00:01hi and welcome to the a 16z podcast in
00:04this episode recorded at the a 16 Z
00:06annual summit event co-founder and
00:08general partner Ben Horowitz talked to
00:10CEO of Kaiser Permanente Bernard J Tyson
00:13all about the state of health care and
00:15where it might be going the conversation
00:17covers how an end-to-end health care
00:19system like Kaiser works in terms of
00:21assuming risk responsibilities
00:23maximizing value and lifetime care over
00:26ahead in the bed and the infrastructure
00:28that delivers on total health what is
00:30the health care infrastructure we need
00:31most today and what does truly
00:34Affordable Health Care look like and
00:35finally what is the impact of technology
00:38on healthcare and where are the
00:39challenges in deploying the newest
00:41technologies into the modern healthcare
00:43system all right so this is Bernard
00:49Bernard runs Kaiser Permanente which has
00:5312 point 3 million members the largest
00:55healthcare provider in the United States
00:58he's also is kind of one of the best
01:02CEOs that I know so you know it's you
01:05know CEO is kind of studying CEOs is my
01:08hobby and Bernard is one of the best of
01:11those so we'll get into all of that
01:13welcome Bernard well yeah I'm scared to
01:16say something now why don't we start off
01:19with a little bit about you how did you
01:21get into you know how'd you get into
01:23healthcare how did you get to Kaiser and
01:25you know kind of rise to be CEO it like
01:32many families my there was sickness in
01:35my family so my mother who was still
01:39alive and still kicking Wow how old is
01:42she now it's at 85 her she she was sick
01:47all the time when we were growing up and
01:48so we spent a lot of time in hospitals
01:50and she had a wonderful wonderful
01:55physician who not only cared about and
01:58cared for her he also showed compassion
02:02to us so I've always wanted to be a
02:07doctor I still want to one day
02:13we open up a medical school in 2020 here
02:17I keep hinting I want to be the first
02:19student right take me forever to get a
02:22degree yeah but so far no takers and but
02:27as I grew up I then sort of gravitated
02:32to the business side but one of the
02:34things that was a hot moment for me was
02:39the whole thought was in my mind was
02:42that everybody was treated that way then
02:47I discovered what we talked about today
02:49which is healthcare disparities that we
02:53were very fortunate we had someone who
02:55was an advocate for my mom and for the
02:58family and later learned that that's not
03:02true as a universal statement and so I
03:07have been not true like what what did
03:11you kind of bump into where somebody
03:13wasn't getting that kind of care well it
03:15was most dramatic when I was in
03:19undergraduate studies to become health
03:23at first I wanted to simply be a
03:25hospital administrator there was for me
03:28a big deal to be a hospital
03:29administrator when I was doing
03:31internships and I was working at a
03:33particular hospital and I began to see
03:36how people were being treated and the
03:38fact that people were coming into the
03:40emergency department for emergency care
03:42and I knew that if they had gotten into
03:45a physician office upstream right they
03:49wouldn't be in the emergency department
03:51almost at deaf doors at times oh wow
03:53yeah and so that was a passion and I
03:58probably took more of a liking then to
04:02the business I and then I started down
04:04that path okay so tell us about Kaiser
04:09and because Kaiser is very different
04:11than how basically almost all other
04:14healthcare works in the United States so
04:17what is Kaiser Permanente how does it
04:20work and you know why is it different
04:22why is it better in your view
04:25it's the the line-of-sight for Kaiser
04:30Permanente is to be a total in the end
04:35system and we talked a lot about taking
04:40care of people from birth to end of life
04:43we also talked about the fact that our
04:47building blocks for our organization is
04:50different from the rest of the industry
04:52in most cases we assume total
04:55responsibility for the total risk of an
04:57individual because our financing system
05:00is one in which we get paid a capitated
05:04payment for the entire care
05:07responsibility of the individual
05:10secondly we have all the pieces of the
05:14delivery system inside of the four walls
05:17of Kaiser Permanente whether that's
05:20physically there are virtually through
05:23the contractual relationship but in both
05:26cases we still continue to assume the
05:29total risk right and the rest of the
05:31industry is pretty much still the
05:33fee-for-service system is based on
05:35volume and some other ingredients
05:38it's piecemeal and siloed and so the
05:43easiest way to describe it I get paid
05:46the whole dollar to assume the whole
05:48responsibility right many of my
05:50competitors get a piece of that dollar
05:53and so they're trying to maximize how
05:56much of that dollar can they get so you
05:58take for example in my system we own 39
06:03hospitals they're not even revenue
06:05centers their expense centers right
06:09right if you go to the rest of the world
06:11the revenue is generated by having what
06:15we call a head in the bed right for me
06:18is no difference with the payment
06:20because so you only get paid if the
06:22heads in the bed right roads you might
06:24want somebody to be in the hospital
06:26that's right or someone really doesn't
06:28need to be in the hospital because I
06:30have the whole dollar I've built the
06:32infrastructure alone the whole continuum
06:36and others can decide the best location
06:40that the person should receive care and
06:43the physician is not in scented or
06:45disincentive one way or the other so
06:48they're not making a choice based on the
06:50economics they're making that based on
06:52the best interest of the patient and the
06:54efficiency of care so you end up at
06:58Kaiser Kaiser then trying to minimize
07:01the cost of a patient over their
07:04lifetime or maximize their health
07:06whereas the other system is doing a
07:09local maximization on what they can get
07:12paid for a procedure or a visit if you
07:17look at if you look at the the
07:20distribution of the healthcare dollars
07:23number one the vast majority of the
07:26dollars are spent in a couple of areas
07:27is the spent on chronic care and is
07:31spent on the last 30 to 45 days of a
07:34person's life right great it's at one
07:39time I don't need people spending look
07:42at the least amount of money that's
07:45being spent is an upstream in prevention
07:48right if you come in and you look at my
07:51model we invest billions of dollars in
07:55testing and preventing prevention for
07:59early detection early diagnosis early
08:01treatment well that's better care
08:03upstream to invest to deal with an issue
08:08very early on then the wait until the
08:11issue progressed and weakens the body
08:14and cost much more to manage and to
08:18maintain right and does it cause you a
08:22problem then that you're different than
08:25the rest of the industry because like
08:26when we come in like we'll see an
08:28entrepreneur who might have a diagnostic
08:31tool that can be very valuable but they
08:33have trouble finding a business model
08:34for it because most people you know most
08:37insurance companies don't want you
08:38diagnosed or won't pay for a diagnostic
08:43don't want your diagnosis noise but it
08:45won't pay for a diagnostic
08:48you know and then the provider you know
08:53isn't a strong advocate for it either
08:54because it's not that kind of highest
08:56billable thing so it doesn't cross so do
08:58you get the best technology that you
09:00could given that you're in a system
09:02where everybody's got different
09:03incentives yes we we fully embrace
09:08technology but we also scrutinize
09:11technology because we look at it from is
09:13it going to enhance quality is it going
09:17to improve the service experience what's
09:21the cost factors associated with it and
09:24when can we produce a better outcome and
09:28because I have the whole dollar and I
09:32have to invest in the infrastructure for
09:34care because that's embedded in my
09:37financing model right then my incentive
09:40is to make the best choice and so where
09:43it really starts to get real and this is
09:46where both my competitors and friendly
09:52competitors come in to look at our
09:54systems you know and I make the terms
10:00very simple we look at this thing called
10:02you know patient days yeah and you look
10:05at it per given population and and so
10:08you hear people say things like we're at
10:11215 commercial days per thousand and
10:15we're at you know 1,300 for Medicare and
10:18all that right well if you come in to
10:20the Kaiser Permanente system you will
10:22see that commercial days are something
10:25like a hundred and fifty per thousand
10:27and Medicare is now down to seven
10:30hundred but then what you look at in
10:33terms of the stark difference is I have
10:36a whole infrastructure at Kaiser
10:38Permanente we have a whole
10:39infrastructure and so our physicians
10:42could have you in the hospital for two
10:44days and then you're ready to go home
10:46there's a whole different set of
10:47resources that's gonna take care of you
10:49when you're at home right and so it's a
10:52whole continuity of care and so to the
10:55member it feels seamless because you're
10:57going from one setting to the other
11:01we believe strongly that within the next
11:03five to ten years there's a certain
11:06percentage of our admissions into the
11:10we're going to be doing in the homes
11:11right so Jen you are kind of out front
11:14on telemedicine why is it that Kaiser
11:18has been able to kind of get in front of
11:21that faster than the rest of the medical
11:24system you know what's preventing them
11:26from okaying kind of in-home visit you
11:30know via telemedicine well for us
11:32there's been an evolution we invested
11:35early on in building a comprehensive
11:40medical record system then we over time
11:46continue to upgrade it to add additional
11:48features and so it became for us very
11:51functional clunky at times but very
11:55functional for use for both quality care
11:59and also comparing our results across
12:02our large system you take that as the
12:06foundation then you start to build
12:08additional technology on top of that
12:10then you begin to create a new
12:13infrastructure in which you can care for
12:16a large segment of the populations
12:19around the country virtually and in
12:21other ways and so our members love to
12:25use the virtual technology because
12:27number one they know the physician and
12:30the care team has all the data right in
12:34front of them number two they know who
12:36they are so there's a relationship and
12:40number three we've built the incentives
12:43for making it very easy to use and to
12:47understand and as you would expect it's
12:51well received by our members in the
12:53organization yeah no I don't know
12:55anybody likes going to the doctor so
12:57make sense so was the Affordable Care
13:00Act a good idea yes and why so well to
13:08simplify the this country decided in the
13:14that they were gonna take care of two
13:16people two classes of people the elderly
13:20and poor people right and we solidify
13:25that pact in America with the two
13:28massive legislated legislations
13:31Medicare and Medicaid right so I tell
13:36people all the time don't get caught up
13:39in the name of the Affordable Care Act
13:40it's the 21st century version of the
13:44Medicaid approach got it so the two
13:48major pieces through the ACA it really
13:50is around the affordable care act which
13:53really was the added definition to
13:55Medicaid to say we have a whole new
13:57class of poor called working poor that
14:01is not accommodated in the Medicaid
14:04system of 1965 because the theory of the
14:07Medicaid system back in the 60s where
14:10people were really poor right right
14:13by the way Medicare is the other area
14:15that we have to take on in this country
14:17when we did Medicare it was for people
14:2065 and over people basically died when
14:24they were 65 66 yeah and so we don't
14:28have an infrastructure today for the
14:31long-term trajectory of how long people
14:33are going to be able to live in the
14:34future and those are the most expensive
14:36patient those are the most expensive
14:37patients yeah so we did not do very well
14:41as a country in the rollout of the ACA
14:45but we're gonna have a bigger challenge
14:47eventually when we take on the rollout
14:50of a revised Medicare program and so the
14:56rollout didn't go perfectly but does it
15:00does it solve those V does it actually
15:04cover the people that Medicaid wasn't
15:07covering that need to be covered has
15:08that kind of gap been felt for a for
15:13more people today then before we started
15:18and the whole objective was to target
15:22the 30 plus at the time 30 plus million
15:27did not have access to the front door of
15:30the American healthcare system yeah
15:32so we're better off right the second
15:36thing is and it's important in the
15:39rollout the infrastructure of the bill
15:45it was always known that we needed to
15:48add regulation to regulate it to achieve
15:52the outcomes that it was intended okay
15:55that has never happened because one of
15:59the biggest lessons that I've learned in
16:01being a participant and the whole
16:04structure of the Affordable Care out the
16:06rollout of the Affordable Care Act is a
16:09partisan passed bill for a major change
16:13in this country is not a good thing
16:16and so part of the reason why it stalled
16:18is because it was approved by one half
16:22the Democrats right and so all by the
16:26Republicans right right and how much was
16:29that the Democrats fault versus the
16:31Republicans fault versus both like where
16:33the Democrats wrong and the way they
16:35forced it through where the Republicans
16:36wrong and the way they reacted I I just
16:41stay away from that whose fault it is
16:43I'm just saying that in the country
16:45where we must have compromise both
16:49parties needs to be at the table working
16:51on ironically many parts of the
16:54Affordable Care Act was actually modeled
16:57after of republican-led Law Institute
17:02Romney yeah how about that so you take
17:08for example the issue about pre-existing
17:12conditions I remember when the law was
17:16being written someone came to us and
17:19they asked specifically how we felt
17:20about this issue of pre-existing
17:22condition and our response was duh you
17:27need to have it in there yeah and then
17:29the question came back again
17:31and we said here's the issue so you take
17:36yourself you can have anything
17:40heart disease cancer you name it if you
17:44in a group of three or more you could go
17:47to any insurance company around the
17:48country and you don't have to worry
17:51about your pre-existing condition all
17:53right right but if you're an individual
17:55it's covered yeah but if you're an
17:57individual the laws were written years
18:00and years and years ago that said if you
18:02basically sneezed the insurer can say
18:05you have resistant condition we can't
18:07cover you because you had by law to
18:11price it to that individual and many of
18:14the companies said it's not worth it
18:15would never work all this kind of stuff
18:17and so if you take now a new class of
18:20people in a new insurance pool which is
18:24the ACA you can spread that risk across
18:27the entire population right right right
18:30so if you had twenty million people you
18:32were projected in the ACA and of the
18:35twenty million about three million had
18:37pre-existing conditions you can spread
18:40the risk of the three million of Christ
18:42and five million yeah so it was a no
18:45brainer that we needed to do that that's
18:48before you talk about the ethical issues
18:50of not covering someone yes who really
18:53needs coverage because they get sick
18:55right yeah and so the law thought
18:58through those kinds of things it it was
19:02engineered to create a competitive
19:05environment where everyone will compete
19:09for the members the best example of it
19:13working fairly well is in California we
19:17compete on price we compete on service
19:20we compete on quality a bad example is
19:24in one of my other states that I won't
19:26mention those thing where you didn't
19:30have the guardrails built up front at
19:32the state level and so that guardrail
19:35said like you're talking about like what
19:37guardrails do you need to make it work
19:39we all agree how we're going to compete
19:41in the marketplace the
19:44the state government played a critical
19:47role in how to convene all of us
19:49together to say we want competition but
19:52we want it done in this way that the
19:55citizens of California will be the
19:57winners right and so everyone agreed to
20:00go our trails and it will prevent like
20:02people from cherry-picking the people I
20:05went into the market mm-hmm and it
20:09really is gonna cost me a thousand
20:11dollars to provide the care and I'm
20:13charging $700 because I want to get the
20:16business mm-hmm and then I take the
20:18market and shift it to my direction and
20:21then the next year I lose a lot of money
20:23and then I get out you've destabilized
20:26the entire market okay and and the law
20:29was written in a way to counteract that
20:32and it used to be called it 3 R's and so
20:36everybody paid into the insurance for
20:38example so if there were 10 people Frank
20:42and I had three of the 10 and it turns
20:45out because of my model I had the most
20:47expensive three the market will pay me
20:51through this reinsurance more because I
20:53have the greater risk so it was a
20:55zero-sum game for all the people who
20:58competed right and then you got a market
21:01that's behaving in a very different way
21:03well if you don't have the government
21:06playing the appropriate role to regulate
21:09and modulate it in the right way at the
21:11right time then it goes crazy and then
21:14people start moving in and out okay so
21:16it'd be interesting to see what happens
21:18over the next several years as we
21:20continue to work on that piece of the of
21:24the bigger issue by the way is
21:26affordability affordability for the
21:29country well the country right so so the
21:32ACA has gotten a lot of airtime but the
21:35real issue is many Americans who are
21:38covered cannot afford the additional
21:41cost that's on their backs right for
21:44care and they're not covered by the ACA
21:46some of them are covered by right so
21:48we're gonna move more people into the AC
21:50right exactly yeah yeah interesting and
21:53so like let's get into that so you know
21:56one of the big challenges
21:58with healthcare in the United States
22:00which is somewhat even unique to the
22:03United States as the cost keeps going up
22:04and the outcomes don't they get kind of
22:08the same or worse you know where does
22:13is there a way to change that dynamic
22:16and start getting kind of more
22:19competitive worldwide where other
22:21countries spend less and have better
22:25I mean I think that's the transformation
22:29of healthcare that we need to think
22:31about in this country right so there are
22:37areas where number one I would challenge
22:41the premise a bit because actually if
22:44you look at some of the data you would
22:47say well actually no people are now
22:49living to 85 87 and they were living to
22:5365 70 75 so you get that progress second
22:57thing is you start to ask well what that
22:59product is though what is the quality of
23:01life right right there right so are they
23:05just breathing are they functional and
23:08people living their lives like they want
23:09to live their lives and with the new
23:13medications new treatment new way of
23:16catching diseases earlier you now are
23:20seeing over time that functionality is
23:24much better now than ever before but you
23:26have a long ways to go when you begin to
23:28compare us against some of the other
23:30countries who aren't spending nearly as
23:33much but are getting equal if not in
23:37some cases better outcomes which were
23:39mainly used to the third thing which is
23:41I think the AHA for us and AHA I think
23:45in this country that we need to come to
23:48terms with is we've probably outlived
23:52the model that we have in place I mean
23:55the the whole health care industry was
23:57created as you know because a couple of
24:01things happened we figured out how to
24:04deal with sanitation and food
24:06preparation and all that stuff people
24:08started living longer yeah
24:10in the past 27 it passed 27 right and so
24:13when people started living longer stuff
24:14started to happen yeah
24:16very sophisticated turn stuff yeah and
24:20we built them all right somewhere on
24:23earth there was the hospital built we
24:25moved a lot of people into it and begin
24:27to take care of them that basically
24:29turned out to be the infrastructure that
24:31is still in place today mm-hmm you now
24:34have the big question about what's the
24:38definition of healthcare in the 21st
24:39century right and I would say it should
24:41not be a sick care system because a big
24:44part of our knowledge that we've all
24:48known but for sure we know it now is
24:50that a lot of chronic illnesses that
24:53people are dealing with are preventable
24:55and so the question is do we have a new
24:57role in healthcare that really focuses
25:00on the behavior of people and what that
25:03does to the health and well-being and
25:06how do we manage that in the new
25:08paradigm right and so let's get into
25:12that a little bit so you have said that
25:15you know healthcare needs to get out of
25:17our Lane so and you talked about we have
25:22to treat not just the individual but the
25:24community and so talk about that and
25:27what that means in terms of changing
25:30health outcomes and how you how you
25:31treat people outside of the hospital
25:33yeah the the you know we have people
25:40using terms like the social determinants
25:42of health in how do you think about
25:45community health and all those things
25:47and we have historically played a major
25:50role in that but but I would say the
25:52couple of things are difficult ly
25:55different now is that and we used to
26:00call it Community Benefit and now is
26:01community health we we fully understand
26:05now the direct linkage of the community
26:08to an individual's health and we've been
26:12at this for a while and so it starts to
26:14play out with our role in assessing the
26:19fundamental infrastructure in
26:20communities in which
26:23we take care of now twelve point three
26:26million people so is the community
26:30deprived of normal things that you would
26:34expect places to go buy groceries right
26:38and in many of our communities around
26:42the country they are deprived of some of
26:44the basics like that so you don't get
26:46the you know the the stores that
26:49delivers the produce that you know
26:52towards better health and you start to
26:55see that being replaced with the kind of
26:57fast-food restaurants that is really bad
27:00for hearts and weight and all those
27:04other things and you start to see that
27:06shift and we now have the kind of
27:08collective data where you can see it
27:10would obesity some of the other
27:13challenges if you living in a community
27:15where it's unsafe you find people
27:18confine more to the inside of their
27:20homes and that's likely to be out in
27:22recreations and things like that and
27:26then the third thing that we're working
27:27on right now is this old issue about
27:29which is the worse of all things if you
27:31don't have a basic shelter over your
27:33head and you're going to bed every night
27:36on the streets of America you're very
27:40vulnerable to all of the health
27:41challenges that we're talking about
27:43right and then so the question is what
27:45role do we play in making sure that our
27:49members and our populations around them
27:52are basically having the right
27:55infrastructure that delivers on what we
27:58call total health got it got it and so
28:03kind of talk about a little bit the
28:05other kind of site of improvement which
28:09is technology which you've invested a
28:11lot in but you know those of us in
28:13technology world feel like it's not
28:15going fast enough in healthcare so what
28:17do you think is the impact of technology
28:19on healthcare how are you using a Kaiser
28:23and then what are some of the challenges
28:26in in deploying some of the new things
28:29that might be able to improve outcomes I
28:32think the I think the field is wide open
28:37so you don't think we go fast enough no
28:41kinds of stuff coming there we go home
28:44every night tired no I mean I mean the
28:51challenge we have in health care there
28:54are a couple of things one as I as you
28:58it's basically building technology on a
29:01fragmented system right right you and I
29:04both know that either that's gonna be so
29:08dramatic that you just start from a
29:11blank sheet of paper
29:12yeah and that's very hard for us in the
29:16right yes the second thing is it's a
29:19strong culture it's a it's it's you know
29:24working inside of the healthcare
29:25industry on one hand is it's beautiful
29:28because you're talking to and working
29:31with some of the most intelligent people
29:33on earth I would argue and so the
29:36intellect is very high and the ownership
29:38is deep right and so when you're
29:42introducing technology there's a healthy
29:46dose of skepticism and there's a fear of
29:51the change all right right and that's
29:53before you get to making the technology
29:55work yeah slow progress to get to that
30:02next stage I would say that we're in a
30:04different place than Kaiser Permanente
30:06because we've been at it so long and we
30:09don't feel like we go fast enough I want
30:11to be clear now we still have systems
30:16that we've jerry-rigged over the years
30:18to get them to talk to each other right
30:19and so when we say we're gonna implement
30:22something that Kaiser Permanente and we
30:24think is a very easy system to do and
30:27then you get started and you start to
30:30learn that we have all these interfaces
30:32that we have to create and all this
30:34stuff right because we're integrated
30:36system that's mission-critical it
30:39becomes a very delayed process before us
30:44I think where we are very excited now
30:48that a lot of smart people are creating
30:52and then final thing is and you may not
30:56like hearing this one of the things that
30:58I'm talking about right now inside of
30:59Kaiser Permanente is I I strategically
31:05don't support we're just innovating in a
31:08corner and I can't scale right right so
31:12that's nice to have it in the corner but
31:15I'm looking at the whole system and so I
31:17want to pay for and promote innovation
31:20with technology with the sight of how
31:24can we scale it and leapfrog as a result
31:27of it as opposed to we have a thousand
31:29points of light and we have a thousand
31:31points of light right I think George HW
31:35Bush got there I think where you have
31:39incredible opportunities is that now as
31:42an industry I think we have come to
31:45terms with we got to figure out how to
31:48leverage technology for the whole
31:49consumer experience so that's just prime
31:52time and the Kaiser Permanente for
31:55example you know right before coming
31:57down here I was on the team with my
31:59executive team all day the majority of
32:02the time we were talking about
32:03technology and there are a couple of
32:06people on my team I have a Speak Up
32:08environment my team gets to say whatever
32:10they want to say to me it's based on the
32:13theory we live in a great country you
32:14speak your mind right right sometimes
32:17they talk a little bit too much but one
32:25of my executives rightfully so saying
32:26well I think we have to be careful on
32:28his third line item ya call strategic
32:31investment in technology because it
32:33feels like as too much of the shiny corn
32:36or whatever he's a coin that's something
32:38that yeah you know and I was a little
32:40irritated because it clearly was an
32:43indirect message to me yeah but his
32:46point was well-taken the the point was
32:48let's not set ourselves up where we're
32:52gonna have people chasing the shiny
32:55object right his real point was Bernard
32:58you're after efficiency and
33:01better outcomes for our members with the
33:03experience that's really focused on the
33:06investments in that direction yeah and
33:08we can go faster right and so there's
33:11that mindset out there but it's hard for
33:13us and we're getting much better at it
33:15well what are the technologies that you
33:19think are imperative that you have to
33:21get to that you're gonna find a way like
33:24whatever we do we're gonna get to you
33:27know whatever it is understanding our
33:29data better or telemedicine or yeah what
33:33are what are the areas what you really
33:34you know telemedicine no question a
33:36moment we just see tremendous
33:40opportunities in that in that direction
33:43I think the I think the the AI is a big
33:48opportunity but it has to be focused
33:51because many organizations right now are
33:56chasing the AI and not clear what
33:58they're trying to answer right yep and
34:00we've had many debates with well is the
34:02fundamental opportunity here is to let
34:05the data lead to discovery or do you you
34:10know for me that's like walking in the
34:12wilderness right now nothing negative
34:14about it it's just not our approach
34:17we're just trying to figure out how do
34:19we take all of this incredible data that
34:22we have now and how do we begin to use
34:25it to predict ahead right and so we
34:28should be at a stage now where we know
34:31enough and we have enough information
34:33that I can predict what would happen if
34:37you keep doing these three things or
34:39these four things and I want to work on
34:40these four things and I and in some ways
34:43we've done that without all the
34:44wrappings of AI in our past we figured
34:47out the importance of not smoking right
34:50right and and really took it on by any
34:53means necessary to try to prevent people
34:56from smoking because we're very clear
34:58about what it was gonna cause well we're
35:01very clear that obesity calls many of
35:04the things that we're dealing with right
35:05you know there's not as clean in terms
35:08of how do you address it in an
35:10aggressive way like smoking because it's
35:13more complicated yeah it's it's
35:16broader-based for sure yeah yeah there's
35:18no warning some sugar labels yet yeah no
35:24no very interesting so what is the state
35:27of Kaiser Permanente's data set today
35:30because we always you know hear that
35:32this huge advantage of China is that
35:34they just take the patient data there's
35:37no HIPAA there's nothing they can use it
35:40run all the AI against the diagnosis any
35:42disease etc for your twelve point three
35:46million members like do you have kind of
35:50comprehensive access to the medical
35:51records can you start doing these
35:55longitudinal studies can you figure out
35:57what causes what yeah I mean our
36:00physicians in in the Permanente Medical
36:02Group we have the we've always done the
36:06research and and we've always used the
36:08data for the benefit of our members and
36:11patient care and all that right we have
36:14added sensitivity today because
36:17everybody is even more concerned about
36:19making sure that we're not missing using
36:22their data and making sure that we're
36:25not using it in ways they didn't
36:26authorize us to use it very very
36:30that being said yes we are becoming much
36:35more aggressive in the use of the data
36:37to better understand many of the things
36:40that you are talking about and the other
36:44benefit of our system is we have all the
36:47data man is great longitudinal data
36:50because our members stay with us much
36:53longer than any one of my competitors
36:56how long the Kaiser members stay with
36:59you well right now on average about 18
37:01years oh wow so I mean we can even
37:05calculate and this is before AI week
37:07exactly that if a new member drawing
37:10if we do all the things right in the
37:12first couple of years we can predict now
37:14forecast how long they stay with us it's
37:17very important in our model and in our
37:20value proposition because we invest a
37:23lot in all of our new members
37:26to understand what's going on with their
37:28bodies to write deal with the medication
37:30changes and so there's a lot of prep
37:32work upfront but it pays off with their
37:36health with their well-being and with
37:40the efficiencies of care mm-hmm and but
37:42the longer you keep them then the better
37:44they are from a business standpoint all
37:47the way around I mean that's the beauty
37:49of the model right when it's really
37:51working the economics of it works well
37:54over time and we're not incentivized to
37:58maximize profits or anything else like
38:00that so it's tie really to our mission
38:02of affordability right and what's your
38:05philosophy in terms of you know
38:07competitive advantage versus being open
38:10and advancing the world in terms of your
38:14data set and then your findings from
38:17that data set like do you keep that all
38:20to Kaiser do you share that or how do
38:22you think about that we share it because
38:24number one we are predominantly we're
38:29not-for-profit organization / 501c3 we
38:32get great benefits from that number two
38:35we we think two things one if we stay
38:40sharper in strategy we've turned the
38:43corner before our competitors mm-hm
38:45and if we stay clean on execution they
38:48cannot catch us that's our great least
38:51that's our mental working model right
38:52we're working on right now we have some
38:54editors that are trying to replicate our
38:57model and if you came inside of Kaiser
38:59Permanente you're here to say something
39:01like and when they knock at the door to
39:03tell us that we're here we'll be gone
39:06all right it's energizing yeah because
39:11it's not based on I'm trying to hide
39:15something from you it's based on we just
39:17want to keep getting better right and so
39:20if we can enhance the entire industry
39:25then we're serving the bigger purpose
39:27which is what we believe we're here for
39:30as well right there's not just the
39:32members that we have the privilege of
39:34taking care of we also have a
39:36responsibility to the entire
39:39community right right great so let's
39:42talk about something that you kind of
39:44personally have gotten very involved in
39:46in that I think most people don't think
39:48about the world doesn't understand that
39:50well which is the connection between
39:51mental health issues and physical health
39:54issues can you tell us a little bit
39:56about your philosophy on that and what
39:58you believe in why Kaiser Permanente is
40:00investing so much and including
40:02marketing campaigns and yeah we I talk a
40:10lot about that one of the things that we
40:14did in the industry and in society is we
40:20detached the head from the body and we
40:25overtime we built a culture around
40:29mental health as a bad thing yes right
40:33and so we had all kinds of negative
40:36names for it we call people bad things
40:41and that they were you know nuts and
40:44stupid and and all that stuff we built a
40:48whole medical system as an industry
40:50where they went through a special door
40:53right to institution mental institutions
40:57and we separated the records from the
41:00general records and we put extra laws
41:03around to protect them so the world
41:06didn't know they had a mental problem
41:08right and the work that we're doing is
41:12to say no we're actually now reattaching
41:15ahead to the rest of the body and we're
41:17going to force the industry to come to
41:19terms with number one the brain is an
41:22organ like any other parts of the body
41:24and so now we're very comfortable
41:25talking about heart disease we ought to
41:28be as comfortable talking about
41:29something that's going on in the brain
41:31the second thing we said was look we
41:34needed to help lead the parade in how to
41:36distinguish mental health and how to
41:41talk about it in a way that people can
41:43relate because guess what the mental
41:46health challenges are in all of our
41:48families is in our neighborhoods it's in
41:53it's in our communities it's something
41:55that the majority of people are dealing
41:58with in one form or the another and what
42:01what kind of percentage of the
42:02population do you think has a you know
42:04fairly serious or an important mental
42:06health condition well depending on
42:10hardly know exactly it's hard to tell
42:12but depending on where you find defining
42:14it you can go upwards of 25% of the
42:18total population when you talk about it
42:20should be in treatment or other things
42:23250 75 percent when you add things like
42:26everyday stress and stress anxiety and
42:28all the other stuff that we see as a
42:30common practice right and so what we're
42:33doing now is redesigning our care
42:36delivery where we're integrating mental
42:39health directly into primary care for
42:41example we are creating different tools
42:44for how people who are dealing with
42:46anxiety and other issues who are not
42:49sick enough that they need to be
42:52hospitalized and or inside of the
42:56delivery system but they need an
42:58extension of who I can talk to when I
43:00need to deal with the fact that you know
43:03at two o'clock in the morning I'm now
43:05very tensed about what I'm about to go
43:07into for the next day or week or month
43:10right and so we have been redesigning
43:14the whole mental health protocols and
43:18our physicians and others that integrate
43:21now mental health into the practice of
43:25medicine like everything else and do you
43:27believe that from an economic standpoint
43:32this will actually lead to a better
43:35economic outcome because mental and
43:37physical health are connected locally
43:39yeah we did we did a study in one of our
43:42regions and did this for a prolonged
43:45period of time and discover that about
43:4930 plus percent of the members patients
43:53who were coming in for an appointment
43:55when you began to drill down into the
43:58questioning about 37 percent of those
44:02visits in this study was really based on
44:05a mental health issue
44:06right so the person may have called in
44:09to say look I need to come in because
44:11I'm suffering from back pain Fran I
44:13can't take it anymore then in the
44:15questioning of how are you sleeping not
44:18well right how many hours you sleep at
44:21maybe two if I'm lucky is everything
44:25going on in the family no really I'm
44:26dealing you know all those things that
44:28leads to a warm handoff and having
44:32somebody to come in and say let's talk
44:33about some of the other issues that's
44:35going on with you because maybe there's
44:38some additional things that we can help
44:40you with and you begin that kind of a
44:42dialogue which is much more of our model
44:47right so right now one of the beauties
44:49of our model you can come in and see
44:51your primary care physician something is
44:54going on with your knee she can say look
44:56I have dr. Smith down the hall he's an
44:59orthopedic doctor here and he come in
45:02and look at this he could tell you right
45:03away what's going on would you like him
45:05to come in absolutely right
45:08look I've noticed you're not sleeping at
45:09night based on what you're telling me
45:11I have a behavior health specialist
45:13right down the hall she can help you
45:15understand what you might want to do
45:17differently so you can get a good
45:19Frank you say oh absolutely very
45:22different yeah Mary do you have a mental
45:24issue going on I want you to go to that
45:27private door and somebody will see you
45:29and then all of a sudden you've been
45:31labeled yeah the perception yeah well if
45:34it's available otherwise they treat you
45:36with the police or prison or something
45:37like that that is a huge problem so last
45:41question around that you know Kaiser is
45:45so different so you can you know you've
45:48taken a leadership role because you are
45:52responsible for the whole patient and
45:53the whole lifecycle of the patient for
45:55the rest of the system you know a lot of
45:59insurance doesn't cover these kinds of
46:01issues people you know the number of
46:03untreated people the Ronald Reagan
46:06deinstitutionalized California on this
46:09and created a lot of homeless when he
46:11was governor many years ago do you see
46:14how do you see Kaiser helping the rest
46:18of the system understand
46:20the better economics about treating
46:21mental health as part of health yeah you
46:24know actually the good news is it's one
46:29of the things that we have done is we've
46:35you know we've spent money on
46:36advertising we talked about that we
46:38invest in it and then we open our doors
46:41for others to come in and take a look at
46:43it and I think that we are seeing the
46:47beginnings of a shift at the in the
46:52governments around the country
46:53state-level governments the the nation
46:56and some of the issues that we've been
46:57talking about we are hearing much more
47:01from employers who's dealing with
47:05workplace issues of stress management
47:07and you know absenteeism and all those
47:11kind of issues and we are embracing that
47:14with them and saying let's work together
47:16and figuring out what we can do about
47:19this in the worksite and on the
47:21workplaces and and those kinds of things
47:23I think I think the last area is most
47:28importantly as our members become more
47:32bold and being willing to talk about
47:35their life experiences there's nothing
47:40more powerful than the storytelling that
47:42goes along with that where people are
47:44willing to become more open and say look
47:47this is what I'm dealing with and here's
47:49the help that I I can get and then you
47:52have the you know the real serious
47:56issues of mental health suicide we're
47:58doing massive Studies on suicide to
48:02figure out are there additional things
48:05that we can do in the prevention aspect
48:07of suicides I mean you probably know
48:10this unfortunately over 50% of
48:13individuals who commit suicide just
48:15shows no real sign of it yeah what
48:19that is just mind-blowing - yeah they
48:23think about that's no warning yeah no
48:25warning interesting great well thank you
48:27so much this has been like fascinating
48:29conversation I'd like to thank Bernard
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