewards may not, uh, be quite where, um, they should be to justify the lift to put forth. The difference was banner had evolved to where banner was not only entering ACO contracts with payers, but also owned insurance products. And so banner was following suit. Speaker 2 00:43:19 As many integrated healthcare systems have to be both the payer and the provider, which gives you even more levels of control and gives you more insights into the population you're trying to treat. And so at that time, banner was a, uh, joint venture owner in the banner Aetna commercial insurance product, which you're the chief medical officer of today, uh, also, uh, was owner of banner university health plans, which is a Medicaid plan, which had an El techs plan and a decent plan or plan for dual eligible and was also a joint venture owner of a Medicare advantage plan with blue cross blue shield. So that was complexity that I was attracted to because then there were all these other contracts as well that were upside only. And the other thing that was appealing was banner was in multiple markets. So Arizona care network was somewhat limited to the Phoenix Metro area. Speaker 2 00:44:19 And here, back at banner again, uh, had significant upside and downside risk in the Tucson market, the Phoenix market. And then also with lots of the physicians employed in the front range of Northern right, uh, which has called banner network Colorado. So it was just an increase in scope, complexity scale, and I kind of gravitate toward those things. And so I called up some of my old friends that I knew and asked if, uh, uh, this made sense for me to apply and the rest is history. So currently I'm the COO of banner health networks and the insurance division, uh, which has continued to evolve. We are right at a million lives in various risk-based contracts. And again about, uh, probably about two thirds of those are in products where we either fully owned or are in a joint venture with another. Speaker 1 00:45:12 So give us an idea of what your day to day duties activities are. Like, what would you see as the primary role that you fulfill as the CMO of, uh, the banner insurance division and what things are you tasked with accomplishing? Speaker 2 00:45:29 Absolutely. Um, I will, I will start with what the role was pre COVID. How about we do that? And then we'll, we'll come to the, what does it look like in this world now where I sit, I'll start with kind of their responsibility I have for the network. So one of the things I'm passionate about, which kind of tracks with my career entering into informatics and other stuff, is figuring out how we can help physicians, not just primary care, but all physicians and providers in our network, more easily do this work. And so that's helping those folks aligned to us, helping our teams better support them. What are the engagement models in those offices? What are the strategies, tactics, and other things we do to share information with them, to pull information back and how do we create meaningful incentives to where we're not creating just a evolved version of fee for service, where they think, Oh, I have to do all these tasks. Speaker 2 00:46:26 I can perform all of my scorecards. So then insurance division can give me a check. Is it really trying to make it meaningful for them so that they can reconnect with that? Why I went into medicine because I'm making a difference in populations and we're lowering costs collectively for society, because that's the other thing that a lot of folks don't understand. And before I continue to talk about my role, now, what I find interesting is I think the work of folks like you and I, and ACO and others to lower cost of care and improve outcomes and stuff is one of the best kept secrets out there. And when I, you know, talk to colleagues who aren't in medicine, who I knew in college or others who do all kinds of other things, when I explained to them what we do, yeah. They're fascinated. And they're like, you mean, doctors are actually trying to lower cost of care. Speaker 1 00:47:18 Yes. They don't get it and they want to learn, Speaker 2 00:47:23 Or they want to talk more. And it's like, I, you know, when you watch the news or reading, you know, the, the, uh, in the press about the cost of healthcare, you generally don't hear about what the folks on the front lines of healthcare are doing to lower cost. You don't see that it's just how expensive it is and it's not unsustainable. And then it evolves into just a political discussion. Right? And so I want to just give some kudos and shout out to those who have been doing this work over the last decade, because it's largely, I think unrecognized, and again, now there's been something in it for many of these folks who've done it because the savings generated. They've gotten a portion of those, but, um, it is, it is really good to see that these models are evolving and CMS is evolving how they're positioning these things, because you gave a description of what, you know, what is upside risk or downside risk. Um, the studies have shown that if you don't have downside risk, it's much less likely that you'll actually at a lower cost, because again, you have to have some skin in the game. Right. And so Speaker 1 00:48:32 I, I really appreciate that, uh, aside, and I think that there are a whole lot of people working really hard to tame this beast and it's incredibly complex. It's, uh, if it were easy, then, you know, we would have done it long ago. Uh, and, and it has to do with interoperability. It has to do with, uh, uh, legacy, uh, both systems and, and it, and it speaks to one of the, the issues that I feel strongly about. I, you know, hear not infrequently about all the bad guys in healthcare, right? The insurance companies are evil. The pharmaceutical companies are evil. The doctors are evil. There's always somebody who has to be the whipping boy. And the truth is almost always good people and bad systems. And if you give good people, the right systems, and most doctors are like you and like me, and that they went into this profession because they really wanted to help people. And if you give them the right tools and put them in the right system, it is amazing, uh, to, to see the transformation. And, and so I just want to say that, yes, I appreciate you calling that out. And, uh, let's hope that we get that word out there, that there are people really trying to do the right thing. Speaker 2 00:49:44 Absolutely. So back to kind of what the day job is, a lot of it is figuring out again, how do we support the providers in the network to do this? And so a lot of that is sharing actionable data with them and data at the point of care. So that is incredibly important because if a patient who is in one of these arrangements where we are, um, incentive to do all these things, is there, we have to tell that practitioner at that time, what are those things that they can do to help us collectively get there? Because again, uh, people don't walk in an office with a label on their head saying, Hey, I'm in a banner, a Medicare advantage plan, and the incentives are different. I'm not just a fee for service member. Um, and, uh, so we spent a lot of time partnering with our operators, it and others to figure out how to make this easier on folks. Speaker 2 00:50:34 Because again, we really want to try to avoid when folks get any mail from me or my team, the Oh great. Ed wants me to do one more thing, right? So we spend a lot of time on that. We also spend a lot of time with our care management team. So we have, uh, teams of nurses, social workers, uh, transitional lists, and others who are focused on who are those patients, who we think are most impactful, who need our help, that help could range from, uh, a nurse. Who's a diabetic educator, working with someone who doesn't understand their diabetes, the nutrition, the meds, and all these things. It could involve a social worker who might be working with somebody who is failing to keep their appointments and discovering it's because they can't afford the cab ride, or they don't have any transportation, or they're a single caregiver for their loved one. Speaker 2 00:51:26 And they can't leave to go to the doctor for themselves. So it's really helping build those programs, get those resources in place and helping connect them with not only those patients and then the services to get them care. Um, and then, uh, another significant portion of this time is in partnering with the payers that we enter into these contracts with to talk about our performance on these mutual patients and members. And so working with them, educating them, getting help from them, um, you know, to monitor this performance. And so that is a big part of the role because there are so many different relationships we're involved with. Um, then lastly, the other part, which is the most fun of this is what are the innovative things that we need to do collectively across all of these contracts that we're in to really differentiate us and improve outcomes, lower costs, all of these things and so perfect. Speaker 2 00:52:27 That could be as well. And a lot of times I find myself in discussions with folks like you, or you specifically when it comes to that. Um, Oh, and last but not least, we still have to function as a traditional insurance plan though, right? Because to your point earlier, um, most docs do the right thing. Every time, give them the right information, they'll do the right thing. There are, you know, some bad apples in society. It just doesn't matter what profession you're in. You know, you do occasionally hear the stories of fraud, waste, and abuse, which unfortunately those are usually the stories that ended up on the news when it relates to physicians and Medicare. And so we do have a team who maintains those traditional departments of prior authorization, concurrent review, and other things just to say, okay, if somebody got care, it was, it justified at that time, was that the right care at the right time? Speaker 2 00:53:19 And so, so we do have a department who does those things. The good news is though we are gradually taking some of those innovation things and bring it over to be part of that team, to where their work is different than it has looked historically. So instead of it looked feeling like a gatekeeper function where a busy primary care physician is out, great. I got to check all these boxes and fill out these forms to tell the insurance plan that this patient actually needs this, that there are some ways emerging to make that more automatic. And so, again, that part of the value prop that we want to bring to a provider wanting to join us to say, we make it easier for you to do this work not only in your day to day and the paperwork and grind, but then it's resulting in lower costs and better route, Speaker 1 00:54:03 Uh, that is a, uh, a tour de force of a career. And I just want to say that it has been amazing to watch this all happen, and I'm grateful every day that we've got people like you trying to make things better for our patients. I want to shift gears now and talk a little bit about COVID-19. Speaker 3 00:54:31 <inaudible> Speaker 1 00:54:42 Welcome back. We're here with Dr. Ed Clark. We're going to shift our focus. Now this is a continued conversation, Dr. Clark you'll recall as the chief medical officer of the banner insurance division. And, uh, we're going to talk about COVID-19 now and a confession to make I'm new at this podcasting thing. And, uh, we've been having a great conversation for about 20 minutes now, and I forgot to push record. So those of you who would like to have a little fun at my expense, there you go. So, uh, and I don't know if you can say it with the same passion that you said it with earlier, and I don't even remember what the questions were that I asked, but let's go back and talk about COVID-19 and maybe, maybe we'll change it up a little bit and try to capture some of the sediments that will be forever lost in the ether. Talk about the day that you realized that this was going to be a dramatic change in the way that banner health does business in your life and in the lives of everybody around you Speaker 2 00:55:44 Be happy to. So it, it was, uh, in the middle of March, maybe around March 13th or 14th, I can't remember the exact calendar date. And I was in an all day meeting our quarterly business review, which is an eight hour day of presenting with the insurance division team about our goals and projections and things. And since I'm part of the chief medical officer team, though, I was monitoring email and the email completely changed, and it was the COVID is real. It is hitting hard, and we're all going to have to completely change the way we look at our work. And it was pretty much overnight. The next day meetings were canceled everywhere. New meetings were started up and pretty much everybody involved as a chief medical officer, chief nursing officer, and in the care management infrastructure of banner was figuring this out and what can we do, or what do we have to do as a system to handle what was coming? Speaker 2 00:56:41 And so it was scary. Just be completely honest, not only as, you know, a, uh, physician involved in the healthcare system, because, you know, we were seeing horror stories in the news on the East coast, in Italy, just the things that were going on and thinking, gosh, is that going to happen here? But then just as an individual, right? Like, what does this mean for me? What if I got sick? Uh, my parents and my in-laws live here and it was just, it was really rough for everyone. So I've been blessed that none of my close loved ones have become significantly ill from it, but yet life completely changed. And so we went into the mode of how do we best prepare when I say we, the insurance division and the network, how do we best prepare our network of physicians and other caregivers to deal with this? Speaker 2 00:57:32 And there's no playbook for this right now, especially not for an insurance division or an accountable care arm, because we, you know, kind of sit around and trying to figure out how do we many ways reduce healthcare expenditures, right. And reduce things. And here we were with mandates telling people go home, which means, guess what, if there are sheltering in place, you're not going to the doctor. They're not going to get these elective procedures and other stuff. So healthcare utilization just took a nosedive here in this market, which was a very interesting place for us to find ourselves because from one thing, uh, an insurer at the time seeing, uh, expenditures go down was potential. That that is one good thing from their lens. Right? Of course the outcomes are what's happening was not good. But we started to say, okay, what can we do to make sure our network is armed and able to handle this? And so we were fortunate again, to be part of banner health and have lots of smart folks in the care management teams and everyone who was, Speaker 1 00:58:35 And folks that are trained for disasters, right? I mean, Dr. Marjorie bustle is specifically trained in disaster management and that has come in. I have to guess extremely handy in a situation like this. Yeah, Speaker 2 00:58:48 Absolutely. I was just a member on the team, but, you know, we had well daily chief medical officer calls, multiple cause to hear what was happening, what the updates were, any new protocols that were built, how are we going to potentially prepare for triage? You know, all of these things. And what I found most beneficial too, is, um, various folks on the team were able to aggregate all the information that was coming in so fast and package it in a way that then I could take that and educate the rest of the network, specifically the docs and others out there and, uh, um, the community. So there's someone on the team who is focused on what's the latest, uh, around, um, testing. I mean, we couldn't even order a COVID test at the time, which is unbelievable. Think about where we are now, how do we get folks tested, um, folks focused on, do we have enough ventilators? Speaker 2 00:59:41 Uh, I mean, just all these things. And so we were able to get that information out to the network. Lots of questions are also flying at that time around telemedicine. So, you know, we talked earlier about how we're largely 80% independent physicians out here, and we're kind of an under primary cared part of the world, honestly. So there hadn't necessarily been a reason for a lot of providers to adopt telemedicine. And so our network at the time, I think we had about 40% of our network had some ability to render telemedicine, but that doesn't mean 40% of their claims or visits were through that. So within two weeks we helped our network stand up that capability. And within two weeks, 90% of our PCPs were offering telemedicine visits. I mean, and they did the work. We just helped aggregate what we could about what vendors are the easiest to work with, what were best for patients. Speaker 2 01:00:35 We just aggregated all the feedback and all of the various codes and new things they had to learn to do it. Right. And we were then also advocating with the payers in the market to reimburse those visits because historically, and one of the reasons why a lot of the offices didn't adopt it is because some payers would only reimburse telemedicine if it was with a preferred vendor of theirs, which a lot of times it was a national vendor, maybe that didn't have a local presence. So, so luckily some of our practices have still maintained around 50% of their visits today even are through telemedicine. So, and I'm hoping this means telemedicine is sticking and it's here to stay because that has really ultimately created access for folks. And so I'm sure it's not going to stay at the level it is now, but that is one of the silver linings of this is that we've seen innovation occur and adoption of what was already there through that. Speaker 2 01:01:32 So yeah, this stuff, Scott stood up so fast. Uh, we got past the first wave, which was in that kind of March and whatnot. And here in Phoenix, you know, we certainly were not Italy at the time. Right, right. And everybody kind of Pat ourselves on the back, we kind of relaxed and a lot of the kind of mandates and other mitigation restrictions that were, you know, coming from the governments, whether it be state or local, they kind of passed. And, you know, we had inconsistency and mask being required or not depending upon which suburb you were in and other things. And then here come the wave of the summer holidays with Memorial day and other things, and sure enough, we found ourselves in another spike. And so one of the good things was though we were somewhat prepared from all the work that was done in the spring. And so that really helped position banner in, and really the rest of the systems in a good place. And there was lots of collaboration between the health care systems in town, which is one of the, uh, other great things that came out of this. So I wasn't directly involved in that, but lots of good collaboration there. Yeah. Speaker 1 01:02:40 One of the things that I was most proud of as a state is the ethics group got together under the leadership of banner ethics doc and others. Obviously she, wasn't the only one, uh, a woman named Patty Mayer, who has spent a lot of time training and ethics at Cleveland clinic and came back to banner and got an agreement that every hospital in the state we're going to abide by the same ethics rules and concerns. Should it get bad enough to come to a triage? And that was a huge relief to everyone that we can all agree on. What is the best way to proceed in the event that this disaster gets beyond our ability to cope with it in, in the normal way. And it may be there now. I don't know how you feel about this particular wave that we're experiencing. Arizona is the hotspot and Phoenix, the hotspot within Arizona. It is the number one place in the world for COVID-19 infection right now, not just the us, but the world. And I have been impressed with the way that banner has handled this wave. Lot of that I'm sure had to do with the preparation in the, in the first couple of bumps that, that we rode out. What's different with this wave, both positive and negative that you see right now, what's it like to be in the middle of the hot seat? Speaker 2 01:04:10 Yeah. So I think some of the positives are, like you said, the team is somewhat hardened and experienced at this point. There are more treatments now for these folks. I mean, especially when they're critically ill. So, you know, the whole, all the discussions around proning and use of dexamethazone and the monoclonal antibody therapies, those weren't here, or we weren't talking about them back in March. So a lot of the panic of what can we offer these folks? We have some things to offer. What's it say? No is, I mean, our hospitals are basically giant ICU wards, right? Um, I might get the numbers off by plus or minus 10 or so, but banner university medical center, Phoenix went from, or I heard not good Samaritan previously known as yes. Uh, in one of the updates I heard last week, at that time, they were at 150 ICU beds and they were just expanding to go to 190 ICU beds and Speaker 1 01:05:08 Perspective for us pre COVID. How many beds would be occupied at the banner university. Okay. Speaker 2 01:05:14 That's when I, I, I don't have walking sense of what those numbers are, but I'll say when I was an intern at what was called good Sam at the time, if we had 15 total folks in the ICU as an intern, we were all panicked because that meant we were up all night. Right. Um, so no, it's just, it's unbelievable. And when you walk into the facilities because of visitor restrictions and everything, if you just walk in the doors and look around, it's a ghost town and you're thinking like, well, gosh, what's going on here, but it's because if you go behind the doors of the COVID ward though, where nobody gets to go, unless you're one of those care teams, that's where the action is. And so my hat goes off to those guys. Who've been there, grinding this out for this long. It's just unreal, how things have changed. And so it, it is frustrating somewhat, as you know, if you drive around town to run errands and do other things, you just still see so many folks packed at restaurants, uh, at bars, no mask on, at least in my commute in. And when I run errands, I see this every day. It is unbelievable. And so I, again, I'm proud to be part of the banner team and know that we're doing everything we can, it's still would be phenomenal if some of the basic mitigation was mandated here and it was getting done. So, yeah. Speaker 1 01:06:37 Yeah. It's been frustrating to, to watch that happen. And I, I can tell you from having just traveled across the country, there's a huge variation in how seriously folks take it. And we were in Manhattan. Everybody has a mask on, even walking outside. People for the most part are wearing masks. You can't get into a store without one on when we were there, which was after the big wave indoor dining was still off limits. Outdoor dining was okay. And the weather was still permitting at the time. Compare that to say, rural Kentucky or Tennessee. And you wouldn't know that there's a pandemic in those places, at least out in the community, you'd know it if you go to their medical centers. But for example, for the most part, even in Phoenix, what I've seen is that the folks that are running the convenience stores, the folks that are running the growth, they have masks on well in rural Kentucky and Tennessee, even the folks that are running the stores don't bother to wear a mask and it's become so politicized that you almost feel singled out if you're the only guy with a mask on, I mean, there's peer pressure to do the wrong thing, and I'm not singling out Kentucky or Tennessee. Speaker 1 01:07:53 I'm sure it's the same, uh, in many parts of the country. And it is frustrating to see that. And, and to know that there are some very simple things that don't require a lot of sacrifice. We're not asking you to storm, you know, the beach at Normandy. What we're asking is that you respect this virus, it's deadly, and that you put a mask on and that you social distance and you your hands every now and then this is not a tremendous sacrifice. Put the politics aside, you know, what, if it doesn't help. Okay. Maybe you have been slightly, very slightly burdened for a little while, but what if it does help even a little bit and you didn't do it? I don't want to be in a position of having to deal with that moral dilemma long term. And I hope everybody else starts to get the message that yeah, shutting down the economy is damaging. There's no question about that, but overwhelming, our healthcare system has long-term consequences. And I don't know. And if you see this, but I think we're reaching a point where there's just a level of fatigue that is a burden for everybody. That's trying to do their best to take care of really sick people. And it has to be disheartening to look outside and see folks, uh, you know, in crowds, shouting and laughing and, and acting as if there's nothing going on. Speaker 2 01:09:11 It is. And what gives me hope is that we do have a vaccine right now that is being put in arms today. Um, Arizona we're unfortunately kind of behind a lot of the other States in the country, but lots of the same folks who are, uh, uh, within, uh, at least banner and know all the other systems are doing this well, are running various vaccine pods, more bringing stood up, uh, they're expanding the criteria, I think to group one, B or one C next week. So that's the thing that w we really need to get us over this hump, but yet it is incredibly frustrating to see that for some, it, it just doesn't seem to have the same level of significance in their life. And I, I just hope that they make it out of this. Okay. And their loved ones do as well. Speaker 2 01:09:58 So, yeah, absolutely. Yeah. Because what I'm concerned about, well, there's less than max concerned about in my, in my role, but, um, so let's assume we do get vaccines in arms and, uh, some of these restrictions go away and we come back to some degree of normalcy in my seat. And you probably think about this well, in your seat, you know, as we look at populations and how do we improve their health over time and lower their medical costs and other things. So let's throw aside the decrease in utilization we had for a little bit, cause I said, that's kind of been leveled here. Data are emerging to suggest that, you know, a high percentage of folks who had a COVID infection continue to exhibit some sort of symptoms, even six months afterwards, right? And this, in some of these include damage to major organ systems. Speaker 2 01:10:47 And we just don't know what this is going to look like on the back of it. Plus the emotional toll, this takes caregivers are, you know, uh, some degree of PTSD, but incidents of depression is going up dramatically right now. And you, and I, uh, understand, and many of the listeners probably do as well that a depressed patient generally has a much higher total medical expenditures for their care in a given year. And so just really concerned about what this is going to mean longterm, because if we have folks with long lasting effects who are ever more depressed, you know, how well is our networks and our systems going to be able to pivot, to deal with these long-term needs. Right. And what is that going to mean? So again, we're incenting this type of thing more this year. So we're kind of pivoting some of our scorecards to address this address, those social determinants of health and our care management teams, and others are doing more outreach for folks we feel are at risk or have had a history of anxiety or depression or otherwise. And so we'll continue to refine our approach has more data come in. But, uh, again, that's one of the things that we're very concerned about and are keeping a very close eye on, Speaker 1 01:12:04 You know, one of the things that's, uh, in, in, thank you for that. One of the things that's puzzling as, uh, citizens of the USA is before the pandemic, you know, we used to send folks to deal with Ebola. We had the most respected experts in the country and in virology, maybe we still do it, but we'll talk about that. But there's been a profound public health failure. And I wonder what your perspective on why is it that the United States has failed so badly at addressing this pandemic? Speaker 2 01:12:38 So one of the things that I am putting you on the hot seat a little bit, yeah. That's, that's fine. I do think that we need to reinvest or recommit ourselves to national level infrastructure for public health and these things. So you having worked at banner leading our care management department and others, and probably going through the, uh, Brent James course at inner mountain. Yes, indeed. One of the commitments and things we try to do is reduce variation in how we deliver healthcare, right? The conversations I've had have been limited to, you know, either a what's happening in the ICU ward in this set of clinics or whatever, but wait, the same can be said for a national level response to a pandemic, because right now there is incredible variation everywhere. It's different in Arizona than it is in California than it is in Kentucky in that variation is what tools are those team members have? Speaker 2 01:13:34 How do they process the information? And so I do think there are some times where, and yes, I understand some political parties might have the stance of less federal level intervention, let the state control it. Here's a perfect use case for why we need this guys. Like we need a coordinated national level response, not only to help us finish this pandemic, but to be better prepared for what's to come ahead. And so I hope, and at least what I'm seeing early on with how some of the cabinet moves are being done and other things that, that will get back to some degree of that, cause people are tired. And I think we've shown that, um, I think memories were short. We all needed to read about the influenza pandemic early 20th century. Uh, and just remember that this can happen to us too. Speaker 1 01:14:27 So, uh, one of the fascinating things to me is I hear a lot of folks say that the response doesn't seem to influence, uh, infection rates. In other words, places like California that were pretty draconian in shutting things down and mandating, uh, masks and so forth, have not fared any better than places that were more liberal in their approach to it. How do you, how do you, uh, see that? How do you, Speaker 2 01:14:54 Yeah. You know, so, well, one of the things is I know that there is still travel, that is Kering in California, uh, interstate, right. And we're human, right. I mean, like there is a fatigue that is going to set in and we had a wave of holidays that come through and after everybody was already exhausted and fatigued, you know, from March through, uh, you know, October to then have a Thanksgiving holiday come up and people have been avoiding their loved ones and others for so long. I think it was just something that was just almost too much to ask folks. Right. Or like, I think that's where the tipping point was. And again, given that there are so many asymptomatic folks with this disease, they don't know. I mean, that's the difference between this and the flu pandemic in the early 20th century, right. If somebody has high fever, sneezing and you know, okay. Speaker 2 01:15:50 Yeah. They have the flu, so stay away, people just don't know. And so I do think it was just, we had this double whammy of the Thanksgiving holiday and folks getting with loved ones in those small gatherings that were 10 or more. And then that caused a spike, uh, you know, which you're going to see, you know, 14 or so days afterwards. And then here comes the Christmas holidays and new year's. And so I think that compounding is really what got us where we were. Um, and since California is the most populous state, they're going to have more numbers. And, uh, but I do think had there been a better coordinated national level response before this, that California would have been, uh, would have fared better? I mean, you look at some other nations. I have not looked at Australia in a while, but I know they've had a totally different pandemic experience. And, um, we had to this point, so, um, we have a ways to go. Speaker 1 01:16:45 I, I tend to agree with you on all of those points. I think that it is not a failure of the, uh, public health strategies of masking distancing and, and washing hands, what it points to is fatigue and inconsistent messaging, uh, at every level and, and variation that is unjustifiable. And when you, when you have that inconsistent messaging, and as you mentioned, you have those critical holidays that are very meaningful to people. They can justify a little bit more than they might have been able to, uh, had we had consistent messaging from the very beginning. And so I'm, I'm deeply in agreement with you. I do believe that masking has an impact. I do believe that distancing and hand-washing make a difference. And the failures that we've seen have less to do with the failure of those measures than they have to do with inconsistent messaging and fatigue, people are just worn out. Speaker 1 01:17:46 And if they can justify a behavior based on somebody's message, who's in authority, they're more likely to do that. And so, uh, yeah, I, I, it's a shame that this has happened, but I gotta tell you, I think we're very fortunate in one regard, this is a very significant pandemic. It's a severe pandemic, but thank goodness the mortality, the case mortality rate was not much higher or the exposure of these cracks in our preparedness would have been devastating. And this is our test run. I don't think this will be the last pandemic. Maybe not even the last one in our lifetimes given, uh, increases in population and exposure to animal populations, et cetera. And so this is our test run, and I think there's a tremendous amount of learning that has gone into this. I just hope that our memories aren't so short that we forget about this. And one other issue I wanted to touch on is efficiency in healthcare has been, uh, we've been working on efficiency for a long, long time, just in time inventories, those sorts of things. And we have neglected surge capacity for lack of a better term. How do you see that changing going forward? Do you think that it's possible that we can do that in the, in the setting of rising healthcare costs? Unsustainable, how do we prepare for the next pandemic without driving costs up further? Speaker 2 01:19:09 Yeah, I do think that has to be accounted for somewhere and perhaps what the new administration and reforms that are going to come forward, that that will allow that because you're right. It's, it's so expensive to maintain these facilities and every square foot in a hospital is incredibly expensive to maintain. So that's when I needed to think a little bit more about complex. Fair enough. Maybe we can talk about that down the road because you know that, and like I said, just exploring and seeing kind of how we handle the emotional impact that this has on us. But, um, I think that is one area where we have to have federal intervention, uh, with how medicine is practiced. It's just absolutely critical because the healthcare system, I don't think in handle too many more of these. Speaker 1 01:19:55 Right, right. Um, um, integrated with you on that. I want to end Dr. Clark if we can, on, on a high note. And so I'd like to know what you believe the positives are about this whole experience. How will this change the way we think about healthcare? How will it change the way that we think about pandemics? How will it change the delivery of routine healthcare going forward into the future? Do you have any predictions for us about that? And I'll try to keep it on the, on the positive side. There may be some negative predictions. We don't want to hear about them right now. So what are the positives that come out of this whole thing? Speaker 2 01:20:31 Yeah, what I do think is positive is that, um, we know, or we have seen that the, our healthcare delivery system, although to some of our earlier conversation had talked about how the incentives historically, maybe had been upside down, can pivot and, and still really meet the needs of, of hundreds of thousands, you know, in a pandemic, not only from having smart folks with the training and the technologies and other things to rapidly stand up a COVID ward or disseminate information around proning or novel therapies and other things which may be pre pandemic five years ago, would have taken multiple years to work its way through the literature and the trials, and kind of get out there to actually be practiced frontline and medicine. So I think that's one of the benefits. The other thing too, and we touched on this a little bit. I do hope that access to health care is easier for folks because of some of the innovations and how we've stood up. Speaker 2 01:21:31 Telemedicine. I hope that continues to grow and evolve. And lastly, I'll say, I hope that this has further kind of shown that more reforms are needed because, and with how we reimburse those who deliver care. And so we talked about a lot that we talked about ACS and kind of how this whole thing works, but the reliance that systems have historically had on these elective procedures and other things to see when that goes away, because we had to restrict and just the burden that put on there, and maybe this comes back to, you know, how do we deal with surge capacity and other stuff like we really need the model to continue to evolve. So we made some great progress with setting up ACO is accountable care, value based care and other things. And so I think some of the other parts of how care is done and rendered and reimbursed need to change. And so maybe this is that signal that'll finally get us Speaker 1 01:22:25 Well. Dr. Clark I've kept you far beyond, uh, anything reasonable. You've been very generous with your time. Uh, Dr. Ed Clark, chief medical officer, banner insurance division, and the banner health network. I do appreciate all of your insights and I hope that you will come back, be happy to alright, thank you. And we are out now, you've been listening to the groves connection, your connection to the inside story on healthcare, featuring in-depth interviews with those who know you can find us on Apple podcasts, Spotify, and anywhere else, you get your podcasts. If you like what you hear, give us a five-star review to keep the connection going and hit the subscribe button to be sure you never miss a beat. The groves connection is produced by Dr. Robert groves, original music editing and creative direction provided by Alton groves, production, support, content guidance, courtesy of Janae sharp, and Elizabeth, Speaker 0 01:23:26 Thank you for listening.