Dr. Sachin Jain, MD, MBA, FACP (CEO & President of SCAN Group and SCAN Health Plan) joins the show to discuss the 12 unsettling lessons he learned while trying to make healthcare better.
David Williams (00:00):
John we’ve had CEOs, we’ve had doctors, what do you got for me today?
John Driscoll (00:03):
Well, I’ve got a doctor CEO with a lot of opinions, our friend Dr. Sachin Jain CEO of Scan Health Plans.
David Williams (00:10):
He checks the boxes. Welcome to Care Talk your pandemic home for incisive debate about healthcare, business and policy. I’m David Williams, President of Health Business Group.
John Driscoll (00:29):
And I’m John Driscoll the CEO of CareCentrix
David Williams (00:31):
John, is there a doctor in the house?
John Driscoll (00:33):
Oh, Dr. Sachin Jain. Welcome Sachin. Sachin is the CEO, MD and leader of Scan Health Plans.
Dr. Sachin Jain (00:43):
Thank you very much. Great to be here, John, David.
David Williams (00:45):
I was reading your article in Forbes. As I recall wasn’t Forbes, didn’t they call it the capitalist tool, wasn’t that what it was? So, I don’t know if you’re a capitalist tool or not but you wrote something about 12 Unsettling Lessons About Healthcare and there were some that stuck out but why did you write that?
Dr. Sachin Jain (01:05):
Well, it was at a time where I was really ready to reflect on an almost 20 year journey trying to make healthcare better and running into a predictable set of obstacles, a repeatable set of obstacles that I think got in the way. And I would say I’m far less naive than I once was but in many ways because I’m now more aware of some of these obstacles and challenges I’m far more hopeful. So, it was just a moment where I wanted to reflect on some of the things that I’ve learned and share them with others.
David Williams (01:42):
John, Sachin gave us a dozen lessons. What were your favorite ones?
John Driscoll (01:46):
How can shared savings be a bad idea Sachin? I mean, you’ve got this notion that there’s way too much spending in healthcare, there’s a ton of waste. If you could identify it why wouldn’t you share the savings with the constituents so that we can also accelerate reforms we need? I mean, isn’t that the whole premise of value-based reimbursement?
Dr. Sachin Jain (02:09):
Look I’m all about sharing savings. If I had a nickel for every person who wanted to share in the savings I’d have a couple of hundred thousand bucks right now because everyone’s intervention is supposedly going to create a 35% reduction in cost. If I use several of them how do I attribute one person’s savings created versus another’s? And so, that’s why I think that this notion that everybody is going to create shared savings is one that is challenging. I was just reflecting the other day on Proteus which is a digital therapeutics company, the company that was going to tag pills with some microchips that would enable us to sense adherence. And we had had a number of conversations with Proteus and what they wanted to do is take credit for reductions in readmissions. Meanwhile, this was when I was at CareMore. We were doing a hundred different things to try to reduce readmissions and the question I asked is why should you get credit for all of those hundred things?
David Williams (03:07):
Well Sachin I think somebody was on to them because I think with those nickels you have in your pocket you could have purchased Proteus for what they eventually sold for.
Dr. Sachin Jain (03:13):
I think you’re right. I think you’re right.
David Williams (03:16):
John my favorite one was the very first one which I thought was a provocative one and like a really sharp, pointed stick which was things are the way they are because someone wants them to be that way. Where’d you get that from?
Dr. Sachin Jain (03:27):
At the end of the day one man’s waste is another man’s profit and that’s something that you start to realize when you start to follow the money and I think we don’t do that enough. We sometimes get stuck on these superficial perspectives on, “Oh well, such and such company is introducing this intervention to improve chronic disease management and it’s going to save the world.” When in fact, when you follow the dollars you realize that as a healthcare industry we make a lot of money off of really poorly managed chronic disease. And so, sometimes these efforts are more cosmetic than they are real. We have to realize that. We have to have honest conversations about it. One of the first lessons I learned when I was a student of public policy was you have to get the explanatory model right meaning you have to understand why things are the way they are. And I think in healthcare we oftentimes don’t get the explanatory model right and as a result we build the wrong solutions because we’ve defined the problem.
John Driscoll (04:29):
Isn’t that kind of hard Sachin because everybody in healthcare is at some level, either indirectly or directly part of the heroic healing process? I think of what we’re trying to do at CareCentrix and what you’ve done at CareMore and at Scan helping keep people out of hospitals can seem rather uncouth at a period when the hospitals are seen as the centers of healthcare. I mean, I think that your point about the explanatory model is fair but I also think it’s added to this heroic model of healthcare which also gets us in trouble. It’s not just about money, it’s sometimes about the broader social narrative.
Dr. Sachin Jain (05:08):
I couldn’t agree more. And that’s why I would say you can’t hate the players you’ve got to hate the game. But I’ll say the game is really set up in many ways for the players to act the way that they’re acting. And part of my work at CareMore was working with delivery systems around the country to try to help them transform their business models and move from this volume-based fee for service model to risk. And at the end of the day it’s very challenging to get people to think about this alternative way of operating.
And then you realize that even though you’re presenting them with an alternative way of operating they’re so fixed in their business model we make money with heads and beds that they don’t want to make the change. And these are the uncomfortable facts that we need to have more and more conversations about. The CareCentrix of the world, CareMores of the world, Scans, I think we’re aligned around business models that create value when patients are less sick but that is the exception not the rule. And I think people like us we spend a lot of time in the exceptional world and so we forget that the dominant healthcare system that we have in this country is one that rewards people disproportionately for taking care of really sick people as opposed to rewarding them for making them not sick.
John Driscoll (06:33):
Sachin one of the things that we’ve been very effective at is empowering looking at the agency problem of patients and caregivers and how in many ways whether it’s directly or indirectly people are enfeebled psychologically and practically as patients and as families trying to get care. When we can really empower, inform, and support the patients and really get they and their families, show them how to help navigate it we’re far more effective. But do you see that enfeeblement as a global problem and how are we going to solve it?
David Williams (07:11):
Sachin before you answer that one, John is good at coining these phrases and I think they should be trademarked. He came up with patient empowerment movement and now he’s coming up with a patient enfeeblement movement which I think could be just as effective.
Dr. Sachin Jain (07:21):
Well, I think the fact that we need to quote unquote empower people and give them tools to navigate is a reflection of the fact that the system is so sorely broken to begin with. And so, I think the redesign shouldn’t happen with patches that we apply to the system although those patches are helpful and necessary right now given the system that we have. But I think we have to take a deeper look at figuring out why it’s so freaking hard to get an appointment to see someone when in fact in almost every other industry you can go online and click a few buttons and actually solve that problem.
We don’t necessarily think about these issues because we have access to lots of people but I can tell you I’m in the process of navigating some care for my mother right now, it’s hard. It’s really, really hard. Even with all the social capital we have, all the financial capital we can bring to bear to solve these problems the system is just, it’s just hard and clunky to get around because it’s not built to be easy for patients. I don’t know that it’s built to be easy for anybody honestly. I think there’s a lot of folks who historically have said, “It’s built around the people who deliver the care.” Well, ask the people who deliver the care whether they think that’s true and they would tell you it’s exactly not the case. So, it’s just over complicated. It’s a bit of a mess and it’s designed without a real design.
David Williams (08:46):
Sachin not to take anything away from your point about what you’re going through now but you also said that using your own experience is often a poor way to design healthcare, what do you mean by that?
Dr. Sachin Jain (08:56):
Well, and I mean that because at the end of the day, most of us who were in positions of leadership in healthcare don’t actually have authentic patient experience. Before this call started I was talking about the experience of getting my dad on home based dialysis. We have as a family we’ve got a lot of social support, we’ve got a lot of people who can help my dad. My dad is a physician himself so he’s got a lot of connectivity and understanding of his medical condition. I can’t even imagine what it would be like to be my dad without that social capital, without that knowledge. Because and frankly there are more people like that then there are people like my dad. And so, if I were to take my father’s experience and say, “Well, everyone should have home-based dialysis because my dad is having a good experience with it,” I might make a logical mistake there because at the end of the day there’s a lot of folks who don’t necessarily have the same kind of support that I have. So I still stand by that.
David Williams (09:53):
It’s like when John plans the Christmas party he just generalizes from his own experience he’s inviting 100 people and so he orders 10,000 gin and tonics and 900 lobsters and somebody’s got to figure out why there’s so many leftovers.
Dr. Sachin Jain (10:06):
There are people who are not CEOs of Fortune 50 or Fortune 100 companies whose experiences are far worse and those are the people whose experiences we really need to understand and solve for because they’re not going to be able to break into Boston Children’s or Mass General at a moment’s notice.
John Driscoll (10:22):
Yeah I guess I’d take the other side of that Sachin in the sense that I think we need to build on those to generalize. I mean, just having had the experience of trying to get my mother an appointment at Mass General which required the conversation with her doctor, the only way I ended up getting the doctor to call me back was to tell the person that my mother was going to die in an hour and that works by the way. But I think from a user side I take your point particularly elite folks in healthcare really don’t have a clue because they have a lot of connected capital. But I think if we can build on the, and honestly validate the insanity of the consumer experience, the patient experience, I think we actually would chip away at some of the reforms we need. What’s the biggest thing you learned at CareMore taking care of complex chronics where you were a part of a large organization and that you’re applying now at Scan now that you’ve got control of the wheel and are running the helpline? What’s the biggest change you’ve invested in?
Dr. Sachin Jain (11:29):
Well, the one thing that I can say was most compelling for me was actually seeing the power of the transition of care away from centers to actually the home. We launched a number of different home-based products. We had our Islip product which is our touch product. We had a home-based primary care model in your backyard in Connecticut [inaudible 00:11:54] What we were able to begin to optimize really was the delivery of care to the home. I think historically people have not seen that as a financially viable model because on a fee for service chassis it isn’t but in risk-based models when you have the right patients you can actually do magical things for people. Now, coupled with advances that we have in remote patient monitoring I think that there’s some really exceptional things that can begin to happen and it’s why one of the first things that we’re working on right now is actually a build out of a home-based geriatric primary care medical group that’ll also have some virtual elements.
David Williams (12:33):
Sachin, do you think that seniors can handle technology or is that really just for the young folks?
Dr. Sachin Jain (12:38):
I think everyone can handle technology. We need to titrate the level of support that we give them. One of the most interesting benefits we introduced this year at Scan was actually a help desk, a technology help desk for seniors so that we could actually answer a wide array of questions that they have around how to use technology in addition to the questions that they have around how to access healthcare through technology. And I think COVID proved that all the stereotypes we have about seniors and their ability to access technology were just those, they were stereotypes. And so I do think again, there are certain populations that have health literacy issues, literacy issues more generally and again our job is to titrate the level of support to the needs that people have.
John Driscoll (13:22):
Sachin, as a doctor how much of the current problems in the system, the over complexity is really driven by the fact that we’ve built a system around doctors and for doctors and how much of it is because we haven’t engaged the doctors enough? There are strong opinions on both sides. A lot of folks in managed care organizations think they know more than the doctors and the doctors feel the same way about managed care. We’ve got this ongoing war. At the forefront of innovation now that you’re on both sides of it and as a managed care person where do you sit on that argument?
Dr. Sachin Jain (14:00):
Yeah and I would say again I don’t mean to give you a hedging answer here but I think doctors are a heterogeneous group and you have to separate out primary care docs from specialists and view these questions very differently. My personal perspective is that we have not sufficiently empowered or built a system around primary care. One of the key concepts I took from my time at CareMore was something one of my colleagues Dr. [inaudible 00:14:28] trained me on which is this notion of the confident generalist.
We don’t actually empower a confident generalist in a traditional fee-for-service healthcare system. We actually ask generalists to farm out lots of care to lots of different people. As a result, we create this highly non-coordinated patient care experience. So I think we need to build the system around the primary care relationship with patients and I don’t think we’ve done that. And I think most doctors would actually agree with that provided they were paid accordingly. And again, I think the system has just, we have everyone on this treadmill of trying to produce as many RBU’s as they possibly can to make what they made last year. That’s not sustainable.
David Williams (15:15):
Sachin, you had an experience earlier in your career working for the VA and I know you have a legit job now but what if the new president Biden asked you to run the VA, would you do that?
Dr. Sachin Jain (15:26):
Look I’m a Patriot at heart. I will always serve if I can serve but I don’t think that that’s going to happen. I think at the end of the day I’ve made a commitment to Scan, love what I’m doing, love the opportunity that I have. But the opportunity to create change at scale is something that we all have to embrace when given the opportunity.
John Driscoll (15:48):
Sachin, another question on that same topic, you’re the brain trust for the new sector of the VA and other than avoiding cranky congresspeople and senators what’s your advice to help reform what appears at least from a distance to be a pretty broken system?
Dr. Sachin Jain (16:07):
So I actually think the VA does some things tremendously well and there’s a certain number of conditions that I think people acquire when they are veterans that are traumatic brain injury, downstream risks associated with certain exposures that you get when you’re in the military, that really can’t be bought in the private sector. So, what I think is that we do over time need to evolve to a model that I think looks a little bit more like an integrated payer provider model that leverages the best of the private sector but also provides the things that you can’t otherwise buy in the public sector for veterans, and provide care in those instances but then pay for care in other instances.
So, I personally believe that the VA does a lot of things that the rest of the healthcare system can actually learn from. The integration of a payment provider, the fact that everything’s on a common information system makes it actually really easy to be a patient in a highly functioning VA system. Now, what I will say is not all VA systems are created equally. There are similar platforms but the quality is highly variable across the country and I think that’s where we need to start to look at some of the opportunities to reduce the variation that exists across VA’s and across geographies.
David Williams (17:33):
So Sachin I’ve got a question for you, should the patient be thought of as a consumer or are those two separate things?
Dr. Sachin Jain (17:40):
I think these words are silly in a lot of ways. I think and you hear managed care executives call patients consumers it drives me. You hear patient advocates get angry that they’re called patients, that drives me a little bit crazy. At the end of the day, I am a little crazy, at the end of the day what we’re talking about is people and what we want is people to be treated like people. And what I mean by that is we want to be able to treat people like we would want our favorite relatives treated. I wouldn’t say treat them like mom because some people don’t necessarily treat their mothers all that well but like our favorite relative that’s what we have to treat people like. And whatever language we use we have to imbue those values into it.
The reason I don’t love the word consumer is because people don’t always want to be shopping for healthcare in their most vulnerable moments, they just want to be cared for. The reason that the word patient gets challenging for people is because it places them in a sick position as opposed to an empowered position. But I would say I’m not convinced everyone wants to be empowered when they’re sick. Most people when they’re sick just want the right things to happen for them more often than not. And that’s really what we should all be [inaudible 00:18:55].
David Williams (18:56):
Well, that is a great way to end this edition of Care Talk. I’m David Williams, President of Health Business Group.
John Driscoll (19:02):
And I’m John Driscoll the CEO of CareCentrix. Thanks for listening.