 This is Think Tech Hawaii, Community Matters here. This is Craig Thomas, your host on Much More on Medicine, part of Think Tech Hawaii's live stream series, and as usual, assisted by Ray and Rich, our engineers, and today I would like to welcome Stephanie Bialetti, she is Senior VP of HMSA's member operations. Brought to the new position for Stephanie, congratulations and welcome. Thank you, Craig. Happy to be here. Thanks for having me on the show. It's my pleasure. We've known each other a fair while now and in fact our spheres are, should we say areas, as in geographic, of effort overlapped for a lot longer than that. Stephanie, until last fall was the CEO at Kahuku, and we provide emergency department and inpatient services there, so we got to know each other pretty well. And I'm thrilled you're in your new role, because I think that the challenges and good things that we share in, across the state and Kahuku is a very, in many ways, representative slice of the state apply everywhere. Yes, definitely. And yes, it's been an exciting couple of months. I transitioned from Kahuku Medical Center to HMSA in October of last year. So being on the provider side for the past 19 years and being able to transition over to the payer side and being able to see things from kind of a little bit of a different perspective, but definitely striving for the same goals in regards to a healthier Hawaii. That's one of the things I've always liked about you, striving for a healthier Hawaii, because if that's not what we're trying to accomplish, what are we doing? Exactly. So over the course of the spring we've talked about issues of how much care is the right amount, where it should be delivered, how people get from one place to another, where it should be done, the harms of doing too much, and the importance of standardizing care pathways so that we all get the right amount of care and the right care no matter where we are. Today we're switching gears a little bit. Those things are all important, and we can certainly talk about them because HMSA has a big role in helping coordinate standardized and standardized care across the state. But I really like what your focus has been the last several years. The Blue Zones Initiative and the fact that I'm going to stay healthy. I better not eat too much, I better exercise, I better do things that contribute to my happiness and the people around me, and that will improve my health. So we've, and I'm sure some people have heard of our strategy Mahia 2020, and I think our slide one shows what we're striving for and really being able to keep the member at the center of all that we do and our focus. So really trying to switch being a health plan, which was established by social workers and teachers back in 1938, a long time ago. So making that shift from being a health plan to a health organization and really being able to focus on the member and all aspects of well-being. So that's what Mahia 2020 is focusing on, being able to create more partnerships, collaborations in helping members achieve, being the healthiest that they can be. You know, I think that's fabulous. We, so when I started doing emergency medicine, God help us 35 years ago this year at Wahiwa, so near Kuhuku, we were doctors. And people came to us, we took care of them, they went away. Sometimes they came back. But I've come to recognize over time that my impact on health that way is very real, but can have a much bigger impact on health by working it out of change things. So we got involved in drunk driving legislation and are very supportive of your efforts in exercise and soon we're going to be talking next week probably about drowning. These things all are the premise of if you can prevent a problem and whether it's drowning, a car crash, diabetes, it's much better than trying to treat a problem. Definitely. So Blue Zones was founded a couple of years ago, I think 2015, and really focusing on helping communities improve their health. So working with employers, organizations within the community, establishing more eyes for walking, for eating, for gathering, really focusing on being proactive and versus addressing issues when people are sick. We definitely continue to do that, but really making that shift to provide healthier options for people within their own communities. Exactly. And really hats off to HMSA for doing this. And hopefully providers across the state, and I know some are, there are doctors leading community walks for example, I know this is happening in Hilo. I think it's likely happening, I hope, across the state. Good for us to walk and it's good to share both the exercise and the community with everyone else. Because health is complex. It requires exercise. It requires social connection. You have to eat more or less the right things, a weakness of mind. And as long as we are focused on disease treatment, we are missing that boat. Definitely. Even within HMSA, I mean, I always, you know, these conversations, I always try and relate it back to me. You know, what am I doing in regards to my overall well-being? And you know, I have to think twice, do I want to take the stairs, you know, versus the elevator? And the stairs is right next to the elevator, so it makes it really easy, but being more conscious. Right, so that's a lot of stairs. So being able to consciously and being intentional about my health. But being able to create those opportunities for people. In some stores at Foodland, they have aisles that offer healthier choices, you know, such as fresh fruit, nuts, you know, versus your regular aisles that have a lot of sugar. All my favorites. Yeah, all your favorites, right. Of the addicting foods. No, they are. They are designed to be addicting. Yes. So being able to just create healthier options for people to help them be more intentional regarding their choices. Exactly, and this actually brings to mind, I've been watching all sorts of dietary and other kinds of publications over the years and have decided it's really pretty simple. Michael Pollan has the haiku that describes it. Let's see, what is it? Eat food? Because that's of course one of the problems. It's not like you can't eat food, it's necessary, it's fuel. So eat food, mostly vegetables, not too much. The other thing he said was, eat like your grandma ate. Because the problem is, when we buy that aisle, from that aisle you were discussing, the one that is almost like crack, it's engineered to be addictive, we'll eat too much, but it's also got lots of sugar, lots of salt, lots of fat, lots of calories. So it's not magic. It's just eat food, not too much, mostly vegetables, and mimic your grandma. So there's just those little choices, and I think the Blue Zones Initiative, being able to create these support systems within your work environment, within your community, because yes, they are difficult decisions to make. And we have hundreds of them throughout the day. Do I want to eat that muffin, or should I eat the banana? Yes, exactly. And so being able to create more of the support systems within organizations, within the community, within the health care system is really important. It is, and I think it starts one step at a time. You know what? I love coffee, which thank God so far no one's found anything bad about, and it might even be good. So I drank my coffee, I punted on the sugar a few years ago. So little decisions can help. You also touch on something else. Our network, our friends, the people around us impact how we do with these decisions all day long. There's some fascinating evidence that if your partner gains weight, so do you. They don't even need to be in the same state. If somebody you are in contact with, then you can be in contact with over Facebook gains weight. Your odds are, you kind of might too. We're complicated. We're gullible in the, how should I say it, Resolutions Department. And I think it takes a lot of different strategies and Blue Zones is one to impact this. And honestly, it's the most important thing we can do for our health is to eat right, be more or less right weight and get regular exercise. Doesn't need to be dramatic exercise. Definitely. Yeah. So just trying to figure out how to be able to, HMA is really this shift to focus on wellness and health versus disease management, which we know we still have to do. So a lot of areas of opportunity for us to continue collaboration and increase our partnerships. Those relationships are key to be able to help facilitate these choices and try and limit the fragmentation within the health care system. Well, it's interesting you should mention the fragmentation of the health care system. Compared to the rest of the, our peers in the world, other countries, US has, I don't know, we've talked about this all spring, on average about double the cost with very middle of the pack results. Relevant to this conversation, we're also on average fatter, and we don't move around too much. And I've not seen real analysis of our diet, which are probably pretty varied, but I'm sure salt sugar are well featured. Unfortunately, that plague has spread almost everywhere. I was recently in Palau, not a whole bunch of healthy choices in the local market. That's not quite fair. The local produce, fruits was fabulous. Everything brought in from elsewhere, not so much. But the interesting difference between our health system and the rest of the world is related to what you just touched on. It's fragmentation, and it's expense on the sort of business side. We call it the revenue cycle management. But the business side, the charting, the coding, the billing, the getting the information from a pulmonologist to the primary care provider and to the patient, we're terrible at that. And it overall falls under the coordination of care heading. And although we have middle of the road results on outcomes, and we actually are good at some things. Our rate of hospitalization is lower than many of our peer countries. Our coordination of care is the bottom. And so I know you've been engaged in how to solve that. So are we as our group. And in fact, we have a little partnership going on trying to figure out how to do it better. I'm honestly really excited about it. So HMSA has implemented a care model which is supporting our members who need the most help. So it's really personalized high touch service to two members who have maybe dual diagnosis, different cancers. So we've implemented, so we call it care model, we're kind of these wraparound services for these members and trying to help them navigate the healthcare system. So that's a really interesting topic. We're going to take a little break. This is Much More Medicine, your host Craig Thomas with guest Stephanie Bialetti, senior VP member operations of HMSA. That's a long title. And we'll be right back. This is Think Tech Hawaii, raising public awareness. Ted Rawlsson here folks, your host on Where the Drone Leads, our weekly show at noon on Thursdays here on Think Tech. We talk about drones, anything to do about drones, drones, remotely piloted aircraft, unmanned aircraft, whatever you want to call them, emerging into Hawaii's economy, educational framework and our public life. We talk about things associated with the use, the misuse, technology, engineering, legislation with local experts as well as people from across the country. Please join us noon on Thursdays and catch the latest on what's taking place in the world of drones that might affect you. Welcome back. This is Craig Thomas, your host on Much More Medicine. And my guest today is Stephanie Bialetti, senior member, senior VP. I'm going to get this right yet. Senior Vice President, member operations HMSA. And before the break, we were talking about the importance of all the elements of care in health. And as you can see from the slide, what we individually do is the biggest single element in our health. Clearly there are other elements. And also clearly the health care system can help support our efforts, our individual efforts. I think that's crucial. However, some people do have health issues and that's where the organized portion of the health care system comes to play. And there are, there's a subset of patients who are very high-utilizers and they need special help. And one group you alluded to just before the break is what we call dual diagnosis. That means you got a couple problems. Usually they're related to some sort of substance suggestion and some sort of psychiatric diagnosis. However, those lead almost immediately to all sorts of real medical problems besides just demonstrating how our actions impact our health because people with those two challenges generally don't have very healthy lifestyles. Yes, so and very complex. And I think our slide three just really highlights how complex health care is. And so being able to help our members navigate the system is really important to us. We call it fragmentation or gaps within the system and I think health care just in general is just very complex. There's a lot of rules and regulations and every time we have a new administration then it's like whiplash trying to figure out what we need to do on our end in order to meet those mandates. So being able to operationalize what those rules and regulations are and figure out how to continue to assist our members is an important piece. It's why I like your blue zone focus because my perspective is a lot of the complexity in medicine is because we lost track of what the goal was. The goal is actually health. The goal is not delivery of health care. Now it's a key part but it isn't actually the goal and if you look at much of medicine the confusion about the goal namely we're very good at delivering health care we're very good at billing for it we unbundle it, we list it, we do it let's not talk about that. We're not so good at health and over the years we've gotten sidetracked by things that matter but which still aren't the goal. So for example, patient privacy is a huge concern. The only way to have absolute patient privacy is to never share the information with anyone. You can't do health care that way. If you, I don't know, just got a prescription from your doctor and now you're in trouble in the ER I need to know that. So and over the years we put in lots of band-aids to try and address these things and it's a hobbled the whole system as your slide to my mind dramatically generates it's shocking how complicated it is. Oh definitely. I mean, you know, if you go to multiple hospitals or multiple physicians they all might have, you know, different electronic medical records. No, they're not might have, they do. They do. Yes, they do. And so, you know, you have to log in to all these different accounts to access your patient portal if you want any of your medical records and so sharing that information is very important so you can have continuity of care and make sure that your health is being managed effectively and so that is a big issue and I know you're, there's some awesome projects that are going on right now within the United States on being able to help facilitate that process. Yeah, thanks for bringing that up. It's my personal plug for the spring. There are no new problems under the sun and the state of Washington about six years ago now looked at the frequent utilizers in emergency departments many of them with dual diagnoses and ultimately came up with something called EDIE Department Information Exchange and it's stupendous. I've been up there, I watched it in action and I really hope we get it here. It would solve a number of problems and in essence what happens is your health information sits in the cloud and it has your diagnoses, your medications, your allergies, your previous interventions and your current sort of health footsteps shall we say. So you see your PCP, you see a specialist, you're at the emergency department at Kahuku then later you end up at Castle and if I'm taking care of you at Castle I know those things. And then the next, your regular doctors and the next place you need help say you get worse, you end up downtown at one of the downtown tertiary facilities they know it too. And this is, I imagine, many people assume well of course they know where I was and what I did. It'd be like your bank, our current system is kind of like having your branch bank not connected to any other branches. So every time you go into the bank you say well I do have a whole pot full of money in my account and I sort of know that would never fly and it's not working in medicine either. Very, very true. So we have a new CEO, Mike Stoller. Congratulations. Yes. So he took over the helm in January and he's been with HMSA over 30 years and this is one of, you know, as part of the Mahia 2020 strategy is really how do we connect the dots for our members as well as within the healthcare system. So even within HMSA we're trying to figure some things out, how to provide that 360, that complete view of the member. So to help streamline some of these processes so that we have the most accurate information of the member at that point in time. I think that's where we got to go. I sort of think of this as a variation on the 360. I think of it as a three-legged stool. There's you. There's us providers and there are the facilities and interestingly each of them has their own piece and until, well I won't say that, currently the incentives for aligning the efforts are inadequate and the barriers to sharing data, for example, savings, those kind of things aren't happening and it needs to. And so I'm hopeful and it's human. We are all invested in our own world. We all think the others should play but we're not so excited about sharing our stuff but unless we break that down we're going to struggle. I completely agree with you. I think that was one of the reasons why I came over to HMSA is because I truly believed in their mission and vision in being able to improve the lives of all of Hawaii. And to get there is will take a lot of hard work because as you said we're all on silos, we have self-preservation issues but really focusing on creating a win-win which is Mike Stoller's goals as well creating a win-win and increasing partnerships to be able to strive to create a healthier Hawaii is really, really what's important. I agree. One of the challenges in America is we're capitalists and if you're making widgets probably good or even if you're making on-the-fits my preferred vehicle but if your goal is improving health that's much harder. How do you measure that? How do you reward it? If your goal is, I don't know doing a whole bunch of a procedure and we could list a cabillion procedures Nearthroscopy doesn't usually work on old guys like me but it's definitely a billable procedure that capitalism works great for that except for the fact that I shouldn't have had it in the first place and the buzz word is payment transformation. It's essential and it's going to be tough. Crossing that great divide yes, it's very challenging we refer to it as the bridge strategy because one payment is in fee-for-service one foot's there and the other one is in payment transformation. I think that, yeah we're just trying to sort things out and figure out what works in order to make that great leap. Yes, and we're also going to just like in other parts of shall we say national debate nostalgia for the past won't get us there so there's great nostalgia for Marcus Welby the all-knowing time for everybody family practitioner being sort of the portal and be all an end-all and gatekeeper for healthcare. We still have great providers in the community but the truth is the tools have changed dramatically. When I started if you'd come to my ED evenings or weekends and look like you had a stroke we were to put you in bed next morning they would have got the CAT scan. Now all sorts of things happen you get a CAT scan you may get an MRI you may get a CT angiogram if you qualify we'll get a clot breaking medicine and if that doesn't work you'll get shipped to a tertiary center there are only one or two places in the state that do this to get the clot removed it's better it's an example of how things have changed and for acute or emergent conditions Marcus Welby is going to send you the ER and so my sense is we should figure out how to facilitate that but then also change the costs associated with that the problem isn't the ER the problem is the way we set up charge structures so then we allocate costs probably in a way that distorts how we should be providing services and this is a challenge for our decade we have a little bit of time left what would you like to leave people with? I think I guess what I want to emphasize is that we're all in it together we all end up paying as taxpayers for our health or lack of health and so we pay personally of course too I'm talking about if I can't walk up the stairs because I haven't exercised that's a price definitely so personally and as as in a community as a state that we are we are literally all in it together and so being able to take it to heart what is Stephanie going to do about my overall well-being and how do I contribute to the community and just striving to create more partnerships and win-wins as we strive for that ultimate goal Perfect I think it's the only way we can succeed so Stephanie I'd really like to thank you for coming today I appreciate your enthusiasm and perspective and focus on health so with that we'll close till next time I hope you're back this is Craig Thomas your host on Much More Medicine part of think tanks Hawaii's live stream series thank you very much