 Hello. My name is Sue Peppen and I serve as the Director of Health and Clinical Partnerships at Arizona State University. I want to welcome you all to the second of our four events in our biomedical innovation series. I want to thank the Arizona Biomedical Research Center for sponsoring the series and ASU Knowledge Enterprise for their work in fostering innovation through research and discovery. The structure today is going to include some remarks by Dr. Lee, followed by discussions. Please go ahead and start putting questions into the questions ability on Zoom, and we will try to get to those later. So it's now my great pleasure to introduce to you, Dr. Vivian Lee. Dr. Lee has had an incredible and varied journey in her career. She is also a health care executive and the author of the long fix. Solving America's health care crisis with strategies that work for everyone, which we're going to talk about some today. She is a senior lecturer at Harvard Medical School. And she is the president of health platforms at Verily Life Sciences. Prior to joining Verily. She served as the dean of the medical school and the CEO of the University of Utah health care and integrated health system with a budget of over 3.6 billion, including about 1400 member physician group and health insurance plan. During her tenure in Utah. She really led to change in health care delivery at the system with real innovations that enable higher quality at lower costs, and with greater patient satisfaction which we'll hear some about. Prior to Utah, she served as the inaugural chief scientific officer and New York University's long game long gone medical center. She's elected to the National Academies of Medicine as over 200 peer review publications. I could go on quite a bit, but with no further ado. Welcome Dr. Lee. Thank you so much. It's wonderful, really wonderful to be with you and for those of you who have known Dr. Pepin for a long time, you will share my admiration for her. And you may not know that actually I think we've known each other for a long time now. I don't know if I really want to share how many years but it's been a long time. It's just so wonderful to be able to be with you today and thank you for inviting me. As you mentioned this, I am on this virtual book tour, and I really enjoyed the opportunity to talk with people from all over the country, whether it be some brand rounds or speaking like this at a university setting, or with medical students or in the community. By talking about the book and by having discussions like this, it really gives me a chance to reflect more and particularly get a sense of your thinking about health care. And so I'm really looking forward to the discussion with Sue and with all the community today. I was particularly drawn to writing this book and I'll just show you. I was really drawn to it because I found this issue of our health care system in the country to be just a really fascinating question or really a real paradox to think of our times. And I think as most of you know, and I wish we were in person because it's just so much more fun to actually see people and have that engagement, but hopefully we can do one. But as most of you I think know the real paradox of health care in this country is that we are just spending so much money on health care. In this country, per person we spend around two, two and a half or even three times as much per person per year than other high income countries. We would expect us to be two, three times better. But in fact, actually our performance always comes in among the lowest of other high income countries. And that can be measured in many different ways from everything from infant mortality or maternal mortality to life expectancy. So for example, the average baby born today in the US is projected to live for five or even six years less than the average baby for example born in Italy or in Israel or in Australia. And so, unlike many of the other really challenging problems that we face in this country, like poverty and education, you know, this where we are significantly under resourced, you know, there's really a major issue with the fact that we just don't have enough resources for those problems. In health care, it's really the opposite. It's not that we're not spending enough, we're actually spending too much. And with the ultimate irony is that many of the people who you would think would be benefiting, you know, the physicians, for example, administrator. They should be really, you think they'd be happy because somehow this money is pouring in, but in fact they're actually among the most frustrated and most for that. And so I think what we conclude is that our industry, our business, unlike most other industries just isn't really working efficiently. It's really, we're not getting the market efficiencies that we would expect, where innovation and competition and capitalism will be driving to better and better outcomes at lower costs. Somehow it's just not working for health care. And trying to understand why that is is one of the main reasons why I wrote this book. I actually really loaded for our medical students because I was trying to explain to them what was happening in health care in this country because I feel that the future is in their hands. And so I wanted them to be a little more equipped than I felt like I was when I came out of medical school at residency. And the good news is that the solutions for how we can get to a better, more efficient, more effective healthcare system. I think the ideas there are actually pretty well defined among the people who have been thinking about this for a long time. Kind of remarkably, especially in this week. I would say that there's actually bipartisan support, and it's very much a shared vision for the way forward in health care, really moving away from a fever service model to a model where we are paying for better. In fact, when I interviewed people for the book I interviewed about 100, over 100 people in the course of writing this book and you know people who have come from all different walks of life in health care. And I asked them what's the one thing if you could just wave your magic wand and fix one thing in healthcare. What would that be and the vast majority of them said what I just shared with you which is the business model change the business model. And that was the most important language so what I then spent a lot of time thinking about in the course of my career and then in my years sabbatical when I was working on this book was, well, what are better models that could work in this country and what are the things that are already have already been going on that already have the data of successes, and how can we leave together the stories of those successes into a coherent national strategy, and do it in a way that actually addresses each of our individual roles and responsibilities, whether you're patients, whether we're clinicians, no hospital administrator type people. So that's really what what the story is about and I thought what I would do is read just one just a segment of the book was one page or two that maybe gives an example of new ways of thinking about practicing medicine and some of the lessons that you can draw and also what's happened during COVID actually with those. So I'm going to find this page I'm going to read a short section from early part of the book. It's in chapter two this chapter is called an apple a day keeps the patient away. And it's about my interview my conversation with a guy named Christian man starts like this with a quote. Go see that crazy Chinese doctor who takes care of all the poor Cubans. Christian grins as he told me how people used to read about his father's clinic in Miami. His father had started as a typical primary care doctor and private practice. He was paid fee for service, which meant the more patients he saw the more he earned. Then in South Florida in the early 1990s a few insurance companies started experimenting with new ways to pay doctors. Instead of fee for service, they gave them a fixed amount per patient for you. If a patient needed expensive imaging costly drugs or long hospitalizations that added up to more than that amount. It was the doctors. Chris's dad, the doctor, and his mom, the office manager, experimented in this new model. They welcomed referrals, but other doctors sent them only their frailest and forest patients, the ones they knew would be grossly unprofitable under this new way of paying. That's how Chris parents began the 250 of the sickest people in Miami. They told who would have been almost impossible to keep well at any facility at any place. It looked as if the chance that signed up for a financial suicide mission. Because resources were scarce and their patients needs were many the chance decided to focus on primary care and prevention. Their fragile elderly patients had to be seen frequently by doctors. Once they got sick, it would be too late. So they set up monthly visits, even if there was nothing wrong. The clinic would be tough for many of them. So the chance provided free door to door transportation. They worked out that averting the cost of just one ambulance ride and stay could pay for a year. They opened a pharmacy in the clinic so their patients could conveniently cheaply and reliably focus. And since their patients often had complex needs, physicians in the clinics conferred several times a week about how best to treat those who weren't doing well. So that crazy Chinese doctor and his wife, not only provided outstanding care for the patients, including many who often didn't have enough to cover co-pays with the doctor. But they also managed to make them healthier. They reduced hospitalizations and even more moving they broke even financial out of desperation, the chance invented a better way to do this. So the model that I described that Christians family developed has evolved into a business called Chen Med and Christians the CEO of that business. And it's now the program that is run by Medicare called Medicare Advantage. Medicare Advantage is now covering about one third of all seniors and it's expected to grow to as many as 50% by 2025. So it's an example of how changing the payment model from what traditional Medicare does, which is fee for service, which is, you know, the model where every time a patient comes in you have to do something to them in order to build Medicare for that visit. So it's led to these very rushed visits with many procedures often associated with Medicare Advantage by changing that model by paying the physician to fix the amount of money and then giving them the autonomy and the latitude to decide how to spend those dollars has really radically changed the way in which they run the business and Chen is just one of many, many organizations that are now so that was an example that I wanted to share of how moving from a fee for service model to paying for better health can not only do good, but as a business model, it can also be very successful model. And in the rest, much of the rest of the book, the, while in this example I'm talking about care for seniors and really focusing here on keeping them out of the hospital. In other parts of the book, I talk about examples of what the same change in mindset paying for better health, what that would look like for hospital based care, and what that would look like if we help the pharmaceutical industry and other industries like the big data industries, accountable for delivering better health outcomes instead of thinking in the future service. And then later in the book, I also take the perspective of the payers what how should payers people who are paying for health care, be doing things differently if they were really expecting more of a model of better outcomes. And particularly I focus on employers who cover health care for about half of all Americans, and then a government based system actually look at the military health system, and then finally wrap wrap all of that up at the end of the book with some policy lessons. So, I'm happy to maybe now turn podium or would turn this back over to you and have more of a conversation soon. Well, thank you. And we so much we could talk about we need, we need a full day. What I find really powerful about the book, and you being a really good person to write this book is because you've practiced in medicine, you've been, you know, the chief scientific officer with overseeing research and discovery, you've been in leadership roles of education and future workforce but also in, you know, of a healthcare system, which branches, of course, well beyond medicine, or, you know, the doctors, but all of the allied health surrounding that and now you're in technology. Just like health care, it needs all those components to work together to move in a direction that is increasing access better outcomes and reducing costs. So I'd love to hear because you've played roles and have experience and all those, all those places. Tell us a bit about you and what drives you and and how has your drive evolved so to speak, in the span of your work. Well, you know, while I have been in the technology space now for two years, of course I spent my whole life in the university setting. So where most of your audience is rooted so I will start there by saying that I think that I'll tell you a little story about how I ended up getting into healthcare administration and even thinking about the job and you talk, and it came from this visit that I made when I was the chief scientific officer at NYU. I went up to the Mass General to visit an old friend, Greg Meyer, who you also know, who was at the Mass General and I was actually doing a field trip to learn more about how their research administration works since I was just new at this job in NYU and I wanted to learn more about it for them they were really very generous about that. And at the same time during that visit, a Greg who was responsible for safety, quality and safety of the Mass General. Pulled me aside and he was just showing me some of the work that he was doing. And I had kind of an epiphany when he was taking me through this because what he shared with me was, they had built their own homegrown electronic system. And of course they were only able to do that because they were in this very rich academic environment with people who had expertise in biomedical informatics and data. And so they could actually conceive of building their own HR. And then from having built that HR, and they decided, I don't know who actually had the idea but they decided that they would start negotiating with the state of Massachusetts to be paid differently. So until then they've been paid for service and every time somebody came in, they built the state and got paid. And instead he said, we thought we should be getting paid for improving health outcomes. And so we negotiated with the state to say that if we were able to improve the blood pressure of our patients by a certain amount on average overall, then we would get a bonus from that. And because they had this EHR, they actually had data about how they were doing, and they had reasonable access to those patients to be able to intervene. And so they had some sense of where they could probably move the done. And so they really opened up this entirely new way of contracting the state and pushed I think the whole field forward into a more of a paper performance model here. And because they had their EHR and all these really brilliant data science type people and wonderful clinicians, they were actually able to meet and succeed those applications so they did well financially for the hospital as well. And it was that point when I thought, why aren't more academic clinical centers leading in this kind of healthcare transformation. We have incredibly talented people across all of the areas of expertise. We have kind of our own built in consulting teams. When I was at the University of Utah, we really wanted to move through this whole 16th Sigma kind of training program, we being a state institution could not really afford the big consultants, you know, a bazillion dollars an hour. And so instead we reached out to our business school where we happen to have some outstanding faculty in operations with graduate students who wanted to write papers about us. And so they came in and they serve as essentially consultants for us. So I think they're just that those, it's the intersections of these different areas of expertise that universities happen to be really concentrated in, which I think makes them incredibly exciting places for innovation in any space but especially, especially. Part of the inspiration for this speaker series was using the lens of Phoenix as a location that is an up and coming biotech center, and that cross between, you know, universities, industry, the city, but also arts and culture and living spaces and you know thriving cultural events and residencies we have this area in Phoenix right now we're calling it the Phoenix biomedical area. So talk to us about what your work was like in Utah I know you had a similar experience and while CEO of the hospital system and Dean of the medical school. Sure, that's, you know, Phoenix is a beautiful place. And it's so nice. So, and there are so many things to do there so I think this idea of the strategy is a good way. So, so Lake City also had its own attractions which I hadn't fully appreciated until I moved there so. I'm going to take the most advantage of that if you can. We had some really interesting innovation is that took place as a result of both what was possible within our academic entities, as well as in partnership with the community. And maybe I can give you an example each so we had so at the University of Utah we have an integrated health sciences campus, so it included the School of Medicine, as well as pharmacy, nursing, a college of health, which was essentially a college of outside health, speech therapy, nutrition, and so on. And then we actually started a branded dental school I understand which was actually really fascinating. Plus, of course the help to deliver systems so it was when we got together there was a lot of, we put a lot of energy into thinking about how can these different teams learn from each other we had all kinds of really interesting retreats and off site. One of my favorite projects that I learned about in that early days was a project that had been funded by the NIH. It was a big program project grant to the College of Nursing to help monitor. And it was a very simple program when it started. It was simply that the nurses would call the patients or call their caregivers at home once they got there and to check on them every day. Actually was automated. Now that I think about it, it wasn't even a person but it was one of those press one if you're feeling good press two at the other issue things pretty low tech right this started to start maybe 20 years ago. And, but it had a huge impact, it actually significantly lowered readmissions because it detected, you know what people were starting to a little nauseated, you know before they get completely dehydrated. Also, it turns out that it was very positive for the caregivers, just that know that somebody was checking on them and if something was going wrong that they could actually that there would be somebody that we'd be following. We first learned about that project you know it's just academically interesting that we had that but then of course we connected them with other parts of the system. We actually over time partnered them with the video gaming folks who could write apps and make it was more digitized rather than voice. And that even led to some really interesting work within the system on hospital and building out kind of more of an intensive home based experience. So that was an example within the university and then the university to the community was also very important it sounds like it could be an opportunity for you as well. In Utah. Now it's really grown into this silicon slopes idea a lot of work with tech companies, as well as with the community. And one of the areas that was a high priority for the community was increasing access to rehab facilities, which didn't have enough to have facilities. We actually had some folks in the community, including donors who stepped up and said, you know, we really want to build a new you have facility. Maybe, and how can you really make this a compelling, compelling case for why it should be done at the university as opposed to somewhere else. And actually it was our one of the really compelling arguments that you were able to make was our video game team, who came out of the College of engineering computer science and media arts. It was a very much a main campus group, and they came in and they really inspired everybody with these ideas about how video gaming, for example, you know you're a post stroke patient. And there were these video games where, you know, there's a, let's see, it's a farmer and these animals are trying to eat your vegetables and you have to swat away these animals or whatever and with your, your we stick or whatever your video gaming devices are. So this could actually be used to not only measure, but also interact with the video games, so that you were doing the right kind of physical therapy that was necessary. Right rabbit was stealing your rabbit, your carrots from the right coming from the right angles so that you have to be right. That vision of bringing video gaming into rehab was what I think took this over here to actually get supported. I was one of many factors, but it was a very important one. So I think there are a lot of opportunities. Yeah, thank you for that. You know I don't want to miss the fact that your background your PhD is in medical engineering. And that's really was a foundation for you that we so many of our efforts at the universities are connecting, you know, biology with engineering health care. And engineering in the solutions that connecting engineers to clinicians can be developed and that's with ramps out to industry and startups but can you talk to us about your experience. Now that to will, I'll attach that to what you're learning at Verily. I'll tell you all a little bit about Verily I don't normally I would ask for a show of hands I don't know how to do that here unless you want to type it in the chat box. If you know anything about Verily I'm curious because we've had a pretty low key approach generally so verily for those of you that I want to talk about is is a company that was originally called Google Life Sciences. It's a part of the alphabet family. And when Google became alphabet we were one of the bets that was spun out, and then we were rebranded from Google Life Sciences to do their research. And we were purpose built to commercialize life sciences, and now health care products. And so I joined two and a half years ago to really need the health care side. What I find, and maybe I'll just say a word about why I decided to do this because I had really been planning on staying within health care and I was actually getting ready to go and meet another healthcare system. I was actually very excited about this new system. When, when I had to follow another conversation again with Verily, and it actually comes back to this book because when I was talking with the CEO about why he really should find someone else because I was. Okay, just to give you a sense of it I still have until six months ago I still had my blackberry. So just to give you a sense of where I am on the tech spectrum. And, you know, he came when he came back and talked to me about why I should think about doing it. He just said, you know, you should just come and do your book. Your book is supposed to be about fixing health care. And that's what we want to do here, except that if you go to a health system, if you're lucky, maybe you'll help improve that one health system in that community. What I'm going to do is really do things at scale. And that's actually, I found that really fascinating that idea. And so that's what convinced me, I guess, to have a go with this technology side. And in terms of what I've really discovered what the realization now that I am in this company and I can't speak for all technology obviously I can only speak for my real experience here is that the technology is one piece of what is really, I think interesting, we are seeing it a lot for example we can talk more about telehealth and digital health solutions. But the other piece that I find really fascinating in this company is the mindset about how the company thinks about people, thinks about patients and physicians and pharmacists and people that we work with. In the sense that it's really a company that is a consumer based company and I think embraces this idea I have this. There's this idea that I talked a little bit about in the book called co producing health that as healthcare providers I think traditionally we've often thought about healthcare as, as like something that we kind of control and will work with you and will help you but we're the ones that give you your health, you know, like in the hospital in the intensive care unit we restore you to health. But I think for most of healthcare, and most of ambulatory care certainly it's really co production it's really we help patients produce their own. And that mindset is very much how the folks in technology think about consumers, at least, you know, at least the folks like the ones that I work with who are looking at software apps. And what it leads to is a very different way of interacting with people so the way in which we build our products, the user experience researchers the user experience designers these are really behavioral psychologists. The ways in which they think about how we interact with people to help them achieve the better health and understand what's important to them, what are priorities to them, rather than I'd say a more traditional healthcare view which is we know what's best, we're going to just tell them what's not connected with them, etc. And we know that generally that. So I think what what's been interesting to me is the combination of data and technology with these insights about how people actually actually thinking how. And we're starting to get some really, really thoughtful questions and I want to try to combine them that when the areas that I want to cover, you know, with the, to follow up on that with the increased use of telemedicine and digital health. Obviously there's been an increased focused on remote monitoring and home care for people particularly with chronic medical conditions and high risk pregnancy patients. How are outcomes being evaluated and do you see those metrics being utilized in addition to being baked into a value based care model. Great question, really great and very important question because I think we're at the cost of digital health really moving into more of the mainstream of healthcare. And so these questions of how are we measuring outcomes, how are we making sure that we think about digital health as a value tool as a, you know, as a set of tools that really drive better health outcomes, rather than as devices where we just charge per click. For example, you know this is a really, really important set of questions. So, we've been thinking about it a lot here now I'm going to maybe just shift, just where my barely hat for a few minutes just to say about the, the experience that we've been having with respect to the digital technologies that we are actually in the market with, and we have a product, which is called on duo, which is a digital health solution that started in type three diabetes, and now includes other conditions like hypertension, and I will say, you know, I'm not trying to advocate for there are other products very similar on the market like Tomata, Verda, Livongo. So we're one of these we were what differentiated us in the beginning was we were one of the earliest to have a continuous glucose monitor as part of the technology and now many of the others also have it. And just for those of you who maybe don't know much about the space I'll just explain it to you very briefly kind of how these technologies generally work. I think there's something about these metrics, but just so you know what we're talking about. Or narrowly at this point I would ask you for show me as like how many have actually tried a digital health solution, or a wellness app, because I try to encourage everyone to try one, you know, even if it's one of these I think that we're, as I said, we're on the cost and pretty soon I think these are going to become things that people just prescribe and order and it's important to have a sense of what they're about. For the diabetes space or hypertension this kind of chronic disease space. The diabetes is a good example because it includes a new sensor. So this continuous glucose monitor technology and multiple vendors of these technologies and, and they all do essentially the same thing which is their kind of the size of a key fob. Say, like, like maybe about this size, and you put it on your arm or your abdomen and it automatically measures your blood sugars for. So if you're freaking your finger to draw the drop of blood and checking your blood sugar, you stick one of these things on, and there's a Bluetooth chip in it and it transmit your blood sugars to your app, say on your phone. And then you take pictures of your meals and snacks because your diet is so important in terms of your blood sugars. And so you can now visually associate what you with how your blood sugars are tracing up and down. And of course also with your exercise and also how you're sleeping. And so it's just transformative in terms of people's understanding of their own biology. And what we're seeing pretty clearly is that everyone's biology differs significantly. So if we ate the same meal, for example, our blood sugars respond very different. So there's that first just your own insight in your own learning and awareness and then that's enhanced with some AI. So we can see patterns, you can make no recommendations we can say well for you to you know maybe we notice soy milk, we were doing way better with soy milk or vidian, you know, skin stick to skin, that's better for you. Those kinds of observations are actually very helpful. And then there's the telehealth so chatting with a coach or video conferencing with a physician, for example, and having that, you know that professional interaction is important. So when you take that all together, what you see pretty consistently across the literature in across these very products is they work. They really do improve people's blood sugar control. And it's not surprising when you see them working it's really not surprising at all they're actually working. What's interesting about this now getting back to your specific question is, how do we. How do we actually think about these not only as disruptive or innovative models in the way in which we care for people but also innovative in the way which we think about the business of health care. And I've been thinking about that a lot because I'm now responsible for this company, and we started last year, just changing the way in which we're paid so ordinarily, we would be paid a per member from us, you know, we get paid for as many people can get to sign up for this thing doesn't really matter ordinarily it doesn't matter whether you make them better or not you just get paid if they sign up, but we decided to do it differently and say you know what we only, we're going to go 100% at a time where we're only going to get paid with people's blood sugars actually come down. It's if they're high if they're, if they're good and they need to stay good. And we look also at cost of care we're going to do some other metrics that are never considered and I think that that I'm actually really excited about it, it's a little risky so ask me in a year or two how we did. We have some data, you know we have some words of optimistic about it of course, but I think it's an example of trying to hold digital technologies accountable for actually delivering them. And I hope that pairs will adopt this, this kind of approach because the last thing you need to do is to recapitulate people service in digital health is an opportunity for us to move forward. To shift the paradigm and use a model for outcomes not just action fee for service that's fabulous. Let's go a little deeper on health care costs. I, you know Americans sort of have this idea that their health care should be paid for costs are often covered by about 50% by employers or by Medicare. But the reality is we're really all paying for health care, both individually and across the society. And over the last five decades as you have already mentioned we've been paying more and more. And about 8% of that goes to administration of health care. And while fifth of our GDP is spent on health care, we have incredible health disparities in this country. I'd love to hear your thoughts on some solutions in that space. That's really the pressing issue for us now, especially COVID post COVID and the economic impact that COVID is having on this country. The wide need disparities, because of the way in which COVID is affecting our communities. It's becoming, we really are. We really are in that crisis mode where we need to go through that and start changing things very quickly now. The opportunities, if you just alluded to, are huge because we are outspending any other high income nation in terms of how much we're putting into health care, 18% of our GDP, that's far more than most other countries. So it's not an issue of finding more money, it's a figuring out how do we reduce the ways to improve the efficiency. And one of them is really through reducing administrative costs. And I think that the, I'll give you, this is a little bit, so for those of you who are not super into health policy, and I only dip into this very briefly because it's a little bit of a policy walkish kind of a topic, but what happens every year in health care is what I call the trillion deal. And what I mean by that is every year, as employees and our employers, we pay our premiums for our health insurance into health insurance companies or third party administrators. And so there's a big pool of money, it's like a trillion dollars. And during the course of the year, there's this tug-of-war between the insurance companies or administrators or employers who want to hold on to the money, mostly through these insurance companies. And then the health care delivery systems who want to keep billing and charging so that they can stay alive and so they want to bill, bill, bill so they can collect that money. And the back and forth fight between the payers and the providers is a significant driver in these administrative costs because, you know, every time you have denials and then you have to make the claims or you have these barriers where the providers actually have to fill out all the sort of extra paperwork just to justify getting an MRI, for example, getting a referral. All of those leads to an enormous amount of ways. And it's, it is about 8% of the health care dollar, which is significantly more so mostly European countries always see donations, it's about 3%. There's a lot of money that we're wasting. And the problem with that waste is it's really what's making physicians miserable and large part contributing to the physician burnout. And when we can't resolve that tug of war, it falls to the patient. And that's how we end up with these surprise bills and bouncer's that that are leading to so much suffering so many people need an bankruptcy. So one direction forward is if we go back to the way in which I was talking about how Medicare Advantage is paying for healthcare. So Medicare Advantage, in theory, the idea is they pay a fixed amount of money to these medical groups for the year. And, and then it's really up to the medical groups to keep people healthy they have to meet certain quality metrics, and patients have to be satisfied because if they're not they don't have to review after a year. And so in theory in that model, there really shouldn't be the need to do all this coding and billing and, you know, excessive in my view documentation. They still have it in there now because it's sort of residual from Medicare generally how it's administered. But imagine if we really moved to that model. It shouldn't be necessary to do a lot of that administrative paperwork and there won't be that fight because for once in that Medicare Advantage model, both Medicare and the administrator, you know the insurance companies that are administering it, and the doctors are all in line everybody wants these patients to be healthier stay out of the hospital they can and get their costs down. There's a lot less that will be squandered and fighting. That's just one example in the book I talked a lot about other areas of the ways about cost, how we actually can get costs down in terms of care. I talked a lot about safety, medical mistakes are very costly, not only financially but of course massive suffering that's completely unnecessary. There are many other many others but administration is one of those where I don't think anybody would argue in defense of law administration. I think we could all be very joyful. Yeah, and yet we are still where we're at, you know in chapter 12 in your book you start out with a quote from Vice Admiral, Raquel Bobo, which reads, we should be targeting the readiness of all our citizens to do what they're supposed to do in support of our society. There should not be partisan because everyone has a stake in health, and yet it has become. We talked to us about healthcare as a problem with bipartisan solutions. I've been happy to do that. You know, one of the things that I think is so interesting about the healthcare problem is that I do believe that there is an enormous amount of bipartisan support for many of the changes living in two places. And the most obvious example is the move in the payment model. So the payment model move from a fee for service model to more of a value based payment model is that that idea has been around for a while. Many of the ideas that were originally in Romney care were adapted into Obamacare and are now continued to be moved forward under Secretary Asar and Sima Burma. One of the individuals who influenced this book a lot was Mike Levitt. Mike Levitt was the secretary for helping services under Porsche. He was a governor of Utah, three term, and Secretary Asar was actually his deputy secretary back in the day. And he's actually the reason why this book is called The Long Fix, because he's the one that actually planted this idea that these changes, the evolutions take about 40 years. And he convinced me that we were, before COVID, about halfway through one of these 40-year cycles. You know, it was a long fix. So the arguments for changing the payment model have been there across administrations and even now, despite all of the rhetoric around, you know, many other issues in this country. The health policy community, health administrator community is, I think, stronger than ever with the urgency of moving to more of a value based payment model. I actually, one of the lessons from COVID is just the fact that these more value based models are actually also more resilient in the face of the pandemic. So I caught up with some of these folks, like the Chen Meds and Iora Health and the Presby, several of the groups that have that same model. I caught up with them during COVID and I said, you know, how are you guys doing now through this pandemic? And actually, it's proven really much more robust. So for example, in a fee-for-service model, once the clinics shut down with COVID in April, March, April, May, you know, we were hearing about hospitals teetering on bankruptcy and furloughing. I think in April, we furloughed almost one and a half million doctors and nurses in this country is sort of unimaginable. These folks, the Medicare Advantage type programs continue to get their monthly payments from Medicare because of their business model. They're not counting on, you know, every patient has to come in and I got a bill for that. They have what Chris Chen calls a subscription model. It's like, as opposed to a pay-as-you-go, you know, they have the subscription. They already guaranteed monthly payments from Medicare and they were able to use those dollars to be much more proactive about getting patients, whether it's providing more care in the home setting. The folks at Presby were telling me about how they were able to manage a lot of patients with mild COVID even in the home setting with an oximeter and thermometer and regular checkups. They delivered medications to their homes. They converted their clinics into urgent care centers so that their seniors didn't have to go to the ER. So not only did they not have to furlough people, but they were able to use those, you know, the income from Medicare in order to actually provide better care for their patients. And so that's yet another reason why I think there's a lot of support for moving to this model. And the hospitals that are paid in this way, like the military health system or the VA health system, also did much better than the hospitals that are moving through for service throughout this pandemic. So for the first time, I've actually heard the American Hospital Association saying, oh, yes, we are actually welcome discussions about more global payments or capita dependent models, more basic income models. So I think there's a lot of momentum and the fact that the economy has taken such a hit with COVID creates even more urgency. I want to follow up on two points there. One question from from our participants related to, you know, bipartisan needs. Why do you think the Democrats in Congress support ACOs to control spending and Republicans support Medicare Advances programs. And both are really quite similar in philosophy yet they cannot agree on a compromise model. Isn't there a way to get what you suggest that could be bipartisan. I think there's going to be a, you know, I will be the first to say that none of these programs, you know, although I think Medicare Advantage is much better than a fee for service Medicare program. I think we were learning a lot about how that program and the same thing is of course true with ACOs from the beginning. But what we are seeing out, you know, within the, within the agencies themselves, the people who are who have been working in this space for a long time are building on those lessons and continuing to refine how the programs are, are developed in order to kind of make the programs better. What I'm hoping will happen in the next year is an acceleration of that tweaking, because I think the tweaking is been very slow and very incremental. But the need to really change our healthcare system has become much more urgent, much more pressing. The Congressional Budget Office just announced last month a revision in their projections around the insolvency of the Medicare Trust Fund Part A which is originally it was slated, you know, so that's the money, you know, comes from our taxes, and then is used to pay hospitals for Medicare patients and it was originally going to run out around 2026, 2027. And the revisions show that it's going to run out by 2024. So of course it won't, it won't run out. There's a figure something out, but the urgency of figuring out how can we be more aggressive about the way we use these programs. I think that's really happening. And I'm not, I'm not particularly, you know, the Medicare Advantage, well, we can learn some of the, we can learn a lot from what's worked for seniors, we can learn about what's worked for ACOs, and have already been learning about this course a lot. And then we can start to really share those and kind of take the next generation forward. I also want to follow up on another point, you know, you wrote this book, and it came out in early summer so it would have been, it would have been done with it before the pandemic, at least took hold, maybe not before it started. And it sounds like really it's reinforced a lot of your thinking in the book. But certainly, what a stress test this pandemic has been on our healthcare system, to say the least, has your thinking shifted in the last six to seven months with COVID. I think it's, it is definitely highlighted some areas that I did not focus on that much in the book, it hasn't, it hasn't changed much of the underlying thinking, because as we just said I think it's just made it even more apparent that we can move away from certain models to other models. So there is that I didn't have thought much about or hadn't written much about even I have thought about them. They came even more, even more obvious during the pandemic, and are actually things that I'm writing about now for the epilogue so I've been asked to write an epilogue for the paperback version. And, you know, since as you said this, this book doesn't talk about COVID, the epilogue will talk a little bit about post-COVID exploration, and here I'm focusing on areas like thinking a little bit about nursing homes and long term care. And what are we doing in this country to address care for our frail elderly who want to go to this little home. And the fact that nursing homes were hit so bad, and maybe about 40% of all COVID deaths in nursing homes, even though only about 70% of cases have happened there. I think that's really worthy of a lot of attention. I think thinking a lot about rural communities and rural medicine. And then I've been thinking a lot about health disparities, of course. And reflecting on how those disparities are exacerbated, not only by COVID but also by the way in which the economic impact of COVID is affecting our country. It's not affecting you. And what can you, what can you do about that. And so, I think there are new areas to think about as well or new areas to discuss in the book. Many of us have been thinking about for a while that COVID is showing me brighter and more partial. But I think they are many of them still come back to the same things which are that, you know, the health of our country, it's affecting the quote that you read from Admiral Bruno, you know, health is essential, it's essential to the readiness of our country, not just the health of our military to defend our country, but the readiness of all of our citizens to act in whatever roles are acting like teachers or firefighters, local grocery store owner. And we can see that so clearly now. And so if we don't, you know, we just absolutely must think about the health of our population as a strategic imperative for this country and it's not just a financial item. It's really the health that we're primarily looking for. And that's why one of the areas that I talk about at the end of the book is really how would we think about the government's responsibility for health. How would we think about it primarily as like a benefits program that has to pay for health care, or do we really want a government is to that is responsible for improving the health of our population and really measured against that. And obviously you can tell by the way I'm speaking it needs to be both. But we really do primarily focus on better. COVID really hammers that home. I want to get to a one or two more, we have some really good questions from our participants. One is there are many pockets of good practice in the US and elsewhere, but to an outsider the strong cultural attachment to individuality in the US militates strongly against the more collective approach that is needed to underpin a focused approach on population health and you talked to us about use what you see as a political route to reform. One of the that's an interesting. There's a lot in that one pack, I think I would be a little bit more generous I do feel that Americans are very individualistic that's true. But I think Americans also care a lot about the communities, the families and the communities. I think this connects that I see in in the way in which we think about health care is this idea that someone else is paying. And, and as you I think alluded to earlier to one of the points that I make is that actually, we are all paying for health care if you think it's, oh it's my employers paying or my insurance company is paying so I'll just go and, you know, bring my insurance company because I'm not the one paying, then you are pretty, pretty sorely mistaken we're paying for it not once not twice but actually three times we pay for it. Out of our chances obviously as I mentioned Medicare or state packages and federal tax. We're also paying for it in terms of out of pocket costs now those have actually risen those of us who are fortunate enough to have health care for our employers are actual distribution to that is increased to over 30%. We are actually now paying for ourselves. Yes, and then, of course, the most insidious has been the fact that it's actually coming out of our wages so over the last 50 to 60 years. While the economy has grown, our wages should be going, our wages have essentially been flat. And the reason they've been flat is because the whole Delta has been gone gone to pay for our health care. And even some of our retirement needs now are actually being signed off and gone to pay for healthcare so while you may not think that that extra visit or that extra MRI maybe you don't you're not paying for it in the end it's it is coming out of all of our benefits, maybe not today but next year. And I think we need to all recognize that we have a collective individual responsibility for for managing our own health like just in terms of looking after our health, but also making sure that we recognize that more isn't always that you know you don't always need the extra prescription or just in case scan or whatever it is. You're not. Yeah. Well, Dr. Lee, we are so appreciative of the time you've taken to share with this community in Arizona and beyond. But I find your book is really important and what I really really resonated is lays out what each and every one of us can do. And that is so important that we all have responsibility in this, and it takes, you know, multiple sectors but it really takes all of us. So I would just ask in closing what's your final message for us. So, well, I think your final message is. I guess probably what I just said earlier which is that we all have our own role to play in this. What I alluded to earlier was our role as individuals as patients and this family members to be accountable and responsible for our own health but I know in this audience. There are many of you who are in healthcare or in research education. One of the reasons why I have at the end of every chapter and action plan that actually specifically talk to different people is because I think wearing those hats we each have a different different responsibilities as well, whether we're clinicians it's really you know are we delivering the best outcomes we actually know the cost of what we're describing what we're doing because we are responsible we're running the business and we're payers, how are we holding clinicians accountable and our employees accountable for providing them health and lower in cost and of course if we're policy makers have to be accelerating and really push with the way we're accelerating that change. So I think there's a role for everybody and based on what what we're seeing with coven and beyond coven. There's no time like the present the really, really important. I think I remain always very optimistic so, and I appreciate the time, and I should just say that I do have a webpage if you, if I didn't get to a question just feel free to reach out to me on the website I'm happy to follow. Thank you, that is very generous and I know there are probably some that will because we didn't get to all the wonderful questions. Again, thank you all for for joining us in this conversation. I do hope you'll come back next week for for another Friday at 11 in our series. And I hope everyone stays safe and healthy. Thank you so much Dr Lee.