The Value-Based Healthcare Podcast: Brian Lima

In episode 12 of The Value-Based Healthcare Podcast series, Dr. Brian Lima joins Jay Ackerman and talks about heart failure and the many steps needed to normalize preventative care. He also discusses technological changes and trends he views in the rapidly changing healthcare landscape. Dr. Lima is the Surgical Director of Heart Transplantation at North Shore University Hospital as well as Associate Professor of Cardiothoracic Surgery at LIJ School of Medicine at Hofstra University.

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Podcast transcription: 

Jay Ackerman:
Hello, I'm Jay Ackerman, CEO of Reveleer, a software company committed to providing health plans with innovative technologies to maximize their return from quality, risk adjustment, and compliance initiatives. We're back again with yet another installment of the Value-Based Healthcare Podcast where we engage with thought-leaders and visionaries working across the healthcare ecosystem. Through our podcast, we aim to widen the visibility and voice of people working to change how healthcare is provided and the impact it has on all those who participate in the care delivery chain. Let's get started.

I'm thrilled today to be joined by Dr. Brian Lima. Just as a little introduction, Dr. Brian Lehman is a cardiac surgeon dedicated to the compassionate delivery of the most advanced heart care. As a recognized authority on surgical therapies for advanced heart failure, he is also very passionate about clinical innovation, research and education, having published nearly 80 articles in peer reviewed journals, numerous book chapters, and presented at several national and international conferences.

In 2017 Brian was recruited to North Shore University Hospital at Northwell Health. He was recruited to lead the first and only heart transplant program on Long Island and help bring the full spectrum of advanced heart failure care to the people of Long Island, Brooklyn, Queens, Staten Island, and the greater New York City metropolitan area.

Dr. Lima, let's begin with a few questions regarding your career journey. So first, could you tell us a little bit about yourself and your journey into the world of medicine?

Dr. Brian Lima:
Sure. So, it was very fortuitous and definitely not what I saw coming. I'm a son of Cuban immigrants. My parents came over in the late '60s on the freedom flights from Cuba, and was kind of a working-class family in Northern New Jersey right outside of New York City. Really it was just a matter of working really, really hard, putting in a lot of effort to follow my dream, and my dream was to get into medical school. I liked science, I liked math, and it just seemed like a natural fit. But I really wasn't 100% sure about what kind of doctor I wanted to be, and that all really changed when I was able to actually watch a surgery for the first time.

I was doing a summer program in college at NYU and I was allowed to scrub in on a surgery and watch, and that was transformative. It was like the ultimate epiphany. I knew right then and there that I wanted to be a surgeon and then, sort of it evolved from there as I went through medical school and got exposure to different specialties and really just fell in love with heart surgery and specifically heart failure and heart transplant and an artificial heart pump technology that's been coming along this time.

Jay Ackerman:
I'm struck by the number of doctors that I've spoken to who realized at such a young age that that's the path that they wanted to follow. So, can you share when that really hit you?

Dr. Brian Lima:
So I think it wasn't until... medical school seemed like the right place for me to go because I really truly liked the sciences. They just came easier to me than the humanities, for example. I was a chem major in college and I also really loved organic chemistry. So just the science of human biology really attracted me a lot. But honestly, I think it's one thing to have an interest in something, it's another thing altogether to actually expose to it. Sort of having an immersion experience.

I think that's really, really important because you really can't know with certainty what you want to do with your life or what you want to do in medicine until you've actually experienced what that would be like, and that's kind of what med school's all about and rotating through different things. But I think any opportunity to sort of immersion exposure, kind of like learning a language, I think that's really key cause it could help you formulate your decision and make it all click.

Jay Ackerman:
And just staying with NYU for a second, what do you think of their decision to create the pool of capital to fund doctors coming into med school?

Dr. Brian Lima:
Well, I applaud them. I think United States, this is a whole other debate, but education is free in most developed countries, including medical school and so it becomes prohibitively expensive or helps shape people's decisions for the future as far as not wanting to take on the amount of debt that would be required to go at it on your own, so to speak, without having family or et cetera that can pay for the tuition that's astronomically high.

I think it's a deterrent, practically speaking, for people to not pursue medicine because of just that upfront massive investment and future debt. So, I think it's a great thing. I think it's catching on, other area medical schools are following suit and I think you're going to see more and more of that, particularly at the level of maybe some of the more upper tier or elite medical schools that have a sizeable alumni that can sort of be able to swing something like that. But I think it bodes well for medicine in general in the United States.

Jay Ackerman:
Yeah, let's hope that we see other med schools following suit. All right. So, let's talk about how you found your way into your current position at North Shore University Hospital at Northwell Health. So, what was it that caused you to make the move and be part of that health system?

Dr. Brian Lima:
Well, it was also fortuitous. I received a random phone call a few years back, I guess now three years, by Dr. Alan Hartman, who's the Chief of Cardiac Surgery for the entire Northwell Health system. I had not been in the Northeast for some time. After I finished my training at Cleveland Clinic, I spent my early career in Texas, most of it in Dallas at Baylor, and had managed to do a lot of work in the field of heart transplant on trying to decipher causes for primary graft dysfunction and other areas where we wrote a lot about it and published a good deal. It just so happened that they had decided as a health system here on Long Island at Northwell to launch a heart transplant program, and obviously needed a surgical director to sort of lead the charge for that and get things going. So that's why they reached out to me.

Obviously I was flattered and honored, and as I kind of looked at the opportunity, it struck me for a number of reasons. Number one, it'd be a really neat opportunity to go back home, so to speak, close to where I grew up in Jersey. Number two, it really struck me that all this time there still wasn't a heart transplant program on Long Island. And when you factor in the population of people we're talking about, it's massive. You factor Long Island plus the other surrounding boroughs, that's about 8 million people that have not had a heart transplant program to call home.

So what that means is these folks have to trek into the city, into Manhattan, which on a map is not a good distance, not too many miles. But in practicality, as anyone who's ever been to Manhattan knows, five miles could take you five hours. It's expensive, the parking is expensive, the tolls, and it's really, I think, presented a massive barrier to access to advanced heart services, including transplant. So, having a program right here on Long Island has, to me, felt like the right move and the opportunity of a lifetime to start a heart transplant program. I thought that would be the ultimate legacy that I think that I could proudly back on as for my career.

Jay Ackerman:
Oh that's fascinating. Thanks for sharing that. And here at Reveleer we're a startup that's gone through its first or second stage of growth, and I'm sure that you have some experiences in starting a program from scratch there that probably not dissimilar to what we go through in setting your goals, creating a team around you, building it out, and then obviously bringing the care to people of Long Island and the surrounding boroughs. So, kudos to you and what you're doing there. Let's talk about health and healthcare in the US, and what industry trends is Northwell Health watching most closely in healthcare?

Dr. Brian Lima:
I'd say in general, most would agree that the trend we're seeing across the United States is the transition from the solo practitioner or small group, private practice being purchased and absorbed into bigger health systems, you don't have standalone hospitals anymore, basically most of them are part of a greater healthcare system. Health, hospital system. And so Northwell is, I think, a leader in that. It's growing. It's 20... I keep losing count, every so often it just changes. I keep saying 23 but it's actually 25 or you could be even more. But that's a massive healthcare system. It's the largest private employer in the state of New York, and the largest healthcare system in the state of New York. 

So I think they are uniquely positioned to lead in population health. How does a big healthcare system do a better job of taking care of the people in its service area? When you're that size, you have the unique capacity to do that. One of the original examples of that sort of thing is at the Mayo Clinic where, rural Minnesota, it was easier to kind of do that, just logistically speaking, but in areas that are more heavily populated, et cetera, like the New York metropolitan area and the boroughs, that's really not been done. So, I think it's a unique opportunity to improve the care from a population perspective. So, I think that's where Northwell is really looking to innovate.

Jay Ackerman:
Well, that's a perfect segue to my next question, which is what do you see as the greatest barriers or challenges that affect patient improvement in today's environment?

Dr. Brian Lima:
Part of it, I think, is, like everything else, it's multifactorial. On the one hand, you would like to have more preventive care be embraced. As a heart surgeon, it's not really saying much for my future job security. But if someone comes to see me, that means the wheels have fallen off and they really need something and it's drastic. It'd be nice if it didn't have to come to that. And so I think preventative care, more emphasis on preventive care is huge, and specifically in my niche area of heart failure.

Heart failure, I think, is a major, major under-treated disease process that's going to impact all areas of medicine, and I think that is going to be a major factor in how well or not we do in improving the care of our population. Not to get on a soapbox, but heart failure is as deadly if not more deadly than cancer, but yet doesn't get anywhere near the street cred that cancer gets. Unlike in cancer where if there's even a suspicion, a hint whatsoever, any hint whatsoever of a cancer, it's knee jerk reflex, no questions asked, you're immediately sent to an oncologist and they figure it out. It's all protocolized. 

In heart failure, it's the complete opposite. It's completely haphazard because you have very different... a wide range of specialties that are taking care of ‘heart failure patients.’ You have general docs, family medicine doctors, cardiologists, heart failure cardiologists, sometimes OB-GYNs, and it's not standardized. So there's still not been formalized at what point someone needs to be referred.

What happens then is more often than not, I hate to say, it's not until a patient is really in dire straits where they're clearly manifesting decompensated heart failure, that this sort of alarm goes off and, "Oh, this patient really should be sent to a heart failure specialist because we've really done all we can do." The problem is at that point we've missed our window, and that's what's tragic. If they had just been seen maybe a year or two earlier, it likely could have been avoided. I think if you factor in our aging population, people are living longer, heart failure is just going to continue to grow exponentially, then it's going to be a recurring, bigger problem.

Jay Ackerman:
What do you think needs to happen to bring attention to the broader market or public on heart failure and heart care and the way that cancer has gotten the attention that it has?

Dr. Brian Lima:
Well, unfortunately there's going to be a fixture of time component here. Its just cancer didn't start out that way, and it it's developed over time as far as having the formality to it. I think heart failure will get there. There's data that's starting to make its way to the masses. So, time is one thing, but at the institutional or health system, individual hospital system level, more marketing, unfortunately. Marketing to the public, marketing to referring providers.

I think also maybe, again, something that a large health care system can do is embedding some standardization. You work for our healthcare system, then this is kind of what we… the initiative that we're launching as a healthcare system to improve quality in this specific area. Let's say controlling infections after surgical site infections after surgery or heart failure readmissions. You name it. I think embedding some criteria, electronic health record flags, things that you can sort of... I hate to say enforce, but standardize so that you develop a more cohesive structure to how these patients are managed. That definitely needs to happen.

The other thing that's going to happen just is technology. The devices that we use for heart failure, the artificial pumps that we implant, they're getting better, smaller, sleeker to the point where they're rivaling what outcomes you see with the heart transplant. That technology improves, that's also going to sort of lower the barrier to adoption of these technologies, and referrals for these technologies. Because I think many physicians in the referring community may still have some kind of biases because they think of artificial heart pumps, they think of these old clunky things the size of your head. Boy, I don't know if I want my patient getting that thing. So, there's still a lot of that out there. So again, that's where education and marketing and outreach comes in.

Jay Ackerman:
So just kind of staying on that thread about marketing, outreach, and education. What recommendations would you have for the public regarding their empowerment and ownership of their own health?

Dr. Brian Lima:
Well, speaking again within my area of heart failure, because I try myself, through my social media channels and things like that, to sort of promote awareness of this issue as well in heart failure, and I've written a good deal about it as well. Any patient that has a diagnosis of heart failure or have been hospitalized for heart failure, they really should be referred to a heart failure specialist.

Just to be sure. Just to be sure that, A, we're not missing something, B, that we kind of now have that patient on our radar so that should they decompensate, we're not seeing them for their first time at the 11th hour when the wheels have come off and now we're going to, you know, we'd have to try to finish up the workup but they're gravely ill. Just kind of getting all the ducks in a row. So, I think for a heart failure patient, any patient that's been told at any point that they have heart failure should seek out or request a referral to an advanced heart failure specialist.

Jay Ackerman:
Yeah. So, you're really looking to get them starting to develop a dataset and baseline around their heart health so you can track and monitor.

Dr. Brian Lima:
Exactly. Yeah, because, I mean, to determine if someone's a candidate for a transplant or an artificial heart pump, it's a pretty lengthy workup and pre-cancer screening, a lot of screening tests that we take for granted, assume that they were done, we find oftentimes they haven't. So now we have somebody who's really struggling, very critically ill, and we're trying to piece together our evaluation to determine what our options are, and lo and behold, whoa, they've never seen a dentist or, oh they have never got their screening colonoscopy. She's never had a mammogram. She's never had a pap smear.

Now we're trying to do all this at the 11th hour, it's just had we seen that patient a year ago when they were out in the community, with the disease but more functional, we could say, "Hey, we're going to keep an eye on you, and just to kind of get everything set up, we're going to make sure you get these tests that we noted are missing from your evaluation." Just so that it's all done and we're ready to go.

Jay Ackerman:
So what do you think prevents them from, stops them from doing that? Is it the lack of understanding that that's a step that they should take? Is it potential fear of hearing more bad news at they don't want to face? What do you think is keeping them from coming in early and creating that relationship and starting that baseline?

Dr. Brian Lima:
It's a loaded question because part of it is that all those different doctors in all those different specialties that see and manage patients with heart failure, all think that they can take care of heart failure. In a sense that the idea of referring that patient to a ‘heart failure specialist’ seems excessive, unnecessary. Things you hear are, "What do you mean?" I can treat, I can take care of heart failure. That kind of thing.

So part of it is, again, something that I think will get better over time, is that they're not getting sent to the specialists to sort of get the ball rolling with stuff. They're still seeing their general cardiologists until things really get out of hand. So that's one thing. It's basically lack of referrals by their general cardiologist or whoever is overseeing their heart failure care as an outpatient.

Jay Ackerman:
Yes. So back to your point earlier about starting to standardize the practices around it.

Dr. Brian Lima:
Exactly.

Jay Ackerman:
So you talked about technology a few minutes ago, specific to advancements in heart devices, but perhaps more broadly, what technology do you see having the biggest impact on an individual members care?

Dr. Brian Lima:
I think, going back to the electronic health record, I think that's going to continue to evolve. I think the idea that every single hospital has a different health record, and so if a patient goes from one place to another, one state to another, it's basically reinventing the wheel every time they have to be seen by a provider. So I think we're going to see more just merging of all the electronic health records, maybe some sort of a chip or band watch something so that no matter where you are, where you've been seen before, all of your tests, lab work, imaging, all that is easily accessible by any provider wherever you're seeing.

I think that is a big deal, because when you're seeing a patient and starting from scratch literally and trying to figure all this stuff out, that delays things. It's a different story when you have ease of access and you don't have to duplicate tests or you already know what you're dealing with. So, I think that's going to be a massive development in the future. Then across the board, whether you're talking about, obviously, heart care, but drugs are going to get better, devices are going to get better, people are going to live longer. So, the advancement in technology is going to continue, and I don't see any signs of that letting up.

Jay Ackerman:
Yeah, I think we all look forward to the day when that our own set of information travels with us as comprehensively as you just described. What advice might you have for healthcare executives in navigating our industry during these rapidly changing times?

Dr. Brian Lima:
Even though things are changing rapidly, I think as long as you adhere to the principle of doing what's right by the patient, independent of everything else, I think you can't go wrong. That, I think, will serve to direct the traffic or the efforts to where do we want to concentrate on? Really having a good sense for what are the deficits, what could we be doing better for patients that we're not, then sort of getting more specific down to the granular level of where they are at their individual institution, what the culture is at their individual institution, what could be done to improve patient care or the patient experience. I think... to me, it might be naïve, but I think everything else works itself out so long as you do right by the patient.

Jay Ackerman:
Yeah, I can't agree with you more on that one. I mean, I think with our business and how we try to run our company, we try to keep the same thing there with the customer. As long as we do right by our customer, then all the other goals and objectives that we aim to hit should be able to take care of themselves. So, let's talk kind of regulatory for a second. If you had a chance to speak to leadership at CMS, what regulatory change would you most like to see come from them in the next couple of years?

Dr. Brian Lima:
I think specifically in transplant, organ transplantation, I think the idea that if a program fails to maintain a high one year survival rate, which is completely justified, that they can face disciplinary action and even the death penalty, so to speak, where the program gets shut down. I think that leads to a level of risk adverseness where programs just you get into self-fulfilling prophecy like, "Oh well, we've got to maintain certain level,” so that you become risk averse.

So I think in those scenarios the patient loses out the high risk patient, the patient that may or may not do better or benefit from a transplant. I think having a method for taking into account or risk adjusting more accurately the level of cases, complexity and not dinging programs for their outcomes if they are really trying to do sicker patients, the more high-risk patients. Because, again, doing right by the patient, doing what's right for the patient and not what's sort of... I'm not trying to game your risk profile and your stats look.

I think that would be one major thing I would like to see with CMS. And, again, of course focusing on the heart again, I think CMS does a fantastic job of regulating many things, but one area where I don't think they don't regulate as much as I'd like or standardize things as much as I'd like is in this area of heart failure, and that's where we really desperately need it. Because of the cost containment issues that they are rightfully concerned about will improve dramatically if they can get a handle on this heart failure issue. If patients are seen earlier and we prevent them from spiraling, that's going to lead to a lot of cost containment for our population.

Jay Ackerman:
That's a perfect call-out, and with all the attention around growth in healthcare costs and how to contain them, you're just bringing to light the preventative side on a really tough and tricky area of the heart. So, thanks for sharing those two items.

Dr. Brian Lima:
Sure.

Jay Ackerman:
So last one and we'll start to wrap with our rapid-fire round. A bit of a personal question. What lasting impact do you hope to make in the world of healthcare?

Dr. Brian Lima:
I think a lot of my clinical research and the bulk of my clinical practice is dedicated to the care of patients with advanced heart failure. So, my hope is that with my small contribution at my individual level, that I've improved the level of care of heart failure for patients globally and also for the field. And also obviously locally starting the heart transplant program and on Long Island. I think that, to me, is a lasting legacy that I going to look fondly upon and be very proud of, and I want to continue to make this program the best possible program it can be. So that also will be something that I will focus a great deal of time on. I would say those are the major things.

Jay Ackerman:
Setting small goals for yourself, I can see.

Dr. Brian Lima:
Yeah.

Jay Ackerman:
Yeah. Well I wish you the best of luck with those.

Dr. Brian Lima:
Thank you.

Jay Ackerman:
You've been a great guest, and I know your day's busy, so to be able to peel you away from it and to share what you're doing with us, I greatly appreciate it. We're going to move to our rapid-fire round. So, five quick questions, top of mind. So, what was the last truly great book you've read?

Dr. Brian Lima:
The last truly great book I read was Can't Hurt Me by David Goggins.

Jay Ackerman:
Wonderful. If you could redo one decision in your life, what would it be?

Dr. Brian Lima:
I would have learned how to play the guitar when I was young. I love music and I love hearing the guitar especially, and I missed out. I missed my window, I think.

Jay Ackerman:
I'm not sure it's ever too late. What's the favorite app on your mobile device?

Dr. Brian Lima:
It's probably Amazon. I like to say my wife's the bigger offender of random boxes, Amazon boxes that show up on our front porch every day, but it's really me.

Jay Ackerman:
You're fulfilling your commitment as an Amazon Prime, who I think last data that I saw, Amazon Prime customer averages 40 shipments a year.

Dr. Brian Lima:
Wow.

Jay Ackerman:
We're all going to either work for Amazon, or at least drive their top line. How do you invest in yourself?

Dr. Brian Lima:
Well, I invest in myself by on a health level or physical level, I try to stay healthy, eat right and I try to exercise as much as I can. Some days or weeks are better than others, but I think it's important to lead a heart healthy lifestyle, which includes exercise.

I like to read, I like to read about what could I be doing better, not just in the obvious surgical stuff for my field, but just in general. Leadership skills, mindset, all those things that make you a better leader in your field, independent of what area it's in. I do read a fair bit about things like that, and I am actually trying or working towards an MBA in healthcare management, because the business side of medicine is something I'm still learning about, and something I never really paid attention to or really, frankly, was exposed to as a med student or as a resident. So, I'm kind of embracing that now.

Jay Ackerman:
Well, I applaud you in trying to find the time for that with all that you have with your hospital obligations. How about last one, what's your favorite quote?

Dr. Brian Lima:
Fatigue makes cowards of us all. I thought it was Jimmy Johnson, but it's... the super bowl trophy's named after him, it's the ...

Jay Ackerman:
Lombardi.

Dr. Brian Lima:
Lombardi.

Jay Ackerman:
Vince Lombardi. I haven't heard that one, but that certainly resonates. I'm working hard to up my sleep quotient, and-

Dr. Brian Lima:
Yeah, yeah. It's kind of like the mantra, fatigue makes... it's sort of a... that's when you start to, less attention to detail, but it's mastering that. Mastering your fatigue or overcoming fatigue is key, I think. I like that one. It's short and sweet too. It's not like super long.

Jay Ackerman:
No, that's great. That's a perfect one to wrap up on. And Dr. Lima, thanks again for your time and your openness.

Dr. Brian Lima:
Thank you. I appreciate it. Thank you for having me.

Jay Ackerman:
This has been fantastic. So, this will bring our Value-Based Healthcare Podcast to a close.

Thank you for joining us today. Listen to more episodes at Reveleer.com, or find us through your favorite podcast platform. For episode updates follow Reveleer on LinkedIn.