A lot of work has to happen to shift the current “sick care” system to proactively promote wellness, but the data is now in our hands. Linda T. Hand, CEO of Prealize, shares the power and peril of predictive analytics when addressing flaws in the current delivery of care. In this episode, you’ll learn how health systems can treat millions of patients who have put their care on hold, what technologies providers can use to become more proactive, and how we can start to address racial and social inequalities in healthcare when bias exists in the data.
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Announcer: It’s time to think differently about healthcare. But how do we keep up? The days of yesterday’s medicine are long gone and we’re left trying to figure out where to go from here. With all the talk about politics and technology, it can be easy to forget that healthcare is still all about humans. And many of those humans have unbelievable stories to tell. Here we leave the policy debates to the other guys and focus instead on the people and ideas that are changing the way we address our health. It’s time to navigate the new landscape of healthcare together and here’s some amazing stories along the way. Ready for a breath of fresh air? It’s time for your paradigm shift.
Michael: Welcome to the “Paradigm Shift of Healthcare.” And thank you for listening. I’m Michael Roberts here today with my co-hosts Scott Zeitzer and Jared Johnson. On today’s episode, we’re speaking with Linda Hand, CEO of Prealize, a predictive insight service that partners with health plans, employers, and providers across the nation to power proactive healthcare. Linda, thank you so much for coming on the show today.
Linda: No, my gosh. Thank you for having me. I’m excited about our conversation.
Michael: Absolutely. We’ve got a lot of interesting stuff to talk about here. Jumping right into it, you know, one of the things that is certainly happening across the nation and likely around the world as well, patients are delaying their care for all of the different reasons that we know about, and so some are wondering whether that may prove to be more devastating than the virus itself. And this is actually something we just went through in our family, where we had a family member that had to delay care for pretty lengthy amount of time. We were very thankful that we were able to get his issue addressed in a timely manner after things started opening up just a little bit. So, how can health systems effectively treat millions of patients that have put their healthcare on hold once we’ve gotten the curve flattened out?
Linda: Yeah. This is a really important topic, one we’ve been really focused on. You know, 1 in 10 Americans are living with diabetes. We’ve got 60% of adults who’ve got to manage acute and chronic conditions with some kind of medications, right? There’s more than 7 million people living with heart failure, so, you know, leading causes of hospitalization. And then you’ve got the coronavirus sort of dwarfing the focus on these chronic conditions. You know, patients are staying home to avoid exposure to the virus, and then you’ve got physicians who are completely overwhelmed with their coronavirus cases. So, patients are putting off getting acute emergency care for conditions like heart attacks and strokes. You’ve got those with chronic conditions that are deferring their maintenance care, which is maybe the case that you’re talking about with your relatives. And all of those are gonna continue to, you know, lead to more complications and worsening conditions.
We’re working with our clients looking at their customer data and their member data and seeing like 40% deferrals in preventative visits as a result of COVID. ED utilization is down like 30%. You’ve got mammograms and things like that, preventative care down by like 94% and the list goes on and on. And, you know, as you said, that doesn’t necessarily mean that Americans are healthier. It means, as we’re calling these unseen sufferers, this deferred care folks, they’re getting sicker and, you know, without a way to kind of target them and be proactive about the outreach, they’re just going to enter the system when some kind of major event occurs and, you know, that that’s worse outcomes and higher costs and all those horrible things.
So, I think that the continuing wave, I won’t call it a second wave because I don’t think we finished the first wave, you know, is gonna create a surge of its own, right, unless plans and providers really do a thoughtful approach, an orchestrated approach to kind of prioritizing and managing the flow of patients back into the system. And that’s where Prealize comes in. You know, we help customers kind of see through this crisis to the impending risk, this deferred risk in their populations and give them insights to target and prioritize those members or patients that they should be proactively reaching out to and bringing back into the system, you know, sort of safely and effectively.
And I think what’s really helpful is helping them prioritize, not only who needs care from a clinical standpoint, but what specifically is driving that risk and how, and whether or not they can be reached and engaged in the right kind of way, along with recommendations that, you know, they should take into account. For instance, you know, what are their preferred methods of engagement or what kind of obstacles do they have to care? What kind of health inequities are they experiencing and kind of get them connected to the right care.
And that care might be in office, it might be in their home, it might be through telehealth or some kind of specialty alternative care. I think the other thing that’s really important is that there’s a lot of analytics out there that target those who have gaps in care. Hey, you haven’t had, you know, your annual exam or you haven’t had your mammogram. Well, everybody has gaps in care now because nobody’s going to, you know, the hospital. Nobody’s going to their primary care physician. And so, just to kind of highlight what we’ve been able to show is identifying a man, say in his 60s, who’s got a 75% probability of kind of becoming new high cost, and that cost is significant, $30,000 or more.
But he’s got several conditions, the chronic conditions, which is the case for most of these that become new high cost. He’s deferring his utilization, you know, not able to get to his primary care, he’s not doing his quarterly visits to his cardiologist or endocrinologist. And, of course, there’s a lot of analytics that can see that, but where Prealize really highlights these things is which of those chronic conditions are going to be the cause of that sort of cost bloom as we call it. What is going to be the thing that lights up the machine learning and that the physicians should really be reaching out to them for?
Scott: It’s interesting that you bring that up as you were talking to me, we’ve been talking to a lot of people on the podcast and the takeaway basically has been that boy, those insurance companies, they’re making a ton of money. They’re getting paid, but they’re not paying anything out. So, they’re all very profitable now. But if I was running a health insurance company, I’d be saying to myself, “Guys, we’re about to pay a lot of money for a lot of stuff that people are holding back on.” You’re pointing out very well, like if you’re diabetic and you’re not getting the care that you need proactively, it’s going to come back to haunt not only the patient, which, of course, nobody wants in a lot of different ways, and it’s also going to affect the healthcare company.
So, there’s a real win-win there. I mean, the current healthcare system really treats people that are sick instead of being proactive about it, but there’s a lot of pathologies where that’s probably not the best way to manage that, diabetes being one of them, for sure. Breast cancer, mammograms? Yes, absolutely. Colonoscopies? Indeed.
Linda: Yeah. You know, our mission and vision is around, you know, moving the healthcare system and transforming it from reactive to proactive so that people can live healthier lives. And it’s always bugged me that our healthcare system is so reactive. It is really a sick care system, right? It’s you know, like, and the incentives sort of keep everything in the status quo there, reactive healthcare passively waiting for people to get sick and then reacting with like all the available measures to kind of return them to health. I think we’ve trained patients also to wait longer to enter the system. So, they arrive sicker, right? And it’s this vicious cycle which I think ends up creating this avoidable or more expensive care than if we had brought them into the system earlier.
We like to talk about this particular…she’s a real human and one of our wonderful case studies called Maggie. She’s like a 53-year-old home care worker struggling with obesity and depression. Both of those things are exacerbated by her chronic pain. She’s had multiple orthopedic surgeries, you know, on and on, right? Like, this woman has some things to deal with. And in the world of reactive healthcare, she would just remain under the radar until her health issues kind of went out of control, either she, you know, overused her opioids or she had an ER visit due to a heart attack or something like that, right?
I think just, you know, as you point out, reactive healthcare is just waiting until she’s already in the top 10% of high cost patients before she really kind of gets that attention that she needs that could have avoided and prevented her episode. I think that’s why we have a healthcare system that wastes, you know, over $200 billion per year on inefficient and uncoordinated care, multiple billion on avoidable ER visits, you know, unnecessary medications, the list goes on and on.
So, you know, we truly believe that predictive analytics and healthcare will help avoid payers and providers in this mess, help them see around the corner, like the kind of shape and depth of future risk and then providing insights about what’s going to happen both across the population, as well as down to that specific member level. And then we like to say that we provide them with enough details about the who, the what, the when, the why, so that they can make decisions about it. And those decisions, as you point out, you know, for the health plan might be financial, they might be programmatic. It might be about what kind of care or alternative in this particular scenario, what kind of alternative programs to kind of bring to the table. And I think that’s the only way we’re ever going to change the health trajectories of these individual patients by really looking at what’s going to happen in the future and then enabling the plan or the provider or the employer even to connect them to the right kind of programs and the right kind of treatments.
You know, so if you look at Maggie, right, and the reactive mode, we talked about that, but using our technology, we predicted, we actually predicted that she was going to have a significant event that would have cost her health plan $88,000. And so, as a result, the health plan got her into, you know, they outreached to her with the care management team. They were able to intervene early enough to get her to stop smoking, which was like crazy, and seek alternative approaches to pain, right? So, she enrolled in counseling, got into the smoking cessation program, changed the two alternative sort of methods of handling her pain, and that reduced her cost by like 90%.
And I think, you know, that’s a nice story that we use to illustrate kind of the power of proactive healthcare amplified by a personalized kind of engagement that was really relevant to her current situation. And I think that’s another important thing really to talk about. You know, earlier communications like that build trust and health plans really need to change their relationships. COVID’s broken trust with the health system, and we need to rebuild that. And I think next generation healthcare analytics are going to make that possible and allows them to leverage machine learning to scale sort of those insights across the entire population. One of our customers by switching to kind of proactive healthcare reported a 20% increase in their NPS scores, and another had like a 20% improvement in overall member engagement in particular health outreach program, which is really significant.
Scott: It is. It really is. I’m listening to this and getting excited about it because I think any time when you can be proactive about healthcare, you cut out so much pain and discomfort on so many different levels. Sure, it’s cost-saving, but even when you think of Maggie, this person that actually exists, being able to take better care of herself and hopefully living a better life overall, it’s really where I as a biomedical engineer get excited about technologies continuing to help people. And you’re talking about how it can bring people to be more proactive. And I’m presuming, like how do you measure that? You brought up a particular number of like $88,000. Like, how do you pinpoint those individuals? How do you present back to everybody like, “Look what we did.” Like, I get that from a telling a good story perspective, “Hey, look, we took better care of Maggie,” and I smiled through that whole conversation about how great that is. But how did you get that number and how did you use technology to get that number? And kind of walk us through that a little bit.
Linda: Yeah. So, I think, you know, measurement, of course, cost avoidance is a really tough one to measure. You know, what if it never happened to begin with? So, there’s a lot of sort of leading metrics as well as lagging metrics. So, we work with our customers, first of all, to calibrate if you will, the accuracy of our predictive analytics. We do that with retrospectives so that you can really show that our analytics are picking out those that are truly going to bloom in cost. And then as you go forward, you’re looking at the level of engagement.
Again, somebody has to make a change in order for that cost not to increase or switch medications and take an active approach to that. You have to get them to pick up the phone, first of all, so that level of engagement is a leading metric. Whether or not they engage multiple times with the health plan is also another indicator of sort of active engagement, and in trusting the health plan, right? The health plan’s like arm’s length away, right? If you can get the provider to do the recommendation, that’s even better. Getting somebody to join a smoking cessation program, they’re not going to do that when they’re in the hospital.
So, that’s the thing where the number of people that actually engage in these types of interventions continues to rise. You go from 2% to 3% enrollment in a program to 10% enrollment. So, those are really important sort of leading indicators. And then, you know, the cost curve bends over time. It takes time for change to happen. Sometimes an intervention is more expensive than the one that they were on, but it’s the right thing and it’s the right outcome. Getting someone to a higher value provider for their spinal fusion is a really critical thing. It saves money. We have one customer who does a particular steerage outreach for people who are going to do, say, spinal fusions. And they literally relocate the member and their family to Seattle, to a Seattle hospital to get their spinal fusion because they know it’s going to be cheaper, even with all the costs of travel, and they know the outcomes are going to be better. So, over time the cost goes down because you’ve gotten this, you know, better outcome for this patient, and you don’t have a lot of residual poor effects of a bad surgery done someplace else.
Michael: That’s amazing. So, Linda, when we think about kind of what a practice needs to get going on this, clearly not every practice, every provider is thinking proactively about patient care. What do they need to get started? What technology and data and processes do they need just to start taking some steps in this direction?
Linda: Yeah. So, obviously, our solution is what they need. Predictive analytics. I think you have to be able to see the future in order to get in front of it. And then you need to make a concerted effort to prioritize that. There’s a lot of, as I mentioned earlier, a lot of incentives around keeping the system focused on sick care. And so, what we find with our customers is like on the health plan side, prioritizing some level of capacity in their care management team to do that level of outreach, looking at integrating our insight into what’s going to happen in the future into the contractual obligations that they have. They must do this level of outreach, you know, for these employer’s employees. So, we call it “smerging”, smerging those analytics so that you’re managing your entire business sort of needs, but you’re looking across the population for that.
It’s also a different kind of outreach in the care management team. So, we bring in best practices, you know, how to have that conversation. It’s a very different conversation. They’re used to having the one which says you’re in the hospital, I see you’ve had an event. Let’s get you out of the hospital. What do we need to do to get you your medications, etc. A proactive outreach is not you’re on a list. It’s, what’s going on with your health today? What can we do about… I see that you’ve got this, or you’re taking this medication. It’s really engaging them in a conversation about their health, which is very unique for a health plan. You know, you might have a little bit of a distrust there, but making them aware, did you know that we have this diabetes education program. I noticed you haven’t enrolled in it.
It’s just a really different conversation. And like I said earlier, building that level of trust takes some time. High cost claimants, you know, the people that are already managing a lot of high cost chronic conditions, those are known to the health plan and their care management teams have probably reached out to them several times because they’re having a lot of episodes. You’ve got this other cohort of people that, you know, they’re sick enough, but it’s early in their trajectory and it’s time when you can actually impact them. We’ve had care managers say, I feel like that was the perfect moment of impactability. That was the time that I needed to call them to get them to change their behavior, right?
Jared: Yep. Right. Yep. Yeah. Very true. Now, what if we approach this from a social angle, because this is a piece that the more that healthcare starts waking up to this part of it too, there are opportunities, there are also those providers that just don’t see this quite as part of their responsibility yet, quite frankly. So, how do we start to address racial and social inequities today when most healthcare data doesn’t address a lot of important things like socio-economic status and the demographics and geography, all those parts that we need to identify, underserved and diverse populations. They seem kind of like foundational basic things and we know we need to have those in place. We need to understand that better so that we can actually address healthcare inequities. So, kind of where do we start?
Linda: Yeah. That’s a good question. COVID really has further exposed the serious issues with the healthcare system and specifically in continuing to perpetuate inequitable access to healthcare, so, you know, whether it’s the color of your skin or how much money you have in your pocket. I think we first have to acknowledge just to start at this problem and understand the root of the larger problem of systemic racism in the United States and how that’s impacted an access and trust of the healthcare system. So, people like Dr. Jones, the public health specialist and physician who highlights that, you know, it’s racism, not race, that’s a risk factor for COVID. Looking at disparities in jobs and communities and, you know, disparity in healthcare access, leaving Black and Brown Americans more exposed and less protected, right? So, I think there’s two parts to this. I think we have to acknowledge that a lot of healthcare data holds inherent racism. It relies on historic usage of and cost of the healthcare system as a proxy for need.
So, you might recall, there was this “New York Times” article was something about biased algorithms are easier to fix than biased people. And it found that black patients are assigned the same level of risk by the algorithm and that they’re actually sicker than white patients. The problem with that algorithm, and it’s widely used in the healthcare system, is that it introduces bias because it uses health costs or health expenditures as a measure for health needs. You know, machine learning algorithms learn from the data they’re trained on. So, if there’s bias in that data, the machine will learn it.
For my team, that means that, you know, we really need to be consultative with our clients. We need to help them understand what is in the data. And the other thing, you know, with that article was that it was run on, I think the statistical samples were bad too. There were only like 6,000 African-Americans and something like 40,000 white. You really need to understand where’s the bias in the data and what is representative of that population? And then we at Prealize, we make sure that we are not introducing any additional racial bias, whether it’s in our training or in our predictions or in our case selection.
And I think that that’s really important partnering with, and providers and employers to really get a deeper understanding of their member population, to identify racial or social inequities, to, you know, really give them some predictive insights so that they can kind of tailor the outreach to each member’s needs. We bring in some social determinants of health data to help us provide an additional set of insights, another lens on the members of their populations that might give insights to say, constraints of access to healthcare like transportation, or say they’re working three jobs and so, they can’t get, they can’t take time off to go to the doctor. So, telehealth might be the right way to go, or not 9:00 a.m. to 5:00 p.m. phone calls, but after 8:00 o’clock. And I think that’s really important, you know. And we’ve seen a number of our customers really implement lovely programs where they’re providing either food or transportation, anything to create a little more equality in their populations and in access to the care that they provide.
Michael: You know, it’s really fascinating because so much of what you’re talking about here is really how technology can become more human. A lot of the things that you’re talking about and, in particular, with the way that, you know, sort of the scripts that the teams may have to use to start to reach out to some of these folks, all of those things that kind of live outside of the data, when you’re talking about the social needs of people working three jobs, all that kind of stuff. How do you focus on that and really keep that as a core? Because, I think that that’s so much of what so much of healthcare is looking to do and needs to be implementing. But how can, I guess, how does health system and how do providers, in particular, like start bringing this lens to the equation more often?
Linda: Yeah. I did a talk last year on the AI-enabled health plan and the trajectory that a plan needs to go on. Like it’s sort of basic, there’s a lot of automation that you do at first, just things that are manual and error prone and, you know, kind of bring analytics to that stage and then getting smarter and smarter about that. But in the end, it’s more about technology not replacing the human, but in fact, allowing the human to do the human connection part of healthcare, right? The thing that I talked about in terms of the care manager outreaching, and actually having a human to human conversation about somebody and their health and what’s in their way, we’ve had some surprising stories where somebody lights up as about to bloom, care manager reaches out, and in fact, you know, it’s diabetes, you know, “I noticed that you haven’t gotten into your program.”
Well, in fact, the health plan inadvertently signed her up for an English-speaking diabetes program and she only speaks Spanish, right? But only a care manager connecting with her could have heard that. Another story was around a woman was missing her primary care. She hadn’t renewed her subscription, turns out she was being abused. You know, so the care manager got her connected to an abuse, you know, women’s center for abuse, domestic violence. Who would have seen that? And she would never have gone to the physician. So, I think that analytics really help you see what you cannot see. I mean, it highlights things that would not have come to the forefront and I think allow you to take a more proactive approach.
Michael: I love it. I love it. You know, because so many of the stories that we’ve heard around various technology tools, technological tools that have been implemented have been, this is getting between me and the patient. You know, the doctors are saying like, “This is causing more burden and it’s great that your records look good, but I can’t actually do the communication.” So, I love this move towards real human interaction and getting that. I think that that’s so much of what people idealize about the healthcare of yesterday. You know, like remember when the doctor would get to come over and, you know, you’d talked that way. So, I love that progression. Linda, thank you so much for coming on the show. There’s just so much here that I think our listeners are going to really benefit from. So, thank you again and for everybody listening, thank you and have a great week.
Linda: Thank you. Take care. Stay safe.
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