The Health Management Academy
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Episode 13

Improving Healthcare IT through Handshakes and Handoffs

Episode Description

In this episode, Aneesh Chopra, president and co-founder of Care Journey, joins Renee at The Table. Aneesh shares many insights from his time as the United States’ first Chief Technology Officer and the vision for the future of healthcare from a technology perspective. Aneesh and Renee explore the topics of healthcare data sharing, the benefits of transitioning to value-based care, and the importance and practicality of working together for health equity.

About Our Guest

Aneesh Chopra, President and Co-Founder, CareJourney

Aneesh Chopra is the President of CareJourney, an open data membership service building a trusted, transparent rating system for physicians, networks, facilities and markets on the move to value. He served as the first U.S. Chief Technology Officer under President Obama (’09-’12) and in 2014, authored, “Innovative State: How New Technologies can Transform Government.” Read more


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Renee DeSilva 0:06

Welcome back to The Academy Table. I’m Renee DeSilva, CEO of The Academy and your host and we are happy to have you back with us again. I’m excited to share this conversation with my friend and former colleague, Aneesh Chopra. Aneesh is currently the president and co-founder of Care Journey, a healthcare analytics firm. Many of you may also remember him from his tenure as the United State’s first Chief Technology Officer. I love the perspective Aneesh brings to health IT as both a public servant and entrepreneur. You will see that these lenses intersect frequently across our conversation. Here are my three takeaways from our time together. First, listen to how Aneesh articulates the key problem for improving healthcare interoperability as one of misaligned incentives rather than technical capability or interest. Next, and relatedly, it’s clear that Aneesh is a strong supporter of democratizing data access both as a means of good government and also as it relates to his current work at Care Journey on the transition to value. Lastly, I love Anseeh’s philosophy of handshakes and handoffs as a way of maximizing cooperation and shared understanding between the public and private sectors. With that, let’s head to The Table.

Renee DeSilva 1:34
Aneesh, I’m so happy to chat with you. Welcome to The Academy Table.

Aneesh Chopra 1:37
Renee, thanks for having me. It’s an honor to be here.

Renee DeSilva 1:41
I’ve had the pleasure of knowing you since 1997 and it feels like that was many moons ago.

Aneesh Chopra 1:47
Just a few.

Renee DeSilva 1:48
Just a few, just a few. You have had such a rich experience across private industry, state and federal government, why don’t you start with some of the early forces that you feel shaped your career.

Aneesh Chopra 2:02
If I go back a little bit in time to college, it was right around the time Bill Clinton was pushing healthcare reform. It was 1993-94 and I was a rising senior at Johns Hopkins undergrad. Our university president was named by the governor of Maryland to lead a brand new healthcare access and cost commission. I raised my hand and said, “Can I intern for this fledgling organization, staff have two, to dig into the case for reform and to help brief, if you will, the commissioners on what Maryland and other organizations should do.” I was hooked, Renee. Of all the sectors of the economy that needed public/private collaboration to get the incentives right, to get to better outcomes, to free up more resources that could be reinvested in economic growth or other areas that can help spur the economy, I was hooked on this subject. I took that with me to my first job out of college which was at Morgan Stanley where I worked on healthcare banking issues. A little team at Morgan Stanley took a company public while I was there called Netscape. If you remember, Renee, around that time, there was not a lot of use of the internet in college. It was still there, but it wasn’t critical or central to our lives. I started digging into the capability of the internet and the possibility. If you think about the changes that we needed to make in healthcare coupled with the possibilities of what you can do on this thing called the internet, I was all in and I devoured it like a hungry animal. I went to graduate school, Kennedy School, and wrote my master’s thesis on how the internet and internet-based technologies could reform healthcare. I didn’t have a place to go after graduate school that was an obvious focus on this issue, but the advisory board was so committed to best practices and true north that I thought, let me dive in, write studies, understand the issues of the membership and the industry as a whole so that we could find the home for this subject. Lo and behold, it was a little bit of a window of opportunity to do a study on the internet and healthcare that got me into public service. As the story goes, I was able to serve Virginia as Secretary of Technology because of my passion for healthcare IT. I took that theory, that idea that we have the right infrastructure on data and technology to fuel reform for the rest of my time in the government, when I went to the White House, and then obviously now at Care Journey. Common theme, frankly, since before you and I met.

Renee DeSilva 5:03
Interesting. This blending of technology and healthcare has been the animating force of your work and your career. Let’s unpack a bit. When you were tapped by Obama to serve as the nation’s first Chief Technology Officer, I would be curious as to how that process unfolded. Then, what was the mandate for you as you assumed that role?

Aneesh Chopra 5:27
I had no idea I would ever land a role like this. I was asked to be on the transition team in part because Virginia had a cabinet position dedicated to technology and not many states do that. At a minimum, I could inform what I do, why I do what I do, how to be effective in what I do, and communicate that as a job description for some Silicon Valley luminary who I naturally assumed to take on the job for President Obama. I was maneuvering and was offered the role of HHS’s CTO, which is what I thought would be within my paygrade. The whole concept of this was that President Obama was campaigning on not only tapping the expertise of the American people from a bottom-up, grassroots change because that was a big part of his personal history, but it was critical in his mind that we harnessed the internet to tap into these expert voices to make government work. It was an easy job description to fill because it was clear where he wanted the country to go — a more open, collaborative, transparent government. It was also clear that he made a personal commitment to have someone senior in his administration responsible for these things. When it came time to link up with what that role would look like, here’s how the CTO could operate, when they ultimately came back around and said, “Don’t work at HHS, come over to the White House,” it was almost like, implement the plan that you all have been working on for the last several months which was great. One of the blessings of when you take on a new role is when the boss knows what he wants you to accomplish or, in your case, Renee, what you might ask your team to accomplish. It’s a lot easier for folks to know where they fit and how they can contribute. That is a breakout conversation about how that relates in the healthcare domain which is probably the perfect embodiment of that vision in a few key areas.

Renee DeSilva 7:23
Talk a little bit more about, from that platform, what were some of the initial priorities or goals that you chose to take on? Healthcare as an industry and the government as a segment have a long way to go in terms of making data more accessible and easy to use. What did you think about the initial priority setting in that domain?

Aneesh Chopra 7:44
Yes, Renee, there were three things. First, and this was a day one executive memorandum from the president, he wanted data held by the government available to the American people. Perhaps the most valuable piece of data held by the government that could inform healthcare delivery was referred to as the Linked Longitudinal Medicare Database. That may sound like a lot of words, but what that means is, Medicare operates Part A for hospital and institutional claims, which are separately managed in the database. There’s a separate program called Part B that handles professional claims, physician claims. They added a Part D drug benefit, as you recall, in the Bush administration. What CMS was capable of doing and my first assignment was, if you could stitch together an individual who’s using all three programs, you could learn a lot about the interaction of that individual with the delivery system. Are they navigating it in the best possible way or do we see clear evidence of waste, inefficiency, and, frankly, poor quality. By releasing that data to the public, we felt this could accelerate that proverbial 17-year delay from an insight at a lab to a patient’s bedside. That was step number one. It took a few years to get the machinery moving, but as of today, all of that information is available for commercial use, public use, nonprofit research use. That was number one. Number two, we had to get the digital health revolution right. In particular, we put in what became a $30-plus billion incentive program to reward doctors and hospitals for adopting and using certified electronic health technology or EHRs. The idea I had, and I think critical to the President’s vision of a more interconnected system, was back to the comment I made earlier about the power of the internet. Not a lot of EHRs were built in the internet era, as you know, Renee. I thought we had to have some muscle added to the program that would give us the power of potential the internet to make healthcare better. We took the form of a research and development program with $15 million, which seems like a drop in the bucket and it was, and we drove it towards this vision of a proverbial iPhone app store for healthcare data. That grant went to a team at Harvard, Professors Zak Kohane and Ken Mandl, and that gave rise to a protocol called SMART on FHIR, which fast forward to 2021 is now the regulated law of the land for all government-sponsored health plans and all providers who treat Medicare patients. That unbelievable 10-year journey was one of my greatest areas of passion and, frankly, one of my proudest contributions was this notion that we could introduce something that didn’t exist in the wild and see it scale. Last but not least, we launched the Medicare Innovation Center. Of course, that had a lot of top-down, really smart people. Don Berwick was the CMS Administrator and we had Rick Gilfillan running the Innovation Center. They had very thoughtful views about the role of ACOs and Pioneer ACOs. I had the pleasure of launching what was called the Billion Dollar Healthcare Innovation Challenge which took a portion of the funds at the Innovation Center and did what the President called on my office to do which was to tap the expertise of the American people to solve problems. We crowdsourced ideas on how to change payment to improve quality over cost. That model, that bottom-up versus top-down approach gave rise to programs like the YMCA Diabetes Prevention Program, the University of Washington Collaborative Care Model, and others that were tested, validated by the actuary and CMS, and scaled across the entire Medicare program so that every eligible patient could benefit from these models. That hugging of CMMI was the third passion area for me.

Renee DeSilva 12:02
That’s fantastic and a significant impact in a relatively short amount of time. If you look forward to where we are now as it relates to health IT, starting with a bit more around interoperability, how would you describe the current landscape?

Aneesh Chopra 12:20
The system we operate today largely reflects the incentives on the books. We’re going to separate the technology problems, which this audience will know, “Oh, these systems don’t talk to each other, maybe these vendors are tough or not great.” We can go deep on the tech. To give your members a window into the challenge, it’s an economics problem. The incentives in today’s fee-for-service system don’t value interoperability. We have the technical capacity that’s been around now for 5/6 years, but they haven’t been used because the customers that have been buying these systems haven’t prioritized it over other features. This is unique relative to, say, the financial services sector where if I look at the regulatory landscape, Renee, we had an interoperability problem in banking, an interoperability problem in education, an interoperability problem in energy, and obviously, in healthcare. As you look at how the industry responded to these regulations, what’s amazing is if you think about your mobile banking experience, you can pay people over the internet from your bank account. That works. It’s driven by technical standards. These same internet-based technical standards are at the heart of things like FIHR APIs, but we don’t do that, they’re not in production in healthcare. The irony is that in the banking sector, while Dodd-Frank gave the government rulemaking authority to force banks to open up the data and enable this FinTech revolution to come to life, the agency never wrote the rule because the industry is self-regulated and adopted it. That’s a function of market incentives. Customers demanded it. What I’m saying to you is that the current state of interoperability is probably a grade A, on the technical infrastructure. We now have internet-based data-sharing standards. The same way you and I can transact on a mobile phone to have our financial systems talk to each other is technically capable today in healthcare at a minimum on the core pieces of our medical record, not the entire record, but the lion’s share of the information. However, we have incentives and a market dynamic that doesn’t bring those kinds of offerings to us. We see this today as consumers of healthcare. I think this is changing.

Renee DeSilva 15:06
To underscore that point on the FinTech example, I think it’s something like more than 40% of transactions in any other industry are done through technology. On the healthcare side, it is less than 20%. Your notion around the way that markets are architected, how the incentives flow gives less of a natural pull to make that happen. I do wonder, what do you think are the forces that would drive acceleration in that way? Do you think it comes out of regulatory and accelerating value-based care? Despite the COVID environment, we still haven’t seen the acceleration that one might have expected even 5 or 6 years ago when we were chatting about this. What forces do you think could change the incentives and drivers to make that vision come to life?

Aneesh Chopra 16:00
Value-based care, unequivocally. This is an area where we’ve been dreaming the dream for a decade, Renee. The industry has been talking about it, but the impact has been modest; we haven’t seen the results. We are on the verge of a demand signal for downside risk in a way that will shake the market. I’ll characterize this as the era of consumer-designated networks. If you’ll indulge for a minute, Renee, let me describe what I see happening and then link it back to the interoperability revolution. Number one, Medicare launched a new experiment in April of 2021 called direct contracting. The idea is that you can keep your original Medicare benefit. However, if you work with a physician network that is looking to take on the total cost of care responsibility, you might get access to supplemental benefits, discounts for seeing high-value providers, as well as a certain number of, what I would call, care management services or coordination services that may not be officially part of the menu when you interact with providers in traditional fee for service. That program had a very interesting feature added to it. It allows those networks to market directly to Medicare beneficiaries and enroll them without losing access to their benefits. This is not a Medicare Advantage sales pitch, Renee. This is, “I’m a physician in your neighborhood. Join my network because I’m going to do the following three things to keep you healthy.” It’s pitting physician group against physician group in some ways on how to earn the trust of an individual whose care is otherwise fragmented and perhaps subject to some low-value services. This is an exciting addition to the program. When you directly engage consumers and invite them to join your network, the natural and obvious next step is, what would the digital experience of that relationship be? Will you organize my medical records and give me one locker, for lack of a better term, that puts it all together? Will you provide decision support or guidance to help me navigate the healthcare system in a better way? Will you administer certain benefits that will help me get discounts and benefits financially in addition to clinically, such that I can get affordable, high-quality care. All of those aspects of the direct contracting model are live and they went live in April. Over the next five years, that “Little Engine That Could” may very well hold the key to unlocking the mystery of why we have such fragmented care in the 21st century. Now, I think of direct contracting as a verb, not a noun. There’s a specific thing called direct contracting and it has specific features. Medicare enrolled folks to sign up and serve in that way. They cut off new direct-contracting entities from applying. However, the verb of putting the total cost of care risk into the hands of a physician network or a clinically integrated network, the idea that you can directly outreach and engage beneficiaries offering value-added services like care coordination and the ability to modify benefits without taking away benefits so that individuals can get an Uber or Lyft voucher that’s otherwise not part of Medicare program, I believe that verb, the capacity to do those things will scale in another form of alphabet soup over the next 5 years, certainly from CMS and maybe beyond. Interoperability was built to be solved by these networks.

Renee DeSilva 20:00
I think that’s powerful. We’re talking about the data side of making healthcare more accessible, but the overall, discombobulated consumer experience gets even more difficult to organize as you age. Things like that do make you believe that you start to see some real tailwinds behind some of these issues. That’s a great example.

Aneesh Chopra 20:26
By the way, it coincides with this whole other thing called the regulatory floor. We haven’t even talked about the fact that Congress was like, “I am ticked off that this interoperability issue hasn’t been solved, so we’re gonna put in law (2016, the Cures Act) that every healthcare organization needs to be able to share health information without special effort.” I don’t need to have a custom widget, special secret handshake, interfaces, high administrative burden, none of that. It has to be the same plug and play experience that we just talked about that you might have with digital payments. That requirement turned into regulations that put words on the paper to make the vision that Congress laid out crisp and clear. This also, coincidentally, went live in April. Now you’ve got an incentivized care delivery network, a consumer designated network, riding on top of newly clarified rules to suggest how they can go about solving the problem that a year or two earlier might have been a bit of a high administrative burden to solve. These are just luck of the draw, Renee, landing at the same time.

Renee DeSilva 21:45
In your mind, if you think through the current administration and where they’re likely to go on policy, do you believe that we will see more of this regulatory pressure to start moving behavior more radically?

Aneesh Chopra 21:59
I believe there’ll be a mixture of sticks and carrots. On the stick side, there’ll be enforcement of information blocking rules — a million dollar fine to the EHR vendors if they make it administratively difficult to share data. We’re going to force the question, is this an incentive problem in that the customers haven’t asked for these features to be deployed or is this a bad actor problem where vendors with certain market share are constraining data to liquidity? I believe it’s the incentive problem, not the bad actor problem. That’s just my personal opinion, but we’re going to have the regulatory muscle to prove it. If we start seeing million-dollar fines left, right, and center, it may be more of a bad actor problem than an incentive problem. We’ll see that over the next few years. I think there will be fewer million-dollar fines, but at least we now know that there can be fines. The pandemic has shone a light on this other angle which is health equity. The reality is, while as much as we’re going to see sticks around the issue, there is going to be maybe more value added on the carrots. Let’s reward organizations who reach out and hug an underserved, potentially a minority patient or an economically distressed patient, someone who’s left out of the kind of well-functioning healthcare system that, Renee, you and I might personally have access to just because of where we are in our lives. That encouragement to reach out to serve the underserved is going to be more carrot than stick. That should be good news for everyone. Markets will respond to those incentives. When was the last time a member or health system put out a marketing effort to recruit folks into their ACO? That wasn’t a thing. The ACO serves the patients that the doctors treat, the patients treated by the doctors in the network. Now we think we can marry up the marketing team with the value-based care team and have an economic engine that puts all of this interoperability and value-based care capability to work.

Renee DeSilva 24:05
That’s right. Underscoring your point on equity, we’ve been spending a lot of time with our members on that topic. Equity, in some ways, is a population health strategy. Your recent example is, how am I thinking through the broad population I need to serve and being quite targeted in that. I’m hoping to see both providers, not for profits, and private industry companies come together and start to create a network of offerings around that to start to close the gap on outcomes across multiple demographics. I am optimistic that we see some progress there.

Aneesh Chopra 24:42
I’m very optimistic. One of the interesting questions is, do these dots connect? Do the good, well-intentioned initiatives around health equity look more like the community benefit compliance project or do they look like an integral feature of how we measure and manage our overall value-based care strategy. I hope it’s the latter. That is the test the country will face in the next few years.

Renee DeSilva 25:09
Agreed. I’m going to take us in a little bit of a different direction. The other place that you’ve spent time on is more entrepreneurial. You co-founded a company in 2015, Care Journey. Talk to us a bit about what problem you’re trying to solve through your work at Care Journey.

Aneesh Chopra 25:28
Let me take a step back before I get into the entrepreneurial journey because I see these as linked. A big part of my thesis while in government was that the next decade of change would largely be born at the public/private interface, what I referred to as handshakes and handoffs. Meaning, Congress is Congress. It’s going to maybe tweak rules, adjust here and there, but the big moves on the board in healthcare, the ACA, big moves on the board, it’s in law. We’re the ones implementing, we’re tweaking. At the end of the day, we know that the system has to improve considerably more than it has thus far. It may not move much because of large changes in the regulatory or legislative environment. It may change, in my hypothesis, more so likely to change if we maximize the handoff from the public sector to the private sector. I call this handshakes and handoffs because whether you’re a Democrat or Republican, the idea that we want the system to move faster to value is universal. Congress has already shaken hands that we want this. The handoff is the question that we’re grappling with as a country. A lot of the models are voluntary and a lot of folks have chosen not to participate. Why? What’s the barrier? As I dug into this issue of handshakes and handoffs and the passion I had for open data, for open APIs, for bottom-up change, one of the first and most clear challenges that I saw was a lack of understanding. How does the government see me? How does CMS see me? How do beneficiaries in the Medicare program see me? Most of the conversations I had with health systems around data, technology, and interoperability began with them in the center, not the patient. They would look at their IT systems, inside their databases, understand their performance, but with a fragmented healthcare delivery system that was inherently flawed. We were not making transparent the problems that the system so obviously sees because in our neck of the woods, hey, we saw a patient, we treated them well, we gave them the medications, ran the procedures. Who knew that they had a problem down the street that was unmanaged that we didn’t have responsibility for? Well, who did? I don’t know, but not me. Okay, we move on. The system doesn’t work. I felt we needed to have more transparency from the lens of value-based care. I stood up Care Journey before I had all the tools ready. It began with the notion that if we could almost serve as a proxy voice of the patient and CMS and policymakers and say, “Hey, let me look at the same data that you’re looking at internally from your lens, let me invert it, and suggest how that might appear to someone from the outside.” Almost like an inverted market assessment. In 2017 or ’18, I can’t member the exact date, we went through a 2-year process from ’15 to ’17/’18 applying for and then getting from CMS a license to access the entire backend of the Medicare database, back to my point that you can access this information. We said, “Why don’t we tap this information in a bit of news you can use, you get what you get and you don’t get upset” kind of way. That is, we’re going to look at every patient in the Medicare system and grade how well their journey performs on the move to value. If you’re the quarterback for that patient’s care and it wasn’t performing well, you’ll see that. Our point was, let’s open up this information to the industry as a whole and we’ll democratize it. If a member joins, they get to look up themselves and their neighbors and see the same information that their neighbors can look up about themselves and you. If we had more common ground about how the system is performing — open data, open analytics, open logic, open interoperability, then theoretically we could move faster down the road to value. Today, we’ve developed that hypothesis. We serve over 100 healthcare innovators, mostly hospitals and health systems, but health plans as well. We’re in that “payvider” cohort with the growing number of digital health companies who are trying to be that trusted front door for beneficiaries. We share with all of them the same basic point of view. Which group of patients are getting worse care or better care under your supervision? How can we close those gaps from best practice?

Renee DeSilva 30:16
What’s the biggest surprise for most of these folks?

Aneesh Chopra 30:20
I haven’t published this yet, Renee, but boy has it been a sobering finding. The health equity issues that we’ve been reading about over the last year or so, they’ve been around forever but they’ve recently been brought to the spotlight, compelling us to look at the data and have the following, very sobering conclusion. If you are poor, likely a minority in an economically distressed neighborhood, you’re 30 plus percent less likely to be enrolled in an ACO than if you were in the wealthiest neighborhood. The very people with high ACC scores, low levels of care coordination, high uses of the emergency room for unnecessary services, that group of people you would have expected would disproportionately show up in value-based care arrangements because,, you’ve got the product to meet their needs. You would want to connect the people who need their needs met with the folks who can offer the services to the needy. It turned out, with all the attribution and the physician acquisitions and the networks, maybe the reality is that even health systems that have equity in their mission objectives might own a physician network with attribution of patients that tend to live in the wealthier neighborhoods. Boy, oh, boy, was that a surprising finding and a depressing one that we’ve somehow missed this overlap. We’ve invested in care management, we’ve put in technology, we’ve taken on a lot of this infrastructure, but we’ve put it to work, perhaps, in a way that doesn’t reflect the highest and best use of that muscle.

Renee DeSilva 32:11
It doesn’t close the gap on health equity and doesn’t bend the cost curve either if many of those patients who are driving the most expensive episodes of care are not being managed well, so both.

Aneesh Chopra 32:23
I’ll give you one more sobering statistic. I don’t want to name the member, but the member has adopted as a corporate strategy this life expectancy gap from wealthier parts of the city that they’re operating in to the poorer parts. Here’s the sobering statistic — when they looked at that population who lives in the poorer parts, many of them are dual-eligible, Renee. The dual-eligibles with Medicare fee-for-service are the lowest enrollment in ACOs of any other clustering you can come up with in the program. Are you kidding me?

Renee DeSilva 33:00
It’s fascinating and surprising and maybe not so surprising. The question becomes as an industry, what do we do when we’re faced with that data? How do we begin to course correct? I would hope that as you bring that to light, you start to see some action accordingly.

Aneesh Chopra 33:20
Here’s the funny part, Renee. Now that there’s competition for beneficiary attribution with direct contracting, bring it on. If you’re not going to serve that population, a lot of these new, venture-backed, publicly traded companies are going to come right into your neighborhood and go right where you’re not. That’s okay. God bless America. Someone should do the right thing. I’ll go one step further. You asked a question about what else is surprising. I’ll give you the second one, which is, I mentioned earlier that I was proud of the Medicare Innovation Challenge and the idea that the YMCA Diabetes Prevention Program was one of the first graduates. If you do the math, Renee, something on the order of, I don’t remember the exact percentages, but if you’re prediabetic, you’ve got reasonably high chances of getting full-blown diabetes, but there are things you can do to prevent the onset of diabetes and they tend to be more of the social determinants of health — eat better, exercise more, more on the behavioral change side. The Diabetes Prevention Program was squarely designed for that problem. The actuary — the actuary, not the feel-good, happy social services people, but the actuary — found a four-to-one return on investment. For every $600 voucher CMS paid to get a prediabetic into these counseling sessions, weight loss of greater than 5% was influential to the outcomes, the savings to the taxpayer were $2600 per person enrolled in the model when you balance all the savings and the costs. A four-to-one ROI.

Renee DeSilva 35:01
That’s unbelievable.

Aneesh Chopra 35:02
Here’s what’s unbelievable. In the spring of 2018, that actuary signature and the HHS Secretary policy made that a fee-for-service benefit. Every single prediabetic in America could get it. I hate to put you on the spot, Renee, but at the end of 2020, two and a half years later, by order of magnitude, how many Medicare prediabetic patients enrolled and had the very first visit with the YMCA Diabetes Prevention Program?

Renee DeSilva 35:38
I think it was tiny. I would put it at less than 5%.

Aneesh Chopra 35:42
Yes. We’re talking about 2,000 people.

Renee DeSilva 35:48
Yeah, yeah. That is mind-boggling.

Aneesh Chopra 35:49
Four-to-one ROI. Easy button. There’s no physician capacity constraint. Refer them over to the YMCA, put them in a coaching class. Are you kidding me? What does it say about our system that we don’t route these folks to this service?

Renee DeSilva 36:10
Highly fragmented, not reaching the right populations at the right time. You sometimes can’t get your mind wrapped around it in terms of relatively small things that can have a big impact that become hard to orchestrate. We’re going to go on a high note because I want to be respectful of your time. I asked you what surprised you. Maybe I’ll ask a flipside of that, what are you most optimistic about as we think through healthcare with a more future-focused lens? All of these forces beginning to come together — we’ve got the tech capability, we’re beginning to solve the incentive challenge, we are having conversations on equity and on how race and zip codes do become very big drivers of somebody’s overall success in life, so that conversation is happening at a national level with all of these positive forces converging — what are you most optimistic about?

Aneesh Chopra 37:06
Everything you just said. Even further, if I may put a finer point on it, we’re in the five-year red zone of Medicare trust fund insolvency. That’s usually when the system wakes up. If you recall, in previous episodes when we reach the five-year mark, there’s this sort of Damocles that is hanging over the head of the industry to say, “If you don’t get your act together, we’re going to have to do something to slash and burn rates to get the trust fund back on footing.” Maybe we need the urgency coupled with the opportunity to bring about this incentive alignment, operational muscle of value-based care, the interoperability technology standards that are now in supply, if not in full use. We can finally activate individual beneficiaries, less paternalistic, and they’ll follow the doctor wherever the doctor goes, and more, let’s put some choice in their hands. This is going to awaken that direct-to-consumer empowerment that’s changed every other aspect of our lives, even criminal justice. Renee, having that smartphone in your pocket gives you power. We don’t feel that power in healthcare. For the families of folks who want better service, better care coordination, I believe there will be more products available on the market to help you. I love our Medicare Advantage friends, they’re going to continue to innovate. I love these Medicare direct-contracting entities, they’re going to continue to innovate. I love the new kids on the block who may do this in some philanthropic way if they don’t want to sign these value-based care contracts. The supply of good energy is coming to make offers to our loved ones to get the best care that they deserve. We have no choice but to innovate. That’s maybe the thing that excites me most. Maybe we waited a decade longer than I would have liked, Renee, but I think this is the moment and we’re going to meet the moment. We’re going to work together, Renee, to help people find out how to meet the moment. This is our chance!

Renee DeSilva 39:21
I love that. The urgency is now. The final question I ask all of my guests and I’m curious for your response to this, if you could invite any two people for a conversation at a table that you curated, who would you invite and why?

Aneesh Chopra 39:35
It’s funny that you would say that. We had a cheat-sheet version of this which occurred when we launched the Open Health Data Initiative under my successor Todd Park. He picked two people to anchor it as a symbol of the possibility. It was Don Berwick, whose heart and soul and mission objective around making the system better embodies that spirit and Tim O’Reilly, the father of web 2.0 and the soul of the internet. If you marry these legends of Silicon Valley or the spiritual Silicon Valley and legends in healthcare reform, you kind of put those two muscles together. Maybe it’s not Don and Tim in a decade after we convened them in the Obama administration, maybe it is Rushika, whom I love, on the heart and soul of delivering a better healthcare system. Maybe we’ll find my successor, Todd Park, who’s sort of the spiritual voice of Silicon Valley who wants to move the world into a better place. Maybe we put people who are this generation’s version of healthcare expertise and tech expertise together to find ways to unlock the possibility. We’re seeing that happen more and more. I’m excited about that gathering.

Renee DeSilva 40:51
I love that. That’s a perfect place to land. I appreciate you joining me today.

Aneesh Chopra 40:55
Thanks, Renee, I hope you have a wonderful day, and everyone in the Academy family, thanks for listening.

Renee DeSilva 41:00
Thanks, Aneesh. Thanks again for joining me at The Table. The Table is a podcast produced by the Health Management Academy. Make sure you catch future episodes by visiting our website or by subscribing on the podcast platform of your choice. If you have suggestions for topics or guests, I’d love to hear from you. Please drop me a note at I look forward to talking with you soon.