The Value-Based Healthcare Podcast: Umbereen Nehal

Reveleer welcomes you to Episode 6 of  The Value-Based Healthcare Podcast. Our guest on this episode is Dr. Umbereen S. Nehal. Dr. Nehal is a speaker, council member of the Gershon Lehrman Group (GLG) and an academic clinician at the University of Massachusetts. 

This series aims to assist health plans become more successful through shared experience and best practices used by their peers in the industry. We interview executives at all levels within Risk Adjustment and Quality Improvement groups to share various perspectives. 

The Value-Based Healthcare Podcast is about sharing inspiring and real-world solutions from the people who are questioning the way business has always been done. We aim to educate across the spectrum of healthcare so that managed care organizations, providers and members alike are more successful in navigating and operating in this complex and ever-changing landscape. Subscribe today to ensure you receive the latest episodes!

Podcast transcription: 

Jay Ackerman:
Hello and good day. I'm Jay Ackerman, CEO of Reveleer, a software and services company committed to providing health plans with innovative technologies to maximize their return from quality, risk adjustment, and compliance initiatives, a must in the value-based care world we operate in. I'm back again with another installment of our podcast series, The Value-Based Care Podcast. Through our podcast, we aim to widen the visibility and voice of people shaping significant functions inside of health plans. 

I'm thrilled today to be joined by Dr. Umbereen Nehal. Dr. Nehal is a well-known leader in healthcare. She was most recently the Chief Medical Officer and VP of medical affairs for a large community health center in New York City. A former Medicaid medical director in my home state of Massachusetts, serving as a clinical lead for the successful award of $1.8 billion in new funding from CMS for her program to support delivery system transformation in Medicaid. Lastly, she is considered a top voice in health and has been rated one of the top 15 female voices in the world by LinkedIn. Welcome, Dr. Nehal. 

Dr. Umbereen S. Nehal:
Thank you. Thank you very much for that introduction and for the invitation. I'm excited. 

Jay:
We're thrilled to have you today. Let's begin with a few questions regarding your career journey. First, why don't you share how you found your way into healthcare?

Dr. Nehal:
Absolutely. So, that one is probably the most boring answer, which is that I come from a family of doctors. And in my family, if by age 18 you haven't delineated your path to a doctoral degree, then your father fills out an application for medical school in Pakistan and you leave Wellesley College and go to Pakistan for med school. I ended up in med school by default because I was interested in too many things, and was taking too long to decide. But I think that's actually been a theme in my career, is that I love reading, I love learning, and I like to think of myself in terms of like tipping point terms, a connector who brings together ideas and stakeholders to try connect and create a more comprehensive approach. 

Jay:
Fantastic. Seems that your family is probably single-handedly bucking the trend where many are choosing not to head down a career of medicine, so thanks to your family for wonderful public service. Why don't we talk about your current endeavors? So, you're focused on consulting and speaking, and maybe you can share what you're trying to accomplish now?

Dr. Nehal:
Absolutely. I welcome the opportunity to explore, to network, to consider the right next step. Most recently, I was Chief Medical Officer for a large community health center in FQHC or Federally Qualified Health Center space. So right now, I'm really trying to understand what is the best way to approach these issues in primary care? Right, we talk about high rates of burnout amongst primary care clinicians, amongst doctors.

We talk about issues around social determinants of health. We talk a lot about data and how do we better utilize and connect data? At this point, I'm really looking at how do I take these different problems and find customized solutions to clients that I'm working with? And then try to find ways to capture the pith of those issues, so that when I'm coaching or teaching, that I can transmit some useful tools and solutions.

Jay:
You mentioned burnout in the primary care physicians. We talk about provider abrasion a lot in our business, where we have to reach out to provider groups and hospitals to retrieve medical records and data on behalf of the members covered by the health plans. What do you think is contributing to the burnout with the primary care physicians, and what do you think can be done to drive that down?

Dr. Nehal:
We say that we see a lot about individualized solutions around yoga, and diet, and exercise. I absolutely agree that those things are important, but we really have to think at a system level. Edward Deming said something along the lines of, "The system is perfectly designed to generate the results it does." And so, when you have one third of physicians complaining about symptoms of burnout, as well as 400 physicians committing suicide a year, that is a system-level issue and it is not going to be addressed by only wellness techniques.

So, I do think we have to think at a systems level, so we need to think about administrative burdens. One third of healthcare dollars are spent on administrative burden. So, what are ways that we can streamline, reduce paperwork, reduce click, really allow physicians to, the nurses, all care providers, how can we allow them to rediscover joy in practice, and be able to come to work to do the work that they actually got into the profession for in the first place? 

Jay:
Yeah, amen on that. I think probably a lot of doctors lining up behind what you're focused on. So, let's talk about some of the trends unfolding in the healthcare industry and the change. As you look at the industry trends, what do you see that are beneficial to providers, and perhaps you can also comment on it from the lens of the health plan?

Dr. Nehal:
Yeah, so I think that there's alignment when what is beneficial for providers as well as for health plans in that, this move towards value-based care. A lot of doctors are a little wary, if not flat out cynical about value-based care, thinking well, this is just ACO is another version of HMO. It frustrates me a little bit to hear that because I really would like us to give it a decent chance, and I think there's a lot of opportunity for alignment.

Going back to what I was saying around administrative burden, if you are practicing value-based care, you get away from fee-for-service and you go towards paying for outcomes. Then, potentially, you can get rid of some of the administrative burden as proving, look, I was right to do this throat culture, now pay me for it.

Instead, let's say that we look at things at a population-level. We define outcomes both in terms of cost outcomes as well as clinical outcomes with obviously clinical outcomes taking priority, because you never want to look at costs for lower clinical quality. If you're paying for outcomes, then ideally in theory, you would reduce administrative burden. I think the challenge is that nobody's exactly sure how things are going to turn out in the value-based care paradigm.

There's a kind of holding on to old things that people are used to doing. On the provider side, people are still trying to squeeze out as much revenue from fee for service. On the health plan side, people are still trying to squeeze out as much savings from utilization management. What they're talking about and what they're hoping the other person will commit to, is different from what their continuing to do themselves. I think every stakeholders needs to take a really honest, hard look at themselves as to how much they're actions match their words, and how people can really commit to change. 

Jay:
If you were standing in the shoes of a provider group, what's the one thing you think can be done to have the actions match the words?

Dr. Nehal:
That's a very good question. It's a tough one. I think that engagement needs to be genuine. One is that, listen to your providers, if they're talking about things then find those easy ones. Find the ways to humanize people, so from a healthcare administrator within the provider group.

I would say that there may be ways in which providers and payers can align better. For instance, in Massachusetts under the ACO, Accountable Care Organizations, that were formed DSIPP, or Delivery System Incentive Payments Program that you referenced in the introduction. 

Payers and providers were actually coming together to form ACOs, such that now they were a shared entity. Then, you start to merge cultures, then you start to merge organizations. Then, everybody's got the same kind of skin in the game. I think that is a helpful way. But at the same time, there has to be a thought to how these cultures have historically been very different, and unfortunately in opposition to each other. There has to be a focus on that intentional culture change as well.

Jay:
A couple of minutes ago you mentioned big data, and so if think about it from the lens of the health plan, how can the use of big data, better leveraging the data that's now available, help a health plan truly do their part in delivering on value-based care?

Dr. Nehal:
I'm somebody who has also helped services research train, so I'm trained in looking at data. But as somebody with an academic background, I'm also very aware of the flaws in the data, and what the data can't tell us. Or that there's some types of data that you can't ask certain questions to and get a valid answer. I think that those who may come from a less academic background, I would advise them to think, be more thoughtful about data, and to make sure that you're thinking about flaws in data and gaps in data.

But to your point, what are the opportunities there? I think that we have a lot more information about patients, also called consumers, so we can do more personalized care, we can do more customized care. We can do better engagement. We can match services to what the patient is likely to value or to use rather than just blindly prescribe something and assume that they're going to do it. But I would also say we have to be careful about the fact that we are now getting into value-based care that includes social determinants of health, which is something that has not previously been paid for. 

The reality is that when something has not been paid for, people have not documented it. If they have not documented it, it's not in the data. Then, you don't have prior benchmarks in which to have valid comparisons. I think just keeping all of that in mind about where there are gaps in the data, and where the perverse incentives of the old paradigm meant there weren't data to compare against. 

Jay:
Dr. Nehal, could you give an example where that's taking place, and then perhaps speak to how trying to navigate through it?

Dr. Nehal:
Yeah. I mean, I'm a pediatrician. Pediatricians have often dealt with issues around social determinants of health. Our patients tend to be nonverbal, can't work, and can't walk, can't even control their bowels, right? They're very dependent. We are thinking about the home in which they live. We're thinking about a smoker in the home. Is there lead in the paint? Is there food insecurity? Can mom get the child to school or not? So, these are things we've always thought about. We've spent time asking questions about. We have spent time addressing these problems. There's never been a billing code for it and so it's not been captured. 

Now, let's say an ACO is forming, and you have a pediatrician at the table, and you're looking at historic data as to revenue generation. And you look at a pediatrician and say, "Gosh, I just haven't generated the same revenue because your billing." The billing is just very different in pediatrics. Now, the person who has been doing the thing that the system says is now valued, has no way to prove that value or those outcomes because it hasn't previously been documented.

Going back to your earlier question about how can we engage providers better, and what can we do to reduce the provider barriers to engagement? It could be having that narrative and saying that we know that you've always been doing the right thing, and now there's an opportunity for you to get paid for doing the right thing. It's not about money because look, if doctors were really smart about money, they would never have gone into medicine, they would have joined Wall Street at 25, right? Making the money argument first is not necessarily going to win over doctors. 

But I think if you say that it'll now get paid for so that now you can have the time to spend with your patient that you deserve to have, then I think that's the way to engage clinicians, and say, "We know the data were imperfect. It wasn't capturing what you were doing. Work with us to define the value of what you've been doing and come with us into the new paradigm."

Jay:
That's great advice. Let's kind of turn it a little bit internal to the health plan. So, we're talking about value-based care, kind of a core focus for you. Let's say you get an opportunity to sit down with the executive team in kind of a regional health plan. What advice might you have for them in navigating the industry during these rapidly changing times with the focus on value-based care?

Dr. Nehal:
Yeah, I think that that's a broad question. I would say that all politics is local, all health is local, right? So, we know that life expectancy, rates of hypertension, rates of asthma differ zip code to zip code. I would use that same approach when it comes to health plans. So, if you're a regional director, you need to keep that 10,000, 30,000 foot view. But make sure you've got your people on the ground who are doing true community engagement with providers, with community groups, and really have your ear to the ground.

I live in Manhattan now, I used to be in Boston. I'm sure you heard, it's been in the news around Amazon HQ2 deal falling through. I think that's a perfect example of a 30,000 foot view approach by Governor Cuomo, which may very well have been the right deal to make. I'm not going to judge one way or the other. However, I think in the desire for expediency was a different process that was used that bypassed the usual processes for community engagement. 

So the community partners were not engaged, they had a lot of questions that weren't being answered, and they rejected it. I think it's unfortunate because perhaps that was the right deal, or maybe not, but it didn't get the discussion that perhaps would have allowed it to be successful. 

Jay:
Yeah that's a good example, that's one that's going to get played back over and over. 25,000 jobs moving onto a different community, bound to have many people playing that one out. You were talking about-

Dr. Nehal:
For sure. Can I just add one more thing?

Jay:
Sure. 

Dr. Nehal:
Say the 25,000 jobs is potential, right? You never know how many would have actually come. You never know how many of those would been New Yorkers versus people moving in. It would have been for New York City, but may not have been as much for LIC or Long Island City. To go back to what I was saying earlier, you want to think about federal, state, city, municipal, and neighborhood. Each of those levels has different stakeholders and different ratios of wins and losses. When you negotiate, somebody always has a walkaway point where there's often values that underlie a negotiation. 

For Amazon for instance, it was the availability of a workforce that they didn't have the train up necessarily that was there in New York City. Those jobs probably would have gone to New York City, which is why Google moved in too, without tax incentives. But for the neighborhood, the question was, what's going to happen to our subway commute? What's going to happen to our school? Are we going to get displaced because now my rent has gone up? So, my personal individual life is going to get worse. Again, kind of going back to always have your ear on the ground, have genuine relationships with the community, and expediency versus open discussion, I would argue that you want to go for the latter. 

Jay:
The way you stepped through that, the various constituencies is really important, federal, state, city, municipal, and neighborhood. Let's talk about federal for a second and focus on CMS. If we're talking value-based care, we at Reveleer, we spend a lot of time working with health plans around their Medicare, Medicaid, and their ACA members. What regulatory changes would you like to see from CMS that would be most beneficially impactful to their members?

Dr. Nehal:
I'm probably going to reveal how I'm wired and how I think, but I like to see fewer barriers. I do think that CMS under, Administrator Verma, is doing a really great job about reducing administrative burden. It's called Paperwork, so Patients over Paperwork. That has gone from the prior administration to this administration but with a real kind of ramp up in this administration that I think the provider community and the hospital community is really welcoming. I think that's very important. 

At the same time though, there is some increases in paperwork on the patient side or the member side. I actually did some research when I was a resident in Texas, where the SCHIP, or the State Children's Health Insurance Program that kind of layers over Medicaid for low-income families that don't qualify for Medicaid but may not be able to afford private insurance. And what has happened is that, in order to reduce fraud, abuse, things like that, from a fiscally conservative standpoint, the eligibility period had been shortened. The amount of paperwork to prove eligibility had been increased. The waiting period had been increased. 

What ended up happening when did an analysis is that, we saw that children who had previously been enrolled, experienced a gap in coverage, and then were re-enrolled. Which implies that perhaps they were always eligible. Now you could argue, okay, kids can go without insurance for a couple of months, no big deal, right? So, you save a little bit on their cost of care, they're fine, right?

In fact, when we looked at ED visits, emergency department visits and hospitalizations, that had gone up even with a gap of two or three months. Even though kids are extremely resilient, any kinds of illnesses they get at that age, may not show up then but you're going to get it in your Medicare spending decades later. We should not be penny-wise pound foolish, and I think we should not try to cut corners where we add barriers that prevent overall health over the course of year or a lifetime. 

Jay:
Let's hit the other group. We started at the top with fed, let's go to the bottom to the neighborhood. Neighborhood, and talk like local to the people, so what recommendations would you have for the public, kind of the member, the consumer, regarding their own empowerment and the ownership of their health?

Dr. Nehal:
I would love for us to not divide people up so much by the payer group even though that's the nature of the system. I would love for people, like you said, to be very empowered, and to really think about what is it that I do every day to improve my health? What is it that is aligned with my values that allows me to improve my health? And how can I be better prepared for a doctor's visit, for talking to my insurance? It's unfortunate that our system is so complex that it requires such much health literacy is what it's called, or numeracy, understanding the difference between a deductible or premium.

But the thing is that CMS, going back to the federal level, actually uses our tax dollars in a very wonderful way, where there's a ton of material that's designed for the public to empower individuals. As part of the Affordable Care Act, there was From Coverage to Care, a booklet that was created in conjunction with RAND, that was designed for the average consumer or patient. If you just go to the website, there's a lot of information that's designed to empower consumers. It's called From Coverage to Care. 

Jay:
That's great. Appreciate your insight on talking from the federal level down to empowering the individual member and consumer. Dr. Nehal, you've been a great guest, really insightful and informative throughout, not surprising. Let's kind of bring this to a close and I always like to kind of wrap it up with quick questions. No right answer, no wrong, just kind of top of mind. Right now, what keeps you up at night?

Dr. Nehal:
What keeps me up at night is trying to figure this innovation that I'm very excited about, how we do it in a way that is not too disruptive to the safety net. Because the whole idea of a safety net is that when you have something disruptive in your life and you fall, it catches you. But as we change the system, how do we make sure people don't fall through who might already be kind of neglected or marginalized? How do we bring everybody into the future?

Jay:
So when you are thinking about that safety net, you can't fall back to sleep, so what book might you grab from your nightstand and why are you reading it? 

Dr. Nehal:
There are two poets whom I really get a lot of insight from, and sense of maybe feeling more at peace in the world. One is Maya Angelou, and then the other is Jalal ad-Din Rumi who's a very famous Sufi poet, who's actually I believe the most popular poet in America apparently. 

Jay:
Fabulous. We're going to get a little heavier here. If you could redo one decision in your life, what would it be and why?

Dr. Nehal:
That's a tough one. Gosh, you asked me a tough question. There are probably some emails I would have slept on better. Those are seemingly small things. Actually, I don't believe in regret because everything that I've done, I've learned from. Everything I've done, I made the best decision I could at the time, and probably if I were going to go back to those circumstances, I'd still have the same information. And I'd still be the same person, and I'd probably make the same decision, just try to be wiser next time. 

Jay:
That's great. Well, believe it or not, I have a draft email that has been sitting in my Outlook draft box for 25 years as a reminder of always sleeping on it. I wrote one, realized I probably shouldn't send it, and I've kept it ever since as I've moved from, kind of position to position as a reminder to pause every now and then on some of those kind of hot topics.

Dr. Nehal:
Yeah, that's great. 

Jay:
What's your favorite app on your mobile device?

Dr. Nehal:
I have to admit I'm a total geek. It's LinkedIn, which is how we connected. I'm on it all the time. 

Jay:
Well, you don't get to be one of the top connected females on LinkedIn without spending a fair amount of time on it, which is pretty amazing. 

Dr. Nehal:
Thank you. 

Jay:
Lastly, how do you invest in yourself?

Dr. Nehal:
I do it through small things. I like to read. I like to go to museums. I travel. I get out into nature. It's just a constant investment, and cheesy but stopping to smell the roses. Then, actually part of the reason I'm on LinkedIn is even though apps are kind of known to kind of drive folks a little bit off-kilter, for me, I find great community. For instance, my neighbors had left a bouquet of flowers on my door because they knew that I'd just been through a couple of things that were just a bit challenging. I took a picture of it. I posted it on LinkedIn, it has 190,000 views. It's amazing. People are hungry for happiness, for kindness, for generosity. Just to be able to go into cyberspace and to find a community of people who care, that's amazing.

Jay:
That is amazing and that's a wonderful story. I appreciate you sharing it. Well, with that I think we will bring today's podcast to a close. I'd like to encourage all of our listeners to check out and follow Dr. Nehal on LinkedIn or Twitter. Easy to find on LinkedIn, and on Twitter, Dr. Nehal's Twitter handle is @usnehal. Dr. Nehal, thanks again for your time and your openness, you've been a phenomenal guest. 

Dr. Nehal:
Thank you so much.

Jay:
This brings our Value-Based Healthcare Podcast to a close. Please follow Reveleer on LinkedIn. You may also follow me on Twitter @AckermanJay.