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Dr Isaacs on Healthcare Delivery Innovations


Dr John Whyte, WebMD chief medical officer, speaks with Dr Richard Isaacs, CEO and executive director of the Permanente Medical Group, about how the pandemic has changed our expectations regarding healthcare delivery as well as upcoming innovations in the way in which patients will receive care.

This transcript has been edited for clarity.

John Whyte, MD: Welcome, everyone. I’m Dr John Whyte, chief medical officer at WebMD. The pandemic has changed just about everything in our lives, including how we receive healthcare. Think about it: Before the pandemic, did you ever do a virtual visit with a doctor or perform your own lab test at home? The past few years have caused enormous innovation which has changed both patient and physician perspectives, but it’s also causing burnout on the part of healthcare providers, and our surveys at Medscape have clearly demonstrated that. I had the opportunity recently to spend some time in Sacramento, California, with my good friend, Dr Richard Isaacs. He’s the CEO and executive director of the Permanente Medical Group. He’s also the president and CEO of Mid-Atlantic Permanente Medical Group and the co-CEO of the Permanente Federation. We discussed the current usage of telehealth as well as the growing trend of what I’m calling “do-it-yourself medicine” that many digital tech tools seem to allow. He offers his thoughts on the need to measure social determinants, as well as how we can combat physician burnout. We even had some time to get in a game of cornhole and shoot some hoops. You do not want to miss it!

Rich, thanks for joining me today.

Richard S. Isaacs, MD: It’s such a pleasure. Thank you so much for traveling to come visit.

Whyte: Absolutely. So let’s talk about the impact that the pandemic has had on the delivery of healthcare. We can talk about telemedicine — Kaiser Permanente has always been good about telemedicine. What’s the role of telemedicine now in a hopefully post-pandemic world?

Isaacs: Pre-COVID, I think we knew that telehealth was going to be the future of medicine, but we were not doing it that well. Here in Northern California, we did maybe 100,000 video visits in 2019. And when 2020 hit, because of the shelter-in-place orders, close to 90% of our visits were done with a video care–first strategy, which was just unbelievably phenomenal. I would say that COVID-19 accelerated innovation in healthcare, and has really transformed the way that we connect with our patients.

Whyte: But what is it now? Does it vary tremendously by specialty? Where is it today?

Isaacs: Well, when you talk telehealth, there’s subdivision, subcategories: There’s email, there’s video visits.

Whyte: I want to talk video visits.

Isaacs: If you’re talking video, it’s probably around 20%. Currently all of the department chairs are working with their chiefs to identify what is the value-add of video and how we can really push the needle and bring video to the forefront. As you know, at Kaiser Permanente, we have an integrated prepaid system, which creates unique incentives for us to try to innovate and do very special things. For example, teledermatology: If they’re in with their primary care physician and there’s a lesion, we can take a picture of that lesion and send it in real time to a dermatologist. Or if the patient’s at home and they see a lesion, they’re sending an image of a lesion via secure message to their primary care doctor, who can then consult with a dermatologist and provide feedback. If the patient needs a biopsy, they can get an immediate appointment to come in and see their dermatologist or one of our dermatologists.

Whyte: What about pushback? We’ve heard from patients throughout the healthcare system that expectations haven’t always been met. And some clinicians have also said that, as you know — that they were kind of thrown into it, weren’t necessarily experts in doing it. Where are expectations now on the part of the provider community as well as the patient community in terms of the role of telehealth, telemedicine, going forward?

Isaacs: It’s really about creating convenience for the patient. Early on, patients didn’t want to come in, but as the world has opened up in the second and now third year, people miss that human contact. People really want to see their physician, even if a video will suffice. People miss that human connectivity. And that’s really the challenge of identifying where the value of the video is. Ultimately, the goal will be to have full hybrid integration of televisits, like a hybrid model.

Whyte: I’m going to push you: What percentage of visits next year do you think will be telehealth — 20%? Forty percent? I know it varies by specialty, but what would you say overall?

Isaacs: I think 30% is a good number, but it could be higher. As a surgeon…

Whyte: Hedging… That’s going to be low, probably.

Isaacs: It’ll probably be low. As a surgeon in a postoperative visit, I think it’s reasonable to have a video visit to check a wound. I think it’s very convenient for the patient and it allows us to integrate into the community and go even more rural. Where you are in Washington, DC, for example, it’s really hard to get around the Beltway. I think we’ll see patients choosing — opting in — for video when it’s appropriate.

Whyte: This brings up the issue of capacity, both for Kaiser Permanente and the healthcare system in general. People are coming back in to get those missed screening visits, those missed doctors’ appointments. We want them to come back when they can, as opposed to a telemedicine visit. But people are saying, “I’m waiting a long time.” It’s hard to get that visit to the GI doctor or to the dermatologist, as you referenced, or even their primary care physician. What are you doing to help address capacity? We can’t just turn the faucet on and all of a sudden get more healthcare providers. We don’t have more hours in the day. We can’t be shortening the time. We know they’re coming in with greater acuity.

Isaacs: Yes.

Whyte: So, what are you doing to address capacity?

Isaacs: I think COVID-19 has really created delays in care, delays in screening, so I hate to say it but there’s a queue; there’s a backlog. Because the way that we like to function in Permanente Medicine, it’s a seamless integration of primary and subspecialty care. And in order to have that, you can’t have significant backlogs. We’d like to do today’s work today. So if there’s a primary care visit and the patient needs an otolaryngologist, we want to [take care of that] as close to that visit [as possible].

Whyte: And you are an otolaryngologist.

Isaacs: I am an otolaryngologist — exactly. So it’s really about eliminating the queue. Currently all of my department chairs and my associate executive staff are working to decrease the queuing, eliminate the backlogs. ‘We’re working extra. We’re operating in the 7-day-a-week category now in order to get back to pre-pandemic throughput.

Whyte: You and I were talking before the interview about the role of tech. COVID really has taught patients that there’s a lot you can do to take care of your own health. None of us were doing pulse ox or even had a pulse ox beforehand. None of us did home testing or COVID testing. And now it’s expanded. You can do home lab testing, you can check your cholesterol by getting a test at your local pharmacy and mailing it in, or your A1c. And there are many other tests that they can order. People are wearing devices that check their biometrics. How does that fit into the healthcare system where, many times, we have all this data that’s not structured, that physicians don’t have access to, but it’s important information? I saw a patient who said his watch said his heart rate was 52, but there wasn’t really any way to access that. So how is that going to play into the delivery of care in the future? And what is Permanente Medicine doing about the role of tech? This, in many ways, is the future in terms of how healthcare is being delivered.

Isaacs: What you just described is a wonderful thing for people to be in tune with their health and use whatever available resources they have to monitor their own health. I’ve been saying this for many years. I think it’s really important for us to own our health. So this is a great thing. It does disconnect from the system if people are going out to their local pharmacy and getting a blood test or doing other things. And we’d really like to keep that coordinated in a health record. So my job in Permanente Medicine is to ensure that people have convenient access to us and our system so that we’re able to provide the appropriate care when they do have a self-test that might be slightly abnormal. It’s really important for us to maintain those records. It’s all about convenience. We moved to the “digital front door,” which was a huge innovation that started during the pandemic — Get Care Now, which is an app where every Kaiser Permanente member can go to their smartphone and enter information about their symptoms and navigate through the healthcare delivery system. If they need to chat with the physician, we get them in front of a physician. If they need to have a video visit with their physician, that happens as well.

Whyte: I want to talk about social determinants of health. Kaiser Permanente has always been a leader in talking about those aspects of one’s life, that their ZIP code matters as much as their genetic code. Access to fresh fruits and vegetables, exercise, and [the association with] childhood obesity has always been something that Kaiser Permanente has really been talking about and trying to address. But as you referenced, there are issues of capacity right now. There are cues to get back to just the things we typically do every day: manage diabetes, manage heart disease. And we talk about needing to do a food inventory, because that’s important — can people eat? We need to do anxiety screening and depression screening on everyone. Now, maybe even in kids, we want to talk about loneliness. These are all important aspects in terms of how one maximizes one’s health. But is the clinical community the best place to do all of this? Because some people will push back and say, “Dr Isaacs, that’s not what I’m trained in. I don’t know how to do it. I don’t have time to do it. I don’t know what to do if people screen positive for food insecurity.” So whose role is that? Because right now there’s a lot of discussion that, nationally, it should be the clinical community, that doctors should be measuring these things, too. “I’m just trying to get A1c under control. I’m trying to make sure people don’t have another heart attack. I’m trying to minimize postsurgical outcomes where there aren’t any infections. Now I have to do all these other things.” So where are we on this? Whose job is it, Rich?

Isaacs: It is a social determinant. And every major city in this country and every rural area has food deserts and has opportunity. I think it’s difficult to put all of that pressure on the healthcare delivery system, but it has to be a private–public partnership in order to address these social determinants. I think that the physician group that I lead is very much involved in these communities, but it’s got to be a partnership with the local governments with us to provide the resources to eliminate food deserts, to create more security for health. It’s a big challenge, and I think COVID-19 has exacerbated this.

Whyte: We’re in a mental health pandemic — let’s just acknowledge that and put it out there. We had an infectious disease pandemic, but we’re going to see the impacts of COVID on people’s mental health for a long time. What is Kaiser Permanente doing to address issues of mental health? Let’s start first with the patient community.

Isaacs: I think it’s really about access, and as I think about mental health or afflictions of mental health, it’s really a chronic condition that has exacerbations. And if you don’t have continuity of care or the ability to have access, then you can have exacerbations of mental health disorders. So Kaiser Permanente is leveraging technology up front to identify those patients who need the resources that are intensive, and determining whether there are alternatives within our healthcare system to provide support for mild depression without utilizing the intense resources that we have for more advanced disease.

Whyte: So what’s that technology?

Isaacs: It’s called Connect to Care, and it’s basically a technology hub similar to a call center, but using a smartphone video visit, which allows us to provide an immediate assessment. And what’s nice about it, in mental health, is that it allows us to see the patient in their own milieu. So when I talk to our mental health providers and our psychiatrists, they say that the technology actually gives them a better view of the patient’s home and milieu and the issues that they face locally.

Whyte: But what about issues of disparity? Not everyone has a fancy iPhone or a quiet place in their home to have those discussions. What are Permanente Medicine and Kaiser Permanente doing to address the disparities that exist? Even when people are insured, there are still those issues in terms of disparate care.

Isaacs: I think there’s a lot of cell phone penetration, even in underprivileged communities. And when you create the access to cellular technology, you create the opportunity to have text messaging, telephone, and even video on a relatively primitive phone. But again, I’ve been thinking a lot about public–private partnerships.

Whyte: What have you been thinking?

Isaacs: Is there an opportunity for us to work with the local government or with the public library to create a kiosk where a patient can go to access the technology that gives access to every health system in this community, depending on what your coverage is?

Whyte: What about viewers who will say, “Dr Isaacs, that works for you at Kaiser Permanente, which is a unique type of system in the United States, but it’s not going to work for me in my region of the country. I’m not set up like that. I don’t have the resources. That’s not the culture.” Is that a fair criticism?

Isaacs: Perhaps it is, but I feel an obligation to improve the health of the community. And we need to be innovative and work together to help create basic access to care. We’ve got to hit that. “It doesn’t work for me” is really just an excuse. I think it’s our obligation to improve the health of this community. And what can we do working with other partners locally to help solve those issues?

Whyte: So here we’re talking about how we need increased capacity. We’re addressing issues of mental health. We’re addressing social determinants of health. We know there’s tremendous burnout among all clinicians, physicians, nurses, pharmacists, lab workers. What is Permanente doing about burnout? Do you think it’s going to get worse before it gets better?

Isaacs: I think the demand is high because we’re coming out of 3 years of care delay. Our job is to eliminate redundancy. I’ve been saying this ever since I’ve been with Kaiser Permanente — the more seamless the care, the fewer steps we need per diagnosis, the more capacity we have. So it’s really important about having the right physician at the right time and the right place to provide that care. And when you do that, you eliminate redundancy. That’s why in personalization of care, seeing your primary care physician is critical. Because if you can’t see your physician and you’re seeing a different physician, chances are there’s going to be another redundancy: “I just want to follow up with John. I saw this other doctor in urgent care, but I really want to see my doctor.” So now you have two visits instead of one. But if we could have just done it with one the first time, we’ve created double the capacity.

Whyte: But what do clinicians need? Because there are only so many hours in the day, and you referenced how now you’re going to 7 days a week in some instances. People want to have that work–life balance. We want to have that culture where we promote good mental health among our employees. So that’s what many folks want to know. Our Medscape colleagues want to know. You run the group — what is Permanente Medicine doing about physician [burnout]?

Isaacs: The antidote to burnout is engagement. And we’ve lost engagement because of what we’ve been through for the past 24 months. As we’ve opened up, I’m seeing a lot more human connection and happiness, which is pretty amazing, even in your offices in DC when we’re together. But being engaged in solving problems is another antidote to burnout. So we’ve put a lot of energy into developing the digital front door, which allows patients to get what they need, independent of a physician, which gives more capacity for personalization. I’ve been saying this for a long time. I feel that healthcare is finally catching up to other industries.

Whyte: Why do you say that? Because we’re slow and stodgy?

Isaacs: We are slow. Even my kids are so good at using smartphones to get food or to get a ride share. We’ve had Uber and Lyft for what, at least a decade? Maybe longer? Where was a smartphone app for healthcare?

Whyte: Well, that’s patients’ expectations, right? Why should they have to drive to the doctor’s office 20 minutes or use public transportation? Let’s be realistic — it’s still sometimes a wait of 20-30 minutes for a 15- to 20-minute appointment, and then repeat everything, right?

Isaacs: Other industries are so far advanced and we’re trying to catch up. I can give you a real-life example: AAA. I had a flat tire about 3 weeks ago. I was driving from Oakland to Richmond. When I got to the Richmond parking structure, there was a big red tire [warning] that said, “Oh, you’ve got a problem.” I saw a completely flat tire. So I called AAA and was on hold for a call center. And while I was on hold, I got a text message: “We see that you’re on hold. Your call will be answered in the order it was received.”

Whyte: “You’re number 30.”

Isaacs: It was about a 25-minute wait. But I got an instant text. I pushed the button. They knew exactly where I was, based on GPS. They asked me, “What type of car do you have?” And they knew that I didn’t have a spare tire. “We’re going to dispatch a tow truck.” I’m still on hold with the call center and a tow truck arrived within 10 minutes. Why can’t healthcare have that type of seamlessness?

Whyte: So, why can’t we? You’re in charge of that.

Isaacs: Well, that’s what we’re building. That’s the Get Care Now promise — that patients will be able to go online and navigate in a hybrid world: digital chatbot video when necessary, appointed care when necessary, from the comfort and convenience of your smartphone.

Whyte: That leads to better outcomes, right? That’s what we’re really interested in. And how do we measure those outcomes?

So, what does healthcare look like — I don’t want to ask you for that typical 10-year forecast or even 5 years — I want to know what does it look like 2 years from now? How is it different 2 years from now than it is today? Because as you said, there’s tremendous innovation going on.

Isaacs: There’s tremendous innovation, there’s the patient convenience component, and there’s also the care delivery component. You have to look at both of those. Patient convenience is access when you need it, and you use your smartphone or other types of technology to get what you need. We also are able to move expertise. For example, with tele–critical care, we have two hubs here in Northern California where we have critical care pulmonologists monitoring all of our ICU patients 24/7, which is amazing. You’re moving expertise, not human bodies. Telestroke is the same thing: If someone shows up in any one of our 21 emergency rooms here, we’re able to provide instant expertise from a neurologist who’s central, who can dictate the thrombolytic treatment in real time, which is amazing. So, we’re already there on the care delivery, but we’re continuing to push the envelope on that. And then as far as the patient convenience component, it’s really about getting adjusted to what is appropriate; where is the value-add for a Get Care Now app? And we can navigate that, so that’s what we’re working on right now — navigating patients through the system using these smart apps.

Whyte: You seem very excited about the future of medicine, the future of healthcare. We know that there are issues, though, with early retirement of health professionals — “quiet quitting” — you and I were talking about that earlier. You have family members who are new in their careers in medicine, and I know you talk to a lot of students and young residents. What are you hearing from them about interest in becoming a doctor, becoming a nurse, becoming a pharmacist? Is there that same level of interest that you heard early on in your career? Or is it people saying, “Hey, maybe I’ll think about something else”?

Isaacs: It seems like there’s a new interest in healthcare. Medical school applications are way up. People want to be infectious disease experts like I’ve never seen before. So I think that we’re in a transition, we’re in a moment right now. People are feeling the sequelae of working hard for 3 years, dealing with the volatility and uncertainty of a pandemic. But the nursing applications and physician applications are way up. People want to be part of care delivery, which is pretty inspiring to me. I’ve got two daughters. One’s a resident in internal medicine, and she loves what she’s doing; she actually was a pandemic intern. And I’ve got a fourth-year medical student here in Sacramento who’s looking at a family medicine career as well. They’re really inspired to be physicians.

Whyte: Would you become a physician again?

Isaacs: I would. I think it’s the most noble, honorable thing you can do.

Whyte: Well, Dr Isaacs, I want to thank you for taking the time today to share your thoughts on where we are in terms of how we’re going to be delivering care in the future. And thank you for all that you’re doing to address the social determinants of health, both in California and nationally.

Isaacs: It’s such a pleasure to see you and to be live. We’ve done a lot of video connections, but this is great. Thank you.

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