Rae Woods (00:00):
I am about to go live to record a Radio Advisory podcast. This is part of a big event that Advisory Board does. It's part of our Clinical Innovation Summit. We've literally spent the last day talking about novel products that are going to change healthcare, and now I get to do it live and talk about a very big challenge of making sure that we're going to do this equitably. No pressure. Here it goes. From Advisory Board we are bringing you a Radio Advisory. My name is Rachel Woods. You can call me Rae. I'm going to get all of you involved right away here. We are at Advisory Board's Clinical Innovation Summit, and we have spent a lot of time talking about innovations that have the power to transform healthcare. I want you all to clap for me if that makes you excited. Tell me if you're excited in the power of these innovations about the future of clinical decision-making, about curative treatments, about new drugs, new therapies, new diagnostics, changing the way that we deliver care, the way that we pay for care.

(01:04):
Yes, you believe in the power of these innovations and so do I. Here's what makes me nervous. First of all, none of these products are going to be a silver bullet. They all have their own challenges embedded within them. We can't ignore that, but we also can't ignore our challenges. We all come from an imperfect system, a system with longstanding inequities. So, please admit for me now, clap if all this talk about innovation makes you nervous. Yes, yes. I was worried. I was worried that you all were going to be afraid to admit this, but this is the thing that keeps me up at night. It is literally my job to understand the biggest pressures on health leaders and help them make better decisions. And this specific problem is the one that wakes me up in a cold sweat. And make no mistake, the problem is about equity. I travel the entire country talking to health leaders like you, and when I talk about health equity, there tends to be a focus only on a handful of things. Some conflate health equity as just being about diversity, equity, and inclusion.

(02:25):
Some say, hey, health equity is actually the provider's problem. They're the ones who are biased at the bedside. They're the ones who need to figure this out. The most important thing that I want you to take away from our time together is that health equity is a much bigger ambition and given the pipeline of new clinical innovations that we have been feeling and will be feeling the squeeze of very soon, equity in innovation must be at the top of the executive agenda going into 2024. Now, I am not going to have this conversation alone. I am thrilled to invite two fantastic health leaders to the stage with me to have this conversation. First is advisory board's own Michael Mejia. He is our Director of Life Sciences Research. Michael, go ahead and bring up the stage. Everyone give Michael a round of applause. And next up is Maia Laing. She is the SVP of Health Equity for UnitedHealth Group. Maia, welcome to the stage. Welcome to Radio Advisory. How are you two feeling this morning? Are you ready to have this conversation?

Maia Laing (03:42):
Super excited. Thanks, Rae.

Michael Mejia (03:43):
Yep, thrilled to have it.

Rae Woods (03:46):
It would be okay if you weren't thrilled. It is not every day that people do this in front of almost 300 people, and let's admit this is going to be a hard conversation to have. In fact, I think we're going to make some people uncomfortable. Do you think so?

Maia Laing (04:04):
I hope so.

Rae Woods (04:05):
Yeah. I think we wouldn't be doing our jobs well if we were ending at comfort. I don't think any conversation about health equity can do that. I actually think we should lean into the discomfort right away. So, if I'm honest, health equity really kind of became in vogue in healthcare in the world a few years ago. With the murder of George Floyd, suddenly we saw this flood of interest in anti-racism, in equity, and this was true in healthcare and beyond.

(04:36):
And in the last three years, I don't know about all of you, but I've really felt a lot of that momentum has started to dissipate. And that's in part because we know that a mission statement alone, an individual person who's elevated to a brand new health equity role or DEI role can't do this alone. And one of the things that we landed on in the research is you have to bring strategic rigor to any equity strategy and that can be uncomfortable. My question to you Maia, is what's the business case for equity in innovation? Why do we need to be focused on this and why do we need to be focused on this now?

Maia Laing (05:16):
Yeah. Thanks Rae. A lot of the challenges that we see in the business case is that it often reinforces the existing kind of structure and system that we have in place. And it doesn't go so far as to understand the nuances in population. So, better understanding the different demographic factors and elements of any given community, specifically any given individual. How do we engage with them? What are their unique characteristics? Has put our business cases at a deficit as we advance and we innovate.

(05:55):
When we get to new solutions, we need to develop a new business case around the value towards advancing towards health equity. Health equity in my mind is the aspirational north star of the healthcare system. And that when the system is designed right, we are getting the right solutions to the right patient at the right time. And the way that the business case functions today is that it over-indexes on what we describe as the majority without taking into account the nuances of other populations that continue to go underserved. And where we can drive additional value is getting to unique understandings about those populations which will drive value to the business.

Rae Woods (06:43):
Michael, what do you say to the why now? I hear this business case, but I also am very aware of the fact that healthcare is in a very hard, tough place right now. Hospitals and health systems in particular have slimmer margins than they ever have. When you have a health leader that's saying, yes, I believe in this, but why should I be doing this right now, headed into 2024, how do you respond to that?

Michael Mejia (07:05):
There is a point to be made about how a health equity did come into Vogue several years ago, but I think over the past couple decades really there's been small steps that we've seen and shifts in policy, regulatory guidelines, and even the medical community. Shifts that are leading towards a different perspective of how we treat the patient and how the patient expects to be relating to that care.

Rae Woods (07:28):
Yeah, this movement is happening. Get on the train here, folks.

Michael Mejia (07:31):
That's right. And in the meantime, we've been seeing all these innovations and all these emerging technologies as well that are being shaped by those changes as well. And they're coming together at this point in time right now, and that's why we're seeing such a similarity in that theme, that underlying theme of Bespoke Care. And it's something that they need to keep in mind now because it's not just a social responsibility to be focused on health equity, but it's really a strategic kind of edge that you can't overlook.

Rae Woods (08:03):
Yes, I could not agree with that more, and still I have to channel the mindset of the health leader who is perhaps overwhelmed by the enormity of the challenge. I tend to find, and I'm curious if this is what you hear when you talk to folks, but I tend to find that folks fall into four camps. One is hell yes, we've really got to focus on health equity, we've got to focus on social determinants of health, let's make moves. The second response is, oh, shit what am I supposed to actually do about this?

(08:34):
How am I supposed to make progress as one individual or one organization? And the third and fourth response is perhaps the most dangerous, which is finger pointing. That person needs to get their side of the street cleaned first, or I'm just going to wait and see. I'll do it, but I want you to go first or you to go first. I want to help our audience kind of conceptualize what they should do. Let's give them a framework that more easily tells them how they can make forward progress when it comes to equity and innovation specifically. Michael, how do we want to break down this problem for our audience?

Michael Mejia (09:11):
Very straightforward way to look at these is really in the design. How are we designing these? How are we deploying them? What do we need to think about in terms of deployment and how are we paying for them? I mean, it's really as simple as that along with the purpose, obviously.

Rae Woods (09:31):
Yeah, the purpose, which we were starting to talk about of you need to make sure that you're aligning your mission, your vision with the strategic rigor that comes with a business case. Purpose, design, deployment, finance. Let's start with design. I'm actually not sure that I even understand that this is a problem. Why is it that we need to interrogate the way that not just clinical products in the future, but the clinical products that real health leaders, real clinicians are using today are not necessarily equitable?

Michael Mejia (10:08):
Yeah.

Rae Woods (10:09):
What does that mean?

Maia Laing (10:09):
Yeah. One of the things that, when we talk about the design process and the things that we can't see, one thing that I can see is going into a pharmacy and picking up medication and seeing an individual walk away without that medication because they don't have the appropriate insurance. We sometimes over-index on building out the business case to justify that we need to create something without leaning enough into our intuition and the things that we see to start to pursue why we need to look at things in a different way. So, it's convenient to say that it's not present in the data as it exists today, but the data currently reinforces the model of the system that exists in this current framework. And the value of innovation is that it's going to propel us into the future. And so we have to start to seek out insights that are not apparent today.

(11:07):
And I remember doing this type of work, even from a process improvement perspective in the hospital. Our systems didn't capture the data that we needed to know to drive improvements inside of the hospital, but our clinicians inside of the hospital knew that there were massive amounts of inefficiencies. There were patients that they weren't able to adequately serve. And so we had to lean into that to start to become very inquisitive around where the opportunities are. And sometimes when we try to boil the ocean, we can justify not taking action, but when we focus on an individual need, we can start to see the opportunity that innovation can bring to not just one person but multiple people over time. And so we really have to challenge ourselves to exercise a different muscle when we think about designing and who we're designing for.

Rae Woods (11:56):
Yeah. Who we are designing for, that is such an important point. And we have to remember that the data output that we're going to get is matched the data input that we're going to get. And a lot of the products that are designed, let's take drugs for example, right? This is starting at the clinical trial phase. Data in if we are only testing products on white men of a certain age, we don't even know, to your point, what that output is going to be for different people. So, tell us about what it means to at this extremely upstream moment in the clinical trial phase, what does it mean to ensure that we're thinking ahead to the equity problem?

Michael Mejia (12:35):
You touched on it on the last question as well, in terms of bias that we have already. When we started looking into all these emerging technologies and innovations, one of the questions was, how are we going to figure out what's going on with equity? How are we going to figure this ... And the truth is, we haven't figured out how to fix equity that is already in place, let alone what's coming with the technologies. And the equity that's in place is also in place in our processes and our protocols and the guidelines that we use in our standards of care in many ways.

(13:10):
And so one of the things that we need to do is really be able to reflect on that and see where our biases are being, not just have the potential to be baked into future guidelines through the AI algorithm that we introduce our biases into, but the biases that are already there. And it's very similar in terms of clinical trials. With clinical trials, the way that we're looking at those, the way that we're looking at the data that we get from the clinical trials is leaving out a big portion of the population. And we're not understanding how these products, the drugs and devices are impacting different groups differentially. And that's something that we need to look into to get a better understanding.

Rae Woods (13:56):
And talk about business case. You're saying that the product that you're developing, the innovation that you're developing literally might not work on other groups of people. I mean, I can't think of a stronger business case for that. I wonder if we have examples of this, right? It's easy to think about, all right, what are we going to do moving forward after August 2023 into 2024 and beyond? But there's also clinical products that we already have today. Do we have some examples of some that we should name that perhaps don't work on different type of people or weren't tested on different groups of people?

Maia Laing (14:32):
I think Michael's going to know a lot more about the products out there that are available in that way. What I would say is we keep squeezing the same lemon and we're not getting any more lemonade out of it. And there's other fruit in the bowl is what I would say. And that I can look at, and I know we're going to maybe touch on this. As I live with a chronic health condition, sickle cell disease, for example. Oftentimes the research that's included on that population, the step therapies that are needed, the hydroxyurea that's recommended, the nuance of the population, the therapies that are available oftentimes don't yield the outcomes that we're looking for. And we don't get inquisitive enough around what is the right path, what are the right interventions for this individual, and then how can we start to multiply this? So, what I will say is the products that are out, we keep deploying to the same population, looking for the same outcomes, getting the same outcomes, and being really comfortable with that narrative.

(15:31):
But I think many people that are going to be listening to this, many people in the audience today have a medical need that's going unaddressed, and there is a medication that may be recommended to them that still isn't yielding the outcome that they need to live a healthy life. And something about it tells us that this isn't right, and yet we keep showing up in it in the same way. But the technology through AI, through the groundbreaking curative therapies that are coming out start to open a new door and a new path to people to live lives in a very different way. And so we should start to become inquisitive around those opportunities and not accept the status quo around, I don't feel so great. I don't think this is right, but somehow I just keep doing it.

Rae Woods (16:20):
And you're so right to point out that this cuts across many levels of the patient journey. I am thinking from the moment that you enter a doctor's office and you put that SpO2 monitor on somebody's finger, which by the way doesn't work, does not work on people with melanated skin. I'm talking about tragic stories of people ending up in the ED because they've had a seizure and they need to understand what's happening in their brain. So, they do an EEG test, a test that is not designed for kinky hair, and these people are waking up from being unconscious with their head shaved because we did not think to design a test that would work for different kinds of populations, let alone what you're starting to get at when you start talking about life-changing therapies. And I wonder if we should go there. Now, what I'm about to share, I am going to share with permission, but I do think it is important, even as we talk about our role as healthcare business, that we always ground what we are doing in a patient story.

(17:28):
And Maia, I'm going to tell you our story. You are straddling two worlds. You are a health leader, you are an executive, and you are a patient living with a rare disease that is literally inches, inches away from having a cure. We expect a new gene therapy for sickle cell to be FDA approved by the end of this year, a treatment that will cure people like you. A lawyer would ask me to say curative intent treatment. For a population that is largely representative of black communities and affects a hundred thousand people in the US, right?

(18:10):
We say rare disease, but that's not that rare. And yet you know all too well that a $2 million treatment for people with sickle cell, let alone any of the other cell and gene therapies that are coming out, let alone any of the other clinical products that we've been talking about over the course of this event, all of which are going to be expensive. You are in rooms with leaders who are grappling with what to do next. My question for you is, how the hell do you do it? How does it feel to be straddling both worlds, your role as a patient and your role as a health leader?

Maia Laing (18:45):
Yeah, I think I'm still processing. Last week I had the fortune of sitting in front of community-based organizations that are doing work in sickle cell and talking about the value of partnerships. I participate in community-based organizations, and recently the president of the organization lost their daughter at 50 to complications of sickle cell disease. And I show up every day very excited to be a member of the healthcare community and compelled to challenge the way that my colleagues and people in the healthcare space think about their ability to transform the lives of people around them. And I recognize that it can become very easy to get comfortable in the work that we do and to continue to run things as we did yesterday. For me, every day I'm confronted with the reality of my condition and I am fighting to do as much as possible as quickly as possible to help ensure that individuals that live with rare diseases, not just sickle cell, are able to get to places where they feel fulfilled in their lives.

(19:57):
And I see the amazing work and groundbreaking science that we are able to get to. I'm so excited about what these curative therapies can do and what the healthcare system and what people when they collectively look at a challenge can solve. And so it is something to balance. I always tell my colleagues, there is no conversation around sickle cell that I'm unwilling to show up for in any fashion because I have the fortune of being able to speak to the complications of the condition and the challenges of it where other members of the community are not able to be heard because they are frustrated by feeling as though the system does not work for them and they cannot get the answers that they need. And I am challenged knowing that we are so capable and so smart and can be so compassionate and can be so compelled as a people to solve anything that's in front of us and wonder why we haven't gotten to the answer when it comes to sickle cell.

Rae Woods (21:08):
You described your personal role as to challenge, and I think that's what the three of us should be pushing the audience here today, the audience at home to do, to challenge how we are going to disrupt legacy systems, systems that are not grounded in equity so that we can actually advance towards a common goal. Michael, you talk to life sciences leaders every day that span the whole spectrum of life sciences companies. My question is when they hear a patient story like Maias' or so many others that we could have shared today, what is their reaction? What do they see as their role when a story Maias' comes up being so close to a treatment and not sure if they or anyone is going to be able to foot the bill for it?

Michael Mejia (21:52):
There's been a shift, I think here as well to where in the past there was a lot of focus on more of the products or drugs that would work at a larger population level. And with a lot of the advancements, there's shifts to where there's even benefit to identifying drugs that can treat fewer people or still worth investing in. Still worth looking into where in the past sometimes it was a lot more difficult to get that interest and to get buy in.

Rae Woods (22:25):
Yeah. But are they frustrated? I mean, I'm just thinking about the central kind of tension that we've been talking about across the last two days, which is that science has kind of done their job and we haven't done ours. I mean, I'm thinking about the manufacturers, I'm thinking about the pharmaceutical companies. Is there this sense of, hey, we got this to the point that we needed to. Y'all need to step in now. Is that kind of frustration there when you talk to life sciences leaders?

Michael Mejia (22:50):
Yeah, it is. And I think that part of this, when I think about the way these conditions or rare diseases or disparities in the way that we understand different conditions come about, I always go back to kind of my roots to clinical trials and research because that's where it starts. That's where it starts a lot of times, almost every time. We know the disparities, everybody has an idea of what the disparities are like in terms of clinical trials and the lack of representation of racial and ethnic minority populations in clinical trials. But even though there's been some inroads there, it's not enough. Certainly there's a recent study that looked at clinicaltrials.gov and 10% of the studies that they found that had data on race ethnicity were a hundred percent white.

Rae Woods (23:42):
Wait, say that again?

Michael Mejia (23:43):
Yeah. There was 10% of the studies that had data on race, ethnicity.

Rae Woods (23:47):
That even reported race ethnicity.

Michael Mejia (23:49):
Yeah, indicating that there was studies that had no data whatsoever on the race ethnicity, but 10% of those were entirely white. And what it makes me think about is what we're basing our designs off of. When we look at the data that we get, not only are we basing it off of a non-representative sample, but the types of data that we're looking at when we look only at clinical endpoints and we're not looking at the patient's perspective, we're overlooking those aspects of their care that are most impactful and personally meaningful to the patient that matter the most to the patient and take it together with the discordance between the patient's reports of symptoms and severity of their symptoms. When you look at their reports' comparison to the providers, providers, not for any malicious reason, but can miss up to 50% of the symptoms either under report or overlook altogether.

(24:54):
And when it's reported, the severity tends to be under-reported, at least in oncology, these are the findings. And if you think about the percent of racial and ethnic minority participants in a clinical trial and then you consider that up to 50% of these symptoms and the severity are missed, what are we really looking at? So, sometimes when we think about trying to increase representation in clinical trials, there's all these reasons why you can't do it, all these challenges that they face and costs and logistics. But perhaps if we look at the data that we have, the data that you do actually collect and you don't lose 50% of it. And what does it take to do that?

Rae Woods (25:38):
This is such a good point because I kind of started off, and I want to be careful, I don't want to let the life sciences companies off the hook. I think that some of their frustration is very valid, especially if I think about that central tension of what science has done and what health business still needs to do. But to your point, Michael, there is still a lot that needs to be done in the clinical trial phase, in this upstream moment to ensure that we're actually advancing equity. We'll be right back with more Radio Advisory after this short break.

(27:06):
I want to keep kind of thinking about different stakeholders. We talked about the patient, we talked about life sciences. Maia, I have to believe that you're in conversations with lots of different purchasers, whether it be health plans, the government, employers. I'll just admit it, these are the folks that I'm the most worried about when it comes to at least the financing part of the equation. When you come to them again with an example of a multimillion dollar treatment or a $50,000 treatment, $20,000 treatment needing to say, we need to develop whole new clinical products, what's the reaction from the purchaser?

Maia Laing (27:40):
Yeah, it's expensive.

Rae Woods (27:43):
Yeah.

Maia Laing (27:44):
I mean it's expensive and we don't have an answer here. I spent time working in the CMS Innovation Center looking at payment model reform, and one has to ask themselves, who does foot the bill and where is the right place to put a $2 million charge? I think about a number of different things.

(28:12):
One, as a people, I think we should be striving towards a healthier population in general. It's best for everyone. The other way I look at this is that there were many opportunities to come to a different solution. There are ways to support people today that don't necessarily require curative therapies, but innovation in the healthcare system could better solve for and they could be much more affordable. Sometimes people say, you could feel a little bit of pain today, or a lot of pain tomorrow is sometimes how someone would describe it. When we kick the can down the road, we start to get to a point where there's a critical juncture where we need to do something different.

(29:00):
So, I think one thing is that there are many things that we can do today around innovating in the healthcare system and driving equity through the system that improves the quality of life for people today as the curative therapies emerge, there are people who are significantly impaired in their lifestyle that are going to most benefit from curative therapies in a way that we will eradicate certain conditions moving forward. And historically, we see precedent for this. We've done it before.

(29:32):
And so we are approaching a moment in time where we will do something very groundbreaking that we will look back on and say, this was a thing yesterday and it's no longer a thing today. And so we ask ourselves, what is the cost of that statement? I think as a people to be able to make a statement like that, I would take great pride in that. What cost? I don't know where it sits. I think we will figure that out. I know employers want a healthy population. I know that people want quality of life, and I know that as a society, we strive towards innovation and we strive towards a healthy population. It's best for all of us.

Rae Woods (30:19):
Maia, I appreciate this answer so much because I think there is a tendency, there's this gut reaction to almost vilify the purchasers, right? I had a physician once refer to a health plan as the mafia to me, which kind of speaks to the underlying tone, especially when we think about the idea of coverage for these drugs. But it's important for us to remember that these are risk bearing entities who are trying to figure out for completely new treatments and very, very small populations repeated over and over and over again. At least in the case of curative treatments. They're trying to figure out how do we provide the right care to the right patient at the right time, but no more, right? But no more. And I think that's the part that is really going to be the decision that all of the purchasers are struggling to make right now.

(31:07):
And if I can say this out loud, they're going to have to decide very, very, very soon if they have not already. At least in the example of a treatment for sickle cell that again, the end of the year is three, four months away, not far away. And that's when we're expecting that treatment to come out. We haven't talked about the providers yet. Again, ground yourself in the patient story. Do providers even understand their role in helping to support, to design equitable products, helping to deploy products equitably, helping to finance them? Do they even understand where they fit here?

Michael Mejia (31:45):
I believe so. I think that with the changes that have come with the technologies, the emerging technologies, the healthcare innovations, having people revisit things that they already held as kind of firm, as set. For a long time, I don't think that people probably paid attention too much to what was going on, what it meant. But with innovations, you have to revisit those things. You think that in terms of AI, for instance, one of the most common concerns that comes with that is us programming the AI with our own biases in it. And as I said earlier, we've got our own biases and our protocols, but what are people thinking about now with AI? How can I use AI to identify those protocols, to identify those guidelines that are already causing or exacerbating these health disparities? And how could I use this tool instead of it being a cause for alarm or something that's going to introduce more bias? How could I use it as a tool to identify bias and then address it?

Rae Woods (32:54):
You're clearly much more of an optimist than I am. I've been talking about all the ways that this is going to go wrong, and you're doing a really good job of reminding me, hey, the power of these innovations can actually do a lot of good in solving challenges that have happened for a long time, let alone the new ones that we are going to be facing headed into 2024. And I appreciate that push that these innovations really can be used by any of the stakeholders that we're talking about for positive change. Is there a stakeholder we haven't talked about yet that we want to name and talk about how they're grappling with this particular problem? We talked about the patient, we talked about the purchaser, the provider. Is there anyone we haven't talked about?

Maia Laing (33:34):
I just still go back to the broader society, and I may just be too pie in the sky here. But when we put the onus simply on the patient or simply on the provider or simply on the health plan or simply on the, I mean, there has to be some sort of moral empower that says that we can do amazing things and when we can do amazing things, we will do amazing things for all. There is value to bringing these types of innovations to individuals that may not even fully appreciate the innovation. That is the exciting part of the things that we're capable of doing. The provider, and I do want to get back to that point, is closest to the patient in a way that understands the challenges of the patient and oftentimes is not fully empowered to be able to solution with the patient.

(34:27):
They also oftentimes don't have enough time with the patient to be inquisitive. They don't have enough resources to be able to advocate for. Many of my mentors are providers. I know clinicians that own their own practices that spend much of their times on the phone ensuring that they can get coverage for things that are needed for their patients and making justifications for that. And this starts to get back into getting the right solution to the right patient at the right time. Our health plans, our plans are designed with benefits in them that over-index on some things and under-index on others. And we create these clustering models of, well, we're going to need this cluster of benefits, but these ones we don't need because only a small population that needs it.

(35:12):
And I just imagine a world where we just got the right solution to the patient and whatever that meant, whatever that looked like would it drive value in a system because we wouldn't be over or under deploying any resource to any given individual at any point of time. And so it's just easy to throw a bunch of things in a bag and say, hopefully there's enough tricks and tools in here for you to get what you need. And if there isn't, oh, well. But I just imagine if we got the right solution to the right patient, how that would rightsize the system and we would no longer over invest in things we don't need and we wouldn't be under investing in things that we do need.

Rae Woods (35:52):
And I do think it's important to understand every stakeholder's kind of perspective in their role in grappling with this challenge. But let's be clear, no individual stakeholder is going to be able to address this problem alone.

Maia Laing (36:01):
Absolutely.

Rae Woods (36:02):
Let alone address it. They will not be able to make forward progress alone. And so I want to talk a little bit about partnership, and I'm going to admit that I don't love this word. I think it's used as a buzzword. I think it's used to often kind of gloss over what partnership really is, which is compromise. It might mean losing money, it might mean short-term sacrifice. So, when we think about this challenge of ensuring equity in innovation as we're designing products, as we're deploying them, as we're financing them, what ways does the industry need to come together and make sacrifices so that we can make collective forward progress as you're describing?

Maia Laing (36:45):
Yeah. I mean, we have to get to aligned incentive, and that's why we talk about health equity as an aspirational, true north. If we can all align to a common goal, then we can accept the trade-offs that drive us to that value narrative. And so when we have differing interests and we don't have commonality in what it is that we're looking to get to, it's very difficult to partner. And we see this, I mean, you'll see this inside of organizations. One part of a business may not work in partnership with another part of the business. And driving value to one side of the business requires reducing value to another part of the business. And so we don't see the collective value that these trade-offs could make, and that is where we have to align to a common vision in where the healthcare system can get us to as a people.

(37:36):
And we have to talk a lot more around what the healthcare system seeks to do. And that gets me back to just working my time in federal government. It's advancing the health and wellbeing of the American people. And you can broader that statement, and it's advancing the health and wellbeing of people, and that drives a collective good. We all benefit from that, from diseases that we've eradicated before. We all benefit from not being subjected to those diseases. That is the benefit that we have today. And we can do that again with all of the technology that's happening. And we've designed a system that worked yesterday and it's got a lot of great pieces to it, but for us to get to the next groundbreaking moment, we're going to need to reconstruct elements of the system to drive that value.

(38:28):
And we don't have all the answers, but I have watched very intelligent people get together and come up with solutions by saying, we will take one step at a time in order to get to that place that we want to get to. Recognizing that we don't have all the answers, but with the willingness to take one step. And so it always comes back to being inquisitive around what are the needs that are going unaddressed? What are the tools that we have today that we didn't have yesterday, and in what ways can we bring these things together in order to advance to a different tomorrow? And we want to do that not just for the things that are understood today, but for the things that we don't understand simply because we can.

Rae Woods (39:10):
Yeah.

Michael Mejia (39:11):
When I think about what kind of unifies it, I mean I always tend to go back to the patient. If I'm asked where I want to turn to next, I always tend to go back to the patient. But the patient really is that kind of a unifying factor. If you look at all the different sectors, in reality, they're all working towards one, at least one goal, ostensibly the same goal. And it has to do with the patient, the way that we understand what it is that we're providing to the patient, the way that we understand what it is the patient needs. When I was talking before about getting a better understanding for the adverse events in our clinical trials for what it is that we're developing, if we don't understand what matters the most to the patients, if we don't understand what's most impactful to the patients, then we're not going to be providing the best care.

(40:00):
We're not going to be providing the best services, and we're all going to be working towards something that ultimately is not the patient's best choice. And for me, a lot of the time, it goes back to the design the way that we think about that. We really need to understand that patient perspective in there and stop thinking about, I think the way that we kind of measure and define performance and success of drugs is a really important piece of it. The way that we define value, value to who, how do we know that that's the value? We need to stop thinking about this as a drug that performed well on a disease and think about it as a treatment that's being taken by a person and an outcome that's being felt and experienced and lived.

Rae Woods (40:46):
I love that you just said how we define success and how we define value because I agree wholeheartedly that we need a singular mission, singular purpose that brings different stakeholder groups together towards a common aim, and this is very important. We have to layer then on structures that enable us to work together so that we're defining success in a shared way so that we're defining value in a shared way. And this might feel really hard to do, but we have examples of this, right? We have examples of risk-based contracts that do this. We have examples of health plans that are saying, hey, providers, you're telling us that you want to do equitable outcomes? Yeah, we're going to measure it, and if there's too much of a spread in your outcomes' data, we're going to penalize you for it. That's an example of a structure that can be put in place where one stakeholder can help hold the other one accountable towards a shared goal.

(41:43):
And honestly, that's when I start to get excited because then we're not just talking about this kind of gauzy goal that every single person in this room has. You're not in healthcare if you don't believe in making care better for people. What we need to see more of is the structures that allow us to get over the incentives that we all know are not aligned, and it is going to be the most difficult I think for deploying and financing the innovations. We actually have a lot we could say about this first step about design. But deploying and financing, it's just a horse of a different color. So, if I think about the experiments that we want leaders to run, the small steps we want them to do to just inch the ball forward, what kinds of small things do you want to see health leaders from any of the stakeholders we've talked about do to kind of help each other along, help hold each other accountable?

Maia Laing (42:35):
Yeah. I think it's just that it's how do we stack hands and hold each other accountable? What I'd like to see is just that how do we have a measure of success that we hold our colleagues, our friends, whoever's in this with us accountable to in a way that we can have a dialogue about? Oftentimes we define a measure of success. We say it's too difficult, and we move on. And we've done this again before. As much as the outcome that we're looking for looks different, the process to getting to a new outcome, there are ways that we have within a system to advance towards new outcomes. If we needed to increase the bottom line, we would change the way that we hold people accountable when we think about risk-bearing entities. And when value-based care rolled out, we designed shared incentives and we had conversations around how we were doing about that, and we drove innovation.

Rae Woods (43:37):
And we tweaked and we tweaked. And we experimented and we experimented. And CMMI made 50 different innovation models, something like that.

Maia Laing (43:44):
And going.

Rae Woods (43:45):
Yeah, and the number goes on, right? Yes.

Maia Laing (43:47):
And going. So we've done it. We've done it before.

Rae Woods (43:52):
It's almost that the industry needs to adopt a different kind of innovation mindset. We've focused on innovating on these specific products for these specific groups, and it's almost like the next phase of innovation is about running these small experiments and saying, okay, how do we make sure we're experimenting on continuing to improve on design, on deploying these in different ways, on financing these in different ways? Because it's not going to be easy and it's not going to happen anytime necessarily soon. We have to keep moving the ball forward.

Maia Laing (44:26):
Patient-centered measures, baking them in where the engagement can be understood, where the outcome can be aligned. I mean, there's many different measures we can start to include. I know people struggle with these patient defined measures, but if the goal is to treat a patient and a patient doesn't feel good about what they're receiving, then we have to ask ourselves, are we doing the right thing here? And so we struggle with listening to the voice of the patient throughout the process. I think that's a challenge and a measure that we should be held accountable to. We oftentimes will say that the opportunity doesn't exist because we don't pursue the data and the insights to say that it's there. So, when we start to look at different groups by race, by ethnicity, by language, by sexual orientation, by gender identity, when we start to slice the population and we start to hold each other accountable in these different areas for these different populations, we then start to have a different conversation.

(45:25):
And so I always say it's very easy to dismiss the needs of someone that isn't sitting in front of you. And I often say, I'm sitting right here representing many different populations that are not currently addressed by the healthcare system and asking people who are sitting next to me to share in this common interest of a community that I represent, many communities that I represent, and saying, we can solve problems together. And it's getting to a shared measure and value, and we don't evolve the success metrics as Michael has said, and we have to put those at the forefront.

(46:07):
And then we have to stack hands and say, I know this is going to be difficult, but we're going to hold each other accountable. And people do this in partnerships all the time. There's upside and there's downside, and so we do this, and so we just have to say, health equity is one that we want to do too, and innovation is going to be something that's going to help us advance towards health equity, and we're going to take all these new tools and we're going to take approaches that have been proven before. We're going to deploy these tools and we're going to close gaps, and we're going to get to new outcomes.

Michael Mejia (46:35):
Yeah. I couldn't agree more when it comes to patient-centered care, patient-centered approaches and outcomes as well. I think for a long time, as outcomes developed out of a quality of life, there was a lot of perspective of outcomes as being soft metrics, just kind of soft information. Everybody kind of mentioned that they agreed with it, but when it came down to it, you were really looking at those clinical endpoints, and in reality, outcomes have been shown to have survival benefits in oncology. When you include patient reported outcomes, like the patient reported outcomes' version of the CTCAE, for instance, has been shown to have survival benefits.

(47:19):
It's been shown to improve quality of life. And when you take this approach to get a better understanding of the patient's perspective without being afraid that that's going to mean that they want to ask for the world and get mad when you can't give it to them or that it's going to mean that every treatment is going to be some kind of unique treatment that we're not going to be able to handle because of the variability. That's not the case. It's about understanding their needs, about understanding their perspectives, and getting a better understanding on how these treatments are differentially impacting all these patient groups that we were blind to before because of the way we were measuring the outcomes.

Rae Woods (47:58):
I'm really struck by the idea that the three of us up here on a stage are all health leaders, we're all people, but we're also all patients. We are patients literally sitting in front of people in positions of power asking them to make change. I want to ask them to do something specific. Before we end our time together, can we give today's audience, the listeners back home, all the health leaders that are going to be listening to this podcast, let's give them an action item. What do we want health leaders today not to do when it comes to the innovation challenge? And what's the one action step that we want them to take home to their organization as they start to push forward on a challenge that is extraordinary and is necessary? What are your action steps?

Maia Laing (48:51):
Yeah. What I would like for people to stop doing, one stop assuming that how things work for you is what works for the next person. Start getting inquisitive around the things that you don't know. Stop putting easy challenges in front of very thoughtful people and put something that people can actually chew on in front of them. And as a leader in the space that you're in, ask the people that look to you to solve something very exciting and something big that they can be a part of, and do that by pushing the ball just one step further than where you felt comfortable and asking other people to come along with you.

Rae Woods (49:43):
I love that you just said, you even came back to our initial one. You are going to be uncomfortable. Moving the ball forward is going to require discomfort. Can I cheat and give one? How blunt am I? This is my own podcast, so I get to be pretty blunt, huh? Never before have I experienced an industry knowing that disruption is happening and is coming and so unwilling to engage in solutions. There is no more time. There is no more time for, I'm going to let someone figure it out. We are going to need brave first movers. I'm speaking to you. If you come from a capital rich organization with good change management who is eager to make positive change, it will require you to be the first mover to then be able to bring others along so that they don't have to reinvent the wheel so that they can be a fast follower, but it will take that brave first step.

(50:51):
With that, can we give our attendees a round of applause? Michael and Maia have been so brave, so vulnerable with us. It's such an important conversation. We're going to stick around if you all have any questions. Otherwise, we'll continue on with more from the Clinical Innovation Summit short break, and then we'll head to our breakout sessions. Thank you all again. Okay. I know that was a tough topic, but I can't stress enough how important it is. The takeaway that I keep thinking about in my head is the energy we need to take into the next phase of innovation. We need to see more experimentation, and we need to see it as we design, deploy, and finance clinical products. And remember, as always, we're here to help.

(51:44):
If you like Radio Advisory, please share it with your networks, subscribe wherever you get your podcasts, and leave a rating and a review. Radio Advisory is a production of Advisory Board, and this episode involved help from so many people. It was produced by me, Rae Woods, as well as Lauren Woodrow, Michael Mejia, Katy Anderson, Kristin Myers, and Atticus Raasch. It was edited by Dan Tayag and Joe Shrum with technical support by Chris Phelps. Additional support was provided by Gina Lohr, Solomon Banjo, Rachael Peroutky, Darby Sullivan, Amanda Okaka, Fanta Cherif, Carson Sisk, Leanne Elston, and Erin Collins. Thanks for listening.