There has been no shortage of questions about what the future of our industry could look like in a post-Covid world. Executives across health systems are asking, "What should I be doing today to change my strategic plan to better match what the industry is going to look like moving forward?"
To help, in part one of two-part series for "Radio Advisory," I've invited Intermountain President and CEO Marc Harrison onto the podcast to share his perspective on how the Covid-19 epidemic will change the delivery of health care going forward.
Read an abridged transcript below, or download the podcast to hear the full conversation.
Rachel (Rae) Woods: Marc, I want to jump into a conversation about the future of health care. Now, I think every leader in health care has had the same lightbulb moment across the last six months when they realized that as challenging as Covid-19 is, it also provides a real opportunity for us and for our industry to innovate, to break the status quo. So I'm curious, when did that moment happen for you?
Harrison: You know, Rae, I'd say that for me, Covid-19 has actually validated our strategic plan as much as it changed it. So when, pretty much overnight, we went from having probably dozens of telehealth visits per week to about 9,000 telehealth visits per week, I realized, "Boy, that investment we made in distance health and taking care of people, where, when, and how they wanted to be cared for was really spot on."
Woods: You're saying you went from a dozen telehealth visits to 9000 a week? And it's still 9000 now in September?
Harrison: Yeah, we were at 8,500 last week—and we're absolutely not letting things go back to where they were. We don't think that's the right thing to do. In fact, I think systems that are intentionally moving back to face-to-face visits because of revenue are making a huge mistake. They're missing an opportunity to deeply transform their institutions for good—not only in the long run, but in terms of it being the right thing to do for the people they're serving.
Now, we knew that a digital platform was going to be important, so a couple years ago, we started to invest in the creation of a digital front door. We suspected that AI-powered health care was going to be really helpful. We didn't have a ton of use cases for it at first, but as Covid-19 ramped up, our nurse answer lines got super busy, our InstaCares became overwhelmed, and the ED was overwhelmed. So we fired up a AI-powered symptom checker for Covid-19, and within the first couple of weeks, it had about 250,000 uses, while we saw about a 30% decrease in InstaCare and ED use.
So the experience has validated that this approach was going to be valuable. It was person-light, consumer-centric, accurate, and democratic in the sense that everybody could use it—and it allowed our face-to-face clinicians to do the things that only they could do.
Woods: So it sounds like this was already part of the strategic plan for Intermountain but perhaps when Covid-19 hit, you saw this as a moment to turn the dial up to 11 and move from tinkering around the edges with some of these digital solutions to saying, "We're diving in head first."
Harrison: I think that Covid-19 really did catalyze the sort of change that we all knew we could do. Some of us were already on the path, and for others, it got them on the path. In my mind, it actually creates a no-excuses environment. We now know what we can do when we need to move. We saw unbelievable innovation and collaboration within and between health care providers, to the betterment of society and our neighbors and the people who trust us.
And I don't want us to go back. I want us to keep pushing hard because we know that health care is too expensive, and quality's not always what it should be. And, boy, we really know that inequities and health disparities are a huge problem.
Woods: This brings me to how health care could or should be different going forward. And I want to start with care delivery itself—you've already mentioned telehealth; how are you thinking about profitably carrying that momentum of telehealth into the future?
Harrison: There's a payer answer to that and a delivery answer. And then for some of us, it's the same answer. You see, what we learned through Covid-19 is that insurance companies made tons of money, some maybe even made unconscionably large sums of money, because their MLR changed dramatically. They didn't spend very much on taking care of people because people were staying at home. We learned that providers who were stuck in the fee-for-service (FFS) mentality got crushed. We learned that integrated delivery systems with a high-functioning payer-provider model did pretty well. And so for us, our FFS business, which dropped, was hedged by the risk-based business where we keep people well. And if anything, it re-emphasized our belief that we need to move even more towards a risk-based model.
So the answer for me is really simple: Do the right thing for patients, and that ends up paying off—and that alignment of incentives is maybe the most important thing we can do.
And look, I respect my colleagues immensely. I don't know a single person who's devoted their life to this who isn't trying to do the right thing. But I think a lot of them are working in the wrong model, Rae.
Woods: Let's talk about that, because I think the realistic response to that question is, "Yes, this is the right thing to do by patients, but how do I get paid for it?" What's your response to that question?
Harrison: Well, I think sort of the gateway drug for a lot of folks is Medicare Advantage (MA)—MA provides an opportunity for pretty traditional systems to learn to take risks for the population.
I'll be a little partisan for a second: There are companies like Castell, which we started, that allow affiliated providers to take risk on our primary care patients. We connect them through contracting, provide them with a technology stack, and monitor their outcomes and expenses. So, you can be in a two-person provider practice and have the opportunity to get paid to keep people well instead of just cranking out volume when people are sick, just like somebody who's part of our medical group.
Woods: Now, Intermountain has a very different business model than the traditional health system—a lot of our listeners are in the business of being hospital operators, and, for better or worse, risk is not coming to them—even if they want it. So, what do you see as the role for those organizations, if any, in achieving kind of the goals that you've set out?
Harrison: First, I think they have to work with their boards to make clear the necessity of investing in the shift to value. They need to ensure their governance understands that this is an important strategic investment for the future, because everything I see suggests that this change is going to be inexorable. And the time when you want to make your change is when you can afford to do so, because when you learn to do new things, it takes money, time, and attention.
And I worry—and I think Covid-19 may have brought this to the fore—that it's going to be very hard for a number of organizations to make that pivot. And you start to develop a "have" and "have not" scenario in our health care delivery system in which those that know how to take risks are going to do okay, while those that don't are going to get progressively worse. So, I think the first step is that investment piece.
After you work on the governance, then you look for opportunities to exercise thoughtful control over how care is delivered and decrease variability, things that are very important in delivering population health—bundles are a good way of doing that; you can work with commercial payers on that or lobby your state legislature to move to managed Medicaid. And then I believe that we, as an entire health care system, need to put a stake in the ground that this is the right thing to do and push our payer colleagues to embrace this as well.
Woods: Marc, you've been pretty vocal about the need for the industry to shift its focus from providing health care to providing health. And Intermountain has focused on being an integrated delivery system with a payer arm and a provider arm so that you can actually provide that accessible, low-cost, high-quality care.
Now, that's very much in line with the early efforts that CMS made at the beginning of the decade, about pushing health systems to take on risk—but as you've said, we haven't seen many other health systems dive in. And so CMS has shifted its focus and said, "Now we're putting the bets on physician groups. We're putting our pennies on those independent of a hospital as being the arbiters of risk." So my question is, why do you think the status-quo health systems fell short?
Harrison: It's too easy to make money doing the wrong thing. Same with the commercial payers who didn't want to do risk-based products; it's too easy to make money doing the wrong thing.
Now, I'm not saying each surgery that was done was wrong or badly done. And certainly, I'm a beneficiary of highly technical care. I'd be dead if it wasn't for a bone marrow transplant unit. [Editor's note: Marc was treated for, and is in remission from, the blood cancer multiple myeloma.] So why would most organizations rock their boat when they were doing just fine? It's just pretty simple stuff. But it's also not the right thing to do, because we know that health outcomes in those sorts of communities are generally not as good as communities where it's health-oriented.
Woods: And I should say that while the hospitals that want to be hospital operators are kind of forced into the model of being hospital operators, there are still things they can do to achieve some of the goals you've set out—streamlining their structure, acting like a system, stripping all the unnecessary cost out, and maybe even be willing to operate on a lower price.
Harrison: That's the point, though, Rae, is that's all true. And, actually, I think our orientation towards risk actually makes us more effective from a cost-per-case standpoint on the FFS business that we still do. It allows us to operate at a much lower cost and a lower price for folks.
So anyhow, I gave you my somewhat pithy answer that I really think is true—it's the too easy to make money doing the wrong thing—but that's changing. The writing's on the wall—I think Covid-19 spray-painted it on the wall—and now we've got to go ahead, and I hope that we see changes among some of the legacy institutions.
Woods: You know, it's easy to think about the FFS and value-based business models as totally separate, but I actually think the Venn diagram of tactics that support a system under risk and a system under FFS actually has a bunch of productive overlap in the middle—the "no regrets" strategies. What in your mind is that productive overlap that organizations can focus on regardless of their business model when it comes to the future of care?
Harrison: It's close attention to cost. How much does it cost to produce a unit of service to a person? And consider productive uses of technology, in terms of consumerism and cost reduction. Because automation, machine learning, AI—all of that can address people costs in a very productive way.
And I think judicious use of scale can help a lot as well. Now, there's a cautionary tale around scale—in many markets, M&A activity looks like it not only drives up costs, but it also has had no impact on quality, which are the two things that are usually touted in a merger situation. It's probably very seductive for a lot of organizations to ignore their ability to negotiate better rates from the payers instead of using that scale to drop the prices that their people are being asked to pay.
Woods: To switch tack a bit, we know that care delivery and payment transformation aren't the only ways that the business of health care—or, frankly, business in general—might look different going forward. I'm curious, are there any internal innovations that Intermountain has tested during the pandemic that you're planning on making permanent?
Harrison: You know, I think we'll incorporate some of the ways we communicate. For instance, I've been really impressed by how successful distance meetings have been. In fact, we had a strategy deployment session recently with our top 50 leaders, and I swear the breakout sessions were better using the tele-platform than they were face-to-face because there was no place to go and we got people's undivided attention—for us to be able to seamlessly share ideas was just brilliant.
And look, we went from having under 1,000 people working from home to over a quarter of our workforce—11,000, 12,000 people—working from home. And I don't think many will want to come back full time. So I think we are going to incorporate that work-from-home piece across the organization in very substantial ways, for a long time. In addition to providing people with more time with their families, it will allow us to lighten our real estate footprint and decrease the cost of care yet again. So that's not going away.
I also think we realized that it is a national security issue to have some domestically sourced personal protective equipment (PPE), as well as domestic sources of drugs. So, from a supply-chain standpoint, we will make sure we diversify those sources so that if something like this happens again, we don't get caught with our pants down. (And I will just put a plug in for Civica, the nonprofit generic drug company that functions like a public utility that we helped to start, because they've really pitched in on a number of drugs that have been in short supply because of Covid-19 and have helped be part of the solution for a more robust drug supply network.)
Woods: Marc, as we near a close, I wanted to reflect a bit on your reputation as someone who pushes transformational change and big-picture innovation. So I'm curious: What's in your to-do list when you want to move something from inspirational idea to practical reality at Intermountain?
Harrison: So that's a good question, Rae. There's a doctor leader at Intermountain who I really respect a lot, and she recently asked me, "Marc, you're really direct and challenging with us and you ask us to do hard things, but for the most part, people are excited by it instead of threatened by it. So what's the gig? How come that works for you?"
And I had never really thought about it that way, but I think that is mostly true what she said. And I said, the first piece is that the challenge or the directness has to come from a place of respect and love. So, if the person understands that you truly care about and support them, then it's okay. The second piece is the demand should never be about you. It should always be about, "How am I going to make something better for somebody else?" And then the third piece is there has to be a belief that that person can do the job. And when put together, those three pieces—respect and love, no self-interest, and confidence that they can do the work and that you'll provide the tools for their success—really works.