Kerry Amato : 0:00
Hello changemakers we have a very exciting episode for you this week, my co host Indu subaiya, President of catalyst at health 2.0 and senior advisor to hims, will be speaking with Farzad mostashari, co founder and CEO of Adelaide and former head of the Office of National Coordinator, Dr. Farzad mostashari, will provide an expert perspective on what a 21st century public health system should look like, including real time disease surveillance, targeted prevention, and the smart allocation of resources. He will discuss how healthcare providers could effectively partner using new technology and data enabled primary care models over to you and do.
Indu Subaiya : 0:53
I wanted to start off like big picture, Farzad with you and ask you a little bit about what an ideal public health system could look like in the future. And if you had to kind of just describe that to me, and compare it to where we are today. What would that look like?
Farzad Mostashari : 1:11
There's two parts of health care and public health that i think i think about. One is the environment. And what is the context within which each of us make decisions, that's public health. That's the most powerful form of public health. That's structural changes in public health, that's whether people have, you know, places where they can walk, that's whether people can afford their medications. That's whether,you know, a pack of cigarettes costs $4, or $14. Those are the decisions and for me, an ideal public health system is one where all of us, it's easier to do the good thing for for our health than than the bad thing. The second is almost neglected in public health discourse. For many years, it's actually healthcare, which is funny for people in health care to think that public health doesn't think much of them. But historically, the all the stuff that we do around health care, other than, you know, vaccines, just a few things have been almost besides the point, it's really been those structural measures. But there was a paper recently by cherny, and macwilliams, that looked at the improvements in life expectancy of the 25 year period. Almost half of the gains now are from basically medications, blood pressure medications and statens. And that stuff works except we only do it about half the time. It despite all the trillions of dollars we spend on needless and harmful care, wasteful care, we don't do the things that actually make a difference. So that to me is the other part of it is having healthier societies, but also having health care. actually give a darn about doing the things consistently that make people live longer.
Indu Subaiya : 3:21
I think there are so few people actually that straddled the worlds of healthcare and public health in the way that your career has taken you. I really love that you highlighted that tension, because I think a few years ago, I wouldn't have cited drugs as the reason, you know, people are living longer, we would have said something about, I don't know, diet and exercise or more of that public health kind of, you know, approach. So I think that is fascinating.
Farzad Mostashari : 3:47
But yeah, if we could, if we could just get the behaviors, right, social distancing, and the and then supplement that with a tighter connection to healthcare, getting the people who need to be tested, identified and tested quickly and then hooked back into the public health system for contact tracing. That would be the formula and it's not as if it's impossible here. There are countries that have done it. And we have lacked the will.
Indu Subaiya : 4:16
Speaking of both the will and the means, you have been an advocate for the role of technology through it all. And I would say both technology is infrastructure for healthcare and technology is infrastructure for public health. Where are we in that journey? Is it harder to get that data and tech uptake in public health versus healthcare? you've worn hats across the board. So what is your lens today?
Farzad Mostashari : 4:45
Um, I mean, I came of age in public health, late 90s and early aughts and the 9/11 attacks changed public health funding for data and informatics completely. And we experienced what public health departments are experiencing today, which is a somewhat chaotic gush of resources that you want to take advantage of quickly because you know, it's not going to be sustained. And I think that's, that's the lot of the people who are doing really, really interesting things in public health informatics, then migrated to moving over to work on Healthcare Informatics. And then, you know, we, under the high tech act, we spent $30 billion digitizing American health care doctors and hospitals, which was an incredible investment. If you think about that, we just like that was Tuesday on the stimulus that we just pumped the money out for nothing, right, we've been given &100 and $50 billion and stimulus payments this year to hospitals, mostly, and haven't done anything to show for it. So that was a great investment. But there was no equivalent investment in public health. So we got a lot of EHRs. And a lot of, you know, we set requirements for the certification for the EHRs to be able to communicate with public health, we set requirements for doctors and hospitals to send data to public health, but public health wasn't funded to be able to receive it and to do something really effective with it. And, you know, we went from, you know, complacency to complacency in terms of and then now, you know, there's a pandemic, as it's kind of predictable, that there would be eventually a pandemic, right, and we're like, why is public health so underresourced? And why can't they accept this data? And why aren't there you know, systems in place, fix it, right? You have till October, fix it. I just heard, you know, on the news that there's a parallel effort that they funded Deloitte, and Salesforce to set up the basically a covid vaccine Information System, we're going to just like, they're going to solve the patient identification issues that vaccine immunization registries at the state level have been struggling with and iterating on for 15 years by October. And then and then what's the leave behind? Nothing? The leave behind is nothing leave behind is it COVID immunization registry not strengthening our fundamental capacity for the next.
Indu Subaiya : 7:26
Sounds a lot like in a sense, you know, the vision around kind of the democratization of data, big picture that you've done? Yeah, it does. And I'm thinking of your words, you know, back in 2010, 2011, as you were leaving open data and saying, We've got to make this available to everybody and leverage it at that time, you were saying leverage the spirit of the individual entrepreneur. But here, you're talking about the spirit of sort of individual care providers and their relationships. I think there's
Farzad Mostashari : 7:57
they're entrepreneurial.
Indu Subaiya : 7:59
Yeah. And you've done some of this work in rural areas too some of your data shows sort of the impact is actually higher, to some of that, because we've sort of ignored a lot of pockets of this country in a sense. And your data is actually, I think, more encouraging in some of those areas.
Farzad Mostashari : 8:18
So yeah, some of our most successful groups are in Mississippi and Kansas and West Virginia. And one of the things I love about those docs is they understand what it means like to be accountable for our community. Sean Purefoy is one of only two primary care practices in Malvern, Arkansas. So he gets it. He's accountable for that population. Everybody who's going to see, right in the store, at church on the street, he could be accountable for them for their care, and he can act that way. And that's to me, like one of our values is owning it. And even when you don't control all the inputs, right? And that's such a hard thing for humans to embrace, right? Am I going to own this? Or am I going to be willing to say, yeah, there's 1000 reasons why I can't I don't control this thing. I can't, I can't be accountable for this. Like, I'll do my piece. Sure. But don't make me accountable for that, like that. No one who believes that ever changed anything, right? And so our docs act as if they can have an influence.
Indu Subaiya : 9:32
We are taught in medicine to own it, I think, I think how you're trained in medicine is to own it. And, you know, you may sign off to a colleague, because you know, you have to go home and go to bed, but you own it as a doctor, I think and I think that it's so interesting that this model goes back to the roots of what you're trying to do for a patient. So I think that's really interesting. So I'd love you to sort of think about then and help us see that if we have primary care, that's more data-enabled, we invest more in public health, we have kind of big tech there to help in a, in a useful way, in a pragmatic and useful way. Here we are now, in this moment, how do these things stitch together today? And in the era of COVID, and moving forward? Has your vision changed because of the pandemic?
Farzad Mostashari : 10:30
Well, one of the things that the pandemic did was accelerated a lot of trends. It's not necessarily creating new trends, but really accelerate, you know, like, down the street here, a couple of department stores are boarded out. Right? It's not that other than on boarded up, because like their business model was super healthy before, right? It's just that now it's like really obvious that we're not they're never going to reopen. I think fee for service showed that it's not stable and reliable. Right? Like you can't, what kind of business is this? If it literally requires you to, like see a person face to face for 15 minutes to be able to bill at $4. And like, in the middle of a pandemic, when we need health care the most, you're laying off your staff, because you didn't bill enough visits. That's crazy. And so I think that was a that was a wake up call. We're going to have our Aledade, our best growth year ever. In the midst of this pandemic, when we couldn't visit practices. We actually CMS didn't let you start in UAE SEO in 21, because of the pandemic, and we're still going to have the most practice growth we've ever had. Because people are realizing that they can't rely on fee for service. The other thing that we did really immediately was turn on telehealth. And it was no longer like we talked about it like sure this could be a good thing. And then it's like no, no, we telehealth now, and within 12 days, we went from 100 telehealth visits among our practices to 10,000 televisits in 12 days. Over a weekend, we turned on 150 practices on telehealth. So those are the kinds of like radical changes that make you realize like, no, like revolutions are possible, change can happen. And it can happen quickly. And you can like reminding yourself like oh, I can still sprint, you know. And I think health care showed that it can be very adaptable very quickly. And things can change. that's mostly what I'm taking away from this cobit experience is: these things are not givens.
Indu Subaiya : 12:55
I wanted you to comment a little bit on testing, there was an interesting exchange between you and Tom Frieden on Twitter, around the purpose of testing and how it is actually misunderstood in terms of saving lives versus containing or tracking spread. And I'd love you to just unpack the value of testing because even five months into this pandemic, I think there's still confusion around why we should test,
Farzad Mostashari : 13:23
Just as I described at the top, right, that there's public health, population wide. And there's individual health care, right? I'm seeing with testing, there's a purpose of testing, which is I want to better treat this human being who's under my care, as a physician trained in internal medicine, I get that. And you can say, Oh, you know, if you're not severely ill, or hospitalized, the treatments the same, so don't get tested. Um, there's the other use of testing, which is to interrupt transmission chains. And for that, you want to test people as soon as possible. And you want to test their asymptomatic contacts, because you want to interrupt chains of transmission. You want them to change their behavior, so that they're like less likely to pass it on and you want to change the behavior of those who they've already contacted in recent days. And this is where, again, it's baffling to me that the average delay between symptoms and being reported as positive is seven to 10 days now. Even that data is hard to find. But if you think about that, almost all of the people you're going to infect you've already infected by the time you know. So that's useless for the purpose of public health purpose of interrupting transmission. This style of testing is useless doesn't matter how many tests you do, and there's like this became like, the touchstone is like, how many tests are we doing? Are we leading the world in the number of tests? I'm like, are they useful? Right? Are we testing the right people at the right time in the right way so that we can actually get public benefit from it. And it again, the lack of strategy around this is anything but smart testing. Zeke Emanuel and I wrote a piece in March, saying we don't just need testing, we need smart testing. And I'm telling you, we're not getting smart testing right now.
Indu Subaiya : 15:20
So I'd like to unpack carefully the reasons for that gap. And I think you've talked a lot about, you know, on the one hand, there's will, there's, you know, then there's sort of resources and natural tools, there's data and insights, how do you sort of categorize the reasons for that gap? And then, for cities moving forward? What are the ways we begin to close that gap?
Farzad Mostashari : 15:47
I think one of the things that we have to do and I already touched on this is there has to be sufficient public health capacity and resources has got to be sustained. I think there needs to be kind of mandatory funding for public health preparedness at the state and local level. Not leading it to the you know, they have to balance the budget every year, I think there should be dedicated funding, maybe take a couple of percent of from everyone's health care dollars, right, maybe there should be a health insurance tax, as a couple of percent. That is earmarked for the counties, those people live in the public health capacity in those counties so that when pandemics do happen, as they do happen, there will be enough of a capacity of local responders to respond. These surveillance systems are smoke detectors, you still need firemen to go into the building and see what's going on. And if you have cut the funding, year over year, every year out of public health, then when the fire alarm goes off, there'll be no one there. And we're going to spend 10, or 100 or 1000 times what we would have spent in in the economy losses in the economy. So that's the that's the hard easy answer. Right is sustained local funding for the local responders, the first responders from a public health point of view. I also think that we need to do more openness with the data, many, you know, I said it was two weeks before the city shut down. But that's not true. The city de facto shut down by March 14, because people did it themselves. People took action themselves. They didn't wait for the governor or the mayor to tell people the restaurant business are already down 95%. And we need to give people more the tools and more of the data to be able to make decisions for themselves. And I'm, as you know, been a big proponent for the open data movement. And that's partly, you know, again, why I'm, you know, both excited that we have the data systems we have today and frustrated that you can't get the New York City style dashboard of what's going on with syndromic data across the country. The data exists. But it's not publicly available. And that's just infuriating to me.
Indu Subaiya : 18:23
What is on your mind today? What do you get to go and do after this?
Farzad Mostashari : 18:27
Yeah, we just had Medicare release the results for 2019. So it's pretty good. I'm going to go talk to some reporters.
Indu Subaiya : 18:33
Did you guys do well, this year? How much did you save?
Farzad Mostashari : 18:35
$180 million.
Indu Subaiya : 18:39
Oh my god. And that's from I remember in 2014 reading you had launched in 2017. When you had just when you did a piece describing kind of validates early success. You still hadn't saved money yet. Am I right? It took three years to start saving money.
Farzad Mostashari : 18:57
Yeah. I am. Now the flywheels turning.
Indu Subaiya : 19:02
That's fantastic. So congratulations, and thanks for sitting down with me.
Kerry Amato : 19:07
Thank you, Indu and Farzad for that amazing discussion, and we hope you will join us for future episodes. Until then, be bold, be you and keep on accelerating. Transcribed by https://otter.ai