Health Economist Jane Sarasohn-Kahn @HealthyThinker on 'Health Citizenship'
From the PopHealth Week Archives: In this episode from September 23, 2020, PopHealth Week engages with Jane Sarasohn-Kahn, an author, health economist, advisor, and trend-weaver supporting organizations at the intersection of health, technology, and people. Jane founded the popular blog THINK-Health after working for ten years with health care consultancies in the U.S. and Europe. Jane’s clients are all stakeholders in health: technology, biotech and life sciences, providers, plans, retail, financial services, food, and consumer goods.
Gregg Masters 00:06
PopHealth Week is brought to you by Health Innovation Media. Health Innovation Media brings your brand messaging alive via original or value added digitally curated content for omni channel distribution and engagement. Connect with us at www.popupstudio.productions. Welcome everyone. I'm Greg Masters Managing Director of Health Innovation Media the producer and co host of PopHealth Week and publisher of ACOwatch.com. Joining me in the virtual studio is my partner, colleague and lead co host of PopHealth Week Fred Goldstein, President of Accountable Health, LLC, a Jacksonville, Florida based consulting firm. On today's show, our guest is Jane Sarason-Kahn, author, health economist, advisor and trend Weaver supporting organizations at the intersection of health technology and people Jane founded the popular blog Think Health after working for 10 years with healthcare consultancies in the United States and Europe. Jane's clients are all stakeholders in health technology biotech, Life Sciences providers plans retail, financial services, food and consumer goods. In her new book "Health Citizenship, How a Virus Opened Hearts and Minds", Jane weaves together six months of new data, including consumer market research, health policy developments, health care, industry updates, clinical evidence, Biostatistics and pop culture to make sense of the next normal for life health, healthcare and the evolving American Commons social contract. This timely piece tracks how the novel coronavirus, SARS COV 2 has and will likely continue to reshape our world. So with that introduction out of the way, Fred, over to you, let's catch up with Jane.
Fred Goldstein 01:59
Thank you so much, Greg and Jane, welcome to PopHealth Week.
Jane Sarahson-Kahn 02:02
Lovely to be with you, Fred.
Fred Goldstein 02:04
Yeah, it's fantastic to have you on again. And once again, you have another book out a fantastic book, I just read it How a Virus Opened Hearts and Minds Health Citizenship. So what made you decide to write this one?
Jane Sarahson-Kahn 02:17
So the end of last year's book, which was called Health Consuming, that asked the question will health consumers in the US move to health citizens. And that looked at things like social determinants of health and zip codes, versus genetic codes and the growth of digital but at the end of the day, we still were missing universal health care and a really solid digital privacy law which we needed because so much falls outside of HIPAA. And then the pandemic hit. In February, I had my last plane trip February 28 out to Scripps down in San Diego area and flew home that day. And Laurie Garrett, the famous pandemic writer who won the Pulitzer asked on Rachel Maddow, who do you want to be with for the next many months? And where do you want to be? And I called my husband who was in Brussels where he lives a lot of the time now, as I'm trying to do and said, You better get home because Laurie said, we have to be together for the foreseeable future. And I started to put together the fact that this pandemic is really changing us in so many formidable ways, in the great lockdown of the pandemic separate from the virus, the financial impacts, the mental and emotional impacts, the fact that our homes were increasingly becoming not just a hubs of health that I've talked about for a long time, but the hubs of school and learning and work and cooking and baking sourdough bread for people who never did that before. And it struck me that we were changing in a new experimental way, collectively around the world. And so I tracked data from every source, where I've been mining data for years from Accenture, to the Pew Research Group to general fund and Kaiser, but even Nielsen who wrote about the pandemic pantries, and how we were keen on food and hygiene, and all that relates to health, health care, and ultimately, health policy. And so I collected data, vociferously, absorbing it for six months, and wrote a little 112 page book on Kindle with everything I learned in those six months condensed into that little form, to then ask and answer the question. Is America ready for health citizenship? And the answer is, if not now, quit.
Fred Goldstein 04:45
Right. So the virus has created this huge change for all of us. And as part of that change, you know, where we're stuck or in our houses, obviously, healthcare systems been hit pretty hard. You talked about a couple of key areas. One of them that everyone's kind of focused on so far has been telehealth. And one of the quotes I took from your book was Nicholas Blooms comment that it's the ticking time bomb for inequality.
Jane Sarahson-Kahn 05:10
Fred Goldstein 05:10
Can you talk us through that?
Jane Sarahson-Kahn 05:12
So as we entered 2020 people's finances were pretty solid in January, but many more people, millions of more people were uninsured as we enter 2020 versus when we split in 2016. So we already had 27 million uninsured during 2020. And the pandemic only fanned the flames of that, at the same time in the state at home era work from home the hashtag WFH, you know, became trending, we were in this great lockdown. So you have the virus, pandemic itself, the disease, right, everyone trying to risk manage COVID exposure. But in the great lockdown, we have the recession now, which is sitting heavier on people of color, and on women. So, you know, some of the work I do is in just economics, looking at macroeconomics, and the 2008 recession hit you and Greg, harder than it hit me theoretically, it was, it was a man's recession, in terms of the industries and jobs that were hit in 2008, 2009. But in this round, it's heavily hit the service industry, jobs that have to be done up close and personal. home health aides, a lot of healthcare actually got hit in terms of electives and clinic, clinic care, teachers, retailers. So folks who were doing those jobs were largely women, and largely women who were black or Latinx. And so this has been a recession that, you know, again, a financially toxic effect of the pandemic. And then the third epidemic or pandemic that's been raised this summer, with the death of George Floyd has been the civil and social wake up call, again. And again, which is not new news, but surprisingly, this summer, some of the polling data that I share in the book from the American Psychological Association, in June, done a couple weeks after George was killed in Minneapolis shows that many more white people were sympathetic to either Black Lives Matter specifically, or peaceful protests. And this was a new, new thing for this girl who grew up in, you know, Detroit, I've been well aware of issues of race, structural racism, social determinants of health for a long time, as you know, and especially in health care. But something was different this time, the hopeful part of the book is that I quote from the service for when John Lewis was was memorialized, the pastor from the Ebenezer Church said, we're not all in the same room, because we were watching on, zoom and on video, but we're all on the same page. So I don't know that we're all on the same page. But I think and I'm hopeful that most of us are on the same page right now, when it comes to income inequality and all these social determinant issues.
Fred Goldstein 08:18
Yeah, it's really a fascinating question. I noticed we exchanged some emails before the call about this, where you had quoted said most people in the US have arrived on the same page about health, insecurity acutely aware of our collective need for Americans to step up, not just as citizens, but as health citizens. And on the one hand, I agree completely and other hand, I see what's going on around us. And you cover some of this in the other parts of your book and talk about trust and issues like that. And do you think things like the change in telehealth and the change in this belief system that we're beginning to recognize and these fundamental structural issues around social determinants inequality? Do you think we're going to have the oomph to get over the top on those? You talked about being positive?
Jane Sarahson-Kahn 09:07
Yeah. So I mean, there's what I do a lot of scenario planning right now, because we honestly don't know where things are going to go in a straight line. It's very curvy and very uncertain, but a couple of the wild cards, which are the things that could blow our forecast to smithereens, a couple things to think about are one, aside from a quote who wins the election, November 3, November 10, or December 17. Whenever we we get that information because we know it won't be on the third due to the big male and votes that that are forecasted is the role that business has been playing. So I started to see places like and I'll just talk about health, CVS quitting smoking a few years back, taking a pretty bold public health move, analysts cynics, you know, stock analysts said well, that they made it up by the specialty drug side and PBM and whatever. The fact is, they gave up a very profitable business line called tobacco. And they did that several years ago and rebranded from CVS Pharmacy to CVS health. And we we know what CVS has been doing since then, really vertically integrating and merging with Aetna, etc. And then a couple years ago, when the school shootings became very visible and frequent, sadly, tragically, Walmart decided to take a lot of firearm stuff off its shelves, not everything, but but some some pretty serious firearm categories and different support items for that supply items. And so Walmart's been taking a very strong stand in health and in public health. And we could see of this the role that both CVS and Walmart have been playing in the pandemic. So I'm at the end of the book is the fourth chapter, which talks about the health citizenship question, I bring up the business group, the beside sorry, the Business Roundtable, which talks about the safe sustainability goals ESG, Environment, Society, Governance, and in the social part, the "S", they talk about things like fair wages, and doing things in local communities for the good of the community, beyond the share holder, beyond the investor. And this group of CEOs sign this Manifesto, a year, year and a half ago or so. So a lot of us have been watching to see. And certainly Jamie Dimon, one of the leads on there, the banker, he's been doing some amazing things, even before the pandemic, in terms of very anti redlining stuff, anti redlining and things for his communities where his banks are. So the role of business stepping up, the long winded answer is, is this question because while business can't mandate clean water, in Flint, Michigan, and that's a big public health issue, but do a lot of other things in terms of education, income, literacy, access, diversity and inclusion, doing the right thing in communities beyond stake as shareholders. So I see business stepping into health, certainly, because health is a fifth of the economy now, but business also in this diversity and inclusion moment, some walking the talk, I'm not saying everybody will, but I think it's a big deal. And I sit on the advisory board for W2O group, the the agency, and Jim Weiss, the W in W2O. He's taken some major moves. And one of the reasons I agree to work with them is that they're walking the talk and just plugging it here. It's only because it's an example of a company that's giving people the day off to vote, time off to be political. We're however you want to be political this moment. And we've been talking a lot about what that means in terms. What does inclusion mean? So I think a lot of companies are having that discussion now. So this is one area I think I have hope for in business. But the other wildcard is what happens with the public sector. And so will we get to climate change seriously, because we know as of today, there's tremendous flooding going on in the south, and burning stuff going on in the West, and I'm in Philadelphia, and we have some dirty air in the sky, my sundown snow coming from the west. So we are all in the lifeboat, right. We're all in a commons. And that's a theme in my last chapter, which we are a commons, whether you like me or not, like I wear the mask for you, and you for me. So there's this role public sector should play when it comes to environment, clean air, clean water, transportation policy, food security and food safety policy, and of course, education, education, education, let alone healthcare. So health is baked into public policy or not, and to get where we want to go for helpful on health citizenship. It's not just about health care, it's about being healthy. So we don't need the downstream bed. We want to care for care. We want to have care at home, care in the community. And that's why I talk about retail so much and the role of the black barbershop and the why, because in fact, this is where we can we can make care and socialize and so have that social connectivity along with the health care connections. So telehealth is a bridge. And I think it's it's terrific. We need the business model for telehealth needs to be sorted out along with quality and figuring out where it's appropriate, where it's not. So as everybody in our field is saying, We stood up to you know, what could take two years, two weeks or 20 years in two weeks, or another quote that came across to me in modern healthcare today was something like COVID-19 blew opened the door for virtual care. So the question What's the sustainability of that? So again, what will public health do for that reimbursement and so on.
Gregg Masters 15:07
And if you're just tuning into pop Health Week, our guest is author, health economist and advisor, Jane Sarason-Kahn. And with an assist from HIMSS we're discussing her new book Health Citizenship, how the virus open hearts and minds, a timely piece that tracks how SARS COVID 2 has and will likely continue to reshape our world. For more information, visit www.healthcitizenship.com and do follow Jane on Twitter, via @healthythinker.
Fred Goldstein 15:39
And, yeah, quickly before we get the next one on that whole issue. Do you see I've heard you know, health plans saying we're gonna go ahead and stop paying for telehealth now we're through this portion where we needed it. Is it gonna slow down? Obviously, there has also been this huge growth in telehealth companies, new entrants, the market, public buyouts, you name it. Where do you feel that goes?
Jane Sarahson-Kahn 16:03
You know that this is a big question. And certainly I'm tracking a lot of what the American Telemedicine Association is doing under the leadership of Ann Mond Johnson, who in full transparency has been a friend of mine for 30 years, when we were both young girls working in Europe and healthcare. So that's where I met her. She's one of my oldest friends in the field. But she's really reestablishing what is telehealth in the ATA, and it has amazing membership. She's building some tracking what they're doing. under Dr. Kvedar, of course, as well, who's the board chair there. You know, we need to care for people in lower cost settings. And we need to care for people at home. So this is our moment, again, an opportunity, let's not blow a crisis. Opportunity, as Churchill was want to say, are quoted as saying I should say, this is health politics, it's politics, because it's economics, because it's a whack a mole, we take money away from the bed, and what is the nature or definition of a hospital, and many hospitals now in America, you know, AHA did their study in June. And then Kaufman Hall updated in July, a hospitals will lose upwards of over $300 billion this year. And there are many cynics who say, well, there's a lot of waste and all that it's real. I mean, 50% of hospitals, Kaufman Hall said in July would have negative margins in the fourth quarter of 2020 50% of us hospitals. We've already had an erosion of rural hospitals in the last few years anyway. So I think we're at this turning point, again, of what is the nature of healthcare, is it sick care, well care. And this is the time for us to, to keep pivoting to telehealth where it's appropriate, care to the home, self care, teaching people how to care for themselves, reversing pre diabetes, right?
Fred Goldstein 18:01
I agree with you completely. So here's my issue with telehealth, as I see it being rolled out today. It's an add on that the physicians essentially say, you need to pay me the same as if I did an office visit. But in reality, if you did telehealth, right, you wouldn't need the office, you wouldn't need the staff, you don't have the bed, all those costs. So it should be cheaper. But we never seem to pivot there. Is it going to happen this time?
Jane Sarahson-Kahn 18:27
Well, I mean, it didn't happen with fax machines did it or computers or lots of things. Healthcare always adds technology on top of technology. So you get an MRI, but you don't get rid of the PET or you don't get rid of the X-ray. And, you know, this is what has stood up a lot of medical technology companies for many years. We can't afford to layer on anymore. We're so broke, we're broker than anybody realizes. I'm an economist married to a banker, we don't hardly sleep anymore. Worried about in our respective jobs, what's going on global finance for him. And for me, you know, we don't have sustainable Medicare right now, or social security trust funds. Because of the recession that we're in, I keep going back to the macro economics, because we're not paying this year tax monies we working people who lost jobs or who had ours cut into our social security funds and Medicare funds. So they're, you know, the trust fund will run out of money a few years earlier, the forecasts say, so when you broke like in the UK, when they started the National Health Service, God bless them, you know, they were looking at the fact that they had to budget money and we've never done that in America because we think it's I don't know socialist, but now, the fact is, we will be broke, broker than we have felt in a long time in terms of GDP, and then tax coffers and at the state level, Medicaid and Education, I mean, state finances are really going to be broke because of the situation. And, you know, 2022 will be when people will start to dig out. But next year is going to be a world of hurt in terms of household economies, and consumers won't be able to buy health insurance out of pocket. I sav 1000m 2000 bucks a month, because people will be cutting back a lot. So we will, we will remember with wistfulness, what Andrew Yang talked about, you know, a $1,000 a month of basic income, because in fact, that will resonate with a lot more people in the coming weeks, months, maybe 18 months between now and when we'll start digging out in late 21 and 22. So no, I think necessity is a mother when you're broke. And I think we're going to have to start to realize that we can't keep layering tech on tech on tech anymore. And that's why I raised the question, what is the nature of a hospital and we've already had some hospital systems Intermountain Mercy, virtual really taking on telehealth in a major way. And in my city, and you know, Thomas Jefferson hospital very well, from work that you do, they just announced a huge plan in the middle of a pandemic, to reimagine what is a hospital in this urban area. And I couldn't be more delighted, because there's a ton of virtual stuff that's going to happen from there. So you know, we really have to reimagine companies like Philips, a pivoting hospital to home. This stuff's been going on now for some months, starting before the pandemic, which has been really an accelerant to it.
Fred Goldstein 21:43
Yeah, I think it's, it's gonna be fascinating to watch, because it is certainly I always think of the Shrek onion, you know, we added another layer, and it's just layers on layers. I just am concerned that hospitals, yes, at the one hand, there's huge losses. But on the other hand, we need to be taking these costs out. So where are they going to come from, if we got to pay all the money back into that, it creates a really tough political and financial and operational situation.
Jane Sarahson-Kahn 22:08
It really does. But the nature of buildings is changing with half of the people in America not wanting to leave home. And we've seen even very nice uptake. And I say nice, because I believe in this in virtual care amongst people over 50 based on AmericanWell, numbers that I've seen, though, with the fastest growth with with older people in doing virtual care. And I think some of these life flows are going to stick with people. So there'll be pressure from the bottom up from consumers, and pressure from health system saying and insurers saying, let's keep going with some of this. That's appropriately done.
Fred Goldstein 22:48
You mentioned earlier, the toxic effects financially of the pandemic, you also talk in his book about the toxic effects mental from a mental health perspective? And how do you see that playing out? Are we going to begin to address those issues better? Or there are new technologies or other ways we can do that in the new world? Yeah,
Jane Sarahson-Kahn 23:06
So I've been worried about this area for a long time since I was a big fan of Paul Wellstone when I was a very young consultant, who really argued for advocated for parity in paying for mental health. So if we don't bundle mental and behavioral health into primary care, we will continue to screw ourselves out of good health outcomes. Because as it turns out, most chronic conditions, whether it's diabetes, or Parkinson's, or fill in the blank, have a comorbidity of anxiety or depression, in some phase of that life cycle of the disease at diagnosis in the middle toward the end of life or throughout. So we need to just think of mental and behavioral health as health and think of it as just part of part of the care, but it needs to be in prime it be in primary care. So when we think about up fronting a checklist with asking some good questions about, you know, how you doing, how you feeling, how's your sex life? You know, did you lose your job? Did you get a new job or your kids making you crazy? And in the pandemic, every young parent is saying, yes. So we're seeing again, this top this other side effects of mental and behavioral health. Some people who drink alcohol, the first three months of the pandemic, were upping their alcohol purchases via e-commerce and Nielson tracked data that showed a tremendous amount of supersize alcohol purchases, then, along with a lot more gun purchases. Again, something worrisome. I'm not saying I'm anti gun, I'm saying having more guns around is a public health risk. And we have data data supporting that. So I mean, yeah, though, the pandemic and After the pandemic, or the epidemic as the pandemic is mental and behavioral health, PTSD, big P, little p doesn't matter, but everybody has been stressed. And we all have to work it out in our respective personal ways based on our own values. So the good news is, I've been tracking and doing quite a bit of work in cognitive therapy via technology for over 10 years now. It starting in the UK with, the with the organization Beating the Blues, interestingly Beating the Blues used to be a CD ROM program. And a NICE night Exactly. I'm that old, Nice watch, look it up in Google, my young friends, but NICE, which are the evaluators of health technology, the health economics outcomes, folks in Europe, evaluated Beating the Blues as a substitute and a first line therapy for when an NHS doctor diagnosed a patient with mild to moderate anxiety or depression, before the NHS would allow that doctor to prescribe fluoxetine a generic, this patient had to use the CD ROM to see how they would do and it with mild to moderate anxiety or depression, over 50% of patients never needed the pill. I'm a huge fan of CBT I think we could all benefit from cognitive therapy, particularly right now. But really every day because life is hard. I mean, particularly our digital lives before the pandemic, but now of course, isolation, loneliness. So there's lots of hope there for tech.
Fred Goldstein 26:43
Absolutely. No, it's fantastic. And we're coming up. Now, obviously, we've gone through only a small portion of this fantastic book. So I want to close with something that you closed with in your book, and I'm just going to read this directly. I loved it. "The pandemic has made itself evident that healthcare is a civil right, that Americans have undergone digital transformation that requires attendant data privacy rights, that trust has eroded, and without it people will not share that valuable data to benefit public health. And that the new social contract is truly love for one another and for our country. Onward health citizens." Fantastic. Well, thank you so much, Jane. With that back to you, Greg.
Gregg Masters 27:23
And thank you, Fred. That is the last word on today's broadcast. I want to thank author, health economist advisor and friend Jane Sarahson-Kahn. Follow Jane's work on twitter @healthythinker. And for more information or to order “Health Citizenship How a Virus Opened Hearts and Minds” go to www.healthcitizenship.com. For PopHealth Week, my colleague Fred Goldstein and Jane Sarahson-Kahn, this is Greg master saying please stay safe everyone. We will get through this together and please do mask up when in public we can slow the spread of this deadly virus. Bye now.
About the Hosts
Fred Goldstein is the founder and president of Accountable Health, LLC, a healthcare consulting firm focused on population health, health system redesign, new technologies and analytics. He has over 30 years of experience in population health, disease management, HMO and hospital operations. Fred is an Instructor at the John D. Bower School of Population Health at the University of Mississippi Medical Center and the editorial Board of the journal Population Health Management.
Gregg is a seasoned senior healthcare executive, having provided leadership and consulting support for hospitals, health systems, capitated medical groups, IPAs, PHOs, MSOs, and several hospital/physician managed care joint ventures. He is Founder & Managing Director at Health Innovation Media, the publisher of ACOwatch.com, and is consistently recognized by his peers as a thought leader in healthcare social media via @GreggMastersMPH