[Podcast] Creating A New Healthcare

I recently had the pleasure of interviewing Dr. Zeev Neuwirth, a physician, author, podcast producer and speaker who’s made a career out of identifying opportunities for innovation in our current healthcare system. I first saw Dr. Neuwirth speak at the 2019 Society for Healthcare Strategy and Market Development (SHSMD) Connections conference in Nashville where he spoke about his new book, Reframing Healthcare—A Roadmap for Creating Disruptive Change, and passion for leading change.

I highly recommend you listen to our entire podcast, but you can also find a synopsis and full transcript below.

“Creating a New Healthcare”

According to Dr. Neuwirth, the healthcare system we all know—and do not particularly love—was established well over 100 years ago and its purpose was quite different. Back then people needed acute, episodic and life-saving care. There was no emphasis on doctor-patient relationships or preventive health.

Today, however, consumers don’t want a doctor to just provide damage control; they want a health care partner.

A call for disruptive change

Dr. Neuwirth went on to say that Americans are trapped in a flawed and harmful health care system. “Hundreds of people are dying every day in U.S. hospitals because appropriate, affordable care just isn’t accessible. Those working inside the system are also struggling. On average, one out of every two doctors is burnt out, depressed or demoralized.”

During our conversation, I likened the issues surrounding today’s healthcare system to a Gordian knot, or something so big and complicated that it can’t be fixed without bold action—something Dr. Neuwirth spent years observing and discusses in his book. After working inside the system and seeing its weaknesses firsthand, he decided to study the fundamentals of business management and process improvement. This allowed him to refocus his efforts on redesigning and reorganizing healthcare for today’s modern world.

The marketing mindset

Dr. Neuwirth argues that if we want to transform health care delivery, we must reframe our medical-mindset to a consumer-oriented marketing mindset—and I have to agree. We’ve already witnessed fundamental reframing and reorganizing in corporate America and it’s finally starting to reshape and humanize healthcare.

The marketing mindset consists of rebranding, redesigning and reorganizing. Rebranding is the first important step. Understanding your patients, their needs, pain points, and the problem they’re trying to solve is the first step in creating a customized solution to solve modern problems. Enter platform branding.

Platform branding: The way forward

Platform branding provides an infrastructure for corporations to easily transition between and service different user groups. “We're going to see a move from systems, healthcare systems and hospital systems that are trying to integrate and coordinate care to platforms that are actually going to be the integrating and coordinating force for healthcare,” said Dr. Neuwirth.

Dr. Neuwirth further explained, “We need to have primary care brands with a complex chronic care model, an urgent care model, a women's health model, a wellness model, and a continuity of care model for those with chronic disease.”

Restructuring the healthcare model empowers those working in it to provide highly individualized care. Let’s say a child visits the emergency room regularly with asthmatic exacerbations. What if there was another, low cost care option? Dr. Neuwirth believes there is; a care specialist could visit the child's home, identify potential allergens and recommend low cost changes. Imagine the impact this small, yet fundamental, change could have on our communities.

He leaves readers and listeners with a final thought: “It’s time for healthcare to do the right thing, lower costs, improve healthcare, and provide unique care services for the elderly. This and so much will be accomplished when we create disruptive change using platform branding with a marketing mindset.”

Again, I highly recommend you listen to the entire podcast, or read the transcript below.

Complete transcript
Stewart Gandolf:
Hi again everybody, it's Stewart Gandolf here I'm pleased to have you to our podcast again. Our loyal readers and listeners will know that I often talk about changes structurally in healthcare and patient experience and how we can all make healthcare better. And while I'm not a clinician I love using this blog as a chance not only to talk about marketing, but talk about how they can all work together to make healthcare better. To that end, I am interviewing today somebody I'm super excited about Dr. Zeev Neuwirth. And I first saw Zeev speak, at SHSMD a couple of weeks ago in Nashville at SHSMD, and he has now authored a new book called Reframing Healthcare: A Roadmap for Creating Disruptive Change. And I'm super excited to interview here today Zeev, welcome.

Zeev Neuwirth:
Thanks Stewart, I'm really appreciative of this opportunity. Thanks for having me on.

Stewart Gandolf:
Excellent, outstanding. Again, I think, I feel like we're like minded already. And I was joking with you offline, I have a big head start because I got a chance to read your book. But for our listeners today, I'd really love to start by just telling us a little bit more about your background, you're a clinician and how you came to write this book, and why write this book?

Zeev Neuwirth:
Yeah, I've been in healthcare for nearly 30 years. And I started out as an physician in internal medicine. And I practiced for many, many years, I spent the first 10 years of my career in academic medicine, essentially teaching young doctors generations of young internal medicine physicians, and then I felt that I really went into academics because I really wanted to make a difference in health care and thought that by teaching the future generations that, that would make an impact. But I realized after about 12 years of doing that, that that was really the system that needed to change. And so I began to study systems and business and management and process improvement quality, improvement and then got into innovation and caring design.

Zeev Neuwirth:
And of course, got into clinical operations in my roles as a manager and executive and was going along, obviously, my career has been spent trying to change healthcare. And couple of things happened to me about four years or so ago. And I just had this epiphany that I needed to really start to speak out in a different way. And so, it's hard when you're in an organization, you're just trying to do the day to day work, and I almost felt like we needed a third space. It's almost like that Starbucks third space, it's not home. It's not work, it's somewhere in between. And I feel like in healthcare, things are so frenetic and so tumultuous and everyone's got their head down, and I just felt like we needed to a different place to be able to have a different dialogue and so I started to actually speak and then I was asked to write and that led to the book and the book led to me doing interviews for the book, which led to my launching a podcast.

Zeev Neuwirth:
And so, very much like you, I think there's a need for a dialogue in this forum. And so that's really why I wrote the book. Now the book is called Reframing Healthcare. And essentially, it's a roadmap. It's a guide for how to really create a much more consumer oriented value based type of healthcare.

Stewart Gandolf:
Outstanding, and it's funny when one of the points you make in the book as, "The vast majority of people in around healthcare really want to do the right thing, but the system is not ideal clearly." And this is a big sort of Gordian knot, trying to fix it. Without being a dead horse, I think it's really important because one of the things that got me excited about your speech was, how honest you are with what's wrong with healthcare today. There's a lot and, we should probably go on forever, but not a negative standpoint. But I don't think we can get to where we want to go, if we don't at least acknowledge where we are today. Can you share with us some of the observations you had in your book about what's wrong with health care? And we'll talk about how to fix it shortly. But right now, what are some of the things that are really important trends that you think we should at least address?

Zeev Neuwirth:
Yeah, I think that's a very important question. And you're right, we don't want to dwell on the negative and is so much positive going on. And by no means do I take any of this to be a criticism or critique of the individuals in health care whether they be providers or staff or administrators, I think everyone is by and large and do the right thing. But we're in a system that is so wrong, and so flawed and so harmful. And so, let's just start with the issue of quality, and I've been a quality officer for many, many years, and so been working against this, but the truth is when you look at the system as a whole, and I mentioned this in my talks is somewhere between 500 to 1000 people in this country die every day and hospital systems, avoidable deaths, so that let me say that again, avoidable, preventable death, which makes our healthcare system in the top three or four causes of death in this country.

Zeev Neuwirth:
When you look at the statistics of the opioid crisis, you look at other things like the percent of people who get appropriate care, these numbers are so tragic and terrible. And so, quality is an issue, cost is really a serious issue. The stats here are just horrifying. Health care is just not accessible to the vast majority of Americans. It's the number one cause of bankruptcy for a family of four employers of paying $28,000 a year that's really literally like every employer buying a new car for every one of their employees every year and then trashing the old car. I mean, it's mind boggling. And again, this is just the system and it's a burden for those who the system serves but it's also a burden for those who are serving in the system.

Zeev Neuwirth:
And I think one of the greatest, greatest tragedies of our time as a result of the system is the amount of burnout in healthcare, one out of every two doctors on average is burnt out. And this is not just hearsay, this is research and that means that they're depressed, they're demoralized, they're depersonalized. The cost to themselves and their families is tremendous. But there's also a cost in terms of patient safety patient quality. I mean, no one wants to look up from an operating room table and see a surgeon that is burnt out. That's the last thing you want or walk into an exam room and have your doctor be depressed demoralized. But that's just not good care and not good customer service. I think that from a cost perspective, a quality perspective, from a human perspective, we cannot continue. The system is wrong, it's unsustainable, it's not serving the people within it and it's not serving the people it's supposed to serve.

Zeev Neuwirth:
I'm happy to have this conversation with anyone happy, the numbers are there, the data is there, the stats are there. Some would argue... and then from a consumer perspective, I don't even touch that. But from a consumer patient experience perspective, it's appalling. I mean, our consumer experience is so poor that we're not even rated on a lot of consumer experience scores, we're not even in a game and so I think on no account do I believe that anyone could justify the current healthcare system we have, and while everyone is working so, so hard and this is really the point of my book and my talks. Everyone's working hard to improve it. I think we're working at the wrong level, clearly you have to do continuous improvement and process improvement.

Zeev Neuwirth:
Clearly you have to do innovation but really fundamentally the system has to be reoriented, it has to be reframed. And every leader I know who's outside of the system says that about healthcare and increasingly a large number of leaders within the system understand that it has to be reoriented and I've had the opportunity to interview well over 100 CEOs and entrepreneurs and innovators in health care who are extremely successful and doing great things and they all say the same thing. The system has to be reframed. And that's what my book is about it the roadmap on how to reframe healthcare.

Stewart Gandolf:
It's funny on one of the other talks that the show has made, that really intrigued me and other PhD was observing, rather, what's going on in healthcare and the whole changes that we talked a lot about is that the corporate America is coming in. And it's really funny because they were talking about how for example, a hospital, which should be transparent in the building. And the answer is, we can't do that. And there's all kinds of reasons why, but that's exactly why corporate America is intrigued by this. Well, if you can't figure it out, perhaps we can. And so that's really, there's so much going on. In addition, the patient experience part you brought up earlier, is so vital. This topic we speak about a lot as well. It's not just, if the patient is satisfied, it's deeper than that, obviously, by a big measure and outcomes can be better when the experience is better, and these trends are happening, whether we like it or not, the trend for consumerism is not a fad.

Stewart Gandolf:
It's not passing, the competition, the consolidation, their entrance of corporations. So if we choose to put our head in the sand, we're just going to be left behind because this movement is happening. On that note, you mentioned reframing healthcare. I would love this... Explain a little bit what that means too because you talked about it, you touched upon it, but the idea of incrementalism, and best practices on an existing model versus creating something new. Tell us a little bit more about what you mean by reframing.

Zeev Neuwirth:
And answer you said it in terms of primary care?

Stewart Gandolf:
Well, yes, well, yes. Let's use a primary care as an example. I guess the point I was making is that as you touched upon it, the doing more of what we're doing and making it incrementally better is not big enough, right? And so you mentioned reframing healthcare, and I thought that your example for primary care really helps make that real and tangible so, I love that so spend a little time on that.

Zeev Neuwirth:
Yeah, sure. This is exactly the point. And it's a great example, as you're saying, so we've been trying too, and I've been part of this movement for over two decades. Well over two decades, we've been trying to improve primary care. And we haven't really moved the needle at all. And so, if you think about it, primary care we've been innovating and innovating. But the problem is, it's fundamentally being done the wrong way. Now, let me just say this primary care, by the way, is the backbone of any health care system here in this country and across the globe. The more primary care you have and the better primary care is, the better health outcomes are in a community and the lower the cost of care so everyone wins. If there's primary care and good primary care around everyone loses if there is a positive primary care or poor primary care.

Zeev Neuwirth:
We know this, the literature has been demonstrating this over and over again for the last 20, 30 years. Primary care is the backbone of any healthcare system. And I would suggest to you that our backbone is broken. And we can see this in so many different ways. One of which is the fact that no one wants to go into primary care anymore. It's really hard to get medical students and residents to go into primary care because it's broken. And fundamentally, it's the business model. It really is this marketing mindset that I talked about.

Zeev Neuwirth:
Think about this, in this little shop, you've got a doctor, a nurse, you got some staff, and it doesn't matter what the problem is, everything comes into this little shop, whether you have a headache or a heart attack, or a hangnail, whether you have depression or diabetes or type 2 triculitis, it doesn't matter, everything goes into this little lane and somehow one doctor or one PA and this one nurse are supposed to have literally facility to take care and treat thousands of conditions but 10s of thousands of medications and have the policies and protocols and procedures and staffing and resources.

Zeev Neuwirth:
And it doesn't matter if you're 30 years old, and you come in for a quick little thing, or if you're 85 years old, and you've got 10 major medical problems, you just came out of the ICU on 20 medications. Somehow this little shop is supposed to be able to meet everyone's needs to try to be what I say everything for everyone, everywhere all the time. We know that from a business perspective, that is absolutely ludicrous. Clayton Christensen, the preeminent professor of business at the Harvard Business School, says that the business model for healthcare is a 200 year old model that is defunct, and we need to change it to something that is consumer oriented and value based. And so what I suggest is... and I would argue that it's not a hypothesis, it's actually happening in the market. I could demonstrate this, is that we need to start to create segmented units in primary care.

Zeev Neuwirth:
We need to have primary care brands that are focused on what I call the complex chronic. Because people who are older with multiple complex medical problems, they need a completely different model of care, then those of us who are younger and have something minor, like a laceration, or a headache or something, where it's a quick in and out sort of business. And that's why you need a complex chronic care model and you need an urgent care model, I would suggest to you that we probably need a women's health model, potentially a wellness model. And then we do need a continuity of care model for those who have chronic disease. And so I think that what we're seeing in the market, in fact, and again, the market is driving all of this. We're beginning to see this differentiation, the segmentation of care. And in my book, I also talk about something which is really I wrote about it well over a year ago, I've been talking about it for last couple years. But now we're beginning to see this happen in the market, which is what I call a platform brand.

Zeev Neuwirth:
That people say we this model of is fragmenting care. And if you have all these different types of primary care, and the answer is, it's not because what's also required is an integrating and coordinating platform. And I need a digital platform. And we see this in other industries, and we're going to see it in healthcare. And in fact, what I think we're going to see emerging in the next year or so, it's been happening, there's been lots of companies that have been buying and warring to be the platform for healthcare. And they're partnering with healthcare systems, you're going to see these platform brands emerge. And what I think we're going to see is a move from systems, healthcare systems and hospital systems that are trying to integrate and coordinate care to platforms that are actually going to be the integrating and coordinating force for healthcare.

Zeev Neuwirth:
That's the very, very concrete example of how what I call the marketing mindset, again, a market driven mindset, which is really literally right now, right in front of us, transforming healthcare and transforming primary care, which is really the backbone of all healthcare systems.

Stewart Gandolf:
Perfect. You just brought up something that I really thought was intriguing about your speech and the book as well as the whole idea of the marketing mindset. And what's funny about this, of course, our listeners probably know that I'm CEO Healthcare Success, which is a healthcare marketing agency. I stumbled into marketing in undergrad, I thought I was going to be an engineer, I was really good at science and math. So I'm good at science and math. But I fell in love with this idea of the marketing concept or marketing mindset where most people think of marketing is advertising. But of course, marketing is deeper, much deeper than that indifferent that. Advertising is a subset of marketing and in fact, marketing really is all about considering a target audience and developing a product around their needs, it's not about selling them something that you've already got.

Stewart Gandolf:
It's about starting with the consumer first thinking about their needs, and then solving it. And what's intriguing when you read the book is how much you're a convert to that way of thinking. And tell us more, I guess one of the things also that I thought was intriguing about your book was beyond the marketing mindset, which I'd like you to touch on in a moment, but also the idea of branding. And because I think that both of these concepts are maybe new to some of our listeners, if they're on the clinical side of things, why are we talking about marketing? Why are we talking about branding?

Zeev Neuwirth:
Let me just say, I think you really hit on the core thesis, the fundamental reframe, that is happening in healthcare, is what I call the marketing mindset. Again, it's not a theory or hypothesis, it's an observation. And a discernment of the reality, which is that, every other industry understands this basic fundamental principle that it is about the customer, it's about the consumer, it's about understanding their needs, it's about delivering value from their perspective. And the only industry that's ignored that up until this moment is healthcare. And the problem with that or the good part about that is, that as healthcare is becoming less opaque, and the barriers to entry are far less than they were in the past. You're seeing the day whoosh of new entrants coming into this and some of those new entrants are pretty large and spectacular. Like the Amazons and the Walmart's and CBS of health and the Apples and the Googles and there are thousands and thousands of others that are smaller, but I would suggest you even other others, like a Comcast are getting into healthcare as well.

Zeev Neuwirth:
And as they come in, they're bringing their marketing mindset. And again, when I've had this conversations with physicians providers, I try to make the point which is this, is that I'm not talking about marketing in terms of like you just said before, it's not about selling, it's not about advertising. The essence of marketing is, like you said, it's understanding your customer, specific segment of the market, understanding what their needs are, what their pain points are, the problem they're trying to solve, and then creating a customized solution for them, and making sure that by engaging them, that you create relevance, and you solve the problem for them. This from my perspective, should be the core of medicine. And so what I'm suggesting is we take the medical mindset we've had not ignore it or abandon it, but augment it with a marketing mindset.

Zeev Neuwirth:
And the fundamental goal here from my perspective is not to technologize or to digitalize healthcare but it is actually to humanize healthcare. And I think if we adopted the marketing mindset, we would put patient centered care on steroids, which is my goal. And that's the perspective I come from. But the point is this and I make this to colleagues and C-suite people that I talked to, it really doesn't matter what I want or what any policy people want or what any politicians want. The truth is the market is going to dominate and the market is now full of new entrants that understand consumers and understand how to figure out what consumers need and want and how to give it to them. And they are coming into healthcare in droves, and if we want to be part of the solution, if we want to thrive in the future of healthcare, then we need to adopt what every other industry has adopted along the time ago, which is this marketing mindset.

Zeev Neuwirth:
And I think that, for me is the fundamental principle. And it's solving all problems from that perspective. And if with your point, if we start with the customer and their needs, and again, the idea of experience is not a touchy feely thing, experiences, everything. Experience from a healthcare perspective makes a difference between life and death. If I create a product, or an older complex chronic care patient, which we were talking about before, and that product is limited to episodic visits, like you come into my office, and I'll do great care. The problem is that a lot of stuff happens in between visits. A lot of stuff happens, but most of it happens when the patient is at home, who's actually managing that experience for the patient. And the only way you understand that is through and marketing mindset, and understanding the experience creating an experience of care.

Zeev Neuwirth:
And again, I give you multiple examples of that, but I think it's absolutely the most important thing we have to attend to right now. And I would say it extends to we've been talking a lot in the health care about the social determinants of health. We know that that most of health in our country is not determined by what we do in doctors' exam rooms or in surgical suites it's determined by things like, do you have enough food? Do you have transportation? Do you have safe environment, safe buildings, do you have housing, things like that. And I would suggest to you that even that requires a marketing mindset. You have to know your customer, you have to know the segment, you have to know their needs. And you have to figure out how to create a customized solution to meet those needs. And so it is absolutely critical if we are going to deliver health care and health for our communities and for our country.

Stewart Gandolf:
Fantastic Zeev, it's funny, the timing of your book is amazing. Coincidentally last week I met with the CEO of a hospital, one of our long term clients and friends that I respect a lot and we're talking about a potential rebrand for that hospital. And one of the things he said during this meeting was, I need to understand the roadmap, we don't just change the name. And I said exactly. That was what's so exciting. This ended up being a two hour meeting we spent time talking about, it's so much deeper than thinking about the name and maybe a logo. It's about improving the patient experience, getting the doctors on board, providing better care, building... they're working on currently a clinically integrated network and building upon that. Fulfilling the mission of the community you mentioned a minute ago, the social determinants of health, that community has a really broad mix of demographics from very high end to Medicaid and so you've got to complete... and the mission of the hospital is really important to them, and that's why they haven't consulted with everybody else and they have clinics.

Stewart Gandolf:
It's such an exciting time to think through. Why would we just think about a name it's much bigger, how do we create a better product, which is at the end of the day, those of you that know marketing, the four Ps are the very basics. The product is the critical one, it's not promotion, its product. And so it's really exciting. And on that note, you spoke about branding in the book, share with us some of how you feel branding applies to this whole conversation.

Zeev Neuwirth:
Yeah, I think branding is part of the roadmap. In fact, the marketing mindset is really rebranding, redesigning and reorganizing and branding is the first step. To your point, branding is... people misunderstand branding and think it is in fact a new name or a new logo or new color schema. That is not what branding is. True branding is really, what is your value proposition? What value are you bringing to your community, to your customers, to the world. I think it is one of the most... if you really understand branding, it is one of the most humanistic and empathetic or empathic activities you can do to really, really understand what the need is and what needs you're filling for your customers and consumers. I would say this, there's some really, really great examples of rebranding in the country. There are some really bold leaders out there.

Zeev Neuwirth:
Intermountain Health is one example. Renown in Reno, Nevada is another example. And let me share the one from Renown because I recently spoke to the CEO Tony Slonim, who is just a fantastic leader. I was so blown away by him. And he's telling me the story about... he didn't use the terminology, but I played it back to him and I said, "Oh, this is exactly what I was talking about." He agreed, so this is it, so he realized that they went about rebranding their organization, their multi hospital system, and they realized that the community needed two things. One, they needed a very, very strong hospital system. They needed really good surgical suites and really good intensive care units and really good specialists and so that was one brand that was one need. But the community, larger community there needed another need. And that needed was around prevention and proactive care. That is helping the youth with issues around behavioral health and substance abuse and preventing accidents.

Zeev Neuwirth:
The elderly population and community needed to know how to age better. And so, they realized this and they said, "Okay, well, instead of trying to mess this up in one brand, we're actually going to create two brands." And this was brilliant. They created a care brand, which is all their hospitals and surgical suites and ICUs and urgent care centers, and specialty offices, that's their care brand. And then they created another brand, which they call their health brand. And that's all the other stuff that's all working with the older population, home visits and home care and population health and helping the youth and behavioral health, which is such a big thing. Again, all prevention. And the mission of the health brand is to keep people healthy and out of the hospital. And the purpose and mission of the care brand is if you need a specialist, if you need surgery, if you need a nurse to you, you're going to get the best medical care you can get.

Zeev Neuwirth:
And by separating out those brands, you have a different set of strategies, different tactics, different resources. It's was such a brilliant, brilliant move to take health care and separate it into health and care. And that is a very, very concrete example of what I call the marketing mindset in action.

Stewart Gandolf:
Fantastic and for the listeners just to bear in mind we obviously this is a podcast, we can't talk about every section of the book, but there's so much detail and so many real world anecdotes and so many examples. I think, it's really important to recognize that as Zeev alluded to earlier, this isn't all theory, this stuff is happening now. It's just that Zeev has a good insight and it's pulling it together. You reminded me of Malcolm Gladwell actually a couple times in the way to see some quick insights and draw that and pull it together. I thought it was really, really well done. You talked about redesign and reorganization principles in great, great detail, but give us some highlights of what that means from your standpoint.

Zeev Neuwirth:
By redesign, healthcare has not been designed for human beings. And I mean, either patients or providers, and so that's why you see just such poor patient satisfaction scores and poor net promoter scores. And I mentioned before, there are some markers of simplicity in industries. Healthcare doesn't even rank in there. I mean, we're so complicated and complex and convoluted, and there's so much frustration that's built into the experience of a patient and family member. And the same by the way is true for being a provider. Incredibly frustrating and so the redesign phase after you rebrand, you have to redesign. And I would say, we could spend hours talking about this, but it's basically human centered design, empathy based design. And again, this is not new. This is happening in every other industry, it's beginning to happen more and more healthcare where you see them take a human centered design approach, and again, designing for us as human beings.

Zeev Neuwirth:
And that's critically important because if you don't do that, we won't use it. And so, if you want relevance, if you want engagement, you have to design. That's just human nature, the reorganization approach step of the marketing mindset. Once you rebrand and you have a new value proposition and then you start to redesign for and by the way, there's are in there that I put in the book, which is we have to redesign for different results. The results you're looking for are going to be different than the ones you had before. But once you do that, you begin to realize that the organization you have the way you're structured, probably isn't the organization you need for the future. And so you need to actually take the step of reorganizing. And that's really redirecting your strategies, your tactics and your resources. And again, I've interviewed now, well over 100 leaders probably closer to 250, or 200 leaders, some in new entrant startups and I by startup I mean large startups, and some legacy organization.

Zeev Neuwirth:
And the one principle that I discerned in all of these stories is that sooner or later, they realized that they had to actually reorganize their organizations. The Renown example is a great example. Intermountain Health which I alluded to before, they did the same thing they created two completely separate division. And I take my hat off to them, the courage it took to do that they took their one system and created two systems. They had a hospital system and a community system, very similar to Renown. And by the way, I just heard Gilfillan who was the CEO of Trinity Health. He didn't use this terminology, but essentially talked about the same exact thing. You have to reorganize how you do things, or else you will not be able to sustain the rebrand and the redesign.

Stewart Gandolf:
Outstanding. I love that thinking because again, if you start with those different premises how does it? It's not just primary care and acute care. It's what are the needs we're solving for the community. And one of the things that we've talked a lot about on this podcast before is and you bring up and I guess that's why I feel like we're, colleagues at arms here. Healthcare is built for the efficiency and system and as opposed to from the patient's point of view, and I understand why that all happens. But it's just not consistent with where we want to go. One of the things that you touched upon and again, the reimbursement could be many books about reimbursement and that it's in the heart of so much in healthcare, we talked about follow the money, and you can see what's happening. But you didn't talk about fee for service versus, the population health and computation models and how things are changing.

Stewart Gandolf:
And I'm not sure that, if you're in the trenches and healthcare, you may not really see how much is changing, can you give the listeners a little bit of feedback about what you think these trends are and what they mean?

Zeev Neuwirth:
Yeah, and if you don't mind, I'd love to actually just wrap up the point we were talking about before in terms of the redesign, reorganization. One thing to understand and again, this is the system and unfortunately, it's a legacy system that is so archaic, and so harmful, but if you think about it, it made sense a long time ago. In the past, you know, hundred years ago, literally, healthcare was all about acute care, it was all about this episodic care. I had diabetes for 10 years or so and I came to you and I needed you to save me and save my life. I had my arm ripped off, I needed you to do the surgery, it was episodic acute care. The truth is now that over 70% of all encounters probably closer to 80% at this point, is not acute episodic care it's chronic disease management.

Zeev Neuwirth:
In fact, the vast majority of health care costs somewhere around 80% is on chronic disease management. So much of care is chronic disease and it's preventing the progression of chronic disease, preventing chronic disease, what we call primary, secondary and tertiary prevention. And so if you understand what we're treating today, what we're trying to help people with today from clinical care perspective, you understand that we cannot have the same model that we used to 100 years ago. And yet fundamentally, the model has not changed. And that's why... and by the way, people say, "Well, change takes such a long time in healthcare." I would suggest to you that we're a phase change here. And for those of you who remember, high school physics, phase changes when you have two different phases together, like water and ice. And what we know about phase changes as they happen awfully quickly.

Zeev Neuwirth:
And once you're in that phase change, water turns to ice very quickly. And we are about to see that happen. And for those of us who do not understand the time we're in, and the rapidity of the change, and the type of change, the type of reframe we require, I suspect, they're not going to be around 10 or 15 or 20 years from now in healthcare.

Stewart Gandolf:
It's such an amazing insight about the idea of chronic care versus episodic care and for sure, people service makes sense when it was acute.

Zeev Neuwirth:
Absolutely.

Stewart Gandolf:
But if you ask anybody that is such an amazingly high percentage and you talk a bit in the book about type two diabetes, and everyone knows this national tragedy, but you go even deeper into that, and just how... it's again, you're in the middle of the trenches... Nobody looked up and said, "Wait a minute, the whole world's changed" the path racing down doesn't make sense anymore.

Zeev Neuwirth:
It's funny, I think that point is, I like the way you phrased it. Everyone's got their heads down like 100 years later. And it's like, "What, the world's changed?" You're absolutely right. It's funny, because I heard Rick Gilfillan, as I mentioned before he's talking, I was at Mass General partners the other day and giving a keynote. And he was giving a keynote as well. And he said, he had a picture up on the slide where he showed, the classic thing of the frog in the boiling water. And he said, that's how we've been, things have been changing so slow, but it's at the boiling point, we just haven't realized it and I think he's spot on.

Stewart Gandolf:
Absolutely. And I got time for a couple quick questions. The one thing that was so intriguing, and it's also related to this is the social determinants of health. You mean you touched upon that earlier, but I think that in a day like today, where we're talking about chronic disease management, and obviously, you mentioned in there again, it's just fresh refreshing to see the same concept we're talking about, okay, you're working with somebody who has chronic asthma, and you send them to a dirty home or somebody who has type two diabetes, and they're not really equipped. How do you think that is going to change over time? And is that really from your observation, it's hard because reimbursement, we're not getting reimbursed for that. How does that going to change over the next 10 years?

Zeev Neuwirth:
This kind of picks up on your previous question about this shift from people service to population health capitation. Someone's got to be accountable for the runaway cost of care. And that's increasing, we have so people are accountable today. I mean, it's the government that's paying, the federal government of state governments that are paying for health care costs. And 50% of healthcare bills and almost the other half is for by employers. They're on the hook, they're already doing population health, they're paying for healthcare. And then, of course, you got the payers, insurance companies that are also on the hook, but increasingly, providers of being included in that risk and responsible. And as soon as you are responsible for a population, whether it be a panel of 2000 or 100,000, or a million patients, looking at the science of health and healthcare, you realize that literally somewhere between 60 to 70% of the outcomes of care, the hospitalizations, the surgeries, all the medical costs 60 to 70% is not due to medical clinical care, it's actually due to social care.

Zeev Neuwirth:
And a very concrete example would be, you have a child that comes into the emergency room, every week or two with asthmatic exacerbations. Well, those emergency room visits literally cost thousands of dollars and are using a critical resources and by the way, when they're being used for that child, that means that you have to build bigger ERs and more ERs and so the cost then you get these huge fixed capital costs. And think about this, if you just send someone into the child's home, a nurse, and looked at what are the allergens that are in the home and you find out that, they don't have air conditioning with filter, you find out that they've got carpeting and pets and mites and literally just putting an air conditioner with a filter, swapping out the rugs and carpets, maybe you're doing something about the mites and some spray. I mean, so incredibly low cost interventions that could save literally just with one child and one family 10s of thousands of dollars a year.

Zeev Neuwirth:
And then you multiply that to other conditions. And you begin to see that this sort of what they call these new social determinants of health of the social influences of health are unbelievably powerful levers. And by the way, it's the right thing to do. Not just from a cost perspective, but from a human perspective. And when you're now responsible for that cost, if a hospital system is now responsible for the cost of asthma care for the population of children they treat, you better believe they're going to start sending nurses out into homes to do these home assessments. The same thing is true for the elderly. An elderly person who comes in after falling at home because they slipped on the stairs or slipped on a carpet or rug, or they come in because they got dehydrated or having not eaten because they didn't have food. Well, that costs the hospital system, or the provider system or whoever's paying for that 10s of thousands of dollars, can be hundreds of thousands of dollars a year.

Zeev Neuwirth:
You can prevent all of that by sending a nurse into the home, doing a home assessment and making the home safer, making sure that they're not going to fall make sure that there's appropriate lighting, making sure that their medications are set up, making sure that they have food, making sure that they have transportation. Geisinger is a great example of this. They've gone so far as to actually provide transportation for elderly folks, so they're not socially isolated. And what they found out it pays, it pays for them to drive their older folks to the shopping mall, to church, to their friends and their family. Because when an older person is socially isolated, they decline. They stop taking their medications, they stop eating and they end up in emergency room in the hospital. Again, very, very concrete examples of how healthcare systems, our healthcare system as a whole could do the right thing, humanized healthcare, improve outcomes, and profoundly lower costs, through the attention to these social determinants of health.

Stewart Gandolf:
One of the things you talked about there, and again, I encourage our listeners to buy the book and read it. You talked about partnering and I always think about to for those kinds of issues. Partnering with community, are there volunteers, are there civic groups, religious groups, different to be a good partner can also be part of the solution, which is potentially really exciting.

Zeev Neuwirth:
I see what I think you're absolutely 100% right. If you look at other countries around the world that do this, it is absolutely these multi-stakeholder collaborations. There's no way that the health care system can do housing and food and these sorts of things. Education you need multiple stakeholders. And I actually think one of the most exciting things about healthcare is we're going to see, I think in the next three, five years, definitely in the next three to five years for sure, if not sooner, we're going to see a lot of these other entrants come into essentially what is they enlarge and expanded healthcare system, or health system for that matter, the secretary for the Department of Health and Human Services in North Carolina, Mandy Cohen, she has a phrase, which I really love, she says, "We're not interested anymore in just buying health care. We want to purchase health." And that's what she's talking about. She's talking about that larger, broader approach, which to your point was going to require a collaboration amongst multiple stakeholders that are currently not engaged in the healthcare system.

Stewart Gandolf:
That's intriguing. I mean, you're the doctor, so you have to tell me, but you were talking earlier about the, the nurse coming into the house is some of this... whether that's appropriate or not, but maybe even something lower but having volunteers that have been taught how to help with these things. There are conditions and leverage our resources because I think there's a lot of people who would love to help old people and asthmatic kids get better. That has happened a lot.

Zeev Neuwirth:
I think Stewart again, I think you're you're spot on. And there's great examples of this that you don't have to have the training and expertise of a nurse or a PA to do this. For instance, we and others are using paramedics across the country to do home visits. UPenn is a leader University of Pennsylvania, Penn Med is a leader and using community health workers, they literally go out into the community, they find people that are extremely empathetic, and then they train them to be able to work with people in the community, in their homes, literally in their neighborhoods, because they come from neighborhood and they train them how to interface with nurses and with doctors, and it's a great, great bridge. They're showing really profound outcomes of doing some great research and as it's really evidence based, so I think you're spot on, you don't need the expertise of a nurse or a doctor or a PA, you really can train community health workers.

Zeev Neuwirth:
And there's great examples of this and organizations like ChenMed and Iowa Health where they're taking care of very complicated older patients. And they're actually using health coaches. These are non clinical people, as the core member of their team. Again, lots of great evidence to support what you just said.

Stewart Gandolf:
That's exciting. I can imagine this is a little bit off track, but they would also if they're in the home identify stuff before it goes off the road. That's not their job if they see it's better to have somebody there that not versus somebody who's isolated.

Zeev Neuwirth:
Absolutely.

Stewart Gandolf:
The last thing that...go ahead.

Zeev Neuwirth:
No, no go ahead, you go.

Stewart Gandolf:
I was just going to say one thing that so... as I was reading the book, one of the things that having worked in this industry for 20 years, there's a lot of inertia keeping things just the way they are. And I think you may have brought this quote up, this is a pretty common quote in the book, but I also use it, which is an Albert Einstein quote, which is, "We cannot solve our problems with the same thinking we used when we created them." And what was interesting is I have a former mentor of mine who is more pessimistic, he said, "You can't ask the same people who created the problem to fix it." It's a little more pessimistic for sure.

Stewart Gandolf:
But I was just going to say obviously, though, healthcare has become a morass of complexity, but there's some strong, strong forces kicking and dragging, things are going to change and you talked about this dominant force being business and I feel like if that old show, that old move yet I just can't take anymore I've had a mad as hell and I can't take it anymore.Tell us about business and what's happening there.

Zeev Neuwirth:
I know, I think the great quote to bring in there is from Warren Buffett, who's been saying, for the past three or four years that, healthcare is really the hungry parasite of the corporate America and the hungry taper in this way, we actually called health care. And that's a pretty aggressive perspective. But I think that's actually very much the perspective that corporate America has right now about health care. It's the number one line item, it's the number one cause for most industries and most companies, they don't know what they're getting. They don't know, the return on investment, costs are epic. We know, really, from their data and their literature, that so much of the surgeries and procedures are unnecessary and actually harmful to their employers. And so, this is not again, this is not an academic issue. This is not even a humanistic issue. This is definitely not a political issue, this is the market, the market is had enough, it's not going to take it anymore.

Zeev Neuwirth:
What you're seeing though, which is really, really interesting is that employers... corporate America has very, very quickly gone from being the sleeping giant is what I call them of health care, employees were sleeping, but now they're awake and they're hungry. They're both angry, but they're also hungry. They're hungry for our revenue because they see the growth in efficiencies and ineffectiveness in the healthcare industry. And again, they see a margin in that and they think they could do a better job. And so they're aggressively, aggressively going after the healthcare industry. And both from their perspective as initially as an employer, fixing their own healthcare and we see lots of end runs they're making around healthcare delivery, but they're now actually saying, "Well, we actually think we can actually do this better than you can." And they're not being shy about that anymore.

Zeev Neuwirth:
Now, in terms of the same people doing it, I would say the fundamental thing is this. We know that all innovation essentially, is borrowing concepts from a different field or industry and bringing it into your industry. And again, that's the fundamental point I'm making the book, the concept that we need to adopt and healthcare is a marketing mindset. That is the fundamental reframe of our error. And if the people in healthcare can do that, then yes, we will be the people to change healthcare and be part of that change. If we can't, well, we'll be working for those other people, because they're the ones that are going to be running health care. I think the choice is pretty obvious. And that's why... and by the way, I think it's the right thing to do. I mean, my fundamental purpose is to humanize healthcare, to make it better for the people that are being served by the system and to make it better for the people being served in the system to unleash an unlocked the tremendous value that is currently locked up in our healthcare system, in our providers in our staff, in the system itself.

Zeev Neuwirth:
And ultimately, it's really about saving lives. And I just don't know how to put it in any other way.

Stewart Gandolf:
That's fantastic. And yes, at the end of the day, we talked about this beginning significant wrap up this way. We're not trying to make anybody wrong here. I didn't get that impression from your book at all and your talk. Rather, we're looking for better ways and acknowledging we still have safety problems. We have patient experience problems, we have doctor burnout problems, so it's hard for anybody to advocate, this is great. When you look at it more what else could there be, right? If nobody's happy, there's got to be something we can change. That's important. And I think that, it takes voices that are courageous and willing to look at things new and bring in new insights. And again, our point is exactly the sense of that it's changing anyway, whether we like it or not, whether we want to be part of it or not, it's going to change and it is changing.

Stewart Gandolf:
And one of the things I talked about on a podcast I had, I was pressed some people from Press Ganey was that I'm quoted in their latest white paper was health care has changed more in the last several years in the last three decades. And that is 100% my experience as well. It's just moving so fast and the marketplace is moving it but I think that the difference that you're... I was really intrigued, I was going for your book. And the interesting part of that book was, the business part was at the end, I was waiting for the punch line, like I'm "Okay, how are we going to get here?" Zeev I'm with you. How are you going to get here? I love that you put that toward the end of the book because I thought that was really important. Because it's not just about greedy business guys, but at the end of the day, they're putting the bill and that's where I think so many the issues have been because it's a different marketplace where the consumers haven't directly paid the bill.

Stewart Gandolf:
And another thing I thought you'd put really intriguing was your insight that just saying that, the consumers having skin in the game. It's really not fair as it turns out, and I thought that was really intriguing inside. This book is filled, filled with insights. And I really appreciate your thoughts and leadership. I'm going to close in a moment, but any last comments for our listeners?

Zeev Neuwirth:
Stewart, I think you did a really great job of summarizing it. Now again, I think the overall point here, my point is trying to take what I seen happening, I'm definitely not a futurist and I'm not talking about the future I'm literally looking at what's been happening over the past few years. I've been following the narrative and following the themes and just have distilled it and I've seen this pattern of success. And I'm hoping that people pick up on this reframe and reframe roadmap. I just think it's an effective and replicable and scalable approach to really transforming healthcare, which we all agree we need to do. And so that's really what I'm all about at this point.

Stewart Gandolf:
That's terrific. And again, the last point I'll make on that then is, I think it's important to have that perspective. At the end of the day we're an agency, we get compensated. Do we get compensated? Everybody has their own things they have to do on a daily basis. People that like you that take the time to stop and seriously study and put together connecting the dots because one of the things I've noticed as well, but you actually spent the time to study it and pull it together into a context, all wrapped up into about 250 pages of terrific reading. I thought that was great. And again, I would echo your point. This isn't theories that supports his hypotheses throughout the book. Beyond hypothesis these are actual just observed things that are happening the marketplace. That book again is Reframing Healthcare: A Roadmap for Creating Disruptive Change by Zeev Neuwirth. Also Zeev's podcast which I'm going to link too as well on the post Creating a New Healthcare. Terrific, Zeev I really appreciate your coming on our podcast today and I look forward to working with you again in the future.

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