A Redeterminations Disaster: The Necessity of Patient Engagement with Carrie Kozlowski and Ed Marx

In this episode of the Chilcast, Managing Partner John Moore is joined by Carrie Kozlowski, COO and co-founder of Upfront Healthcare, and Ed Marx, CEO and Founder of Marx Advisory, to discuss the importance of engagement, trust, and technology as part of community outreach in the context of the ongoing post-PHE Medicaid redetermination process.

The episode opens with an introduction to the problem: the concerning number of individuals who have lost Medicaid coverage so far – approximately 38% of those evaluated, largely due to trivial administrative issues – and the significant impact to children when health access is denied during key developmental years. This is also a significant financial hit to already struggling disproportionate share hospitals (DSH means high Medicare / Medicaid populations), creating significant uncertainty around ongoing access to care in some of these communities if margins are eroded any further, possibly resulting in closures or reduction in services provided. 

The three then get into a discussion about some of the social factors contributing to this issue, how technology can address aspects of the problem when applied appropriately, and the importance of recognizing that everyone is different so you really need to meet people where they are to have a meaningful impact. A lot of ground is covered, so it’s best to just go and listen. 

Key Takeaways:

1. Focus on the patient: The guests emphasize the need for a patient-centric approach, understanding patients' unique needs and preferences, and delivering culturally sensitive content in multiple languages and literacy levels.

2. Utilize technology effectively: Technology plays a crucial role in patient engagement – but keep in mind that the right people and processes are critical to achieve the intended outcomes of any tool. Leveraging the right data and adopting an omnichannel care approach can improve both communication and outcomes.

3. Collaborative system redesign: Collaboration and system redesign are essential in driving change. Leaders should work together across departments and with community representatives to implement innovative outreach and activation campaigns. Education and buy-in from local leaders is a must to establish trust.

4. Experimentation and adaptation: Healthcare systems must be willing to adapt quickly and experiment with new approaches, as seen during the COVID-19 pandemic. Learning from companies outside of healthcare and incorporating community awareness can lead to more consumer-friendly care experiences. 

5. Prioritize the patient and equity: The guests stress the importance of prioritizing what is best for the patient as a whole person and taking steps towards equity. Providing a hyper-personalized experience and focusing on the wellbeing of entire communities are some of the best ways to drive better outcomes.

Chapters

• 0:00 Redeterminations: Setting the Stage
• 5:44 Guest Introductions
• 10:26 Framing the Problem: Accessing Care
• 17:30 How Critical is Trust?
• 21:45 Addressing the Data Problem
• 28:30 Psychographics/Omnichannel Engagement
• 36:45 Can Tech-Enabled Services Fix This?
• 45:18 Retail Health Is Here
• 50:30 Advice/Closing Thoughts

Transcript

Intro: [00:00:00] Welcome back to the Chilcast, a healthcare podcast from Chilmark Research, helping healthcare leaders make the best decisions for the populations they serve. 

John: [00:00:14] Welcome back to the Chilcast, our podcast here at Chilmark Research that talks about all things health tech. Today we will be discussing the Medicaid redeterminations and what's been going on across the country as people are trying to reenroll and getting disenrolled through largely procedural issues. My name is John Moore. I am the managing partner here at Chilmark Research and I'll be your host today.

John: [00:00:36] The Medicaid continuous enrollment provision, which had halted Medicaid disenrollments since March 2020 as part of the response to the Covid pandemic ended this year on March 31st, with the official declaration that the was over. As Medicaid is administered by states individually, tracking the redeterminations has been pretty chaotic, with members being disenrolled at different times across the country and some states resuming disenrollments in April, others in May or June or even July or later. This has contributed to a broad amount of confusion, a really difficult approach to trying to manage this at a federal level. The Kaiser Family Foundation has been tracking this and reporting on it since the declaration of the end of the PF and at the time of recording, more than 7.5 million people have lost Medicaid. So this is as of September 26th, 2023. That is roughly 38% of all enrollees who have been evaluated for re enrollment to date. Not all states have publicly available data on total disenrollments so the data reported by the KFF also undercounts the actual number of disenrollments.  

John: [00:01:32] Across states with available data, 73% of all people disenrolled had their coverage terminated for procedural reasons and high procedural disenrollment rates are concerning because many people who are dis enrolled for these paperwork reasons may still actually be eligible for Medicaid coverage. And while data are limited, children accounted for over 4 in 10 Medicaid disenrollments across the 16 states reporting age breakouts, which is pretty alarming. I mean, child health affects health throughout the rest of your life. So if people are suddenly being denied access at a young age to critical health care services, that is going to lead to significant most likely lead to significant problems later on in their life. My new home state, Texas, has one of the highest and largest Medicaid programs, and because of the limited states of reporting on these numbers, Texas has a disproportionate impact on the share of children enrolled, which is approximately 81% in Texas compared to 18% in Massachusetts on August 30th. Because of these alarming numbers, the Biden administration sent a letter to all 50 states and DC to threaten sanctions for improperly removing children from the rolls and from the safety net. The American Hospital Association also issued a statement that they share CMS concerns about improper disenrollment and support the agency's efforts to provide states with tools and technical assistance to guard against loss of eligibility. Aj's concern also lies with CMS recently finalized billion dollar cut to Medicare disproportionate share hospitals. The Aha noted that these cuts from CMS are predicated on the assumption that the uninsured rate will decline in fiscal year 2024, despite the ongoing redeterminations and recent Congressional Budget Office projections to the contrary, these cuts are happening at a critical time for hospitals and the patients they serve who are struggling to afford care.

John: [00:03:14] And we urge CMS to maintain the uninsured rate at fiscal year 2023 levels for fiscal year 2024 and its Medicare DSH calculations as we approach the potential government shutdown due to budget issues right now. Obviously this is going to be a big sticking point since the Republican caucus tends to always try to strip away what they refer to as entitlements like these. Kff estimates that a total of 17 million citizens may be dropped from Medicaid over the course of the year under this Medicaid unwinding process, and we're already seeing the impact of this. So as a result, health enterprises are suffering massive revenue leakage in the wake of the onset of these redeterminations, the median rate of uncompensated care for hospitals in Ashley increased from a third, increased by a third from 6.4% in the first quarter of 2023 to 8.7% in July. And that's just with these initial redeterminations. We're still in the early phases of this, so we can only expect that number to get higher. And that is really bad for a lot of these systems that are already struggling since the pandemic to keep their bottom lines in the black. Margins are thin, rural hospitals are shutting down by the droves, and this will only exacerbate that issue.

John: [00:04:29] So this all points to a broader communications and engagement problem across both public payer administration organizations and care delivery systems. There are better ways to reach patients and activate them to update forms and prevent loss of coverage than what we've seen adopted in many states to date. For example, omnichannel outreach can be personalized to engage patients in their coverage status, prompt them to make necessary updates to maintain trusted health care provider relationships and stop the revenue hemorrhage. However, a one size fits all approach will not be effective in communicating with this diverse audience. Connecting with these different populations requires understanding their unique needs and preferences and delivering culturally sensitive content in multiple languages as well as different literacy levels. Digital solutions are. Well positioned to help states and providers achieve this shared goal of engaging Medicaid patients more effectively. Today, I'm joined by Carrie Kozlowski, Chief Operating officer and co-founder of Patient Engagement Platform, Upfront Healthcare and Digital health guru and CEO of Marks Advisory and host of Digital Voices Podcast to discuss our concerns for the well being of some of the country's most vulnerable populations and how processes enabled by the right technologies can help ameliorate the burden on these individuals. So Carrie, would you want to give a little bit more background about your history in the industry and how you came to be one of the co-founders of Upfront Healthcare?

Carrie: [00:05:50] Sure, John, Thanks. Thanks for having me today. My name is Carrie Kozlowski. As John mentioned, I'm the co-founder and COO at Upfront. Upfront is a patient engagement platform. We focus on serving healthcare enterprises from health systems, medical groups, urgent care, health plans and population health companies to engage patients to serve their needs in terms of growing financial revenue, managing total cost of care, but really all driven by quality. Our mission is to guide every patient to get the care they need. My career kind of took a little bit of a different turn over time. I started as an occupational therapist, and the reason I'm so passionate about helping patients get the care they need is I cared for patients. I observed care transitions between rehab facilities, hospitals, skilled nursing. Et cetera. That went very poorly. And a lot of the times I was serving in safety net hospitals and in the community in urban Chicago and really saw the impact of what we didn't know at the time were barriers to care, but barriers to care and people ultimately succeeding in managing their health outcomes. So that's a little bit about me.

John: [00:06:56] Thanks, Carrie. That's great. Really helps provide some context as to why the Medicaid issue is something that you are particularly familiar with and have seen a decent amount of the issues there. So, Ed, can you tell us a little bit more about yourself and how you came to start your your market advisory service?

Ed: [00:07:11] Yeah, happy to. And thanks also for letting me be part of Chilcast. So excited for this conversation because it's so important. And really at the heart I think of why we all got engaged in health care. So for me, I was 16 and I was a janitor in a health care facility. I know it sounds kind of funny, but I just knew at that point that health care was my calling and I needed to do something. I didn't know how it would manifest itself, similar to Carrie's story starting out, you know, one part of health care ending up in another. But I've had the good fortune of finding sort of my niche on the tech side, on the digital side, and have been able to serve many different organizations as a CIO. And then I also served on the vendor side as a CXO, as a CDO chief digital officer. And really having those two different experiences taught me the value of partnerships and that I wanted to get involved in helping broker better partnerships between vendors and providers. And so that's how I got involved and starting my own firm, Mark's Advisory, really helping the vendor side connect better in the marketplace, have a better experience with the providers, because then I think everyone wins. I also serve on some health system boards, so it's really eye opening and this is a real, real topic of discussion at the board level at our hospitals where, you know, we take this super serious because it impacts the mission of every health system. So really happy to be here to chat a little bit about it.

John: [00:08:32] Fantastic. So before we actually get into the discussion that I've planned, can you tell me a little bit more about what some of those discussions at the board level have looked like and what people are actually saying?

Ed: [00:08:42] Yeah, there's, you know, the majority of individuals on these boards as logic would dictate, you know, live in that area and are very familiar with what's going on. And the importance of health care is so vital to the community. Right? If you don't really have community, if you don't have a strong health care presence, and when you don't provide care to a major portion of your population, especially given the topic that we're talking about, a lot of it is just administrivia, you know, and policy, it's super concerning because it impacts the vitality of these cities, right? Because cities, these communities are people. So the major concern, you know, John, what we talk about is how do we reach out to the community, make sure that everyone has the support they need to get the care that they need. So it is the you know, it's right up there with all the other top challenges facing health systems. And one I think you may have alluded to already or we're going to dive into is revenue. So it's not just the quality of care and quality of life, which is number one, but also the revenue for the health system to sustain itself. And so suddenly, through administrivia and through poor policy, you can't cover lives, then it's not a good situation. So those are sort of the two different ways we look at it. Number one, quality, getting care for everyone. And the second one is cost and revenue.

John: [00:09:57] Yeah, which makes a lot of sense. I mean, if you're not bringing in the money to sustain the business model of a hospital or of a system, then you're not able to provide the care that your constituents need. So, I mean, this is a problem on many factors. So one thing that I want to talk about is a framing for this, the Medicaid redetermination. Procedure. It's fairly unique in a historical sense. This was activated by the ending of the public health emergency. Hopefully we don't have to experience another pandemic anytime soon, so hopefully this won't be another issue. But how does this actually relate to other problems that we see in health care today? How is this a correlate to other issues that are currently being experienced by people trying to access care?

Carrie: [00:10:33] Yeah, I'll jump in and I'd love to hear your thoughts on this, too. I think this is correlated to everything we're doing in health care. Everything we're doing ideally is about how do we engage a patient, help them understand the care they need, motivate them to get that care, and then guide them through a frictionless, ideally process to be able to get that care and access that care. And I think what we're learning here with the challenges in Medicaid redetermination, we equally see when we're trying to encourage people to get preventive care and come in to get colonoscopies, mammograms, well visits, well-child, etcetera. We see the same thing when we have services that health plans and health systems stand up to support patients care management solutions, pharmacy support. All of the patients don't know what those are, how to access them. And sending a flier in the mail isn't going to be the way that people are going to understand it because it's not personal. It's not relevant. It's not timed when they need the information. So I think this is a really interesting microcosm of what we see at the macro level of engaging patients to access and complete care across the board.

John: [00:11:39] Now that's great. That resonates really well with what we're seeing here at Chilmark as well. Add anything to add?

Ed: [00:11:45] I think Carrie summarized it beautifully. And it's really just this combination of tech as an accelerator to all that. I think we'll always still have and I think we'll get into it. You know, this concept of multichannel or omnichannel, like how do we meet people where they are, not necessarily how we think is the best tech solution?

John: [00:12:07] So that's a perfect segue into my next question, which is how much of this is actually a tech problem versus a social problem? I feel like we have the tech and other industries like retail and finance. But what's the holdup in health care? Why don't we have better insights into how to engage health care constituents?

Ed: [00:12:22] I think I'll go first, Carrie, and then Carrie, make it even better, give a better answer. But I think I think one thing is we're really risk adverse as a culture in health care. And there's a wide variety of reasons. Some of them are good ones, you know, because at the end of the day, we have patients lives that we're taking care of. Some of these things are life and death. And so we're always a little bit risk averse, but we're also risk adverse in a negative way, which we're afraid of taking a little bit of risk because we fear for our positions, we fear the unknown. And so this culture of safety kind of in the good fear around that has really permeated culturally all of health care. So so we I believe we take a lot less risk than you do in other industries. That's number one. Number two, we've been very insular in health care. So if you think about other industries and the leadership in other industries, they jump from one industry to the next. You see someone from banking going into you, manufacturing going into retail. If you look at health care, although I've seen some change in this regard, but only in the last three years, we've very insular. So all of our job descriptions at least used to. But I think still 90% at least would say must have 25 years health care experience for any sort of VP or above level. You want the opposite. You want zero in some of these cases, right. Because you want to bring what the great things are doing in retail, the great things that they're doing in finance, finance, you know, all the data analytics that are advanced or all the retail engagement of the consumer. We want that in health care. Why did we become so insular? So I think that's sort of the second macro issue. You know, both this risk aversion and this insularity just made up a word I think, that we've embraced. And so those are a couple reasons why.

Carrie: [00:14:24] I'll build on that, because I think where you're going with insular, I would take even if you double click into how we operate in health care, it's very siloed even within a system or even a medical group. And when we operate in these silos, what we do is we mirror that experience back to patients. And so when we try to solve problems, we solve the problem for this specialty or this operation or this medical group or this service line. And the patients see that reflected back and there's confusion. And that creates greater distrust because you might get slightly different communications, you might get overlapping communications. It's not well orchestrated across my personal journey, and I think that contributes a lot to how do we actually move more quickly with greater agility and bring more minds to come to a comprehensive solution that will meet multiple needs. And ultimately the patient needs. And I think I agree with you, bringing some people from outside health care into that mix, too, is highly valuable. Just to push a little bit, right? That's where good brainstorming comes from. The other thing I'll add, I think, is when you ask if it's a social or a tech problem, I keep going back to maybe it's a clarity problem.

Carrie: [00:15:32] Who owns this problem? I'm not clear on who's responsible for making sure a patient is enrolled in Medicaid. Is it CMS? Is it the state? Is it the provider caring for that patient? Is it the health system that they go to most of the time? Right. Where they're attributed, even if they've never been before? And so I think when we get down to this, ultimately it comes back to where you were going and action follows the dollar and revenue and quality as the drivers points us right back to providers and health systems. Ultimately in some of the managed care plans, I think operating Medicaid plans are probably where this has to get solved because the we can't put the burden on the patient. We haven't given them the information, the access, the ability to set themselves up for success. So we have to decide who's going to to be invested in this and then how do we get them engaged in a way to solve this. And I don't see anybody jumping in, raising their hand, wanting to lead the way in resolving this right now. 

John: [00:16:34] Yeah, it seems like the Biden administration is the only one actually taking a step to try to address this at a broader level. And they're struggling because as we all know, Medicaid is messy because it's state by state and it's hard from a federal vantage point to force states to do what you want them to other than holding back money. And as we all know, a bunch of these states have already told the government that that's not going to be enough of a carrot to get them to follow what the feds want them to do. So, Kerry, you mentioned trust, which was one of the topics that I was planning to get to a little bit later in the conversation. But can you know, that's a good segue way to bring it up. Now, when it comes to engaging with patients, how critical is cultural awareness? One of the big issues we see across all sectors today is a deterioration of trust in once revered establishments. So this is government. Pharma, like every industry, is seeing a deterioration in trust, including health care, which is still the most trusted industry of all industries. And doctors are still seen as one of the most trusted individual professions. But even that has taken a significant hit over the last five years, if not longer. So how important is this trust and how is this deterioration of that trust affecting how people interact with health services today?

Carrie: [00:17:42] I think trust is fundamental to patients getting care. And I think that what we see is a result of deterioration is we like to label it loyalty, right? They don't trust. We weaken loyalty. I don't know if loyalty is the greatest problem as long as someone's getting care and preventive care. And we've guided them as a health care enterprise, as a health care system across the country. To do that, we're making the right. We're doing the right things for patients. But I go back to we did a study with Ipsos last year and found that 41% of people under the age of 45 felt that Amazon knew them better than their doctor. And that is deeply concerning because, well, because of what I just said out loud. And then the other part of it is, is our doctors do know us. Our doctors like it's creepy if you think Amazon knows us better. But we are as a patient, you share so much information even when you're not sick, like your providers, your health care system. They know your employment history. They know. They know your financial status. They know your family history, your social history. Your mental health, your physical health. There's an incredible amount of trust we place and just giving people this data, and yet we're not putting it to use in a meaningful way to help patients get care.

Carrie: [00:18:57] If I buy something at the large retail store, I guarantee you the next day they're going to suggest the shoes that would match the dress that I just bought. Why do we have a patient getting care? And we're not suggesting, Hey, you need to get your annual wellness visit. And while you're here, we'd like to get you in for your mammogram, and we probably should check your onesie down in the lab. We're not using all this information. And oh, by the way, we understand that you missed your last appointment due to a transportation issue. Here's our solution for that, too. We have this information, but we're not packaging it and presenting it to patients in a way that says, Oh, you do know me, you are making my life easier. You're making the path for me to follow really clear and you're taking the friction out of it. And I think without that, we are going to continue to see patients being confused and then not knowing where to get care or what care to get.

Ed: [00:19:49] Yeah. You know, Carrie's anecdote there reminded me of one that I did maybe two years ago. And I was on Twitter now and I was talking about this exact thing about how well does my health care institution know me? So I sent out a tweet and it it had my financial institution, which is USAA, highly regarded for customer service engagement. I mean, it never had a building since their inception. And so they have to be that way. And then I'm a marriott person, so I tagged Marriott and I fly American Airlines predominantly and I put in my health institution, which I won't name because I'm not picking on them. And just they're just emblematic of the whole situation. And I said, who knows me? And everyone responded except for the health care organization, you know, And some of them were like, thank you for being executive platinum. Or they said something that's not too private, you know, not too personal, but at least that they got the gist of it. It was crickets because they don't they don't know me. And it's sad. It's just sad. And I know we're going to unpack maybe some solutions or ideas, but I just wanted to share that anecdote because it related to what Carrie was saying.

John: [00:20:58] Yeah, no, it's a good anecdote. I mean, it's definitely very telling. And to your point, Carrie, I mean, with Amazon's acquisition of one medical and Pillpack, they are going to know even more than our doctors. In theory, they know our shopping history as well as now our medical history, which is, you know, both very interesting from some big data, you know, personalized care perspectives, but also terrifying from just Amazon owning more data on us, which I'm very, very wary of. Quick little plug for our book club. I'm going to recommend for one of our new books coming up in the next couple months to read is Surveillance Capitalism, which talks all about this trend around how Google and other companies have monetized, surveilling us and monetizing that information that they collect on us. Actually, the next question is about data. So also relevant to that surveillance capitalism piece, as we discussed ahead of this recording, part of what we have here is a data problem. Part of what we the issue is that we don't know what we don't know very well and the health care systems. And so can the two of you discuss what the issue is with our current processes when it comes to engaging patients in this kind of outreach? Like, why don't we have better data? What's the problem here?

Ed: [00:22:06] I think one of the reasons is that. We take a very again, this is because we're insular. We think that our EHR is the source of truth of everything data about patients. And it's not for sure the clinical aspects. Yes. And you know, the revenue tie in, but not about your community and all the people and consumers in your community. So a lot of organizations just look at that piece of data that's in there. I would venture to say, depending on how competitive your community is or if you if you compete nationally. But let's just say for an average community that might be 20% maybe of the consumers in that community are in your EHR because they're going to other health systems or they're not getting any care at all, or they're going someplace nationally or retail, Amazon or Costco now, Dollar General. So I know everyone understands it. But anyways, back to the data. So if you're only working off 20% of the population's data, you're in big trouble. You need to have that ability. And they do this in every industry. That's why you know the name of the book that you just referenced. That's why there's a little bit of concern because they are taking data from multiple sources and putting it together. I know of one company in health care. That's what that's all they do and they focus on.

Ed: [00:23:25] And we've used them. I've used them before in my past where we brought in the EHR data. We brought in consumer data from other consumer data organizations that provide it. And then your Chamber of Commerce, you know, your local sources and put it all together, did all the matching and we knew people. So when we called or let's just say it was an inbound call, they called or on their, you know, depending on what channel they use or on their mobile. And they said, hey, I need an appointment or something. We knew right away, Oh, they are related to these three people and they're late for their prostate exam or they're late for their flu shot. And we could say something to prompt them and really take holistic care. And and not only that, but then and I don't want to get too far ahead, so I'll just stop by alluding to this is once you have all that data, you can be super proactive and do a lot of preventative things with that data to reach out in the way that those individuals like to be reached to. So the good news, John, is this is solvable. This part of it is solvable. We just don't do it. And I think part of it is lack of vision.

John: [00:24:31] Yeah, no, that makes a lot of sense. I think it's lack of vision personally. And I also think part of it is that to your earlier point is being this perceived single source of truth. They were never really built to be systems of engagement, the way that we're talking about right now. And that is a big issue there, a system of record. They're trying to position themselves now as systems of insight and engagement, but they're still making it to that level. I was just at and at Oracle Health Conference and the two biggest players in the country, they're both still struggling with the engagement piece and neither of them have a very robust patient engagement solution. If it's not just about messaging your doctor or getting the hospital paid, you know, paying your charges as the patient. So the engagement piece is still something that is significantly lacking in any meaningful way on that front. Carrie, you want to jump in there?

Carrie: [00:25:15] So many thoughts. Also, I'll start with not surprising kind of where Ed's going. When I think of the EHR data, there's a couple challenges. One, it's point in time. I had a visit the last time I saw you. That's where my information is. Who knows? I change jobs, change insurance moved. There's a lot of things that happen in life in between visits, and that's where engagement happens, right? It's not. Experience is when you're in front of somebody, but engagement is around kind of that time between the touches. And I think what we try to do it up front is also build on existing data, but augment it with things that we learn. We're about the patient. So for example, we augment with behavioral science, we're looking at engagement and we're understanding how when, what are they doing with the information we're providing them? Where are they responding More to a text, to an email, to a phone call, and then we're applying psychographics, which allows us to segment and understand from a health care perspective, specifically a person's motivations. So, John, you might be a self achiever. You're a goal oriented person, and we say, hey, you got to tackle this. That's how you want to be spoken to. Ed might trust his physician. So when we say Doctor so-and-so thinks you should do this, he's going to follow that plan. And if you tell that to me, I'm going to be offended because I just want to see all the research and evidence. Thank you very much, and I'll make my own decision. And so we want to augment and get to know the person as more than a patient, but as a consumer.

Carrie: [00:26:39] And how do they make decisions and what are their motivations? And I think the last piece is when you're doing patient engagement, well, it's not unilateral. We have this historical approach of like, we're going to send information to you and now you're engaged. But what we want to do is learn from you like, Oh, hey, you're not going to come to the visit. Why? Oh, you're worried about finances. We have a solution for that. Let's get you in touch with one of our representatives. All of this piece of like, just it should be a conversation. I don't mean like a chat bot. I mean, like, truly like. Understanding patients and giving them information that they need as a result of what they're sharing with us. So I go back to that piece of it. The last little plug I'll make and maybe it's not so little. One of the challenges I think we face in data when we talk about EHR, even some of the CRM, they're really holding tight to the data and there's a fee when you want to move that data. And if you want to leverage another solution to really think about an engagement platform, there's an automatic financial obstacle that is by design in place that keeps people from being able to do that. And in a world where we have slim margins and no IT resources and additional challenges helping to operate, that's a buffer, a real buffer to success in engaging patients and building a patient centric engagement solution.

John: [00:28:01] Totally agree. I don't know how many of our listeners are aware of this or if I've mentioned on previous podcasts, but my first foray into health it got me into the space was when I initially decided that I didn't want to stay in hard science and physical science to try to make an impact on mental health. And I saw the opportunity for mobile health to actually keep patients engaged in their treatment plans and following through on various aspects of their therapy. It didn't end up working out, but have a very fond appreciation for everything you just laid out there. Carrie. So something you mentioned two things that I want to double click on there. So first was the psychographics at upfront uses. And then I want to dive into the topic of omnichannel engagement. But could you just define a little bit more what are the different psychographic profiles that you have and just share with us how you break out your different types of patients that you're engaging with?

Carrie: [00:28:47] Sure. So psychographics is a is a consumer science principle that's been used in many industries for for a couple of decades or more now. And essentially allows us to understand something about a person before we've gotten to know them. And so the classic example is Procter and Gamble and Tide. And if you go to the store, you will see 15 different tides. And John, you might like the one on the white bottle because it feels like there's nothing else in it and it's pure. And I like the one that's orange because it reminds me of my mom. And so these are the things that we do when we make decisions. The same is true in health care. And so we've studied for about 15 years now and built and designed a model for psychographic segmentation specific to health care motivations and decisions and influences. So we look at things like, again, person could be a self achiever. They're very goal oriented. Those are our most proactive people, you know, through the balance seeker. That's the people who like all the evidence, but they'll make the right decision presented the evidence the priority juggler Many things on their plate. But if you tell me to do it because I'm doing it for my kids, maybe then I'll go get that care through the trustful responder, right? And this is where we market the most in health care is that doctor says model. 

Carrie: [00:29:58] And it's less than like 20% of people who actually respond to that. Those that do, it's very effective. But when you're applying it to others, it's almost alienating. And this is why it's really important to think about. And then the last is are willful endure. These are the people who will put up with pain, be a little uncomfortable until they just can't anymore. These are the people who use urgent care the most. Living 65% on most of urgent care visits are willful endures if it's convenient. If we say, Hey, you need to get this care and we say we can get you in the next 4 to 8 hours at a location nearby, then they'll take that, they'll take that that visit. And so when we think about site of care optimization, we think about motivation and helping people make good decisions in their health care. Psychographics is a really important way to help us drive the outcomes that we're looking for.

John: [00:30:44] Yeah, that makes a lot of sense and definitely fits with how you've been kind of teasing what you guys do at upfront throughout this podcast. So the next topic was something that both of you have mentioned during this so far, and that is the omnichannel care concept or omnichannel engagement. So we actually published a report on how virtual care was a factor in enabling omnichannel care a couple of years ago, back in late 2021, and that was when omnichannel is more of just seen as a marketing word in the more retail side of things. But since then we've seen it being used a lot more often in health care. And so can both of you talk a little bit more about just why this has gained steam, why omnichannel is such a buzzy buzzword right now in the industry?

Ed: [00:31:25] Yeah, I think one of the reasons, going back to the insularity that we spoke about is we're getting more savvy with marketing and also with, you know, people that are coming in from other industries or people that are in the industry, long timers who are aware enough that, Oh, I don't want to be insular. So even though I'm in health care, I'm going to go to other conferences, I'm going to read other information from other industries and bring it in. That's another another effective technique. And I think omnichannel is one of those things. And so I was very fortunate where I served as a CIO to our head of marketing. You know, he came from Delta Airlines, and Delta is known pretty well for their omnichannel capabilities. So if you want to go old school, you want to roll old school and hand check in your luggage and, you know, go to a counter and things like that, You can, if you want to use a kiosk, they've got a kiosk. If you want to be all mobile, you be all mobile. If you want to receive text messages three hours before instead of six hours before you can set that up. If you don't want to be text but you want to get emails, you can set that up if you want. Just to get snail mail, you can get snail mail. So that that to me is sort of speaks to omnichannel. It's like, how can you engage patients? Because per the personas Carey shared, you know, everyone wants to engage differently and so you need to meet people where they are. So I think it's really important, especially when we're talking about how do we reach our diverse communities, is you have to go all these different modalities that we spoke about.

Ed: [00:32:54] And also I'm a huge advocate of in-person, the personal, the ultimate personal touch, because if we're going to truly bring health to our communities, we're going to have to do this. So, you know, one of the things not to go too long in the answer, but one of the things that really struck me when I was watching How to Live to be 100, you know, this Netflix series that's that's on all about the blue zones, things like that is you'll find that a lot of these communities and I think they highlighted Costa Rica as one example where people tend to live a lot longer than the average is. They do like home care but not home care that we think of it. But this is home care for everyone. Everyone gets a touch and the medical communities or the medical clinics are in the community. So it's not like you're putting up a barrier, right? What do we do? What have we done in the United States? Largely we've shut down out, let's call them, medical outposts in communities or little hospitals stuff. And what do we do? We force them all to come into the big one, into the city. And but for you and I, maybe most of the listeners, not a big deal. We have our own cars, but not everyone has their own cars. People need public transportation. So we're creating these barriers. And so it's that touch. So going back to the heart of the question, I'm saying, yeah, omnichannel and I and I reference a lot of different really sort of digital solutions. But I think with digital has to always maintain this in-person high touch attribute in order to be successful in bringing health to our communities.

Carrie: [00:34:19] I think humans have to be one of the channels and omni channel. When we think about it, I think it's really important that we don't associate omnichannel with digital. It's just multiple ways to reach somebody and to get that engagement. And we work with a large academic medical center and when we were able to offload that enrollment to care management task right digitally. So we are taking 50% of their time. They're spending cold calling, warm lead calling patients who should be enrolled in care management. These are nurses who do care management. And so when we were able to shift and offload the cold calling aspect of it, which by the way, gave patients additional data in a microsite of like why this is important for them, what does this matter? A video of what the experience could be. They are actually they able to shift their teams to their care. Managers saw twice as many people went from 50% care managing patients to about 98%. So they're doubling their caseload without adding staff and patients who were enrolled through the digital experience were more likely to complete care management and to set goals and make progress against those goals because that content was provided to them and something they could refer back to, right? And so it's all about using the right channel for the job and we don't have enough people. And so we want to use those people. When there's a complex referral, I need to get care. I need to go up to the Mayo or to Tufts or to MD. Anderson Right. We want to be able to support those people through a very high touch, advocate led experience. We shouldn't be using those same people to remind everyone that they need to come in once a year for a wellness visit. And again, some people need that high touch there. But how do we rationalize each of our resources in a way that maximizes the engagement and ultimately the health outcomes?

John: [00:36:01] I totally agree with all that makes a lot of sense. It's kind of similar to what we've been seeing as far as how we look to cover omnichannel. And I think one of the big trends that I'm noticing in all these conversations I'm having at events recently is that people really seem to be focusing more on that people and process piece right now. There was a lot of hype and a lot of expectation that adopting EHRs would be the first step to solving a lot of these issues in health care and all these woes that we have to deal with. But that obviously has proven to be not true. If anything, it has contributed to administrative burden and overhead in a lot of care organizations, which has taken away from the patient, you know, the time that people have to engage with their patients. So as we think about just kind of moving forward, how like what do you think the actual percent is here of the problems that we're dealing with today being a process and people issue versus something that can actually be addressed by technology enabled services?

Ed: [00:36:53] A lot of it is so like to put a number on it. It's difficult because a lot of them are so intertwined with with each other. So I would love to see digital solutions, you know, that at my heart, you know, I'm sort of like, Hey, how can we solve this? How can we bring efficiencies, improve quality of care and patient safety with technology? So but I always see it as an accelerator. So it's never like the main thing, but it's certainly something that can accelerate, you know, our impact in effectiveness in a lot of this. But I do think a lot of it is societal, cultural. But again, if we can move through some of those by offering these omnichannel experiences, by by being really super sensitive and not forcing anyone down a specific path, I think we'll we'll definitely make a lot of progress. So I'll kind of save my thoughts about, you know, some action steps maybe till till the end. But that's sort of my take on it. When you ask for sort of a percentage, I think there's just so intermixed, it's hard to give. Like I think each one of those that you mentioned, John, has like an 80%. If you want to get to a number, 80%, we can apply technology to to to make it better. 

Carrie: [00:37:59] Tech is usually not the obstacle we can create and build great technology. Like that's rarely the issue. The issue becomes technology. You can't just lay technology down and solve a problem. You have to start with the problem. You're trying to solve the workflow, which is people and process. And then technology should be there to support, enhance, adjust. And sometimes it's the catalyst for workflow change and we need to look at problems and say maybe we could be doing it differently now. And one of the greatest examples of this is scheduling, right? Scheduling care, like setting up a schedule and letting a person schedule online is not a technology problem, but controlling the schedules. How we want to manage the schedules, what kinds of patients we want in our schedule, when we want to see those patients in our schedule as a people and process problem. And I think this is true of most things. I just think it's really important that we don't take the lens of I do think the technology is not the obstacle, but it's also not the first answer. You just you can't just institute technology and fix things. You have to do them. You're right. It's all intertwined. If you really want to make a transformation that can be adopted and sustained over time.

John: [00:39:14] So how much of this is actually something then requiring process and system redesign at the health care? Because mean a lot of the issues that we're that we're talking about are just because of this reliance on fee for service. The systems are just kind of built to operate a certain way. And clearly that's dysfunctional at this point. So I guess this comes back to my last question, which is just if it's a combination of all three, then how much of it comes back to just system redesign and what we actually need to be thinking about as we try to revamp how health care is provided in this country?

Ed: [00:39:43] I think you have to find you know, if I'm a provider listening, you know, you don't want to be like, oh, this is such a big problem. Because, John, what you just defined. Right, is at the crux of the matter is like, well, I throw up my hands, I can't do anything. You know, I give up. I'm just going to like, just do my job and get paid some money and eventually I retire. And, you know, but I think most people, again, the reason we're in health care, our heart is not like that or wasn't like that originally. So I think it's incumbent on all of us as leaders to do what we can. So so if you're in a community and you're leading a health care organization, then do what you can in your community, don't like, wait for the government and policy. You want to definitely influence it. I'm not saying stay away and don't get engaged because we need that influence, but you can't use that as an excuse either. So do what you can and get, you know, be very creative. There's examples out there, very creative health systems, doing some really good things in their communities despite all this leverage and leveraging tech and and then work with there's some progressive payers out there.

Ed: [00:40:45] You know, I think of my friend Sachin Jain out on the West Coast. You know, he and there's others like him doing some pretty progressive things. And if I were leading a health care system right now, I'd want to get together with one of those pretty progressive individuals on the payer side and do something damn good in my community and, and lead the way, because I think we can make an impact despite all these other things that we can't control. We can control some things. So don't let that be like the reason why you don't get do anything, do something. And there is the tech, like Kerry pointed out so eloquently, the tech is not the issue. The tech is there. So be creative with your community. Bring in some tech and you're going to make a difference. Is it the end all? Be all? No. But is it progress and taking care of people? Yes.

Carrie: [00:41:31] We saw this during Covid, right? We we we stopped thinking insular. We broke down silos and we were able to make rapid change. And there was experimentation and iteration. And that happened. And we saw that in big health systems and medical groups, an urgent care people adapted quickly. It's possible. And I think this goes back to how do we take those principles of kind of quick decision making, really clear role, right, in what my role is in this decision and then appreciate and experiment. And not every experiment worked that we tried tech wise, process wise people wise. But but people were more, I think, flexible at that time. And so I feel like it's in us, like it's in us as a health care system. And we saw really good work, right? Whether it was, you know, how do we get people care despite precautions? How do we get vaccines distributed in an equitable way? How are we going to take care of our providers and support our patients in the care that they need in this time? I think there was a lot of great stuff and I just feel like we are kind of getting comfortable and going back to some of our our old ways in health care and and I bring it back. I mean, the Medicaid redetermination issue, when you think about the revenue side of it, it actually and then the quality side of it, there's a short term. They're very similar. There's a short term problem we had to solve. There are really sick people. There are people getting disenrolled from Medicaid.

Carrie: [00:43:02] Okay? Now there's this impact in terms of quality. Okay? We are not able to care for people. We have negative health outcomes in both cases. And then there's a cost impact in the short term, we're not going to hit margins. You know, we are decreasing charity care, all this stuff. But then they're both going to have very long term consequences that people delaying preventive care during Covid. We're seeing younger, sicker people getting diagnosed with cancers than we've seen before. We're the same thing will happen with Medicaid. Have an extended family member who is on Medicaid, wasn't getting care, was feeling really sick. And then my parents called and they were like, What do we do? And I was like, Call the hospital in his town. Ask for the person who does the patient financial stuff and ask how he gets enrolled in Medicaid and what he needs to do. And is diabetes was out of control by the time they got in because he was delaying care because he wasn't going to be able to afford it. It was it was a pretty dire situation that cost a lot more money, had a less quality experience to resolve their the system redesign. We can't wait for it. We can't wait for policy to change. We can't wait for system redesign. We have to just start taking positive steps forward. And if we keep patients just in mind, like who's my patient story that I think about every day that motivates me, people will make good choices. 

John: [00:44:19] I like that. Yeah, I like that a lot. I think it's really accurate. Give people the autonomy and the actual power to do the right thing. Give them help them feel empowered to take control of their health. And hopefully, I think more often than not, people will actually will. I think one of the biggest issues is that like some, you know, like taxes and some of these, you know, legal code, these industries or these professions where they are intentionally made more complicated to gatekeep to a certain extent, I think that puts a lot of people off of taking care of their own health because they get intimidated by the health literacy issue. Or just how do you advocate for yourself if you're not very confident in pushing back on your doctor? If you just see the doctor as an authoritative figure and you second guess your own symptoms, but you know that something just doesn't seem quite right, you're going to feel like you're not empowered. So I think that to your point, Carrie, I think that's really important, is to actually give people that autonomy and ability to feel like they know what they're doing when they are taking control of their health. So we mentioned earlier that retail health is kind of going through a big explosion right now. There's a lot of hype around it. There's a lot of investment going on, big dollars being spent. So we're seeing, you know, Best Buy to Walmart, to CVS, to Amazon, all making multi-billion dollar investments in these and getting into health care and actually providing more services in the space. What impact do you think these new models will actually have on access to care and patient activation? And do you think this will help to actually drive some of this transformation that we were just talking about around the health system models that we are currently trying to revamp today?

Ed: [00:45:54] Well, first is I wish that hospitals and health systems would have gone there first. You know, we we sort of spoke earlier about risk aversion. We spoke earlier about lack of consumerism type thinking. And so there was a gap. And who came to fill it. Retail. And I think it's going to work. I wish it weren't the case, though. I wish health care systems would have been the retail and instead we kind of saw the opposite, as I mentioned, because at the end of the day, I'm a big hospital health system advocate and I want to see them succeed. And and I think they've given up a lot of territory and ground to to retail from when I put my hat on as more of a like what's healthy for the community and stuff. And I do feel bad that the hospitals didn't take that space. But that aside, I do think it's going to increase access to care I do believe will reach more people because these facilities are located where the people are. I think we've carried on both, made that point a couple of times. And I think back to some conversation I had with the CEO of a big health system out of India. And you know, what they had an issue with was truck drivers. You know, it's a certain type of lifestyle, very, you know, sitting a lot. And it's like and they were always on the road. They didn't have time to see a health care person. So they had this big epidemic, you know, of stuff going bad with all the truck drivers. So they built a bunch of clinics. Where did they build them? Did they make them come to Delhi, to the big cities to get their checkup? No, of course not. Because they're not going to they put them in the truck stop. So while the truck is in, getting the oil changed or whatever, right there is their PCP and it's made a difference. And I think we're going to I think retail is going to provide the same sort of service because they're right there in the community. 

Carrie: [00:47:41] I think retail is doing the iteration that we're not seeing in health systems, right? We've seen Amazon go through a few iterations of what their story is going to be, what their services are going to be. The bottom line is, is easy to say. They don't know health care. So we're safe, right? We don't have to. But they're here. Right. And there are many others providing care in these retail settings. What I'm excited about is competition, right? So if I'm competing with someone just like me and we've kind of agreed on the rules of the game, then we're we're not going to move forward very quickly. And now we've introduced a new competitor and that should inspire the best to be better. And that, I think, is the opportunity that we have.

John: [00:48:27] Yeah, I think to your point, Carrie, a lot of these systems have gotten fairly lackadaisical about market forces because they control their regions. You know, there's usually very little competition. I mean, I grew up in Boston, so there was actual competition. In Boston, you usually see some competition in major metropolitan areas. But outside of major metropolitan centers, you don't see a whole lot of like penetration of multiple systems. So to your point, I think that that competition will actually drive some innovation and drive some of these outdated hospitals and health systems that have just been sitting on their laurels to actually drive some new innovation and find new ways to get out into the community and provide more community engagement services. You see that with some of the more forward thinking models, you know, people that are more on capitation, they've been much more aggressive about getting out into the community and providing, you know, busses that will, you know, clinical busses that can go out and provide primary care services at a church or at community events. But we haven't seen that really trickle through the rest of the country. And, you know, the entire health system, it's typically only those models where there is an incentive to keep people healthier longer as opposed to just treating them for the sickness that they're coming in to be seen for.

John: [00:49:33] And that's, you know, Chilmark, we've always been big advocates for the shift to value based care. Obviously, there's a lot of criticism about how some of these models have been played out. Medicare Advantage is getting a lot of scrutiny right now for some of the abuses that some of the payers have been, you know, extracting some of the value extraction that's been happening there. But I think that all of that is just what you see when there is a shift in economic systems like this is a tumultuous time because it is a shift, it's a transformation period. And we will continue to see that until we reach a new baseline, reach a new level of equilibrium across the country where health care is actually affordable. It's not the primary cause of bankruptcy for it's for the citizens of the country, you know, and all the other issues that we're all too familiar with being who we are in the industry. So as we get to the end of the podcast recording time, could each of you just share any closing thoughts for comments? What are some action items that you might recommend people follow as a outcome of listening to this podcast? 

Carrie: [00:50:29] I can start editor. I think the maybe the biggest advice I could say is what's good for the patient is good for health care. So if we do the right thing, whether it's helping them get enrolled in care. So we removed a barrier for why they might access care if we help them get preventive care so we avoid a later stage diagnosis of something. If we help kids get well-child visits and immunizations, if we make it easier and consider barriers to care, we will all benefit. The quality of the community improves and the health of the population improves. It talks a lot about the communities, and he's right. Like there is a there's an effect that we have on one another when we do that as well. And we build trust and yeah, like it's it's right there, but we have to do it in a way. It's not what's good for the commercial patient who lives in the zip code. That's most interesting to me. Right? As, as it's, it's all of the patients. If we do what's right in an equitable lens and we will we will reduce the total cost of care and we can make we can make this move. It's not going to happen overnight and it's going to take people taking some risks and trying some new experiments. And I think at the end of the day, it's not about this patient being at the center. It's about empowering the patient to be a successful contributor to how their care is provided and what steps they need to take to do that. And I think that comes from engagement. I think that comes from a hyper personalized experience that results in trust, that results in action.

Ed: [00:52:01] Yeah. And I have three things really quick to wrap up with. One, you know, and not surprisingly, not one of them, at least not one is technical and that is make sure that 25%. So this is any leadership in in the health systems, at least 25% of your team are clinicians, clinicians, 25% are from outside of health care. I think that's going to help you a great deal and help your community that you serve. The second thing is get a get a data system that we talked about earlier that incorporates all these different pieces do not rely just on your EHR because it doesn't have your community in it. So get one of these sort of aggregators that take all of this. I know there's at least one health care specific one. There's probably more and you're going to get much better information and it's going to benefit everyone involved. And the third thing is learn consumerism. And what I did is it's so easy to do what I did once a year is I picked a company I really admired outside of health care. I contacted my equivalent. I said, Can we share? Spend all day together? And they all said, yes. And I did this, you know, with Starbucks. I did this with Procter and Gamble. I could go on and name a bunch more. And so I took my team. We went to their place and a whole day long we exchanged information. We learned a lot from them. Maybe they probably learned a little bit from us. Maybe we learned a lot from them and we took it back and got more consumer oriented, more customer centric. So those are three things. 

John: [00:53:23] John Those are great, especially like that last one, that cross-pollination. I think that is something that's really critical. You know, we brought that up at the beginning of the call too. And then Carey, I really liked how what you were addressing. I think that something that really resonated with me recently in a book that I read was I learned about the curb cut theory, which interjected with When you were talking. And for those of you that aren't aware, the curb cut theory is the idea that when we initially started implementing the federal requirement to create handicap access points on curbs and actually cut that out, it ended up having a lot of unintended benefits to other people that had mobility issues, and it just created a lot of positive benefits to society. And so as we think about this, this movement towards universal design and trying to develop systems and technologies that can meet everybody's needs, not just the majority, I think that your point, Kerry, that addressing everyone and helping everybody get healthy is going to be a net benefit to all of society. And as you develop these systems to help the most disadvantaged, help the most vulnerable, those of us that are healthy and that aren't suffering in the same way will benefit too. It'll make the system easier for us to navigate. So I really love that you called that out. Okay. So I'm going to take a cue from Ed's excellent podcast. He always starts the podcast with this question, so I'm going to wrap with it. What music are you guys listening to today?

Ed: [00:54:40] So for me, it's easy. I don't like I'm not a country music person. But the number one song on country music right now is called Religiously, and it's by Bailey Zimmerman. And my son is the producer and writer of that song. It's number one in all of the world of country.

John: [00:54:55] Wow. Okay.

Ed: [00:54:56] Bailey Zimmerman.

John: [00:54:58] Congratulations to your son. That's really cool.

Carrie: [00:55:01] It's awesome. I don't have anything quite as personal unless I tell you I listen to Taylor Swift because I have daughters. But I will. My my playlist of choice lately has been queen so I like it's good motivation. You're out going for a walk or walking into the office in the morning. So. 

John: [00:55:21] Okay, so how can people contact you to follow up on this discussion if anybody wants to reach out?

Carrie: [00:55:29] You can. This is Carrie. You can reach us at upfront healthcare.com. You'll find our contact information there. And we would be happy to to talk to anyone interested in thinking about how patient engagement and transformation might be part of their strategies going forward. 

Ed: [00:55:45] Yeah, for me, LinkedIn is probably easier, but you'll find all my social channels on LinkedIn. I have a YouTube channel and Twitter and a website, but it'll be all there on LinkedIn.

John: [00:55:54] Yeah, and you're very active on LinkedIn, so I definitely enjoy following your conversation starters there. So thank you both very much for joining us today. This has been an excellent discussion and I really appreciate your respective views on this topic.

Ed: [00:56:06] Thanks for having me on, Chilcast and great to be connected also with Carrie because she's pretty awesome.

Carrie: [00:56:12] Likewise, I'm an Ed fan. You can ask my team. I've been giving Ed isms at work and John, it's great to get to know you better and participate today. Thank you. 

John: [00:56:20] My pleasure. This has been great. And for those of you listening, please be sure to share this podcast if you enjoyed it with your community. And don't forget to subscribe.