RamaOnHealthcare August 31, 2023

Beyond the Walls of Healthcare Today (Part One of Two)

RamaOnHealthcare talks with Dr. Zeev Neuwirth. He is a healthcare executive with 15 years of experience in clinical practice and another 15 years in process improvement, clinical operations, population health, & care redesign. He most recently served as the Chief of Care Transformation at Atrium Health (now a part of Advocate Health). We discuss his recently released book, Beyond The Walls – Megatrends, Movements & Market Disruptors Transforming American Healthcare that has achieved Amazon’s Top New Release in Health Care Delivery and Hospital Administration. His previous book is, Reframing Healthcare: A Roadmap for Creating Disruptive Change.

Dr. Zeev E. Neuwirth, Healthcare Executive

Dr. Zeev Neuwirth, Healthcare Executive

This interview is provided in two parts. Part One covers Optimism in “Healthcare, Massive Potential of Platforms, and The Biggest Challenges”. Part Two discusses “Humanistic Movements, Improved Approach to Senior Care, Strategic Domains, and Disruptors in Healthcare“.

RamaOnHealthcare (ROH): In your book, you mention you are “cautiously optimistic” about the future of healthcare. What would make you entirely optimistic?

Zeev Neuwirth (ZN): First, let me say that I have never been as optimistic and enthusiastic about the future of healthcare as I am today. But I’m also a realist. I become increasingly optimistic when I hear, read, and observe more humanistic counter-narratives in our healthcare system. Beyond The Walls is my attempt at showcasing some of these positive, real-life counter-narratives. This is critically important because history teaches us that every movement and every historic inflection begins with a dialogue and a different narrative. In the book, I provide dozens of courageous exemplars successfully creating a more accessible, affordable, equitable, effective, and personalized healthcare system. This book focuses on what is right in American Healthcare and what we need to do more.

…what is right in American Healthcare….

Regarding my cautious optimism, I will be much more optimistic about the future of American healthcare when:

  • The US healthcare system begins to do what every other advanced nation has done and invests appropriately in primary care.
  • We eliminate the gross inequities in healthcare delivery and the unethical disparities in health outcomes, such as life span, chronic disease outcomes, and maternal-fetal mortality.
  • We provide affordable health insurance to the tens of millions (~8%) of Americans without health insurance so they can receive comprehensive, preventive care.
  • We significantly reduce the crippling medical debt impacting 100 million (~41%) of Americans so they don’t have to make terrible no-win choices about paying for medications and medical care versus basic needs like food, housing, or childcare.
  • We address the tragic and worsening epidemic of behavioral health and suicidality (deaths of despair) that is ravaging our youth and working Americans in the prime of their lives.
  • We begin to recognize and support the 53 million family caregivers in the US who play a pivotal role in caring for the infirm, disabled, and elderly -and who play a critical role in our healthcare system.
  • We begin to widen the aperture and dedicate much more of the American $4 trillion healthcare budget to wellness, prevention, and the social determinants of health.
  • We align provider payment and compensation to value-based health outcomes rather than volume-based processes and procedures.
  • We reverse the epidemic of demoralization and burnout amongst American doctors, nurses, and other providers – which affects nearly half of all providers, and
  • Healthcare associations and prominent industry stakeholders invite folks with counter-narratives to keynote their national meetings and to speak in their C-suites and board rooms.

Until the underlying narratives change – and I’m borrowing this metaphor from a young physician leader I recently met – we’re using paddles to try to steer aircraft carriers. We need to engage the leaders at the helm of these large stakeholder carriers to author, resource, and deploy humanistic healthcare as the predominant narrative. I’ll be incredibly optimistic when I see and hear that happening.

…we’re using paddles to try to steer aircraft carriers.

ROH: In chapter 7 of Beyond The Walls, you talk about the ‘burning platform.’ What is the power and promise of platforms in healthcare? Why is it a ‘burning platform’ for healthcare leaders?

ZN: I use the term ‘burning platform’ because healthcare leaders and legacy healthcare organizations must begin to understand the power and potential of platforms. Over the past few decades, platforms and digital technology have radically transformed numerous industries. The same is about to happen in healthcare. I devote an entire chapter to this topic because if healthcare leaders don’t understand it, they, and their organizations, will fall behind.

Platforms have transformed our daily lives. In the not-too-distant past, you’d have to go to a library or find a hard-copy encyclopedia or atlas to search for information. Now, we have numerous content sources at our fingertips – Google, Wikipedia, ChatGPT, and myriad .edu, .gov, and .com platforms. Consider how retail has been transformed by Amazon’s platform and other online retail venues. We can order almost anything online and have it delivered to our door within days, hours, or minutes. We have witnessed platforms revolutionize other industries like finance, banking, communications, entertainment, and travel – and in doing so, they’ve transformed our lives.

The same digitally enabled platform revolution is about to occur within healthcare. First, we’re beginning to see existing platforms such as Uber and Amazon offer healthcare products and services. Second, we’re seeing new platforms emerge from within healthcare – Amwell, Teladoc & so many others – delivering virtual care and automated services. Third, we’re seeing new disruptive companies, like Transcarent, as a platform for direct-to-employer care. And we are witnessing other start-up platforms, like Xealth and KeyCare, that connect providers and patients to digital and virtual solutions.

There are some key differences between platform business models and our legacy business models, which healthcare leadership must understand to fully leverage the power of platforms. First, platforms are not a traditional linear business model. They are a digital platform that connects customers and vendors. In its most basic form, it is a triangular business model. Second, unlike the typical business model we’re all familiar with, platforms do not create all of the products or services they offer. It hosts them. Third, unlike legacy electronic health record systems, platforms improve as they bring together more customers and vendors. The more vendors on the platform, the more choice and customization; therefore, the more customers it can attract. The more customers on a platform, the more vendors it can attract.

Platforms will offer healthcare consumers more accessibility and convenience, options and customization, information, transparency, cost-effectiveness, affordability, and greater navigation and referral services. From a provider perspective, platforms will unleash the incredible value they offer to a much larger patient base. The opportunity for hospitals is to: (1) serve as vendors and customers within larger platforms; (2) become local platforms – the connectors and conveners of healthcare in their community or region; and (3) collaborate to form networked platforms.

ROH: If you had to choose, what would be the three most significant changes you would make in American healthcare delivery to improve the experience and outcomes of care radically?

ZN: 1. Value-based payment & compensation

Over the past eight years, I’ve conducted in-depth interviews with hundreds of successful healthcare leaders and entrepreneurs. Every one of them, without exception, agrees that we need to shift from the current Fee-For-Service (FFS) system to a value-based payment system. The Centers for Medicare & Medicaid Services has made this one of their highest priorities and is looking to have 100% of Medicare members enrolled in a value-based contract by 2030.

Value-based payment is key if we are to reduce unnecessary and harmful over-utilization. It incentivizes the prevention of chronic diseases. Value-based payments also reward the adoption of services that address the social determinants of health and contextual factors, which we know have a more significant impact on outcomes than clinical interventions. Value-based payment focuses on outcomes of care, whereas the current FFS payment model incentivizes procedures. What we all want, as healthcare consumers, is the outcome of good health, not the process of healthcare itself.

What we all want, as healthcare consumers, is the outcome of good health, not the process of healthcare itself.

2. Appropriately resourcing & supporting Primary Care

Decades of health services research is clear about this one thing. The more primary care in a community or population, the healthier the people and the lower overall healthcare costs. In the US, only 5% of all healthcare dollars are spent on primary care. As a result of this profound lack of resources and support for primary care, we are witnessing fewer and fewer medical students entering the field. The demise of primary care in the US is a recipe for disaster – a downward cycle already significantly harming the American public.

The demise of primary care in the US is a recipe for disaster….

The solutions are straightforward. First, we must proportion more healthcare dollars to primary care and create more equitable compensation for primary care providers. Second, we need to provide greater resources to primary care providers. The job is currently not doable! Numerous peer-reviewed articles have demonstrated that a primary care provider would require anywhere between 18 to 26 hours per day to fulfill all required tasks. Third, we need to align payment & compensation to one of the core professional purposes of primary care – proactive prevention. If we only compensate for visits and procedures, we will force providers and their organizations to be ‘visit vendors’ and ‘RVU generators.’

…we need to provide greater resources to primary care providers.

3. Resourcing and integrating the non-clinical (social) determinants of health

Years of health services research have made it clear that non-clinical factors are the most significant determinant of our health outcomes. These factors have been referred to as social determinants of health, non-clinical determinants of health, and political determinants of health. These factors include financial status, employment status, educational status, housing, transportation, neighborhood safety, local environmental factors, and the integrity of communities. The impact of these non-clinical factors determines well over 50% of health outcomes, while clinical factors have far less than a 30% impact on health.

Years of health services research have made it clear that non-clinical factors are the most significant determinant of our health outcomes.

Another related set of non-clinical factors is termed ‘contextual factors.’ These factors include support services, personal & family responsibilities, emotionality, mental health factors, one’s understanding of disease and illness, trust in one’s providers and the institution of healthcare, etc. The social determinants of health and contextual factors account for over 70% of the impact on our health outcomes and overall health.

So, what can be done? First, although these non-clinical factors significantly impact health outcomes, they receive a minority of the payment in healthcare delivery. We must begin to invest more of the healthcare dollar in these non-clinical determinants of health. Second, we must embed the identification of these barriers of health into daily practice, along with the resources and services to address them. Finally, we need to automate these services and integrate them into our technology – to relieve the burden on providers and their teams, and make them readily available and accessible to the American public.

About Dr. Neuwirth

His previous book, Reframing Healthcare: A Roadmap for Creating Disruptive Change (2017), achieved #1 status on Amazon for Hospital & Health Policy. His podcast, Creating a New Healthcare, has 150+ episodes to date. He is an alum of Tufts University and the University of Pennsylvania School of Medicine with a Master’s in Healthcare Management from the Harvard School of Public Health. He lectures at Harvard and Yale Schools of Public Health. Find more here:

Amazon link for Beyond the Walls

Amazon link for Reframing Healthcare

Reframe Healthcare website

Creating a New Healthcare podcast website

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