Your screen or becoming a member and our partner booksellers as you might imagine are really right now as well, theyre going to be interested in going deeper on the subject of tonights talk use the link to purchase your copy of the long fix through thirdplace books. Doctor vivian lee has been a practicing physician, scientist and healthcare administrator for over two decades. Among her roles, doctor lee has served as inaugural chief scientific officer and vice dean for science at Nyu Langone Medical Center and prior to that she was the vice chair of research at the department of radiology and for six years he served as ceo and dean of the university ofutah school of medicine among other roles in salt lake city. She was elected to the association of american medical Colleges Council of the administrative board and is a member of the Advisory Board of Massachusetts General Hospital and university of Pittsburgh School of medicine and her writing is has appeared in the Harvard Business review, journal of the association of medical colleges and other publications. Speaking of other publications please first book was an academic page turner on cardiovascular mri and im told not for the faint of heart. In the 15 years ive been on this job that is the first intentionally terrible joke ive ever told an introduction. I read this book and what we product tonight is the long fix, solving Americas Health crisis with strategies that work foreveryone. Please join me in welcoming doctor vivian lee. Its wonderful to be with you tonight and im thrilled to be part of this event and really looking forward to a healthy and hearty discussion. And i also want to acknowledge that we are living in some very complicated, complex times and i just want to thank you all for joining us tonight. Im speaking for about 30 minutes or so and welcome your questions so for this time of prepared remarks what i thought i would talk about would be maybe a series of three questions. First, why wrote this book and then i thought i would talk about how its structured and the main premise of the book. And then of the 12 chapters i thought i might dive more deeply into two or three topics depending on how much time we have area so let me start with why did i write this book . I wrote the long fix. It has its origins in a series of presentations i made to our brandnew medical students when i was the dean of the medical school at the university of utah and these firstyear medical students were fresh out of college. New to medicine, relatively new to healthcare and i really wanted to share with them what i wish i had known before i had gotten into healthcare. One is to answer the questions they had about how healthcare works. And in particular to prepare them for how they could really make a difference in the field beyond the practice of medicine. To actually the experience of working within healthcare itself. And many of the questions that i wanted to answer were the same questions that i got when i joined where i now work which is alphabet Healthcare Company and where i have met a number of really talented, bright product managers, research grantors, researchers and the like they also were all trying to understand just how this very complex system we call healthcare works and how they can make a difference. I think that we know we all know in the news or from our own personal experiences that there are many , many components of elf care that feel broken. We know about the rising cost of medications. Balanced billing or surprise billing period or lack of insurance for so Many Americans in this country. But what we havent heard so much about are the solutions. And as i have worked in healthcare for over two decades and traveled around the country and even around the world, learning from others, i wanted to have the chance to share some of the stories of where new and different ways of providing healthcare and paying for healthcare are working really successfully. And in sharing those Success Stories and those bright lights, i found that i was able to weave together a narrative and reached an increasingly clear sense of how we can extend those local solutions into a National Strategy for healthcare. And so thats really why i wrote the book the long fix. I wanted to write an optimistic book that actually offered solutions which is i think something that we very much very desperately need. And it was called the long fix because of the conversation that i had with mike leavitt who is a former secretary of health and Human Services and former governor of utah who was reflecting on the fact that he felt the trajectory of change in healthcare took maybe 30 or 40 years at the time and he was in our conversation he felt that we might be in the middle of one of these cycles of say 35 or 40 years. Since the covid pandemic i feel theres a much greater sense of urgency about tackling some of these problems so im hopeful the long fix be a not so long or maybe slightly quicker fix. Im optimistic about that. So let me now turn briefly to how the book is structured and what i talk about in the long fix. Start by laying out fundamental premise of the book. Which is that the central problem in healthcare is really not so much about the delivery of healthcare really about how we pay for it. Its the economic or Business Model of healthcare. And if i were to prioritize, there would just be one thing i would say we need to focus on and its on changing that economic or Business Model. And that its not so much who is paying for the healthcare, we can talk more about that if folks are interested in the q a. So a lot of the discussions about it we have medicare for all for example. I dont believe it is as much about who is paying for it. Although of course at an individual level it matters tremendously but from a policy perspective i think its really more important for us to solve what is that were paying for in healthcare. And specifically what i mean by that is how our Healthcare System is really focused on paying for action. Paying for procedures, what we call a feeforservice Healthcare System where as paying for Better Health would create a completely different set of incentives in healthcare. And if we did that and i will talk about some examples of where that ishappening in our country today , we would find ourselves investing far more in prevention and in primary care. It would incentivize fiddles and physicians to Work Together instead of in conflict as mortal enemies. As ill talk about a little bit as well. And again, examples of this are already happening in the country where we have situations where we are paying for health, a for Better Outcomes. So thats really what i talk about in the first section of the book and in the second section i look at how the Healthcare Industry would act very differently in this model. Where it was motivated by almost any other industry in this country to actually compete on Better Health, compete on delivering value to patients, to its customers i should say instead of just doing more and more prestigious commitment as we have in our Current System so in the second section of the book i start with safety and i talk about how hospitals can learn from other industries. Ranging from airbag manufacturing plants to the Aviation Industry for example , to make healthcare safer. I talk about the Critical Role doctors play in how our Healthcare System works and how with the right incentives , there are type a , very intrinsically motivated personalities can and are to really improve quality and even reduce the cost of care. And finally the business of healthcare, patients might actually move into the center of the universe of the healthcare business because their health would be paramount. Their health would be driving the Business Model of healthcare instead of the way it is today is really where physicians tend to be the center of the universe in healthcare because the physicians are the ones who generate all the actions and generate all the fees in a feeforservice world. In the next section i delve into the pharmaceutical industry and eight in Technology Sectors and tell stories that reflect on what they could be doing differently if they were competing to make people healthier at lower costs. And finally i focus on systems that actually provide big picture views of how our healthcaresystem could work completely differently , taking the perspective of the two biggest payers of healthcare in our country employers for the Health Care Bills for half of americans in the government but in this case instead of talking about medicare and medicaid i talk about military Health Systems and the va period and use those systems to shed a little light on how government run healthcare could actually pay for Better Health outcomes and actually produce better results and lower costs. And then finally i close in a chapter that summarizes the action plan for the health and in each chapter, its the stories, the narratives, these examples each chapter ends with an action plan for what individuals can do for what physicians can do and lawyers, payers and policymakers. So thats essentially the structure of the book and the content of it. Now let me Just Transition into a couple of ideas that are in the book. And see how much time we have and ill talk through two or three ideas. Let me start with the one idea, one big thing and actually in the course of researching this book i interviewed over 100 different people in healthcare. Our physicians, insurance executives, patients, advocates. Community workers and i had asked him what the one thing you can change in healthcare if you can wave your magic one and two thirds of them said the same thing. They said what i also believe witches they would change the Business Model of healthcare. Ive heard models where you refer to as a feeforservice model. Or what i refer to as paying for action. And in our current model, Healthcare Providers, physicians and hospitals are paid for doing things to people. Laboratory testing, imaging studies. Operations, procedures and infusions. Regardless of whether it produces health. So as a result, Health Systems and physicians are really incentivized to do more and more things to people. And in fact document they are doing more and more things to people so that they can charge and bill insurance for them. And instead, we should be inspecting more as consumers or individuals to really only pay for care when it improves health or when it is likelyto improve health. Even if that means not doing much of anything. Thats really ideally how we should be thinking about the Healthcare System is whether its delivering Better Health. But if you have a feeforService System as we do predominantly now and when i say that i mean that private insurers, payment spaces, the government also is dominantly paying for service. Its still, medicare is predominantly a fee for Service System and what that means is our Healthcare System invested things that generate fees like imaging centers, like surgery centers. Like Cancer Centers and we really dont invest in the things that we see right now during this covid pandemic are essential which are Public Health and primary care. Because Public Health doesnt generate and achieve that so if youre wondering why are Covid Response has been so lame when we have some of the best Healthcare Facilities in the world, its because we havent invested in the things that dont generate fees, we havent invested in a Public Health infrastructure even though plans have been laid out for that we havent managed to do that so we have a 3 and a half trillion dollar Healthcare System that is focused on making four or 5 trillion and the only way to do that is to simply do more things to people. I will stop and say that i believe that most physicians and most clinicians are really trying to do good. They are trying to practice the best healthcare they can. But we have to acknowledge that the economics are such that they are incentivized to air on the side of over treating or over diagnosing and our medical legal system only further supports that or maybe even incentivizes that so what happens is you have hospitals and doctors who are incentivized to do more and more to people so for the people paying the bills, the payers, the Insurance Companies and the government, the only way to limit that spending and that perceived overbilling is to place barriers. For the Insurance Companies that means denial. That means saying if a doctor recommends an mri, im an mri radiologist and i use that as an example. If a physician is recommending an mri the only way the Insurance Company is to manage its cost is to say i dont think thats authorized or i dont think thats necessary or they put into barriers things like whats called prior authorization which simply means amount of paperwork that the physician has to complete in order for that study to be done and paid for so its just really a barrier thats put in and what it generates is an and normas amount of work. So you have doctors and hospitals, the payers denying and putting in more barriers and their fighting back and forth. Its like 1 trillion tugofwar and at the end of the day it generates enormous administrative waste. In the us we spend about eight percent of our healthcare dollars on administration whereas most of our european counterparts will spend three percent, 80 percent versus three percent. That is a huge amount of weight and when we cant resolve this dispute, what happens is we have billing so the money isnt paid for fall through the individual, the patient and thats what we call valid billing or supply filling. At how our system works. And it as you can imagine also generates an enormous amount of other kinds of ways in this system, so much so that today, approximately 25 to 30 percent of all healthcare in this country again, around 3 and a half trillion dollars is considered waste. So when we have discussions about how can we extend health care to all those who are underinsured and uninsured, there are clearly opportunities in terms of being able to recover some of the ways and redistributing that to be able to cause our Health Insurance for a lot of people for everyone. Now the implications of having this completely backwards Business Model of feer flying into the headwinds of capitalism is that instead of competition and innovation working towards a better Healthcare System, our capitalistic tendencies are focused much more on doing more and more. Even if its wasteful. So what we need to do is to think about how we can evolve our Healthcare Systems into a l where we have actually the tailwinds of capitalism driving us forward and of course many of us within healthcare and government have been thinking about this for a while and one example of success is in a Pilot Project for what started as a Pilot Projectand is now expanded in Medicare Advantage. So most of us are aware that medicare is the Health System for seniors in this country and Medicare Advantage is a subset of medicare area it covers about a third of all medicare patients and then within the Medicare Advantage program, theres a special model where the government actually contracts with medical groups. And says to these medical groups were going to pay you a little bit differently and instead of paying you in a fee for service way where you just need to keep seeing patient after patient in order to get paid. Were going to give you a fixed amount of money to care for all the patients in your practice for that year. And that fixed amount of money will depend on how sick thosepatients are. So if there are coe complex patients with many medical conditions we will pay you more. If theyre generally healthy we will pay you a little less but we will give you that fixed amount of money and its up to you how to spend those dollars to keep those patients healthy and were going to track, the government says were going to track how healthy your able to keep the patients. You have to keep them healthy otherwise there are penalties and you have to keep them satisfied because these patients can take their business elsewhere next year if they are dissatisfied. Whats happened in these Medicare Advantage programs, these special programs that include like can met in miami and theyve expanded to about 70 systems across the country. Care more, leon health, theres many of these across the country is th