EPISODE 71

Taking Big Swings - Dr. Sachin Jain, President and CEO of SCAN Health Plan

11-05-2020

Dr. Sachin Jain has always been drawn to taking "big swings" at tough problems, and the disconnect between care delivery and care administration is one of them. As a leader in various capacities in government and the healthcare system, he's tackled this and other complex issues at a high level, but he has also has maintained his clinical practice in order to stay grounded. In this engrossing interview, Dr. Jain speaks with host Shiv Gaglani about the effects of the COVID-19 pandemic, which have included an exacerbation of the loneliness epidemic, as well as renewed confidence in both the American biotech sector and the ability of the healthcare system at large to change. Tune in to this episode to hear Dr. Jain's arguments for more investment in prevention and primary care, the benefits of giving doctors an upfront budget with spending caps rather than paying on a fee-for-service basis, and why he’s worried about “big box” retailers getting into healthcare.

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Transcript

SHIV GAGLANI: Hi, I'm Shiv Gaglani. Today on RaIse the Line, I'm really privileged to be joined by an old friend and mentor, Dr. Sachin Jain. Sachin is currently the President and CEO of the SCAN Group and Health Plan. Before that, he used to run CareMore Health and also had executive leadership roles at places like Merck. He's published well over 100 peer-reviewed articles in journals such as the New England Journal of Medicine, JAMA, and Health Affairs, and was editor of the book The Soul of a Doctor.

He's also an adjunct professor of medicine at the Stanford University School of Medicine and a regular contributor to Forbes and Harvard Business Review. If you ask anybody who's ever been in healthcare or at Harvard Business School or Harvard undergrad or med school, everyone considers him such a dear friend and a mentor. So you get around. Sachin, thanks so much for being with us today.

DR. SACHIN JAIN: Well, it's really great to be here. Thanks so much for having me.

SHIV GAGLANI: We know a lot about your background, but for our audience, which comprises mostly current and future health professionals, do you mind telling us a bit about the common themes in all the different roles you've had over the last decade?

DR. SACHIN JAIN: I would say the thing that's been most exciting to me is solving problems, and I think I've been attracted to each role that I've had because there was a big problem to solve. One of the parts of my bio that was not covered in your very generous introduction was my time in government, where I was part of the founding team of the Centers for Medicare and Medicaid Innovation, trying to build the infrastructure of payment reform for the country. 

I would say I’m interested in that theme longitudinally in addition to, I think, a strong interest in figuring out how we might be able to drive the more rational adoption of health information technology and clinical practice. I would say at each step of the way, I've tried to refine the problem that needs to be solved and try to take a big swing, sometimes successfully, sometimes not successfully, but it's always interesting. There's always a lot of learning, and I think the real privilege for me has been the opportunity to work with just some incredible people to take on some interesting challenges.

SHIV GAGLANI: Definitely. Again, you worked in government. I think government was your concentration in Harvard undergrad, right?

DR. SACHIN JAIN: Yes, I was a government major. I was one of these folks who would go home for the holidays, and I would say, “Dad, I'm really interested in government.” He would say, “You should do government after you go to medical school,” so I tried to find a way to match my interests with some of the expectations that I was raised with.

SHIV GAGLANI: I can definitely relate. I still have not finished med school, by the way. When I stopped it, seven years ago...

DR. SACHIN JAIN: You haven't? 

SHIV GAGLANI: I'm still on leave, though. I keep telling my dad— 

DR. SACHIN JAIN: They're honoring your leave? 

SHIV GAGLANI: They are. I joke with the team that once Osmosis can grant medical degrees, I'll get a degree from Osmosis instead. I know we're definitely going to cover government and obviously life sciences and SCAN and how COVID has affected everything, but first, I just wanted to get a better sense of your current position at SCAN and what was part of your decision to leave CareMore and join SCAN.

DR. SACHIN JAIN: Absolutely. SCAN was founded in 1977 by a group of 12 activists, a very racially diverse group of senior activists who were tired of the status quo in America around aging. They believed that America was essentially institutionalizing seniors as opposed to helping them remain healthy and independent. This is a very mission-driven organization, a highly successful organization over a number of years. 

Even though my time at CareMore was really thrilling, growing it from four to 12 states, eventually acquiring Aspire, getting to a footprint of 33 states, I felt like SCAN - because it was a freestanding organization as opposed to a subsidiary in a larger, publicly-traded organization -- gave me an opportunity to, I think, take an even bigger swing at some of the problems that I find vexing as it relates to aging in America. 

We're taking a hard look at reinventing primary care, behavioral health, palliative care, all areas that I think we're not doing quite enough to serve the senior population, and SCAN has got a board that's excited about solving these problems. It's got a management team that's excited about solving these problems, so it was an opportunity that was too good to give up when it was presented to me.

SHIV GAGLANI: That's pretty awesome because I remember following your career at CareMore and some of the innovations you and your team spearheaded, like the collaboration with, I think, Lyft, and you wrote about that and about how you can get people who don't have transportation to CareMore sites. Also, the other really interesting thing was collaborating with the dentist offices.  I think I did an interview with you for the American College of Cardiology, and you were saying that when they go see the dentist, maybe offering them the blood pressure, vital signs, and then diabetes coaching and those kinds of things. Is that sort of what led you to get interested in this population in the first place?

DR. SACHIN JAIN: I think that at the end of the day, the thing that got me interested in working in the senior population is a desire to think about a more sustainable healthcare system, and when you think about solving the healthcare cost problem in this country, it's a lot like what Jesse James said about robbing banks, “You have to go to where the money is.” A lot of healthcare expenditure in this country is focused on seniors. It's Medicare spending. And ultimately, I believe that that spending is inefficiently allocated. We spend far too much on hospital care and specialty care and not enough on upstream prevention and primary care. 

Both CareMore and SCAN, I think, have in their DNA this notion of really trying to support seniors with truly holistic generalists delivering a generalist-focused care. I think when you take a total cost of care view of healthcare spending, there's an opportunity to introduce innovations like the transportation, innovations that you're talking about. Here, at SCAN, we're very focused on addressing loneliness as a serious problem that I think seniors face. These are not issues that traditional healthcare organizations think about because they're paid on a fee for service basis. 

Organizations like SCAN are paid on a globally-capitated basis from the Centers for Medicare & Medicaid Services (CMS) through the Medicare Advantage program, and then we're subsequently able to partner with provider groups in a similar fashion and pay them through capitation. What that enables us to do is, again, think holistically about the total cost of care and how we may be able to allocate spending to places that will actually make a difference for patients.

SHIV GAGLANI: That makes a lot of sense. On the loneliness epidemic, I know you've collaborated a bit with your former friend from college, Vivek Murphy, who became surgeon general, on that particular topic, right?

DR. SACHIN JAIN: Absolutely. Vivek Murphy was very generous. He featured some of the work I did at CareMore on loneliness. We built what I think is the world's first clinical intervention focused on addressing loneliness by asking primary care doctors to screen their patients for loneliness and then subsequently connecting them to a clinical program that would reach out to seniors on a regular basis. I think one of the most illuminating parts of that was the profound nature of this epidemic. There are many seniors who literally don't have anyone other than someone from what was then called the Togetherness Program, reaching out to them to check up on them.

When you think about what it looks like to live in America as an aging adult right now, there are some profound challenges, one of which really is loneliness. I think that's something that's been exacerbated by the COVID-19 epidemic and some of the challenging rules that have been put in place to protect seniors, which I think in other ways have created this other problem for them, which is this problem of loneliness.

SHIV GAGLANI: That's fascinating. Two previous guests we just had on Raise the Line that I'd love to introduce to you if you haven't met them, are Alan Patricof, Osmosis’ advisor and investor and co-founder of Primetime Partners, and Abby Levy, who was the President of Thrive Global. They created a $50 million fund to specifically invest in organizations and companies that are targeted at what Alan calls the "ageless generation." He's 85. This is his third chapter of work, and I would love to share some of the things you guys have done, obviously, in case there are some start-up spinoffs. 

Going to COVID, obviously, COVID affected a lot of things you mentioned. It's exacerbated the loneliness epidemic. How else has COVID exacerbated or changed your business at SCAN? Broadly speaking, what are some of the lasting changes you think COVID is going to have on our healthcare system?

DR. SACHIN JAIN: I think, for SCAN, it showed us that we as an organization could operate just as effectively virtually as we used to when we were operating in person. I joined SCAN on July 1, after we'd already switched over to fully virtual, and I can tell you the organization hasn't skipped a beat. I think that's a testament to the extraordinary planning efforts of the people here, as well as the dedication of our associates. Taking the broader question that you've asked around the healthcare system, I think, Shiv, that the most significant thing that's come out of this is we've proven once and for all that change in healthcare doesn't need to be slow, deliberate, and plodding. 

I think one of the reasons you stepped away from medical school is you saw this pace of change. You got frustrated by it. It's something I certainly have been frustrated about throughout my career, and I think it's finally shown that when organizations choose a direction and don't get too lost in consensus-driven decision making and really pick a goal, you can actually move mountains. You've overnight seen the move from in-person to virtual care. Overnight, you've seen just massive changes in how people are thinking about the organization and structure of healthcare delivery. That is what we've needed all along. 

It took, unfortunately, a global pandemic to get us there, but I think we need a business model transformation and that you're starting to see a lot of organizations talk about the move to global capitation coming out of a recognition that fee for service was not any way to really sustain a healthcare organization in times of great uncertainty like ours right now. Again, I think the biggest area of change for me is really this renewed confidence that change can actually happen in healthcare.

SHIV GAGLANI: There's this quote I've been sharing with our team pretty often. It’s actually a Lenin quote. Maybe you've heard it. It's, “There are decades where nothing happens, and there are weeks when decades happen.”

DR. SACHIN JAIN: Exactly, exactly. Yes, I know that quote very, very well, and I think it is a beautiful one for the moment right now.

SHIV GAGLANI: Yes. We have some very specific examples. We had Dr. Joe Kvedar, who you know from UMass General...

DR. SACHIN JAIN:  For sure.

SHIV GAGLANI: ...he and Dr. Michael Gustafson, President of UMass Memorial, both echoed the two orders of magnitude increase that most health systems have seen on the number of virtual visits. You've been involved in so many different parts of the healthcare system.  Apart from maybe stopping the loneliness epidemic, capitation models, telehealth, what are some of the other things that we should be thinking about moving forward?

DR. SACHIN JAIN: One of the things that's exciting to me as someone who grew up in the Harvard medical system and was very anti-pharma for some period of time --  and then went to work in pharma through a series of accidents, wonderful accidents, in many ways -- is this renewed excitement and confidence in the American biotech sector. I think for years people have had this, I think, naïve notion that we have all the drugs and solutions that we actually need, and pharma is just developing a lot of me-too products to gouge the American public. 

I think that was a broadly-held perspective, particularly among a generation of medical students that trained in the years before and in the years after me. I'm sure you experienced some version of that narrative when you were at Harvard Medical School. I think that we see now, number one, that we don't have the solutions that we need for all the problems that we face, Coronavirus being the latest example of that. And then we also see the incredible ingenuity of the bio scientific enterprise when applied to solve a big problem, a big hairy problem. 

I think that's good for American society at large because I think the negativity around biopharma ended up bleeding into a lack of trust in medicine, a lack of trust in regulators, a belief that started to pervade the internet that medicines were created to create side effects to then create demand for more medicines -- all of this so-called fake news around medical care. What I'm hoping will come out of this as these treatments are developed, as these vaccines are developed, is renewed confidence in the FDA, renewed confidence in biopharma because we are all going to end up better for the American scientific enterprise. 

SHIV GAGLANI: That's a really astute observation, and I know there were some of the studies showing that biopharma as an industry was rated as negatively as tobacco companies, which always confused me because one is generally saving lives and the other is generally not.

DR. SACHIN JAIN: It's funny. When I was a first-year medical student in 2002, I'll always remember a woman who came and talked about her experience of living with cystic fibrosis. Those were some of the most powerful interactions we had as students. The remarkable thing is because of the work of Vertex Pharmaceuticals - full disclosure, I own a few shares, not too many, because I believe in the company -- but that disease is no longer a death sentence. It's now a chronic disease because of the tremendous efforts of people like Jeff Leiden and his predecessors leading that organization took to actually direct a lot of energy and effort to solve what was previously seen as an insoluble problem. 

Again, I think that those examples are not known enough. They're not shared enough. We take for granted much of the scientific and biomedical innovation that we have and just assume it was there all along, not recognizing the tremendous work and effort that actually goes into it. This is not to apologize at all for biopharma for the very high prices of drugs. I don't want to say that that's OK. But I do think that there are certain problems, such as Alzheimer's, that aren’t going to get solved by just using the medicines we have or by creating a more efficient healthcare delivery system. 

My personal perspective is we have tremendous opportunities to build a better health care system, but we also have an opportunity to improve medical care delivery by getting better drugs into the hands of patients and better vaccines in the hands of patients.

SHIV GAGLANI: I couldn't agree more. One other note on another place where I think public perception has changed as a result of the pandemic is the importance of first responders and healthcare professionals. I know something you invested in a lot at CareMore was caring for your staff, making sure that they were taken care of, that there was less burnout. Do you mind talking a little bit about what you think about the provider burnout epidemic that's been going on and how we may be able to address that?

DR. SACHIN JAIN: This is a profound problem. I had a relevant experience just a couple of weeks ago. I was going to see my very beloved primary care physician here in town, and she said, “Oh, you got to see me on my last day in practice,” and she was not retirement age. She's 47 years old, a former chief resident at one of the big academic centers here. She just said, “I couldn't do it anymore. I was burnt out.” I think a lot of it has to do with the divide that exists between the people who deliver care and the people who administrate care. It is actually a fundamental problem. I think the people who organize and structure care delivery don't know what it's like to actually deliver care. 

I'll tell you a funny story. When I was at the office of the National Coordinator for Health Information Technology, our agency was charged with promulgating electronic health records across the country.  At one meeting of 130 of our staff, I said, “How many of you have actually used an electronic health record?” Two hands went up. One was mine and the other was of my friend Dr. Thomas Sang who had run Federally Qualified Health Centers in New York City for a number of years. That's a problem. When the people who are organizing and structuring a process don't have to live with the process, that's a huge problem. I think that is creating the dynamics that are leading to unrealistic expectations, corporate directives that are divorced from the reality of what it actually is to take care of patients, and it's something we struggled with a lot when I was at CareMore and Aspire. These were organizations that I think that were set up more right than wrong. 

They were paid on a prepaid basis. They were not on a fee-for-service chassis, and so I think that ends up being a big part of the solution, is tying payment to clinicians to the clinical outcomes as opposed to tying them to how many widgets you produce or how many visits you undertake. Again, I think the solution to the problem is to focus on health, not focus on the kind of healthcare delivery as a means of compensating people for the care and the work that they do. 

SHIV GAGLANI: We’ll definitely get into that in a second. I've read a bunch of your papers and your articles, and some of the most powerful I know are the ones where you talk, not as a leader of a major health plan or health system, but as a doctor. That's something I've always respected, is that even though you've gained all these positions, you've still maintained a clinical practice throughout. I remember that really powerful piece you wrote about having a patient who was racist against you. I’d love it if you could comment about what motivated you to stay as a practicing physician? You wanted not to have a gap between administering healthcare delivery and then also being the one to deliver healthcare, so you were in the trenches, and is that sort of advice you’d give people?

DR. SACHIN JAIN: I think if you completed your clinical training, you owe it to yourself, to your patients, to your mentors, your teachers, to your medical school to keep a foot inside of clinical practice. I think it grounds you. It keeps you close to the action. Even as you're pursuing larger systemic changes, the only way that you're going to know if those systemic changes make any sense is if you're actually close to patients and you're close to families, and you're close to communities. I'm in the process right now of getting credentialed at our local VA hospital. We're all workers without compensation, attending some number of weekends a year.

For me, it's super important. It's going to be where I'm going to get my energy. It's going to be where I'll get ideas, and it'll be a reality check as I think about the larger system changes because it's very easy to get out of touch. Sadly, I think you get out of touch only a few months after you've actually left clinical practice. I see it happen with physicians who find their way into alternative careers quite often.  Ideas that seem totally rational at the whiteboard don't always feel rational when they're actually presented to the front lines of care, so I think keeping that connection is super important. Even if your clinical commitment is just a few hours a month, it just keeps you grounded.

SHIV GAGLANI: That's really great advice. I know we're coming up on time, so I have two more questions for you. The first is about some of the other macro trends that are happening in healthcare that I think you've been following that are really interesting. We've been talking a lot with some retailers like Wal-Mart, which is obviously scaling out their health clinics, so their whole premise is if we're going to do fee for service, let's make it super cheap, make a primary care appointment $40 as opposed to $106, which is the national average, and then on the flip side, there's also online retailers or online direct-to-consumer healthcare companies like Ro and Hims going public soon. What's your thought on the consumerization and democratization and “retailization” of healthcare?

DR. SACHIN JAIN: I'm worried about it because I think it is probably a segmented solution, meaning a solution for a particular segment of patients. The truth is that a lot of medical care, I would say the bulk of medical care delivered to most of the adult population, is some form of chronic disease management. That's all relationship-based. One of the key numbers to keep an eye on as these entities become bigger and bigger employers of physicians and nurse practitioners and other healthcare professionals is the average tenure that those individuals actually work at those companies. 

My experience leading healthcare organizations is that staff stability is one of the most important attributes of the healthcare organization because that creates continuity for patients. Every time you start with a new clinician, you actually hit reset on the clinical relationship between that clinical organization and the patient. Too many healthcare organizations rely on replacement players, whoever shows up on that particular day, to take care of a patient. Now, if you and I were sick, you wouldn't call up and say, “I want to see whoever's available.” We would say, “I want to see the best person. I want to see the most committed person. I want to see a person who knows me.”

The problem with a lot of these big-box retailers as they enter into healthcare is that that's not even on their list of design principles, so I worry that we're going to atomize what should actually be a continuous relationship. To me, that is a potential source of error. It's a potential source of poor quality and poor consumer experience. One of the reasons that these entities are getting as much play as they are is because traditional healthcare hasn't focused on the consumer experience. 

You could go to your long-standing primary care doctor's office and wait for 45 minutes or an hour. Compared to other sectors, or compared to even how these entities are going to undertake it, it's a poor experience.  But it doesn't mean that that connection and that relationship and that context building piece of it actually doesn't matter. Again, one number to look at as more and more non-healthcare organizations get into the retail delivery of healthcare is the average tenure of their clinical staff. I think that is going to be the tell.

SHIV GAGLANI: That's fascinating. We should definitely keep track of that. My last question for you is, I've certainly benefited from your advice directly and indirectly through reading what you've written and other thoughts you've given. Our audience, again, is primarily early-stage or current students in the healthcare fields. What advice would you give them about meeting the COVID moment and pandemic and then moving forward?

DR. SACHIN JAIN: I would say, “Keep your cup full.” These are really challenging times or unprecedented times. They're going to be talked about in social studies books for generations to come, maybe even centuries to come. So be kind to yourself. Have a high degree of forgiveness for yourself. If you're feeling bad, if you're feeling isolated, if you're feeling lonely, the worst thing you can do is to exacerbate it by actually making yourself feel worse about it. Have some compassion for yourself.

I think that's something that's very, very important. Pandemic or not, self-compassion, I think, ends up being something that many of us don't develop. It's not how we were raised. In some cases, it's not how we were taught to be, but again, as I progressed in my own career, in my own life, I think this notion of self-compassion is one that I think is very powerful. “Just be good to yourself,” as my mother always says to me.

SHIV GAGLANI: Those are some really heartwarming words to part on. Sachin, it's been an absolute pleasure to have you on the podcast. Thanks so much for taking the time.

DR. SACHIN JAIN: Thanks for having me. Really appreciate it. Good to reconnect.

SHIV GAGLANI: With that, I'm Shiv Gaglani. Thank you to the audience 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.