Reimagining Rural Healthcare

On this episode of Digital Squared, Tom talks with Dr. Kip Webb, a lecturer at the UC Berkeley School of Public Health and Haas Business School. Dr. Webb has dedicated his career to healthcare reform and innovation. He has worked previously as a management consultant, a Chief Clinical Innovation Officer and is now an advisory board member to many health organizations. Together, they discuss his focus on inequities in rural healthcare, how innovation is improving healthcare delivery for everyone, and how the next generation of doctors are learning a new approach to medicine.

Transcript

00:00
Welcome to Digital squared, a podcast that explores the implications of living in an increasingly digital world. We're on a mission to inspire our listeners to use technology and data for good. Your host Tom Andriola is the Vice Chancellor for Information Technology and data and Chief Digital Officer at the University of California at Irvine. Join us as Tom and fellow leaders discussed the technological, cultural and societal trends that are shaping our world.

00:30
On this episode of digital square, I talked with Dr. Kip Webb, a lecturer at UC Berkeley School of Public Health and Haas Business School. Dr. Webb has dedicated his career to healthcare reform and innovation. He has worked previously as a management consultant, a Chief Clinical innovation officer, and is now an advisor to many health organizations. Together, Dr. Kip and I discuss his focus on inequities in rural health care, how innovation is improving healthcare delivery for everyone, and how the next generation of doctors are learning a new approach to medicine. 

01:05
Welcome, Dr. Webb.

 01:06
Thanks. It's great to be here at Tom.

01:08
Kip, you know, your career has been one that you've mixed a lot of different things. Being an MD and MpH. You've always as I've known, you've been pushing the healthcare industry to evolve and transform. Tell us more about your journey to get to where you are now and the things you're working on.

 01:27
Thanks, Tom. That's a great place to begin, I think, really, my journey began in college, where I went in as a pre med. But double majored in Biology and English and biology, part of my education gave me the scientific chops to see the world. The English part was very important as it is it helped me to both speak and then write about the things that I was seeing. Fast forward to going into med school, which I did right out of college. And as you know, from others that you've talked to med school, the first two years is rote memorization of about a zillion facts, followed by your clinical years, where allegedly, you're going to apply all of those facts. But that's not in fact, what we saw when I went into those second two clinical years. And what I saw was, a lot of what we were doing at the bedside was not evidence based only about 10 to 15% of it was evidence based. And the rest of it was based on individual heuristics, the attending physician saying something of I saw a patient once who this responded to this, or I saw this, or what I would call an institutional voodoo. They don't know why we do it this way. We've just always done it this way. I then went on to residency and joined the faculty at Stanford and continued my work there on the faculty doing work basically, as a Bayesian economist, where I was evaluating new technologies and for their both cost effectiveness and the outcomes that they were leading to, and saying, hey, here are some better paradigms and healthcare that we may want to appreciate. And then came the change in my life. And so in 1994, the Clinton Health Plan went down in flames. And I was devastated. As a healthcare reformer, I was devastated by this. And I said, I've got to get smarter. And I went back to school and got a public health degree in Health Policy and Management. And when I was coming out of that, I spoke to the dean and said, now I've got two postgraduate degrees, what do I do next? And he said, You ought to become a management consultant, because you'd be great at it. And I literally said, I don't know what it is. And I'll try it for a couple of years. So I did it. The most of my career was at Accenture, where I both lead their clinical transformation practice worldwide, eventually became the leader of their provider healthcare practice. So everything we did with hospitals and hospital systems, and physician groups, etc. And also their Chief Clinical Innovation Officer. I retired from Accenture in 2019. And what I do now, which is teach at Berkeley in the School of Public Health, and in addition to that, I served on a variety of health care related boards, and do some advisory work on the side, in my retirement so busier than ever, I found.

04:05
Yeah, that's great. We're gonna get to your message to the students that you get to sit with and work with now. But before we go there, as you look back across this and talk about, you mentioned multiple times during your journey, right, being on the cutting edge being a transformer, as you look back, what have been the things that the progress in healthcare that's been made or not been made, and what's frustrated you the most? 

04:34
Yeah,  it's an interesting question, Tom. But I would say that my frustrations have each chapter of my career. And so in that first chapter of my career, my biggest frustrations were with the inconsistencies with the way that we were delivering care. There was obviously a lot of waste, and that's where Lean programs fit fit in. Certainly a lot of errors and that's where Six Sigma programs trying to standardize care fit in. And as I said, there were very little evidence based medicine and what we were doing while we were making the decisions that we were doing. And I knew that we could do better with that. He then moved on to my consulting career. And here I was, as an international consultant really dealing it dealing with a lot of organizations at a national level. And looking at the inadequacies of the health systems all over the world, if we take our own countries a nice example of that when I started this journey, back in 1980, we spent about 8% of our gross domestic product on health care, similar to other industrialized nations in Europe. We now spend 18, 19%, of our gross domestic product of approximately four and a half trillion dollars. And our colleagues over in Western Europe are spending about 12%. So we've grown a lot, they haven't grown a lot. How about from the error standpoint, I talked about Lean and Six Sigma and waste, it's 20 years since To err is human was published. And we still haven't driven down medical errors that we're committing. As a matter of fact, we found new ways of creating medical errors as Bob Walker cited in his book, The Digital doctor. And then finally, clinician burnout is an all time high, which really is leading to both patient dissatisfaction and also the satisfaction of people joining the profession. And so at a big level, the house is burning, we got to put out this fire. And yet we've been really slow to do. And then you get to my current frustrations, which as a lecturer in public health, you know that I look at medical care, and then I also look at the social determinants of health, and say, We're spending money on the wrong things, as we know that social determinants of health accounted for about 80% of our health and longevity. And yet, we're only spending a fraction of that $4.5 trillion that we're spending on medical care, we have to change the system in order to serve people better to give an access to care who people don't don't have access to address the social determinants to give agency patients to try to keep them well, rather than episodically seek care when they're sick. And finally, really just transform the locus in which that care is delivered. No longer is it okay to think about delivering healthcare with the most expensive providers in the most expensive settings, ICT and hospitals, we've got to start thinking about care at home as a really viable alternative. So those are my frustrations. But as I say they've grown and morphed over time.

07:22
Do you find that your current platform in the academic setting? Do you get a chance to really fill the students brains with the questions they need to ask when they leave you and go out and start their careers.

07:33
 That's the goal, right? I'm in my early 60s now. And when I look back on my career, I had this rich experience of traveling probably to 35 different countries around the world, not only seeing what worked for them and seeing what wasn't working, but cross pollinating great ideas from other health systems around the world. It was an incredibly heady experience for me. But in the transition over to the teaching side of my life, now, it was really trying to train the next generation, and say, here's where we've come over my 40 years on health care. And there's still a lot of work to be done, don't make the same mistakes that we've made, start from here and use that as the departure point to move forward.

08:16
You and I share some aspects of where we spent our time and where we spend our time in the health equity, social determinants of health space, rural health care. The story I tell people for me was after I had done some health care work in the emerging markets, and I came back to the United States, I realized that some of the disparities in the quality of care and access to care that I saw in places like China, countries in South America, we had right here at home, in the state of California, where I live, you have those same kinds of disparities. And I know that you've done a lot with rural health care, you care a lot about rural health care. So talk to me a little bit about what from your perspective and experience, the challenges of rural healthcare, and then some of the dynamics that are starting to change in our US healthcare market that you think might be able to improve that situation.

09:06
So first off, as I mentioned, with social determinants, I'm deeply troubled by inequities within any healthcare system, whether they're due to race and ethnicity to financial barriers, or in this case, geography and rural patients we know we're not receiving the same type of care as they're getting out there in the real world. Second thing that sort of drew me to this was this is the real world. But I've spent most of my consulting career to be sure and my clinical career at highfalutin academic medical centers and big major healthcare systems, seeing the way that they practice medicine and trying to improve that rural health where 20% of the American public lives, that's the real world. That's where the battle is being won and lost every day. And what do we see? When we kick the tires on rural health? The first thing is that we see a system in which these hospitals polls are losing money, they cannot even break even such that they can innovate, so that they're just barely able to keep the lights on with that there is a bias that patients are not going to be receiving the latest and greatest in terms of patient care. Second thing is we know that when there are low volumes, a particular condition, you get less good outcomes at the back end. And because we are not seeing the volumes that we see in a regular urban setting, we know that at these lower volume hospitals, that they actually are not getting as high quality care as they might get in an urban setting. And then the final thing is that they're not exposed to the newest up and coming experts that are out there with expert opinions, expert clinical skills, and exposure to the clinical trials that are amazing. The science that we're seeing today is extraordinary, but it is not evenly distributed across the entire population. So with that in mind, I actually joined the boards of directors of two healthcare organizations in Maine. One of them is a hospital system. The other one is a long term care facility. And it's been a remarkable experience for me. Number one I've learned about this is the real world. These are the challenges that people are facing in the majority of the United States that is rural. And I've also been able to bring in ideas from the First World from those urban settings and best practices that I'm seeing in my life as I travel around this country and around the world. So that I know that I'm making a difference now that I know that I'm able to help these organization in some small, affordable way, make the leap to get to the next step.

 11:39
So it's you right some of my board work is in the health equity space. I'm on the board of a organization called OCHIN, which worked with FQHCs. And now with critical access hospitals in the rural settings, bringing first rate EHR tools and the surrounding services. So epic in an FQHC in the middle of Iowa, right or in the middle of Maine. And one of the things that we talk about in terms of trying to drive better access to care, higher quality care is we have some counties, for example, in West Virginia, with a life expectancy of 57, which would qualify as a third world country, in states of in terms of life expectancy, we have 100 million Americans who don't have a primary care physician today, we have some real access issues. So this is a great question for you. Right, a lot of conversation, a lot of articles read I was on a panel just recently talking about the retailers coming in to health care. The CVS is the Walmart and let's not forget 93% of Americans live within 10 miles of a Walmart store. Right? A lot of talk about Amazon as well, though I think they're a different category, because they're going to serve a different segment. But do you think if you look over a five and 10 year horizon that they're going to add to the complexity of health care? Or are they going to solve some of the ills we're struggling with today?

13:01
Well, I think this is incredibly exciting for certainly the entirety of my consulting career. But probably even in my clinical career as well. In healthcare, we've been talking about consumerism, we just haven't done very much in the area of consumerism. And in that vacuum, these for profit, consumer oriented entities have moved into that space to see what they can do. And it's our own fault. If we didn't want them there, we created an ecosystem in which they were invited to come in and participate. The second thing is consider this there are about 1000 counties in the United States. There are about 5000, Walmart and about 10,000 CVS, in the United States. That's three per county. And so when we talk about access to care, this is really making care accessible in places where as you mentioned, there aren't primary care doctors or places they're went in which they might otherwise go for. The thing that's happening with all three of those organizations is that they are both vertically and horizontally integrated. Now vertical integration is across the value chain. Horizontal integration is other similar entities like yourself. So let's take an example with CBS with the acquisition of Aetna a few years ago, they became the eighth largest insurance company in the United States to complement what they were doing in pharmacy to complement what they were doing in Pharmacy Benefits Management, etc. But then they also had urgent care centers and now with the acquisition of Oak Street health, we are developing primary care capability specifically with the elderly population in the United States. And so that gives them this full bore ability to both pay for health care to deliver health care and deliver a lot of add on services that you might not get in a primary care office. For example, access to medications, pharmacists and good nutritional food. Same thing holds true with Walmart, right that Walmart, I understand this in discussions with Chen Med, to build out some of its primary care capabilities that go along with what they're delivering in their clinics that are actually located in stores. And then finally, Amazon doing a very similar thing as well with their acquisition of one medical, and I'm a one medical patient very satisfied, but they are getting the bricks and mortar footprint to go along with what they've developed virtually. And if we think about what they've done, virtually, let's look at the example of pillpack. When they acquired pillpack, what they really got was the license to distribute pharmaceuticals, in 50 states around the country, you combine that with their ability, their channels of delivery, in 24 hours, I can get a free delivery of my pharmaceuticals. Contrast that with the seven to 10 days that I'm currently getting my pharmacy benefits manager, it's a better service. And that's what Americans are looking for right now. 

15:59
It's a really amazing time. And as the person that they usually call a title like 'data dude', these organizations are also very sophisticated in their understanding of how to mine their data, and how to build loyalty programs that keep consumers coming back. And I think you start to look at what they're bringing to the table. And obviously, there's a lot of incentives that have to align. But to your point, that consumerism of health care has never really gotten there. I think this might just push us over into a very new realm, and especially if they help crack the access problem for all these millions of Americans who just are not close to getting a good entry point into the healthcare ecosystem.

16:38
Yeah, and if I can build on that thought, Tom, that you think about, the majority of Americans maybe see their primary care doctor one time a year, you know, for 15-20 minutes, something like that. I'm probably in a CVS once a week, and I'm on Amazon, probably every two or three days. So that getting that consistency of care, or Oh, while I'm here, let me get my vaccine or while I'm here, let me get me my refill on the prescription or some good nutraceuticals or whatever else that it is that I'm looking for. You can see that the consistency of the interaction, I think also is going to augment the possibilities of wellness and creating a well a healthier society.

17:21
Yeah, and as we look to you mentioned this earlier, and your comments, as we look to move more up chain into more prevention, right, keep the healthy person healthy, longer, keep the chronic disease patient properly managed, you create interesting opportunities for these players to do things I was just with some early stage companies I've been working with at the intersection of food and health. And really the nutrition, reengineering of food and snacks to essentially be much more contributing to keeping people healthy, rather than all the salt and sugar that we tend to put in our bodies with the things we buy off shelves today. Now that Walmart might be go to aisle six, and get your blood pressure cuff, and then go to aisle 12, 13, and 14, because these foods are going to help keep your agency level down, rather than use that pharmaceutical solution. Right. And I think that's going to be very attractive to a certain population of patients who don't want to be seen as a patient, but just want to be given more empowerment to make different choices. And again, this is where I think the world of precision health gets really interesting and potentially really fast.

18:31
And a great example there. I would also say Amazon's connection with Whole Foods that not for better or for worse, Amazon understands the consumer patterns that I delivered to their online service. But now they understand also my food consumption perfectly and the services that I'm taking in for them to combine that data to help me to make better choices in some gentle way. For some that's big brother watching and they're scared about what they may mean. For others. That's a great opportunity for us actually to nudge people and shape their choices.

19:03
Absolutely. I understand at Berkeley, you've created a new online MPH program. Can you tell us a little bit about that?  

19:10
Yeah, we've had our online MPH program for several years now. And what's great about it is that it enables students from all over the world to get a Master's in Public Health from a top 10 University here in the United States. And so that's incredibly exciting. But even more exciting, was that Lynn Barr made a charitable contribution to the School of Public Health at Berkeley, where over the next five years, we will be giving full scholarships to 25 students for an MPH that is specifically targeting the problems in rural health. The program is just rolling out now it's an it's a it's second year, but we already have got a lot of applicants who are coming in and some even from Maine, that I'm trying to get involved with this program to join us and get a great MPH specific We need to address those problems that are encountered in rural counties. So thank you for asking that question. Absolutely.

20:05
Okay, for all our listeners out there, get your bingo cards out, I'm going to drop the word now...We've got a lot of new tools that have come into our world Kip and in the labor been around for a while. But generative AI is has caught everyone's attention, right from the frontline employees up to the CEO, in every organization in every industry. What does this look like to you? When you look through your long tenured career in health care? What do you foresee for the next five years?

20:32
Tom, I just knew you were going to finish that went and thank you for buttering me up with the easier questions first. We are finished with a toughy. But here's what I see is that I see a division in the world where there are proponents who think AI can be used to solve a multitude of issues that we face today. And I have to categorize myself as one of those. While there are also opponents who say this could be the end of the world as we know it, and probably neither of us are right. And neither of us are wrong. But here's what I see in the world today. So the first thing that I'm seeing, and this is probably not unexpected, right is how are people? How are healthcare organizations thinking about dipping their toe into generative AI? And the first moves that I'm seeing are around clinical documentation on the clinical side. And to say, can we make it easier for the doctors to write their notes at the end of the day, saving them two to three hours each night that is helping leading to physician burnout? And can we also use generative AI in order to respond to those queries that we get from our patients? It can be used for both. And I think there's actually some really exciting preliminary research in that world. Specifically, with regard to the queries, there was at least one study that has been published, where they looked at routine generated responses versus those responses that were generated by physicians, questions that were posted on Reddit. And what they found was that generated responses were not only more complete than medically accurate, accurate, we probably should have expected that. But what they also found was it by blinded observers that they were more empathetic Denville was written by physicians. I don't think anybody predicted that one. And so it's very exciting the way that we may be able to use these tools, not as a replacement for the physician, but as a tool that is going to make that physicians life much easier. As we move forward, places where I get excited, there are two of them. One of them, is it layering AI tools on top of the medical record, such that we're able to mine that data to ask a good question. Now, one way we might mined that data is to deliver better care, people with rare conditions, where they haven't been in clinical trials that have been performed on a broad swath of people in a statistically significant way. But be able to say, here's what happened the last time we did X to patients who had symptom y. Okay, that's one way. Another way of using it is to say, what is best practice? And what is best practice that may have come out in a Medical Journal last week that I haven't been able to read, but that I haven't caught up with this yet. And I think that's incredibly exciting. The other part is in what I would call in silico. Experiments in silico, basically means computer models of experiments. And we know in the pharmaceutical world, that they've been doing these for years, trying to look at which drug candidates are more promising than other drug candidates using in silico models. But think if we could do that, with patients, and specifically with public health programs, we could pilot a program in silico, such that we could then launch it in scale without having to wait a couple of years for that pilot project to have been completed. I think that's another potential opportunity hasn't been done yet. It's out there on the horizon. It could be incredibly exciting.

24:21
And I want to ask you one more Kip, which is for some of the people who maybe even if they're positive around the impact of the tools, they have a concern about losing our humanity along the way. You've mentioned a little bit in one of your earlier comments, health care at the end of the day, it's a very human, there's a very human element to what we do, right dealing with some of the most challenging aspects of what happens in our human existence. How do we not lose the humanity with this increasingly utilization of technology and data in how we deliver care to people?  

24:53
Gosh, I hope that we don't enter a world like in Star Trek where we have a little scanner that we run up and down the body and say, here's your problem in some very distant way. But I instead see it as a tool. Now, let's come back to where we started this conversation with medical school and in medical school. Those first two years were rote memorization of about a zillion different facts, then I'm expected to call up in real time, when I'm seeing a patient. Wouldn't a patient feel more comfortable, if I was able, in real time to pull the data up on my computer and say, here's what the computer is telling us we ought to do with patients in your situation that would marry my experience with you. I think this is the path that we ought to go down. I just think there's an opportunity for person and machine to work together and actually deliver health care that is more satisfying to patients less wasteful of resources on ineffective or potentially harmful care, and then is more likely to do the trick and quickly bring them to a cure. So I am excited about the future. But as I say, I hope that we never lose the human touch.

26:03
No, I think that's great. We're gonna leave it right there. That's a great ending. Thank you so much for joining us on the podcast and sharing with us these perspectives. 

26:10
Thanks, Tom. It was a pleasure joining you today