Using Walmart’s Giant Healthcare Footprint to Drive Access and Equity - Dr. John Wigneswaran, Chief Medical Officer at Walmart

Shiv Gaglani: Hi. I'm Shiv Gaglani. If you're curious about the role of big box retailers in the U.S. healthcare system, we have a special guest with us today from one of the biggest players involved to provide us with some insight.

Dr. John Wigneswaran or Dr. Wig, as he's known, is Walmart's Chief Medical Officer, leading the company's safety, quality, and training programs, Clinical Program Development and Medical Affairs areas. 

He brings deep experience in the healthcare field to his current role. In addition to being a practicing nephrologist for many years, he spent nearly two decades in a variety of roles at major companies in the pharmaceutical, medical advice, and healthcare service industries. 

In addition to finding out about the role of Walmart Health and Wellness in healthcare delivery, we'll also be asking Dr. Wig about the recently launched Walmart Healthcare Research Institute, which aims to increase access to healthcare research and innovative medicines focused on studies that have a health equity impact.

Dr. Wig, thanks for taking the time to be with us today.

Dr. John Wigneswaran: Thank you, Shiv. Really appreciate it.

Shiv: As you know, our audience comprises many current and future healthcare professionals, and one of the questions we always like to start with is just learning more about you, what got you interested in medicine, and then eventually in nephrology.

Dr. Wigneswaran: Sure. I think if you met me in high school, you'd never thought I was going to become a physician. I was not paying too much attention in school and was pretty heavily into music, and thought I was going to go down that career and was doing a bunch of session work. My dad was a pediatrician, and so through a bunch of different events, I just ended up gravitating towards healthcare. It was something I'd always seen and really admired. It was somewhat of an organic move.

Shiv: Totally. I can definitely relate to that, my father being a physician, as well, and you're growing up surrounded with it.

Take us through med school. What got you interested in medicine then nephrology? That's always on top of our learners' minds...understanding how they choose what specialty they go into.

Dr. Wigneswaran: When I was going through medical school, I didn't really have a clear understanding of what I wanted to do. I was initially gravitating towards radiology. It just was more visual, it seemed more artistic, and I actually did a year of medicine and radiology. While I was doing radiology, I wasn't as passionate about it. I happened to be doing some real procedures, doing some intravenous pyelograms and just started getting interested in talking to people. I switched out and finished up my internal medicine training and then went off to nephrology.

Nephrology, for me, was a lot about having something very objective in front of you. When someone has kidney disease versus someone who has back pain, it's a little bit more esoteric, and I always really appreciated that part of it than the technology aspect.

Shiv: Absolutely. We work with some groups like Fresenius in the dialysis space and it's really gratifying to know the physiology around the kidneys and how they function and the important role they play. It's beautiful, actually, just from a 'how the body has evolved' perspective.

My mentor at Johns Hopkins, where I went to med school, is actually a guy named Dr. Steve Sozio, who is a fellow nephrologist. I've definitely been drawn to that space.

Take us through your journey from being a clinician into the business side of medicine, as well as some of your career highlights prior to Walmart.

Dr. Wigneswaran: Again, another organic move. When I finished up my fellowship training, I was initially going to look at taking a pharmaceutical role at one of Johnson & Johnsons' subsidiaries, and then I just decided I wanted to practice so I joined a clinical practice in Dayton, Ohio. At that time, although I probably wasn't thinking about it too deliberately, I was really looking for places where I could go out and potentially be an owner to a practice and understand the practice, and try to get some partnership where it seems like more opportunities than just working. 

The areas I was looking at, the only places in the country that were having a hard time recruiting folks, they were much more generous in terms of giving you that opportunity, so Dayton, Ohio became one of the places I looked at and went out to.

About a year into my practice, I was in the physicians' lounge and an individual pharmaceutical rep came up to me from a start-up heart failure company and asked me if I wanted to speak about this particular product, which I really enjoyed and believed in. I ended up speaking all over the country. It was such an important learning experience for me even before I got into my career because you not only were speaking and trying to be a subject matter expert and understand, but you were speaking in so many different environments -- to nurses, to administrators, to academic and community docs -- and I really learned a little bit about just how to sell but then more importantly, just understand different perspectives of how people think about the healthcare ecosystem, which I think all of us are grappling with now.

After that, I ended up working for that company. It was acquired by Johnson & Johnson, so I ended up getting a job at J&J, learned bread-and-butter medical affairs from a really great leader, and then worked for another heart failure device start-up, another small start-up company, and then DaVita and Fresenius, learning more healthcare systems and operations, and then moved over to the specialty pharmacy world.

I just tried to take my career in places where I wanted to learn different aspects of the healthcare system, and most recently was Chief Medical Officer at Express Scripts trying to learn a lot about specialty pharmacy and pharmacy networks. I took a couple of steps backwards along the way just more deliberately, but I was just always moved by trying to understand the different parts of the ecosystem.

Shiv: It's quite a resumé. I think a key lesson for our learners, people listening to this podcast, is to let their careers evolve organically and just be curious, be driven by their passion and curiosity, which sounds like what you've been doing over the course of your career.

Let's actually go into your current role as Chief Medical Officer of Walmart Health and Wellness. Can you give us an overview of the organization? I know there have been many clinics you all have set up, so many different things you all do. It's very exciting to see Walmart get into the space in a big way. What's top of mind for you, and can you give us an overview of the company's health and wellness business?

Dr. Wigneswaran: Sure. I think the biggest thing with Walmart is that most people don't think about Walmart and health. I certainly didn't think I would be working at Walmart at some point, but the company actually has a very mature healthcare presence. It's been in the business since the 1970s, starting with the retail pharmacy footprint. There are roughly over 5,000 pharmacies, 4,000 of those are in medically underserved areas. We have a specialty pharmacy business, we have a telehealth asset that we have bought, we have a couple thousand non-medical optometry sites, dental practices. I think most have heard of primary care and the growth there amongst most of the players in the healthcare system. We're trying to broaden into that. 

And then on the retail side of the business and food, we're the largest grocer in the world and we've been playing more in the regulated markets. That's a little bit of the scale. 150 million people go through a Walmart every week. There's a Walmart within ten miles of 90% of the population. So, when I think about my career, one of the reasons I really wanted to be at Walmart is that you're able to touch pretty much every aspect of the healthcare ecosystem and you're touching people that truly have a need.

With nephrology, as you know from your mentor, a lot of this is related to kidney patients or people that really don't have a lot in terms of life expectancy, it's not very long, there's a lot of challenges there, and so being able to be at that place where you could actually make a big difference was the mission. 

For our strategy for the business, we are basically trying to be an integrated omni-channel healthcare provider like everyone, so leveraging data technology. What's different is that we're really doing this within the communities that don't get that.

The last thing I'll say is even within me and the medical office that I'm leading under Dr. Pegus, a lot of our simple messaging is that it doesn't matter where you live in the country. We want your level of care to be the same as if you went to a Mass General or to a UPenn or Hopkins. There should not be a reason that someone shouldn't enjoy that level of care, and that's what we're trying to do and try to bring all of our strengths to bear.

Shiv: That's an incredible vision, and obviously the size and scope -- that 90% of people in the U.S. live within ten miles of Walmart -- is increasingly important given that we know what COVID-19 has accelerated trends like the demise of rural healthcare offerings and hospitals shutting down. That's very powerful that you all are focused on that and are able to be a delivery mechanism.

I will say, I've been following the Walmart story for a couple of years now. We've benefited a lot from meeting some of your current and former colleagues, people like Marcus Osborne, who was on the podcast during the height of COVID-19, Chinni Pulluru who I first met at the health conference in Las Vegas, Carrie Domico, Brad Seusy and a few others, I think are doing great work as far as setting up these clinics. Also, Ro Parikh, who we had in the podcast a while ago, who was part of Walmart Dentistry for a while. It's a great team you guys have assembled over the years.

Going into being able to serve under-resourced communities, tell us a bit more about the Walmart Healthcare Research Institute. How did it come about and what are your main objectives with it?

Dr. Wigneswaran: This is the same question, right? People might not understand the connection between Walmart and research. It's less about research. We're not starting the Research Institute to become a clinical research organization or do a thousand studies. When you think about it, it's really an extension of this access and equity initiative and mission that we have in terms of making sure everybody has those same opportunities. 

We already know that most clinical studies, if not all, are not really including communities from underrepresented populations, and there a lot of reasons for that. It could be that they can't get to a study site, or some have jobs that don't allow them to take time off work. When I think about research, I'm thinking about it in the sense of I have the ability to identify the diseases and drugs that matter to our patients. 

One is that we're able to shine a spotlight on 'these are the things that we want folks to be aware of,' but then when I communicate to that patient or customer, I want to be able to use that point in time as a way to talk to them about their condition, talk to them about a study that might be relevant to them because we are the provider for our patients -- the roughly 30 million people that are using our pharmacy. We're their providers, so they will listen to something we're saying. For instance, "Hey, your son has asthma. Did you know we have a study looking at a specific device for uncontrolled asthma? That's a much more relevant conversation.

Lastly, whether someone decides to participate in research or not, what's equally important or probably even more important is that we just don't leave it there. Whether they're recruited or not, we want to be able to see what happened in the community or with that patient. Did they trust their provider more? Are they more engaged in their care? Do they know more? Was the messaging appropriate for them to really understand? That's really ultimately what we're trying to do to drive safer, high quality, and equitable care, but research is just one of those levers.

Shiv: Yeah, there's great potential there, obviously, given the numbers that you all are seeing and able to provide that service to your members or customers.

You mentioned asthma as one example. I think there's other chronic conditions you all have homed in on like diabetes, cardiovascular disease, COVID-19, especially long COVID-19. Can you tell us a bit about the conditions you all are trying to cover and then any plans to grow and do research beyond some of those?

Dr. Wigneswaran: I think we have a mechanism of which we try to score the appropriate studies, and frankly, even pharmaceutical companies that we want to work with. Obviously, diabetes, cardiovascular disease and obesity are important to us and we over-index on those conditions with our population. But like I said, in terms of our scale and thinking about other things that we can do, we can actually play within the rare disease space. We can find those patients that in a lot of cases are not even aware that there might be a medication for a condition that they might be struggling with. We're having multiple conversations with all the large pharmaceutical sponsors but really focusing on those conditions, those that have an equity impact and those that move the needle on the things that our patients and customers are interested in.

Shiv: Yeah, that's amazing. I can't wait to watch that space and see how it evolves.

I know you mentioned one of the key things you're trying to do with this research institute at Walmart, in general, is moving the needle on diversity, equity, inclusion, and accessibility. Can you tell us about how you guys are keeping track of that? Is there a particular market, specifically, you're homing in on? Obviously, you have a lot of zip code diversity.  I think I just heard the stat that in rural zip codes, mortality is 24% higher just because of lack of preventive medicine and access to care. Tell us a bit about your focus on DEI and accessibility.

Dr. Wigneswaran: You know what? I think it's a really great question. It's also a challenging question to answer because when you focus just on a metric -- I think the FDA and others are looking at just race, for example -- you also miss a lot of the things that you just mentioned. Is there a systemic issue as to why someone doesn't have access, or other issues? We're trying to look at this more holistically. We are trying to determine what are those metrics we should be following, such as trust metrics and other KPIs. 

In fact, there's a lot of work being done at Yale, in particular, looking at not only trying to figure out how do you quantify trust or how do you quantify what constitutes an underrepresented population, but also very interestingly, what constitutes a pharmaceutical sponsor that is also leveraging and keeping these issues in mind, as well. We're spending a lot of time over the next couple of months trying to determine what those appropriate metrics are.

Shiv: Great. Well, again, it's something that I think we'll all be watching pretty closely, just given how much size and scale you guys have.

When you look at Walmart's evolution, maybe over the next five, ten years in terms of health and wellness, what are you most focused on. Expanding your footprint, more states, more centers, more services, the Healthcare Research Institute...how do you see it evolving over the next five, ten years?

Dr. Wigneswaran: I think this is the age-old question in terms of just what transformation looks like or what destruction looks like. One of the reasons I came to Walmart is that we can do things right now, and I'm actually more focused on right now. 

For example, we have the ability in clinical studies to really solve a gap in patient recruitment, which is very difficult. That's something we can do now and we can make an impact. We have the ability with our footprint that to build an end-to-end diabetes program, for example. But we could do wound checks in stores. We could do eye exams in stores. We could do healthy food shopping trips with a community health worker. 

We are doing work, for example, with some leading associations -- including the American Diabetes Association and the Elton John AIDS Foundation -- to train our pharmacists on being certified in how to deal with HIV and medication therapy management. Those are things that we can do right now. 

The way I think about Walmart is we're really looking at the now just because of some of the stats with how people's health is faring. We're going to start to do those types of initiatives now rather than necessarily look at later. I think that's a really core focus for many of us at Walmart Health and Wellness.

Shiv: That's a really exciting vision and cool to see how that's expanding pretty quickly, not just in terms of number of centers but the types of things you guys can can do.  There are over 2.6 million current and future healthcare professionals who consume Osmosis. Many of them are medical students -- that's where we started -- but we also have students in nursing, PA, pharmacy, dentistry, medical assisting, nutrition, etc. What's your pitch to them about maybe coming to join Walmart and this transformation you all are helping drive forward, especially because we know that there's issues with both the training and the retention of healthcare workers as many of them are currently leaving or considering leaving the workforce, given all the stressors?

Dr. Wigneswaran: My take on this is that clearly, the burnout that healthcare workers are facing is pretty significant. There's a tremendous amount of stress, whether it's the pandemic, and frankly, whether it's a lot of things. There's a lot of change and disruption that's occurring. 

What I've tried to at least preach -- and probably preach is the wrong word -- at least what I've learned is try not to define yourself by your skillset in terms of being a subject matter expert. As a nephrologist or as a dentist or a nurse practitioner, you really want to think about yourself in terms of I having more than a clinical skillset. Let's say as a nephrologist, if I'm going to be dropped into a dental practice, am I able to execute on a business with my clinical chops? Because the era of being a subject matter expert is rapidly changing. Information is out there. Everything can be Googled, but what I think is really compelling about individuals -- particularly those that are coming here -- are those that can work cross-functionally and try to figure out how to pull all those things together, how to execute, how to operate, which is very different than what you've learned in school or academically. I've always found that to be helpful and it keeps you relevant as, well.

Shiv: Definitely. Things are changing so rapidly, and that's actually why we launched the Raise the Line podcast. On that topic, what other trends are you excited about watching? What are some trends that you think are here to stay in a, hopefully, post-pandemic environment? Clearly COVID-19 is still happening, but it's less acute than when we first launched this podcast.

Dr. Wigneswaran: I think one of the trends, obviously, is this idea of non-traditional entrance. Whether it's a retailer, whether it's non-traditional data elements, whether it's zip codes, or even if somebody votes. If we know that someone votes, that individual is a much more engaged individual. If I threw a clinical program or message in front of them, they're probably going to respond to it more than someone else. This ability to be able to look at your entire life is, I think, very critical. Whether it's based on your diet, what your pharmacokinetics are, or whether a drug works or not or how adherent you're going to be. 

That, to me, is probably the most interesting trend and probably the reason you're seeing all of these different changes from the way we traditionally used to practice, because they do make a big difference. I think that's going to continue, whether it's a retailer, whether it's telehealth, etc., but this whole idea of going upstream in a more real world is, I think, something that I'm excited about.

Shiv: Definitely. That's really exciting, as well. I know we're coming up on the time, so I just had a couple of quick questions. One is, as you know, Osmosis is a teaching company. One question we like to ask our guests is if you could snap your fingers and teach any audience anything -- whether it's clinicians or patients or some other group -- what would it be and why?

Dr. Wigneswaran: I think I'll go back to something I said about just being able to walk outside your comfort zone as a subject matter expert. What I've found is there's a difference between someone who is a subject matter expert, and, frankly, someone who is strategic and can identify large trends. Trying to get from strategy to implementation and being well-versed in operations and understanding metrics is important for clinicians to know. 

While you can't necessarily teach someone to be an operator, being familiar with what the difference is between being an operator and executor versus somebody who is more of a strategy person or maybe a leader in a different way is critically important. I think clinicians are going to be called on for that. And being an operator touches a bunch of different things -- having direct reports, understanding the important KPIs, understanding how to focus, what are the levers you want to push. If you guys could figure out a learning plan for that, I would definitely watch it.

Shiv: Definitely. The whole business of medicine and actually how to persuade people, how to manage...all of that stuff is important. Having grown Osmosis from one person to 100 people, I have definitely have seen that importance. It's very much like how do you convince a patient to follow a course of action or treatment plan? Same with a direct report. So, it's interesting.

You've already touched upon some advice you'd give our learners about developing those skill sets we talked about. What other advice would you give to them about their career in health care?

Dr. Wigneswaran: I think this is probably very cliché, but really try to love what you're doing. I think you touched on this also, that as you go through your career, it's tough to plan what you're trying to do. I always found that if you're a little bit more intentional, number one, about doing things you like and working with who you like, but then also recognizing gaps and sometimes taking a step back and trying to learn different skill sets along the way, it's really important. 

I don't think I would be where I am if I didn't do that. Frankly, even the individual I report to now, Dr. Cheryl Pegus...that was also intentional, to try to learn from another physician who's done pretty remarkable things. Those are the things you want to try to be intentional about. I found that to be really helpful.

Shiv: I would definitely echo that advice. Oftentimes, it comes down to who you surround yourself with as opposed to exactly what you're working on.

Dr. Wig, I really appreciate you taking time to be with us today and more importantly, the work that you and your team are doing to raise the line and strengthen our healthcare system.

Dr. Wigneswaran: Thank you, Shiv. I really appreciate being here.

Shiv: With that, I'm Shiv Gaglani. Thank you to our audience for checking out today's show. Remember to do your part to raise the line. We're all in this together. Take care.