Building Trust Through Individualized Care - Brantley Fry, VP of Health Equity and Community Engagement at Pack Health

RISHI DESAI: Hi, I'm Rishi Desai. Today on Raise the Line, I'm happy to be joined by Brantley Fry, VP of Health Equity and Community Engagement at Pack Health. Her work focuses on social determinants of health and informing health care policy. She also has a law degree from Vermont Law School and over 20 years of experience providing leadership, management and legal counsel to individuals, corporations, local governments, and federal agencies.

Pack Health has served as a leader in patient engagement since 2013 and their model provides a human-to-human coaching experience that gets to the root causes of health outcomes. As an organization, Pack Health prides itself on implementing innovative strategies to help its members overcome health barriers. She also recently wrapped up time in the U.S. Senate, serving as state director for Senator Doug Jones of Alabama. Thank you so much for being with us today.

BRANTLEY FRY: Yeah. Thank you so much for having me. It's good to see you Rishi.

RISHI DESAI: I'd just like to start out with asking you about how you're doing, how your family is doing? During COVID, so many things were topsy-turvy. I'd love to just do a general check-in.

BRANTLEY FRY: Yeah. Happy to do that. You're right. Things are very topsy-turvy to say the least. We feel really fortunate. We've been among the lucky ones who have had the flexibility to work from home, and we certainly recognize that that is not true for everyone. And so we really have tried to be very grateful and cognizant of that ability because it hasn't impacted our day-to-day work lives. Of course, it has impacted our social life and our day-to-day activities, but that seems a somewhat minor price to pay in order to stay safe and to keep others safe. And like I said, we're just really thankful that we have the flexibility to also work from home.

RISHI DESAI: Yeah, totally makes sense. Definitely a time to give thanks for all that we have at the moment, especially those of us that are healthy and our families are healthy. Your personal background is just so interesting given that you had a legal background and a career in law and now you're doing health. And these two domains, law and medicine, are so daunting and yet you've been able to kind of navigate both and then to add on top of that, politics. I feel like you've kind of meandered through some of the most challenging landscapes ever. I'm just curious about your background. What got you initially interested in healthcare?

BRANTLEY FRY: As you said, I have a law degree. I practiced environmental law for some years, and it seems like such an obvious connection for me to pivot from environment to healthcare because I don't think that we are protecting the environment just for the views. Obviously, the views are nice and we want to be able to get out in nature, but if we don't have a healthy environment, we don't have healthy people. And so to me, it was a very easy pivot from one piece to the next, from the environmental space into the healthcare space. They're also very heavily regulated spaces. And so having that law degree certainly has helped me pivot into the healthcare space and looking at larger policy issues.

RISHI DESAI: Tell me then about Pack Health and digital coaching. For those that may not know, how does it work and what does that phrase digital health coaching mean exactly?

BRANTLEY FRY: Yeah. As you said, it's a digital health coaching platform and we serve our members. We call our patients members. And so we serve our members in between their doctor's visits. That’s one way to think of it. We serve as almost a concierge service so that we're helping them address their healthcare goals in between visits to their healthcare providers. We really think of ourselves as part of the larger healthcare team. We are able to walk them through a particular journey, depending on whatever conditions they may have. We serve about 25 chronic conditions, and as you probably know, so many of these members, if they have one chronic condition, they also have two or three others. It's very rare that someone just has a single chronic condition.

So we work across those conditions to help them identify healthy eating habits, exercise habits, help them with medication adherence so that they're not missing medication. If they have issues that relate to social determinants of health, our coaches get to know them in a way that they're able to address those as well. So those issues range from food insecurity to transportation challenges, lack of social support, some of the other elements that cause challenges for people to meet their healthcare goals. Not meeting those healthcare goals, it's a big determinant and a big driver in whether their outcomes are positive. So as they're meeting those goals, we're able to increase positive health outcomes.

RISHI DESAI: That makes a lot of sense. And I'm just trying to put myself in the shoes of one of your members -- and that phrase is an interesting one and I'll come to it in a moment, but what do you do to make a member feel inspired to trust the advice they're getting? I mean, it's one thing to say eat better, exercise more, whatever the mantra may be, but to then do it is obviously a whole other ball of wax. So how do you actually get people to do it? And what does that health coach do or say that's so effective because gosh, I'm just thinking about my kids and my parents and what should I be saying and doing differently to kind of inspire the changes that you're obviously seeing in your members?

BRANTLEY FRY: That's a great question. And trust is a huge component as you said. It can't just be this random person calling to say, hey, you need to do this. Then it becomes less of an accountability partner and more just somebody who's nagging you about something you may or may not want to do. It's very important that our health advisors develop trust early on. And one of the ways we do that is we actually assign a particular health advisor to a particular member. 

The members have the same health advisor throughout their journey. And of course, having that one-on-one relationship really helps in developing the trust relationship as well. That's one of the things that makes Pack a little bit unique in that we have both this digital element, as well as the human to human interaction, and we've found that that combination allows us to scale so that our health advisors are able to work with a number of members and really make a larger impact from a macro level, but also at the individual level, because they have these touch points that are both human to human, and what I mean by that is we have this omni-channel approach.

We're able to reach our members through phone, through texts, through email. We even have an app. It's interesting because not a lot of our members actually use the app, which was a little bit surprising because we were really pushed to create the app and then it turns out that's not one of the features that our members liked the best. We're able to really meet the members where they are, and part of that is establishing the relationship between the member and the health advisor and the health advisor knows what their preferences are in terms of how they want to communicate. If they want a single call each week, or if they want a couple of calls and maybe more texts, we can adjust that, and the digital platform allows us to be nimble in that way.

RISHI DESAI: That's really interesting, and it kind of gets to my question then around the phrase, member. Other words one might use are patient or customer or client, and you've opted for member. It was a very thoughtful choice. I'm just curious what the thought and logic was around that phrasing and whether you believe we should be using that word more widely across the healthcare space?

BRANTLEY FRY: I think really a lot of times people don't identify as a patient unless they're in the healthcare environment, unless they're in the hospital or in the doctor's office and so that's one reason that we moved away from that term. Also, the word member has a certain level of ownership to it, so that it is driven by that individual, as opposed to the other way around. They're really helping to determine their trajectory and how their healthcare is handled and managed.

So we're able to accomplish these journeys and it is somewhat self-directed. What I mean by that is the health advisors work with the members to identify a particular goal, a longer-term goal, and then over the course of the journey, they have what we call tiny steps to achieve that larger goal. So it is self-directed with the assistance of the health advisor that serves, as I said before, like an accountability partner, not just as somebody who's going to just ping you with a reminder, but it is a caring relationship. There's an empathy there that's established, so this trust and empathy really support the overall achievement of the goals.

RISHI DESAI: I guess then going back to that core thesis that they're the ones driving the behavior change and at the crux of it, behavior change obviously drives 90% of healthcare spending. And you kind of define it interestingly that you guys are kind of filling in the space in between doctor's visits. As a clinician, I can tell you that I feel like the majority of the work is what groups like Pack Health are doing. I mean, that's where all the real work is happening, and at best, maybe I'm serving as a checkpoint, if that.

So it's interesting because I think still in people's brain, they think of hospitals as the core of where they get their healthcare and then maybe stuff like what you're describing as a supplement. But in fact, I feel like it's the opposite. At the core of what's really happening, the difficult work -- the quitting smoking, the losing weight, all these kinds of hard, hard things -- these are daily things that sometimes don't get glamorized, but that's where the real work is in medicine.

BRANTLEY FRY: Sure.

RISHI DESAI: And I'm wondering whether you feel like that's a realization that people are coming to, in a sense. Maybe all the glamorous stuff that happens in the hospital is actually maybe not the bulk of what America needs.

BRANTLEY FRY: I mean, I can't really speak to the glamorization of it one way or the other, but I definitely think that there's a lot of attention being paid to it if for no other reason just the dollars and cents and the cost associated with the patients ending up in the ER rather than taking steps in between visits, or ending up having surgical needs where they could have made changes earlier on and avoided surgery altogether. It really does come down to kind of how we approach our daily lives. I do think that to your point, people don't necessarily think that they're in the health system if they're not at the doctor or in the hospital, but I keep coming back to this piece that I think of as just kind of compounding interest. If we're making small changes that are going to support our health, kind of healthy lifestyle, those small changes really add up over time.

And so that's another thing that we've really focused on with the tiny steps is making it manageable for people because I think when you talk about quitting smoking or you talk about losing a certain number of pounds, that can be really daunting for people. So how do you break that into smaller goals so that you not only can see results quickly because you're meeting these smaller objectives, but also so that you can measure it, you can see kind of that progress over time.

I think that that's one of the big pieces and kind of like you said, in this space in between, if that's becoming more prevalent, I hope it is because I do think it's a way that we can drive down healthcare costs overall. And of course, just as a country, as a society, this is one of the biggest issues we face. I mean, you talk about the number of people going into bankruptcy because they can't pay their healthcare bills. It's a problem not only to those who can't pay their bills, but to all of us.  It's a pressure on our economy that doesn't have to be there.

RISHI DESAI: I totally agree. I was just thinking, we often think of coaching in terms of maybe you go to a gym and you have a coach and it's normalized to get a trainer or a coach in other domains, like physical training, right?

BRANTLEY FRY: Yeah.

RISHI DESAI: You wouldn't necessarily get a physical coach when you've broken your leg. You might call that person a physical therapist. There's a different word for it, and yet with health coaching, I think still the mentality is, well, I go and get a health coach when I have diabetes to help me with my meds or I get a health coach when I need to lose weight. I'm just curious if there's any inroads that you've seen where health coaching is actually done purely preventatively in the sense of normalizing the idea of a health coach for, let's say a cohort of high school students and saying, “Eating well is just a normal part of being an adult and as you transition into adulthood, we're going to get you a health coach to teach you how to cook and eat with whole foods” and things like that. So is that something that you're seeing in terms of the normalization of health coaching before you have an illness, or is it still mostly when you have an illness, you get a health coach and you kind of remedy that?

BRANTLEY FRY: As we sit here today, I think it's probably more in the folks who've had a diagnosis, but the preventative element is huge. I mean, that's critical. We often talk about the top of the pyramid and the middle of the pyramid. The people at the top of the pyramid who have the most acute needs, those are the people who are in the hospital and are under the care of their physician in more frequent intervals. Whereas the middle of the pyramid, kind of the pre-acute need population, that's a place where even though, like you said, they may have been diagnosed already and have a condition, but they are set on a different trajectory if you have the intervention of a coach. So there's most definitely a preventative element to the coaching piece, but in terms of kind of thinking about catching younger adults and catching healthy populations for coaching, I think that's really important. I don't think we're there quite yet though.

RISHI DESAI: That makes sense. Another domain that I think a lot about is of course telemedicine and the role of health coaching, specifically given that now there's such an openness to telemedicine. Have you seen an acceleration in the adoption of health coaching over the last year? And if so, what sort of things have you noticed?

BRANTLEY FRY: Yeah, absolutely. I'll use Pack Health as the example. We’ve doubled in size over the last year. The pressure placed on the healthcare system with COVID has definitely accelerated our growth because we're able to reach patients. We already had a platform in existence. We were able to reach patients where they were on a remote basis, so it's really moved to the adoption curve. It forced more early adoption, whereas we wouldn't have had that otherwise, as it relates to coaching in general.

We’re based in Birmingham, Alabama, and we have members in all 50 states, but when you think about the south as a region, we're a late adopter. As a region, we operate in that late adoption space, but it's been interesting to see the growth come out. I always try to look for silver linings and that's definitely been a silver lining in COVID because telemedicine needed to be accelerated before the pandemic happened.

I just remember my time in the Senate. One of the first events that we did with Senator Jones after he was elected and in office, we were meeting with some of the healthcare leaders in our state talking about telemedicine and the opportunities for telemedicine, particularly as it relates to rural healthcare. Alabama's not unique -- although, I think we do have probably more acute problems -- but we're not unique in losing rural hospitals.

So the idea that now we have telemedicine in place, we've kind of tested the models, the proof of concepts, all of those things have happened at a very rapid pace with COVID. But now that they've happened, I don't think we're going to put that toothpaste back in the tube. People have appreciated the ability to see a doctor without having to sit in a waiting room. They've appreciated the accessibility of a coach who can meet them where they are and understand their needs. And then of course, if their needs require something to be elevated to their physician, that's something we do at Pack Health. If it needs to be clinically elevated, we do that. And so really, it provides this kind of safety net in many respects that members want and need. I hate to say that COVID has been beneficial, but certainly a silver lining in the healthcare space is that it's accelerated the adoption of telemedicine in all forms, not just in coaching.

RISHI DESAI: An interesting thing I've always wondered about, and I feel like you're so uniquely poised to hopefully be able to answer this given your background, is technology moves so quickly and our lawmakers are oftentimes from a different era. They grew up in a different time. Oftentimes, even those that have grown up in the current kind of technological boom, don't have the time to research all the nuances. That's not what they do day to day. There are other things that are taking their bandwidth. How is it that we can create a system whereby they can draft laws on topics where the scope of what they would need to know is just so deep? I get that they have teams. I understand that, but I'm just curious about what your thoughts are on how challenging this must be in a government framework. Any thoughts on that?

BRANTLEY FRY: Yeah, it's incredibly challenging, and it's trying to move a giant ship in a quick way and it's hard to do. But I will say -- and you nailed it -- having a good staff is the key. I was really fortunate to have worked with some incredibly bright people who are knowledgeable about their various subject matter when we were in the Senate. Particularly Katie Campbell, who is our health care legislative assistant. She was also the deputy legislative director. She knows healthcare policy backwards, forwards outside, inside, all of it. She just knows it.

I think having staffers who are open, not only to experts in their field, but also open to learning and hearing from the private sector, hearing about innovation, hearing where the pain points are, whether it's from a regulatory or a legislative standpoint, being willing to fight those fights, so to speak, so that those pain points can be removed.

Going back to tele-health and just the reimbursement, CMS making changes through the pandemic…I think they initially said that some of those changes were going to be temporary, but again, I don't see them going back. Having the reimbursement models reflect the current availability of services is to me, kind of a low hanging fruit. CMS needs to be make changes that reflect the market so that people are not getting hung up on whether or not they can be reimbursed for a service that's much needed. 

RISHI DESAI: I would love to then transition into the final question, which is knowledge gaps. You have so many to pick from and so many pillars of expertise. As a teaching company, we love to impart a little bit of wisdom or knowledge upon our audience. What are some common gaps that you see that you're like, gosh, if there's one thing your listeners ought to know, it would be this thing? What would you say or suggest that we learn about?

BRANTLEY FRY: I think health equity has been such a buzz phrase coming out of the pandemic. It was a problem that existed long before COVID, but certainly COVID, like it has for many other issues, has just shined a bright light on equity. And so one of the things that I would really like to see is the ability for the healthcare system and for clinicians to understand how to talk to patients about social determinants of health, how to engage them in a way that doesn't impart any judgment but that is open to helping them find solutions and recognizing that not everyone is similarly situated.

There are some people who have large family or friends that can support them throughout their journey, and then there are other people who are going through a diagnosis who maybe don't have that level of support. That’s a really basic thing that I think a lot of people take for granted, but you could go down the list. That's true of transportation. That's true of food security. If you think about all of those social determinants -- education, the built environment, all of those pieces -- having the framework to have honest and caring conversations with patients about those challenges, I think, is critical.

RISHI DESAI: Well, that's a perfect, perfect note to end on. I think that empathy and compassion piece is needed now more than ever. So if there's one point, that makes a lot of sense to focus on. I want to thank you for taking the time to talk to me and our audience. Obviously, as I said, a few times, your background is so remarkable and taking the time to share some of that wisdom is fantastic. Thank you.

BRANTLEY FRY: Well, thank you. It's been a pleasure. I always talked about having kind of a non-linear and nontraditional career, and I'm really thankful that it's landed me in some cool places like Pack Health. Thanks again for your time. It was great talking to you.

RISHI DESAI: Thank you. I'm Rishi Desai. Thanks for checking out today's show. Remember to do your part to flatten the curve and raise the line. We're all in this together.