Episode 4 afterward: Can preventive care address post-pandemic staffing issues?

Justin Steinman:
Definitively Speaking is a definitive healthcare podcast series recorded and produced in Framingham, Massachusetts. To learn more about healthcare commercial intelligence, please visit us at definitivehc.com.

Justin Steinman:
Hello, and welcome to the latest episode of Definitively Speaking, the podcast where we have data driven conversations on the current state of healthcare. I'm Justin Steinman, Chief Marketing Officer at Definitive Healthcare, and your host for this podcast. I'm joined today by my friends and colleagues, Todd Bellemare and Brittany Morin-Mezzadri for a follow up or afterward conversation about our last podcast episode, which featured Dr. Mark Pimentel, the Executive Director of the medically associated science and technology program at Cedar Sinai hospital in Los Angeles. Last episode, Brittany and I had a wide ranging conversation with Dr. Pimentel about pandemic related delays in care. Millions of people have chosen to delay healthcare by choice, and then millions more unfortunately had their medical facility to delay their care without a choice. And I think it's safe to say that we're going to feel the impact of these delays and carers for frankly years to come. So Brittany, let's get us kicked off here. I thought Dr. Pimentel had a lot of interesting insights to share. What struck you the most?

Brittany Morin-Mezzadri:
That's a really good question. There were a couple notes I took on really interesting topics, and the one that stuck out to me was his conversation around health equity and access to quality care. So in addition to growing in a pandemic or trying to grow markets in a pandemic, how do we ensure that patients have consistent quality access to care regardless of where they live?

Justin Steinman:
I think that's a really important topic. And that's one that I don't, frankly, have a good answer to. I don't think if anybody had a good answer to they would've solved it, but I think that some of the challenges that we did see in that data was that communities of color were almost twice as likely to delay care in the pandemic. And then there was also some significant challenges of getting good care out in the more rural communities. I think he mentioned something about the traveling nurses leaving the rural communities and going in search of higher paychecks in the cities. And then that was leaving, where the rural communities were already short staffed as it were, it really exacerbated a significant problem. That's a really big concern for us.

Brittany Morin-Mezzadri:
And then he also mentioned that when those nurses are going into those cities, it's driving up the cost of care because hospitals have to pay twice as much for those nurses because they're also feeling the squeeze. So just further exacerbating the staffing issues that we have.

Justin Steinman:
Right. And I was thinking a lot about the problems that were in the rural communities, where there's less of an opportunity to even make an appointment to see somebody. Even the NPs and PAs moving back into the cities and treating patients there, or excuse me, getting hired to see patients there. When you look at the disparities in care for those patients, it is exacerbated much more in the rural communities, but I do think kind of going back to why there was sort of the delays in the pandemic itself. And so when you really look at the statistics for who was being affected and the breakdown of the different disparities of who was being sent to the hospital with severe COVID, it did hit communities of color much harder in terms of just those poorer outcomes.

Justin Steinman:
And so if we get into a point where the people are seeing that on the news, they're much less likely to say, "Well, I'm not going back to that the hospital. I'm not going to that a place where I can get infected." And so it's almost like a cycle that you see it on the news and therefore you delay care, therefore you delay care, and you end up with a poorer outcome.

Brittany Morin-Mezzadri:
One thing that surprised me that he said was how telehealth wasn't really helping that, that surprised me because he had mentioned that folks who... I mean I really thought that Telehealth would help address the limited access to in-person care for these rural communities. But he mentioned, if you're not going to your primary care setting or your endocrinologist, and they're not touching, feeling, seeing you, it's hard to get that initial diagnosis. And Justin, you had mentioned that Telehealth visits are better for ongoing care after that initial diagnosis. And I just didn't really consider the fact that the Telehealth wasn't really an effective stopgap there.

Justin Steinman:
Yeah. That actually caught me by surprise as well. We talk about telehealth as this wonderful panacea, it's going to solve all of our problems, and he had a healthy dose of skepticism about it. It's good for ongoing care, but it's not so good for initial diagnosis. And that definitely caught me off guard.

Todd Bellemare:
I mean, even when you look at the data for telehealth and you look at the different specialties of where it has stuck in terms of continued to stay at a really high level, you look at something like dermatology, where if you look at the data for dermatologists, they actually did see a really large spike at first in the pandemic, in March, April, May...more of April, May of 2020. But once that petered out, there's a huge thousand plus percent increase.

Todd Bellemare:
And then it went down to, still higher than 2019, for sure. But when you compare the stickiness of Telehealth for dermatology, it's almost the floors come out and it's almost back...it's higher than 2019, but it's much lower than everybody else almost. Especially for PCP or for things where you don't actually have to look at a super close view of somebody's skin to determine is it cancer or is it a melanoma? So those sorts of things are...you do see really large ebbs and flows of Telehealth for certain specialties, and that first visit where you have to make a real determination, some of those hands-on specialties, they really have to be in the office for.

Justin Steinman:
And what was interesting to kind of connect some of the dots, so we had Dan Trencher on early this year from Teladoc and we were talking with Dan about telemedicine as really good for mental health and psychiatry. And I was thinking back to some of the things that Dr. Pimentel said, he talked about homelessness and he said there's homelessness because patients can't get medication and then they have mental disease and they can't get treated. Well, if you're homeless, you don't have a computer. So virtual care isn't really an option for you. And then if you think about in the pandemic, as facilities are shutting down, there was no place physical or virtual for people like this to get care. And so it kind of comes back to something you're talking up Brittany around the inequity or the inequity, excuse me, of healthcare. A lot of people out there didn't have any option to get treated.

Todd Bellemare:
Yeah. That a great point so even poorer communities that may not have high speed internet, for sure. We talked about that a while back, the failure of the U.S. To serve their rural communities and building out more access to high speed internet. And so even people who, not that dial up is used that much at all, but the people who just don't have that access whatsoever. So again, it's a cycle where the pandemic exacerbated certain things, whether it's delayed care for mental health or other things, if you had no access to a doctor's office, you sure as heck didn't have access to a computer to try to access somewhere. And it's, again, it's also a question of dollars. If you can't afford, I know I've heard a million ads for online therapy where you pay a certain price and you can get free regardless of insurance. And so that's not really something that's available to every level of society.

Brittany Morin-Mezzadri:
And he had mentioned that for that type of change and for us to be able to affect that population, it's going ultimately to come down to policy. And I don't know that we're in a position as a country to want to address that, to provide that level of service for healthcare. Like you said, I don't know how we fix this. I don't know that we're going to fix it on this podcast, but it's certainly worthy of conversation.

Todd Bellemare:
Maybe moving to Canada.

Justin Steinman:
Well, that's the whole thing. We're not going to talk about, he was a big advocate for the Canadian healthcare system. I mean, socialized medicine.

Todd Bellemare:
Yeah.

Justin Steinman:
I was really surprised by that.

Todd Bellemare:
Right.

Justin Steinman:
I know he was Canadian.

Todd Bellemare:
I was going to say he's Canadian. So it is probably not as much of a jump for him for sure. But we have our advocates.

Justin Steinman:
Are you Canadian?

Todd Bellemare:
No. In theory, not theory in some ways, yes.

Justin Steinman:
In some ways you're Canadian.

Todd Bellemare:
My grandparents are directly from Montreal.

Justin Steinman:
There we go.

Todd Bellemare:
I claim that as my Homeland of sorts.

Justin Steinman:
Well, as long as we're talking about socioeconomic and political things, let's talk a little bit about supply and demand because my big takeaway from that was we are having a classic economic or macroeconomic or microeconomic, back to business school I'm not sure which one it is. We'll just say economic change of supply demand, curve problems. We have got a bolus or a bulge of a lot of patients with pent up demand for healthcare services, all waiting to go back into the healthcare system. And then you've got your declining supply of providers as people run for the hills. I am burned out. I am sick of treating with patients. I'm sick of dealing with COVID. We've got over a million shortage of nurses. We are going to have hundreds of thousands of shortages of PCPs. I think our data showed something like 80,000 providers exited the healthcare system last year by not filing a claim, which is an astounding number. So I have got demand raising faster than we can think about. We've got supply going down faster. That is a recipe for disaster.

Justin Steinman:
And if my old economics training, it's very limited, so my old economics training is there. I think that means constricted supply and exploding demand. That's going to drive prices up even more in a world where prices are already high. So that terrified me for lack of a better phrase.

Todd Bellemare:
I think it's part of the problem. And again, not to reference our friends up in Canada again, and again, they're having some of the same supply and demand problems.

Justin Steinman:
They or we? Are you going native?

Todd Bellemare:
What do you mean, eh? So when you think about that, it's this way that we treat healthcare as a commodity. It's as if we are treating... It's this way that we treat healthcare as a commodity, like it's a jug of milk on the shelf and it's not like we can just go, "Oh, let's just go back to the cows and get more on there." So it's a problem because the way capitalism deals with anything is a supply and demand problem. And so the state can't say, "Hey, we need to set a policy to increase this," because it is part of the way that our economy works is healthcare is such a massive part of it. So I do think that there's a tsunami of healthcare and need coming and we have to get our policy set now to account for it, or else, if we don't, then we're going to have this lag time.

Todd Bellemare:
Oh, now we have no choice, but to set a policy. And so if we wait until the emergency is on us and it's on us, then the lag is going to end up with, again, that cycle of poor health outcomes. And so if we are able to get some resolve within us as Americans to say, "Hey, we do need a better policy here to account for this," in the next 10 to 15 years, we're in a lot of trouble if we do not try to set these policies now and go forward. So I think about what people can do and what can I do or what can you do? We're not going to suddenly snap our fingers and have a lot more nurses and a lot more doctors, that's years and years of training. And I want them to get that training, believe me. But I think what everybody, and I think everybody on this podcast, even listeners of this podcast can do is you can get preventative care. Preventative care has shown time and time again, that if you catch something early and get it treated, it stops becoming a bigger problem.

Todd Bellemare:
Bigger problems cost more money. They're more difficult to treat. And frankly, you could wind up dying from some of that stuff. Particularly if we're in a situation where have a constricted supply of providers. But I think if everybody was a bit more proactive about their health and look, I'm guilty too, I haven't been to a primary care doctor in 18 months. So I'll point the finger right at me. But if everybody was a little bit more proactive, we might be able to get ahead of these problems and theoretically suck cost out of this system through the actions of million or hundreds of millions actions of one. What do you think, Brittany?

Brittany Morin-Mezzadri:
I think I have a couple of thoughts on this. I think that most of the people who are listening to this podcast are in a position of healthcare access privilege-

Todd Bellemare:
Yep.

Brittany Morin-Mezzadri:
... Who can afford, and back to the idea of capitalism, they can afford the jug on the milk. They can go get it when they want to. So yes, we have to access that and we have to take care of ourselves early so that we're not more costly later. But then also, as he mentioned that this is going to be an action of policy, is to engage with our policy makers as that privileged group, to make sure that those who are less privileged and don't have access to healthcare, gets access to healthcare. So we have to be more vocal about primary care, about healthcare, about access, about equity.

Justin Steinman:
Right. But you also could say that, you're right, we have to work on policy, but policy takes a long time to change. And I don't even want to go into what's going on in Washington DC and trying to change healthcare policy. We're not going to solve that. But your point about access and equity is really important. And you're right, us, everyone in this room today and most of our listeners probably are from position of privilege. If you have time to listen to a podcast about healthcare and healthcare commercial intelligence and everything else, you're probably sitting in a pretty good spot, but let's take that home. If I don't get something treated preventatively, I wind up in the ER, taking a spot away from someone who might not the ability to get something treated preventatively. So there has to be some sort of action and ownership over what I can do, because if I'm not in the ER, it frees it up for somebody else. And maybe that's how we start to solve the problem.

Todd Bellemare:
So I'll give you a good scare stat for trying to go after that preventative care. So if you look at the number of patients who had metastatic colorectal cancer from 2019 to 2020, the increase in patients that had metastatic, in other words, the cancer spread throughout the body because it was not treated earlier. It was about 5% increase from 2019 to 2020. Once we look at the data from 2020 to 2021 so you're accounting for the people who just in 2021 who missed out in 2020, because there was a massive decrease in the number of colorectal screenings and colonoscopies in 2020, that increase was 12%. So that is a 60 something percent increase in the total metastatic colorectal cancer patients in 2021 versus 2020. So again, in the increase between those three years.

Todd Bellemare:
And so you know to that point, get that done now so that you're able to not have to go through with metastatic cancer, which is a terrible, terrible outcome, which I'm sure I don't have to explicitly say that, but it's just something to always keep in mind. And the other thing I was thinking, of these three years, so again, it's such an incentive to understand what is happening right now? What is the consequence of delaying that care? And so if you want to be more preventative, go see your PCP, go do the recommended screenings year in and year out.

Justin Steinman:
In other words, that's a public service announcement. There you go.

Todd Bellemare:
It was. Exactly.

Justin Steinman:
That was heading into PSA territory.

Todd Bellemare:
Exactly. Yes. The more you know.

Brittany Morin-Mezzadri:
I want to ask a question about that PSA. We've known that, before the pandemic. We knew that preventative medicine helps prevent more severe outcomes later. Do you think that that is incentive enough right now? Do you think people understand that or people, for lack of better words, respect that, the outcomes?

Todd Bellemare:
I don't. And that's why... That's the trouble with it, so even when we think about ways to, Dr Primentel mentioned things about outreach, they're in a constant state of outreach right now. And I think that is... I think everyone's just kind of worn down over the last, especially the last two years. But I think especially with healthcare information, because we've been bombarded with all of these details about masks, the CDC, the NIH, most of the country probably never knew what the NIH was until maybe a year and a half ago. So now people are oversaturated with healthcare information and it's almost like they're tuning it out. So we do have to find alternatives to show those and I mentioned that stat is almost like a, hey quick scare tactic, 12% increase as opposed to 5%, 64% more colorectal cancer. So FYI.

Brittany Morin-Mezzadri:
Welcome to your doom and gloom podcast.

Todd Bellemare:
Right.

Justin Steinman:
But I'll try to be a little bit more positive. And so I look at what you were saying, Brittany, I think maybe we are at a different point. The world has fundamentally changed as a result of this pandemic. And people think about, I think people are more aware of their healthcare and their health, I think people probably have a bigger appreciation for their health. And maybe we take advantage of this moment in time when people do change behavior, we're not going to get everybody, but I scheduled an appointment with my PCP to get a physical, first time in 18 months because I actually felt guilty about this.

Brittany Morin-Mezzadri:
Check you out.

Justin Steinman:
Yeah. There you go. I'm going to get checked out. We'll see how it works. We'll see. But I think everybody has started trying to do what they can and we're not going to solve this overnight, but we've got to do something about it. And I think that was the big message I took away from Dr. Pimentel.

Brittany Morin-Mezzadri:
Do you know what I think would be interesting? And mostly this will end up being your job. I'm really sorry. If we looked at our data for commercial versus Medicaid providers, payers and seeing the PCP visits and the frequency of them and perhaps those outcomes. So we could say definitively-

Justin Steinman:
Cha-ching.

Brittany Morin-Mezzadri:
You like that? So we could say definitively that those who have access and those that could, should, and this is the gap of folks who aren't. Kind of add to our PSA rainbow. That would be interesting.

Todd Bellemare:
Yes, absolutely. And I do think, when you look at Medicaid and the Medicaid question is always interesting because of how it varies from state to state. So that is absolutely something that we can look at and come back with on another podcast for sure. But I was kind of thinking in the back of my mind here, as we talked about what can we do and talk a little bit about policy and things like that. And I think that when people think about policy, they think of a big policy, like the ACA or the really large attempts at doing things and I think there may be a case now to do things more piecemeal. Maybe it's smaller, little chunks of policy changes that we can make that do take maybe with more of a stroke of a pen type stuff that we just, hey, just get this done, allocate money for certain types of outreach, which I know is already happening.

Todd Bellemare:
But I do think that there are things that we talked about in our staffing episode, which talks about the accreditation across state lines and things like that. Because again, we're talking about a supply problem and if there are ways to make it easier for people to get into the healthcare industry, whether it's home health aids, NPS, PAs, there will be a point in the next 20 years where your primary care is handled by an NP or PA. PCPs are almost... They are now the new PCPs. So whatever we can do to get at to a point where we can accelerate the increase in those numbers. We, again like I said, we got to do that now.

Justin Steinman:
Yeah. There's an old phrase there from my days working at GE healthcare, helping people practice at the top of their license.

Todd Bellemare:
Right.

Todd Bellemare:
And so you're right. I think we are going to get a lot of our primary care from NPs. And you think about the CVSs in the Walgreens. We've talked about the retail clinics before, but they're really moving into that primary care world. So yes, we have a shortage of primary care physicians. Maybe we get more people as NPs and nurses and you get your physicals there, people practicing at the top of the license and home health aids. And then, to kind of connect it all together here, watch this. We were going to talk about, Todd talking about how we can increase the supply. And I had an idea about how we can lower the demand. And so suddenly we're able to move our price point down on our old macroeconomic thing, see what I did there, Brittany.

Brittany Morin-Mezzadri:
I like what you did there. So how do we get the people who are going to make this policy to listen to this podcast?

Todd Bellemare:
Oh, I'm sure they're already listening.

Justin Steinman:
That's exactly right. Exactly right.

Todd Bellemare:
I do think the only other piece that I think could help accelerate those things is technology. And I've said this, this is my thing. I always say like, "Well, Hey, there's a bright future ahead how we can automate a lot of this stuff." And I do think as those NPs and PAs come into the market again, five years from now, when you go see someone for your physical, it'll be an NP with a little robot doctor along, not a real robot, a little mechanical man next to her, him or her, but a program that is... There's a lot of physician decision management software that are out now that will be 10 times more powerful in 10 years. So that's the type of thing that I think will help us get, or at least short circuit some of the poor outcomes.

Justin Steinman:
So some of the provider decision support technology.

Todd Bellemare:
Support technology.

Justin Steinman:
And I do think there is a role for the chronic condition management technology. Once as Dr. Pimentel said, you had that initial laying of the hands feel the nodule, I think he talked about, and then you kind of diagnose the problem and then you use technology to maintain and keep people on that path. Because again, the ounce of prevention type thing. So I think you're right. There's a role for technology. I think we're trying to figure out where and how you deploy the technology.

Todd Bellemare:
Yeah. I mean, as we can miniaturize some of the technology too, there are trials now with taking a pill that actually circulates through your body and then gives results on what is happening in, for gastro in your stomach or in your intestines and that sort of thing. So I do think the monitoring of those chronic diseases is just on the horizon it feels like. Although it always feels like it's just on the horizon.

Justin Steinman:
For those listeners of a certain age, I'm reminded of the movie Innerspace.

Todd Bellemare:
Yes. Way back when.

Justin Steinman:
Yes. Brittany probably has no idea what we're talking about, but.

Brittany Morin-Mezzadri:
No, truthfully I was thinking of the movie, Big Hero 6, but I have a three year old niece.

Justin Steinman:
There you go. That'll do it.

Justin Steinman:
Good. Good, good. So, as we're shifting on here and think a little bit about this, we did talk a little how scary it is and this is scary, but I really liked what Dr. Pimentel said at the end of the podcast. And he talked about it as rainbows, but I do think there's a rainbow element of it and I think it's important. I asked him, "How do we prepare for the next pandemic or the next health crisis or the next earthquake or something else?" There's a lot of fragility in our health system. And he talked about all the way back to 1917 and he's like, "We didn't have oxygen, we didn't have vaccines. Look how fast we're able to develop." And if you really take a macro step back, the speed of which we developed a vaccine for COVID 19 is like nothing we've ever done in science before.

Justin Steinman:
And I think we learned a lot about how we can manage patient populations and how we can treat people. And now we're all coming back to work and this is great. And I feel like maybe we're starting to move towards an endemic situation in the world. And I liked really his optimistic attitude about how we're going to take these learnings, package up, and we'll do better next time, which I think was a really important idea.

Brittany Morin-Mezzadri:
Absolutely. I think one of the big learnings, I mean... I wasn't there in 1917, so I can't really compare my experience either.

Todd Bellemare:
Are you saying that Justin and I were?

Brittany Morin-Mezzadri:
No, I was just saying I wasn't. So one thing that they didn't experience was the political divide of this delivery of healthcare. So I think that what we need to consider next time is how to depoliticize the delivery of this healthcare. I don't think that we were quite expecting what we experienced.

Todd Bellemare:
For sure. So yes and no. I think that if you look back to the influenza of 1918, there were anti maskers and people who didn't want to... Again, that's the low information environment of 1917 is obviously vastly different than it is today. So you don't get the amplification-

Brittany Morin-Mezzadri:
That's true.

Todd Bellemare:
... Of voices back then as you do today. But I do think there will be... I don't know if it's the shots that freak people out or something that causes it to go, or if it is just a political divide, but I do think it's fascinating to think about, again, sort of on that technology front, all the things we learn now, from how we can manufacture MNRA vaccines and what else can they do for us? We have just us proven on the largest clinical trial in our country of using a brand new technology, not brand new, it's over 17 years old so I shouldn't say that, but somewhat newer manufacturing techniques to get stuff out faster.

Todd Bellemare:
Can we apply that to the drug supply chain? Can we do... There's a lot of things we can say, "Wow, this worked great. Let's do this everywhere."

Justin Steinman:
And it's not only the science, it's also the distribution, the logistics of it. I mean, we got shots in arms relatively quick. And if you think back to when they first came out with the Pfizer vaccine, it had to be in super cold storage and they figured out how to solve that. I mean, there was a lot of innovation, and reactive people pulling together as a community. I for one hope we don't lose some of that. I start to see us start to lose some of that as well. You pick up the newspaper every day, your digital newspaper every day, and you see what's going on. But I think there was a lot that we did accomplish and we learned from all of this.

Brittany Morin-Mezzadri:
Absolutely.

Justin Steinman:
And we're going to need that to work through these pandemic related cares coming up. I think it's going to be a big thing the next five years.

Todd Bellemare:
So I've mentioned the metastatic cancer, that was just for colorectal cancer. It's similar for almost all of the different cancers that we've looked at. And if you look at things like diabetes coming in after the time off, time off, the amount of delayed screenings that happened, and people coming in for their first diabetes diagnosis, they're coming in with more severe comorbidities, they're coming in with more kidney problems. They're coming in with more severe diabetes that need stronger medications, stronger treatment pathways. And so those also have longer recovery times and really it's not even recovery because there's a chronic disease that ends up lasting longer. So, and if you come in with any stage of renal failure, that's kind of it. And now you're in that cohort that has much lower worser outcomes.

Brittany Morin-Mezzadri:
So get screened.

Justin Steinman:
Yes.

Brittany Morin-Mezzadri:
Let's come back to that. Go get screened.

Justin Steinman:
Is that the title of the episode?

Brittany Morin-Mezzadri:
Go get screened.

Justin Steinman:
Go get screened.

Todd Bellemare:
Or go to your PCP.

Brittany Morin-Mezzadri:
Go to your PCP.

Justin Steinman:
Yes.

Brittany Morin-Mezzadri:
Keep them employed.

Justin Steinman:
Exactly. Keep them employed, but be nice to them. So they don't get stressed out and leave.

Brittany Morin-Mezzadri:
Yes.

Todd Bellemare:
Exactly.

Brittany Morin-Mezzadri:
We need them.

Justin Steinman:
Exactly. Well good. Any parting comments from you the two, I think this is a really good conversation. Kind of explaining what Dr. Pimentel brought to the table.

Brittany Morin-Mezzadri:
I really enjoyed our conversation with him. At the end when you tell our listeners to rate, review and subscribe, I really hope that they also tell us if they went and got screened, let us know.

Todd Bellemare:
In the review exactly.

Brittany Morin-Mezzadri:
In the review, tell us I did it.

Justin Steinman:
But don't violate all HIPAA, don't give us any results. Just say yes or no.

Brittany Morin-Mezzadri:
Yes.

Justin Steinman:
Yes, exactly. Well good. So I want to thank our listeners for joining us today for latest episode of Definitively Speaking, definitive healthcare podcast. Please join me next week for a conversation with Kamal Gogineni and Dr. Rakesh Patel from Invitae, a leading medical genetics company. The three of us will be discussing genetic testing. What it is, what to do with all the data that it's generating and whether genetic testing is something that you should consider as part of your personal healthcare regimen. If you like what you've heard today, as Brittany just said, we would like you to remember to rate, review, subscribe on Apple Podcast, Spotify or Google podcast. Be nice to your PCP. So to learn more about healthcare commercial intelligence and how it can your business, please follow us on twitter at definitivehc or visit us at definitivehc.com. Until next time, take care, get screened and please stay healthy.