Fixing Healthcare
This week I am talking to Sachin Jain, MD, MBA, (@sacjai) President and CEO of the SCAN Group and SCAN Health Plan that is focused on keeping seniors healthy and Independent. Sachin is a physician by training, but has had tours of duty in the federal government, pharma industry, managed care and care delivery and as a result has a unique and varied set of perspectives of health care delivery and especially discovering how slow healthcare has been to change. The interview was triggered by this article “Healthcare Holdups, Death-By-Pilot, And The Scourge Of Incrementalism” which tweaked my interest
Hey @drnic1 have you seen this? Healthcare Holdups, Death-By-Pilot, And The Scourge Of Incrementalism via @forbes https://t.co/CwwAu0TU5X
— Roberta Mullin (@mssoftware) March 17, 2021
We both agree with the frustrating slow pace of change in healthcare that sees a lot of lip service but very little real and meaningful change. We do need the quantum leaps and big thinkers to make healthcare better and as Sachin pointed out COVID19 showed it is possible to remove barriers and obstacles when the pressure or need is there.
But even with some compelling data to show the inequities in healthcare tied to race, geography and beyond, those factors continue to drive outcomes and health and the disparities remain, while organizations make statements they care and support the cause but much remains the same. As he said, like any good physician we start with a diagnosis, in this case by calling this out as it is, and then
empowering a new generation of leaders who feel comfortable speaking truth about what’s actually happening
Empowering Clinical Leaders
Listen in to hear Sachin discuss potential paths to real solution, and while there are no quick easy fixes to reorientation the medical system as he points out the answers do not lie in government and health policy, which while important won’t deliver the change. It requires everyone adapting to the change, focusing on the success where meaningful change has been delivered, not just talked about. For this to work, more power and decision making should come from the clinical teams who are trying to implement our existing knowledge into actual clinical practice.
Shoot for the stars, but start with small effective steps perhaps?
Listen live at 4:00 AM, 12:00 Noon or 8:00 PM ET, Monday through Friday for the next week at HealthcareNOW Radio. After that, you can listen on demand (See podcast information below.) Join the conversation on Twitter at #TheIncrementalist.
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Raw Transcript
Nick van Terheyden
and today, I’m delighted to be joined by Sachin Jain. He is the President and CEO of the scan group session. Thanks for joining me today.
Sachin Jain
Thanks so much for having me, Nick, really great to be with you.
Nick van Terheyden
So, always important to get the background of folks, you’ve got an interesting background, you certainly been through some interesting companies share a little bit of the details of how you got here and your journey to this point.
Yeah, so I, I’m a physician by training, but have had tours of duty in the federal government, pharma, industry, managed care and care delivery. And I’ve had the privilege of seeing healthcare through a number of different lenses. And it’s helped me see, you know, some of the opportunities and some of the problems that we have, as a collective. And so, you know, my, the broadly, what I would say is that I’m committed to trying to make healthcare better. But I have, you know, recognition that there’s many ways to actually do that.
Nick van Terheyden
I love that answer. I’m gonna steal that at some point, because I have a similar sort of history, but not quite the same, you know, paths or opportunities. So that that’s great. And one of the things that sort of drove this and drove this conversation was a piece that you wrote a little while ago that talked about death by pilot and the scourge of incrementalism. And you could tell, probably from afar, that my neck was bristling a little bit, as I read this, read the title, tell us what was in there and what your thinking was, so that we could talk about this?
Sachin Jain
Well, having been in the Healthcare Improvement game, for most of my career, all of my career, I can tell you, one of the things that has always frustrated me is been the very slow pace of change in healthcare and some of the norms that we’ve developed as an industry around what it takes to actually change healthcare. I think we’ve all convinced ourselves that’s changing healthcare needs to be slow, plodding, consensus, based incremental. And I think that there are opportunities for us to make quantum leaps, so to speak, in the performance of our healthcare delivery system, that, you know, we frankly, don’t take. And I think this last year, the covid 19 pandemic actually showed us that when push to the healthcare system can actually move really fast in a new direction, I think we have to get outside of the mindset, that it is going to require strong intrinsic extrinsic forces to actually transform the industry, and start to begin to think how we can do this from within, I think we have a savior complex in American medicine that Amazon, Berkshire Hathaway and JP Morgan are going to change the game. That, you know, the incumbents actually are off the hook in some ways, from the responsibility to actually drive real change in the delivery of care. And I think that that is a false paradigm that we’ve adopted. And I, personally am committed to at least trying to stimulate or spark a conversation around us moving faster, more deliberately, in a direction that I think all of us want to go in. But frankly, you know, where we don’t necessarily have the leadership wheel in the momentum to get there. We say all the right things in healthcare, Nick, but the gap between what we say and what we actually do is so wide, and I would say widening. And, you know, in some respects, that I think we have to call the question about what I have been increasingly started calling our authenticity crisis in US healthcare. We, you know, there’s it’s nothing short of that, given this gap between what we say we do and what we actually do.
Nick van Terheyden
So, first off, I want to say, I don’t know that we’ve settled, I think we’ve resigned ourselves to this incremental steps. I mean, that’s certainly how i feel i, some of my colleagues, the folks I interact with the sort of, you know, it’s almost a resignation of I can’t change things. And my pushback about around incremental steps, and I agree with you, I mean, I think shoot for the stars. And, you know, anybody that knows me knows that for me, the space program and that quantum leap of innovation. But if you look back, you find that it’s full of all of these small steps that were necessary to sort of go through to get to that reach. So I think it’s about setting the goals, but finding the steps within does that conflict with your sort of challenge to the status quo,
Sachin Jain
it doesn’t conflict, but what I would tell you from a diagnosis perspective is that we have very few leaders, you know, you know, calling their shots, so to speak, you know, pointing to right field and saying we’re going to hit a home run, we have a lot of organizations where the leader is saying, we’re going to hit a double, we’re going to hit a single, we’re going to take some pitches and hopefully get on base. But we’re not necessarily going to hit a home run. And I think we’ve convinced ourselves that, you know, homeruns, are either impossible, or worse, reckless. And I would say, We need more players in this ecosystem, who are willing to point at the stands and say, I’m going to hit a home run. Now, many of them will not. But what we suffer from more broadly in this industry, is a lack of courage. And we we’ve actually even stopped calling things by their names. And we’ve invented terms of art, to make ourselves feel better. So, you know, my, I think the best example of this is probably social determinants of health, where we’ve now created an industry of non evidence based interventions around food and housing and, and transportation, that make us feel better in the moment, instead of calling it what it is, which is racism and poverty. And I think how you define a problem ultimately influences how you solve a problem. And I would say, we’ve not necessarily defined our problems, all that well in US healthcare. And we need a greater level of specificity of what it is that we’re going after. And we’ve, again, we’ve created this whole industry around value based care, we talk about value. And we’ve created chief value officers and health and healthcare organizations. And I look at this stuff. And I say, that is a great way for us to say we’re doing something without actually doing anything. And again, I think we need more leaders in healthcare, fewer administrators, we’ve got a lot of folks who say the right things, but no one holding them accountable for not necessarily doing the right things. And you know, another great example of that, just to, you know, kind of further illustrate the point is how much industry uproar there was around George Floyd, last year, and every organization put out a statement that said, we stand with you no black lives matter, we stand with George Floyd, we ultimately believe in a more just society, we are anti Asian hate when you double click into those organizations, and you look at what’s actually happening under the hood, and what is changing in real time. So a little is actually changing. And so we’ve convinced ourselves that putting out the press release, is actually doing the work. And again, I can just give you an illustration after illustration of that, and the press release is not the work. And that’s why I call this an authenticity crisis in US healthcare.
Nick van Terheyden
I think, you know, great points. And, you know, my sense of that similar feeling exists, absolutely. Across the board, you know, providing verbiage that says we’re doing this, but not actually doing it is to me extraordinarily frustrating. One of my models that I always point to, often times around the space program, but Gene Kranz, if you’re familiar with him, he was the controller for the Apollo 13 disaster. Yep, famous for saying failure is not an option. And essentially, what I found interesting about his approach to this was, it was not failure is not an option. Okay, we’ve got it where Apollo 13 is saved, we’ve got the astronauts back, it was we’re not failing right now. Here we go about it. And I think part of the strategy and I wrote a piece a long time back in the crisis that said, we needed a gene Krantz, which essentially tried to sort of highlight the skill set, and I’m trying to sort of tease out that in the healthcare space, to your diagnosis that says, what is it that we need to do? So? Sure, we’ve made the statement now, Gene basically said, right, assemble my resources, and go after each of these problems, which, you know, I’m gonna say it feels a little bit incremental. It’s not, you know, it was we’ve got to fix the power problem.
How do we do that
Nick van Terheyden
in healthcare, we have this ongoing challenge, but we have to find a way to start fixing these problems that have been here for as long as I can remember.
Sachin Jain
So Nick, I’ll tell you why I think the Gene Kranz quote, is doesn’t apply.
Nick van Terheyden
Okay. Is
Sachin Jain
is? Yeah, and I appreciate the spirit of it. Certainly. I think it doesn’t apply, because we are failing. And we’re not saying we’re failing. So we’re saying failure is not an option. But the reality is we’re failing. You know, why is it that when, in our networks a loved one gets sick The first thing that we have to do is actually like put a bat signal out to the universe of our contacts to say, who’s How can I get in for good care for myeloma or, you know, lymphoma or whatever it is, you know, these are folks who believe in the consumerist fantasy that we’ve perpetuated in American health care, when in fact, the right thing should just be happening for people you get diagnosed for something you should get, you know, into the right seat of the right people with the right centers with the right kinds of care. Instead, you know, we’ve created a system that is so segregated in some regards, and so inaccessible, in some regards, that it literally requires, you know, kind of having, you know, top five or 10% social capital in this country, in order to actually have the right things happen for you reliably. And then God forbid, you’re a person of color who shows up in an emergency room or an inpatient Ward, regardless of your credentials, regardless of who you are, you get treated like a second or third class citizen in some double digit percent of American hospitals. It’s just a basic reality of where we are in American society right now. So we have to think about how we’re going to fix these things.
Nick van Terheyden
So I think, extraordinarily important, and I agree with you, you know, we have failed. I’m trying to focus on you know, let’s, let’s accept that we’ve failed within healthcare. How do we fix that? Because, you know, to your point earlier, what you said was, well, people have made statements where, you know, Black Lives Matter, you know, we care about these problems, but that didn’t do anything. What it is, is the first step, a true acceptance, and we even failed on that
Sachin Jain
score. It is it is, and I think, you know, what I always say is future generations will look back at this generations version of what healthcare is, and we will be embarrassed in the same way that current generations look back at the pre civil rights era and are embarrassed that you know, what we were as a nation and what we were as a country. And so, the first step to making things better is accepting where we are, and actually driving a degree of embarrassment. It’s one of the reasons I think we we need a so called civil rights movement in healthcare. And I don’t mean, just from a racial equity perspective, I mean, from a shining a light on how bad things really are. Because I think as a nation, we’re living in a form of collective denial about how things, you know, really play out for people. And, you know, the reality is, it’s so hard for us to even imagine a world in which the color of your skin or the zip code in which you were born, actually influences so strongly your health outcomes. I mean, for people who don’t carry that burden or carry that weight, it’s actually impossible for us to really fully embrace what it is that people experience. I can tell you story after story of, you know, physicians who get treated like second or third class citizen, certain communities, if they carry a certain, you know, racial or ethnic background, but I can tell you about even more patients, frankly, who, when they show up at an at a healthcare institution, where they’re supposed to be treated for their medical problems, you know, end up, you know, being disrespected end up being given, you know, kind of non evidence based treatment or approaches, you know, because of implicit bias and explicit bias that exists in the delivery of care. And so again, I think we have to start calling things what they are. And every time I see a billion dollar valuation celebrated on Twitter or LinkedIn, I look at this and I say, that’s great. How is it solving the real problems that we have? And I think, you know, frankly, you know, they’re not, and we’re not. And so, again, I think it’s a big country, I think we’ve got big problems, I think the big solution will lie in getting the diagnosis, right? And then frankly, empowering a new generation of leaders who feel comfortable speaking truth about what’s actually happening. You know, it’s, it’s, and I think once a small number of people start speaking the truth as with all social movements, then even more people will feel comfortable speaking the truth, because what we’re doing is we’re verbalizing, long held internal beliefs and values and perspectives that people frankly have been afraid to verbalize. And once we start to verbalize them, we can begin to have the kinds of conversations that we need to have on management teams and boardrooms. And among, you know, kind of, you know, the healthcare industry more broadly, about what we’re going to do to actually fix it. We’ve lived in this fantasy that, you know, value based care has perpetuated this fantasy that everyone can get better, and no one can be worse off. And, you know, you and I both know, Nick that, you know, someone’s waste is someone’s profit. And so if we’re going to really kind of lean out our healthcare system, you know, it may mean that we have fewer hospital beds in some markets, it may mean you know, that we narrow formularies and you know, limit, you know, pharmaceutical choice. In some cases, it may mean that we invest highly in private primary care, to the detriment of specialists. And we kind of refocus our energy on specialty care. But we can’t constantly believe that everyone is going to be better off with no one being worse off in a future state healthcare system. And that’s not to denigrate the value of any part of the broader system. I think one of the things that defines this industry is that everyone is trying to do a good job. And I can say that having now worked across all these sectors, everyone believes that they’re doing good work to solve problems of people. So it’s one of these situations where it’s don’t hate the player, hate the game. But the game needs to be fixed. And I think the problem, Nick, is that people too often look at look to policymakers, and they look to Washington. And we’ve been taught and trained to look to Washington for the solution. And having been in Washington, and now having been in the delivery system and having been in managed care, I can tell you, the problem is within, you know, there’s going to be no magic bullet that comes from DC. And let me tell you something, if you get a magic bullet from DC, it’s not going to be a magic bullet because the baby will be thrown out with the bathwater if we start getting crossed the board policy solutions, but I have to compliment people who’ve worked in Washington over the last 10 or 15 years and health policy, because they’ve given people a number of instruments through which they can actually actualize the right things. Whether it’s Icos or Medicare Advantage programs, or the direct contracting program. The policy instruments are all there, what I see is incomplete uptake and execution at the institutional ground level on those policy instruments. So that’s where I think we have opportunities that have been so far under exploited.
Nick van Terheyden
So for those of you just joining, I’m Dr. Nick the incrementalist and today I’m talking to Dr. Sachin Jain. He is the President and CEO of the scan group, we were just talking about the fundamental flaws in the healthcare system. I feel like we have a diagnosis. But even that I’m not certain of, you know, one of the challenges that I think about relative to this is the sort of internal bias that we all have an acceptance of that I mean, whether you like it or not, I’m not saying you I’m saying me, I have a built in bias that I even though I’m aware of still exists and influences behavior, we have selective memory about the past. And the impact that that’s had. And what you mentioned in there that I think is really important is that this is, ultimately it’s a zero sum game, right? If you take away from somewhere to give you, you can’t, there is no magic King out additional resources, we’ve got a limited part of money, and we have to allocate that as best. And what that tends to do is push people to this position of, well, now you’re talking rationing or, you know, death squads, or whatever it was that I forget that sort of the emotive terms that came out, and there seems to be a failure to accept that, do you think that is something that we can face head on and say that there is a limited part, we have to allocate these resources better?
Sachin Jain
I do, I think we have to choose our language carefully. Because people what people hear in that is rationing. And what they ought to be hearing is, let’s re engineer a better healthcare system. If I told you that, you know, you know, I could give you a, let’s just say, an automobile for half the price of an existing automobile that performs twice as well. But you may have to trade off, you know, with a few fewer features, maybe a little bit less customization, you know, maybe a little less color choice. I think most people would take that deal. And the issue is, is that I think right now, you know, it’s being there’s so many interests at play here, that have confused the dialogue and confused the argument and created massive misinformation we saw that play out around the Affordable Care Act. That, you know, we’re ultimately I think, having a conversation where we’re boxing shadows, as opposed to actually addressing the problems that exist.
Nick van Terheyden
So can you highlight anywhere where you think we’re starting to get this? Right. I mean, you know, we have this sort of widespread problem that’s International. I mean, you know, anybody that perceives this to be an American problem, it’s not you just see it in different ways in other countries. Are we getting it right anywhere? Is there any way that we can learn from
Sachin Jain
you I do think there are pockets? I think there’s organizations that have kind of some of the right DNA. I think there’s also geographies where, you know, there are players that are doing more of the right thing and less of the wrong thing. But, you know, the sad part is when you when you kind of go under the hood and a lot of organizations that are heralded for their kind of new models or their value based care, you realize that again, it’s more Press Release than it is real world delivery. And so, you know, what I do think is that we need to start actually kind of holding ourselves to higher standards of execution and change and transformation. I do think countries that have adopted a stronger primary care orientation, usually do better. Because at the end of the day, you, you know, paternalism is a really bad word in American healthcare. But the truth is, the information is symmetries are so great between patients and clinicians, that you do need trusted guides to help you navigate the system efficiently as opposed to leaving you by yourself to kind of wander and try to make the right things happen. So my personal perspective is, we need to think about a few principles. And we need real leadership, political leadership, that is going to help drive those principles at a high level. And I would say one of those principles is stronger primary care. The second principle I would say is, you know, kind of more power in the hands of physician groups, as opposed to, you know, kind of hospitals. And that’s not because I think there’s anything wrong with hospitals, I just think, you know, part of what we need to do more of in American healthcare is manage chronic disease better, and keep people well, so that the hospital is seen as a failure mode location, as opposed to seeing a seen as a default for what happens to people as they progress and get older. And so again, I think we have to kind of reimagine the set of organizing principles that we have in American healthcare. And I think it would lead us to a place where people did have things like 24, seven access to primary care, where emergency emergency room was not a place that you go to get any of your questions answered, but you actually only go when there’s a true emergency. And that an inpatient admission to the hospital is what happens to you when you actually need it, as opposed to what I think oftentimes happens, which is the so called soft admin, while they’re here, we get paid for a Dr. G, let’s just kind of move them move them in and move them out when when, when some, you know, higher margin procedure volume shows up to kind of take your place. You know, this whole notion of bed day management, within, you know, hospital organizations is really about optimizing case mix and making sure you’ve got sick patients in the hospital. But when there are no sick patients in the hospital, we start to emit less sick patients. That’s just what happens in you know, when you have capacity, it’s supply induced demand. And so again, I think we just need to start talking about these, you know, when I started in this industry, I thought that there were these like, you know, there’s new knowledge to be developed, I actually imagined myself becoming a health services researcher, because I felt like we have to discover the right ways to do these things. And with all due respect to the, you know, many very talented people who are in the health services research field, I think we they’ve helped us figure out a lot of the answers. And the challenge that we need, we need we have now is less answer development and more implementing that knowledge into practice. So that’s, that’s the work ahead, I think.
Nick van Terheyden
So we’ve got a limited amount of time left, I just want to close with perhaps one for that. relative to this, as you know, you talked about primary care. And if you pull that thread, which I agree with you 100% we need more focus on that prevention of disease. The challenge for many folks is to go into that specialty, you pull the thread, you’ve got to go all the way back to medical education, the cost of medical education, how do we address that?
Sachin Jain
I think the answer lies in changing how we pay for it, making it a more attractive specialty. I think when most people when they’re young, and they imagine themselves as physicians actually imagine themselves as primary care doctors and then along the way they they realize that primary care is a bad deal. And because it’s a bad deal, they discover radiology, ophthalmology, anesthesiology, dermatology, you know, these fields that you know, for this for an hour of work will pay you two to 3x. You know what, they pay a primary care physician, even though they oftentimes rely on primary care physicians for referral money. And so again, I think we have to rethink, you know, how we pay for primary care Doc’s and then I think, you know, no new medical schools need to be invented for this. I think that you know, what we need to do is actually just change the change the payment system, and I think people will follow it’s not that complicated. People are smart, and markets are efficient, people will follow the dollar, not because they not because it’s nefarious to follow the dollar. It’s just people are rational, economically minded individuals who are going to make good decisions on the margins, and it’s better to get paid three times as much for the same hour of work than it is to get paid 1/3 as much. So that’s kind of how I how I think this is gonna get solved long term.
Nick van Terheyden
Fantastic. Well, as usual, unfortunately, we’ve run out of time. It just remains. Thank you for coming on the show. I’m just very excited. to sort of have somebody pushing back on the incremental approach, although I will say as I get to, I still think there are steps that add up to that big have to have the big reach. I’m but I’m with you 100%. I think we need radical change. I just think we get by with slightly smaller steps. So sashing Thanks very much for joining me. It’s been a real delight.
Sachin Jain
My pleasure. Thanks so much for having me, Nick.
