Episode 160: Afua Branoah Banful on tele-health and other transformational medical technology

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April 1, 2019

Our guest today is Afua Branoah Banful, an Umbrex member and McKinsey alum with a PhD in Economics from Harvard.

We discuss the spreading adoption of tele-health and other transformational medical technology.

To learn more about Afua (who goes by B.B.), visit her firms’ website¬†http://soundhealthadvisory.com/

HIGHLIGHTS

Will: Hello, B.B, welcome to the show.

B.B.: Thank you so much, Will, I’m so excited to be chatting with you.

Will: So, B.B, I can call up business colleagues all over the world and do a Zoom video conference. Alot of times that can eliminate the need to have an in person meeting. But it’s not so easy for me to just get on a Zoom video conference with a doctor and get diagnosed or have a prescription. I know that you have done a lot of work in telehealth. What’s going on in telehealth, what’s going on right now? And what should we expect to see over the coming months and years?

B.B.: Well, I should say, Will, right now is a really exciting time in telehealth because this year the CMS has changed regulation that industry, this would be the healthcare providers and both health IT vendors have been asking for a while. That is to reduce the number of restrictions on ability to actually use telehealth with patients. In some cases, ability to get reimbursement officially from CMS.

Some of you who have been following telehealth for a while would know that there have been many years for which we said telehealth’s about to explode. But I think right now, with some of these CMS changes, it really is about to happen.

Will: Okay. Just for me, for my benefit, what do you mean when you say telehealth? What’s the definition?

B.B.: That you would hear some folks call it telemedicine, telehealth. I just use it the same term. Broadly, telehealth is the use of communications, electronic communications, let’s say to enable healthcare remotely. You can think of big buckets of applications for telehealth as in one would be when it’s a professional to another professional. Think of a primary care specialist contacting a cardiologist or another specialist to get more information and guidance on what to do with a patient.

Another category, and the one that some of the listeners may have been familiar with is when you as a consumer can directly call up your provider or the provider calls you up, and you have some sort of direct connection between you, the patients and the provider. Let’s call that the direct to consumer visits. Then there’s the third category, which is the use of a device. So, remote monitoring, using some device to collect data and send it to for interpretation or just live track what is happening with a patient and act on it if something happens.

Will: Awesome. Okay, I hadn’t thought about all those three categories. What is the status today? Let’s say in the United States are their other doctors where you can go online and do a video conference and get a prescription? Is that legal at all, or is it more-

B.B.: Yeah. Most definitely. This is where the industry has been going for a while, trying to get these direct to consumer visits more and more part and parcel of how healthcare is delivered in the States. Today, either through your insurance company or through your employer in some cases or the health system, there are various ways in which you can connect with a provider, especially for urgent care. Because one of the advantages that health systems and various providers I found for using telehealth is that it is often cheaper or lower cost sites of care to see patients for those lower acuity conditions like colds or unknown rashes or some coughs.

You can do that today. It is legal. It is nowhere near happening as often as was predicted, but it is happening.

Will: I’ve never done that. Are there companies that have doctors on staff there? Or how does it … I have health care insurance, how would I even go find a provider who would do that? Is it companies or do I find an individual doctor? How does that work?

B.B.: Yeah, let’s talk about again, three models. One is when there is a telehealth company or vendor that has the IT and also decides to bring on physician group practice of some sort to provide services using that IT. You may have heard of companies like American Well, Teladoc, MDLIVE. You can go online right now, download the app and have a consultation with them. They do everything from lactation consultation to psychotherapy to urgent [inaudible 00:04:59] You can do that as a consumer.

There’s a second category where a health system would have bought a technology and the health system’s own providers use that technology to have this with known patients. In some cases, first time patients. Let’s say you have diabetes and you have to go and check in with your provider every three or four months. One time they can say, “Hey, for our next second if everything’s going well we can do this by a video visit. And then you can talk to your own doctor or nurse practitioner using that visit.”

Then this third category where there are institutions, well known institutions in healthcare like CVS. I think yes, Walmart is actually doing a Walgreens for sure. They have minute clinics, all these sites of care in some of the locations. Now, they’re expanding that where you can actually also see a provider using telehealth without having to walk into the minute clinic, right? Even slashing down the time further for you to access care as a consumer using their services.

Will: Oh, that’s pretty cool. That minute clinic is great. I got a flu shot there the other day. It’s easier-

B.B.: They can’t quite do the flu shots over telehealth yet.

Will: Yeah, I got that. Okay. There’s some companies that do this, and then how does it work with the reimbursement? With the companies that you mentioned, like American Well, or MDLIVE, do they take insurance or is it only cash pay with those kind of companies?

B.B.: The short answer is yes, they do take insurance. They have been caveats which have made the adoption slower paced than many would have wanted. This is why the new rule changes by the CMS this year have been exciting to both the vendors and the healthcare providers. In the past, if you wanted to have a telehealth visit, for simplicity of actually executing whatever programs that had been set up, most of these places would say, just give us something like 49.99 or $49 a visit and we will see you. If you have insurance, we will go through the process and help you get reimbursement for that.

Now, health care providers themselves are beginning to adopt and implement telehealth solutions as part of their service delivery. It’s becoming more typical as compared to when you walk into a doctor’s office, give you a card once and they know you and then you can have some services there. Every now and then they’ll ask you, check your eligibility again. You can do it both with direct pay from your own resources or through your insurance with some amount of copay, often minimum.

Will: And then how does it work legally for the health care provider, I imagine that some things you can diagnose by asking a bunch of questions, but some things, historically I would think, I’m not a doctor or anything but they take your blood pressure and they look at your vital signs and stuff. If they can’t evaluate you in person, what limitations does that put on the kinds of things a doctor could prescribe or do?

B.B.: I think it’s useful to think about the sorts of use cases for telehealth and actually look at which conditions require a touch based solution, and which one you can do over the phone or with video. I was particularly shocked to learn that the biggest cost drivers in the EDs, emergency departments or ERs as some people call them were conditions that were actually very low acuity. Most of those kinds of conditions or something like 60% could be effectively treated with virtual or telehealth interaction.

Now, if you think of more acute conditions such as wound care or psychiatric visits, for instance, there’s a whole host of conditions that you can do without having to touch the patients. Think of the last time that you walked into either the minute clinic or wherever you did go. In some cases taking your blood pressure or taking your weight was just a formality. But the meat of what they had to do they could potentially have done with speaking, or observing and this is why video visits really enhances the number of conditions or the range of conditions that you can use telehealth for.

To add to that, there is a whole host of peripherals that have been created now that consumers can have with them at home, that in some cases automatically sends the information that the provider needs so that they can have a richer telehealth interaction.

Will: That’s really cool. That gives us a little sense of it sounds like things are changing in the US. Tell me a little bit about like the rest of the world. Is the US behind some places? Are there some places that maybe doctors are very remote, where this is even more established? They’re ahead of us?

B.B.: I would say that you hit the nail on the head when you talked about remote. It’s not so much US versus the rest of the world. Where necessity has driven, there has been more use of telehealth. For instance, even in the US, in more remote areas, I don’t mean remote … I say more sparsely populated areas, there’s a bigger use of telehealth. It’s more recent that we are understanding the value to even having telehealth in places like New York, Boston, DC.

So, talking about what use cases there have been in the rest of the world, I understand in the military for instance, and Veterans Administration, they have had keen interest on using telehealth for several years, especially for battle situations, and when it’s specialist treatment would be hard to access. I wouldn’t quite say US is behind. It is more of how we are using it and the extent to which we are using it.

Will: Cool. Tell me a little bit about some of the barriers to adoption and some things that are going on to address those challenges.

B.B.: There have been significant headwinds in the past. I’d say, one of them when health care providers have looked at whether to do this or not, is just been not really understanding the regulation and the reimbursement. This ties back to right now, CMS will allow the provision of telehealth in MSA that is not considered rural. In the past, there were certain MSAs in which you could use telehealth and others that you couldn’t. Even when it was allowed, it had to be in specific origination sites. For instance, you had to go to one provider’s site of care to be able to connect with another provider. In my opinion, that defeats the purpose of the convenience that you get. But that was exactly what they were concerned about where that they would be so much overused because it was so convenient.

I think there isn’t hard evidence to say that that is not an issue, but the value of having telehealth more broadly in making sure people do have the interactions as needed is being more and more appreciated. So, that concern is at times put at the back burner. Some of the headlines I say, has been regulation. The other has just been users being both the patients and the providers, not really knowing what it was, and just thinking, well, if you have a condition that you really want attention to you, you better go in and sit in that waiting room with all the other sick people.

I’d say that the third has been the lack of the right incentives. Because if you are asking providers and consumers to change their behavior in some way, there better be incentives in place. It shouldn’t go against their self-interest. With reimbursement not being clear, in the past, you could have been asking a provider to replace an in person visit that they knew they would get, let’s say $150 for with a telehealth visit that you would then say they would only get $50 for.

Will: Doesn’t seem like a very good trade. I would leave my video conference off if I was a doctor in that case.

B.B.: Yeah.

Will: Okay, cool. Tell me a little bit about your work in this space. I understand that in our past discussions that you serve health providers and serve adoption of healthcare information technology. Tell me a little bit about the types of projects that you do.

B.B.: Right. My introduction to telehealth came when I was in the Corporate Strategy Group at a company called Advisory Board Company. I was asked the big question of what should we do in consumer? With my team, this was about five years ago, we looked around and I said, this thing, telehealth here is going to become more and more important, especially as value based care incentives come to the forefront.

So, the work that I did was primarily around understanding the vendor capability at the time. It has changed dramatically over the past five years. And then looking at what the early adopters in the health systems were doing and some of the challenges that we’re facing. I would say sadly, the challenges that they were facing four or five years ago are still very much in play today. They would be in a couple of … You would see these patterns over and over again. Why the adoption that they were trying would either fail miserably or in some cases just be there and wonder why they should keep going on.

I’d say the biggest issue that I saw was not being able to [inaudible 00:15:51] the big strategy they have into tactical goals. There would be a splash around, oh, we want to use telehealth to improve our patient experience or to improve patient access. But they weren’t able to turn that into specific goals, like which population segment are we going to go after? Who are the kind of providers are going to use? What’s the use case? What’s the technology that we need?

Another category of typical issues that observed would be when the health system had even decided on the use case, sometimes they weren’t able to operationalize it. Because often they did not acknowledge the efforts and the resources it took to operationalize. You would have a team of CXO, CMO, CMIO, like Chief Medical Officer, Chief Medical Information Officer, maybe Chief Quality Officer who have very hefty day jobs being tasked with also delivering on operationalizing whatever the strategy was. That never worked well because it took so long, they lost steam and it never really materialized beyond little pilots.

Let’s see, what else? I’d say another area of challenge has been even after they’re able to implement some pilot or have one or two use cases, it falters because they are not able to scale the adoption. There will be pilots that had a lot of enthusiasm in the beginning but one champion would leave and the whole thing would fall apart. Mostly because they’re not able to market what they’re doing effectively so that consumers want to take it up, providers want to use it, and that they’re able to show that they’ve had impact.

Will: It sounds like you came into the whole space of healthcare and consulting in healthcare actually, through that work at the Advisory Board. You did a PhD in economics and I think you did work on fertilizer use in Nigeria, right?

B.B.: Yes.

Will: Could you tell us a little bit about that. And maybe if there’s any things that you learned in your doctorate now that you applied to the work in medicine?

B.B.: Let me actually correct you there. My work in healthcare started when I was at McKinsey.

Will: Okay, great.

B.B.: So the whole story is, to me, it makes so much sense. But someone has told me like, I don’t see how you ended up here. But I’m very glad that you did. I grew up wanting to be an engineer and wanting to go to MIT. When I was at MIT, I discovered the power of the social sciences. So, took up a second degree in economics and then decided to do that in my graduate work and focus on international development. Hence, you see the work in fertilizer and food policy and such. But after doing that for two years, I wanted to have, let’s say, more rapid impact and a bigger scale. I thought private sector could do that.

Went over to Mackenzie and was focusing on doing public sector, social sector work at Mackenzie. Through sheer happenstance because staffing and timing was right, I did ED throughput, emergency department throughput study and was hooked, fell in love. That was I had found my mission driven passion as it were in health care. I started doing healthcare work, mainly hospital frontline operations, hospital operational efficiency, that sort of work at Mackenzie. And then that’s when I left to go to Advisory Board, which is healthcare focus to focus on it.

Will: What are some of the things about hospital operations that you’ve worked on that you’ve seen improved that us as patients walking in we’re behind the scenes. But what are some of the operational improvement opportunities that exist at hospitals?

B.B.: I would say the biggest change, which maybe you as a consumer can begin to see is all deriving from value based care incentives. Now, to explain that a little bit, you may understand that in the past, hospitals were paid on what they did, fee for service volume. It had really nothing to do with the outcome that the patient, so, it’s just what was done to them. This is why you as a consumer could go and have had an X ray a month ago and go to another site of care and they say, we need the same X ray again. We’re going to take it again, not because we think anything has changed, but because we can and we will get paid for it.

This is simplifying a little bit the incentives and some of the reasons why that was done, but it was a very duplicative and wasteful process, and then senses were not in place for that not to happen. Now, with the changes in reimbursement approach where more and more hospitals are being asked to produce outcomes, and are paid for the outcomes, you’re seeing changes in operations where there’s more focus on data sharing, but providers talking to each other more about the patient, trying to make sure that there’s less duplication.

That has positive impact, not just in the cost of healthcare, both to the patient who would have some out of pocket contribution, but it also has an impact on the patient experience and the quality of the care that they’re receiving. I’ve been in health care now for going on eight years. Even in that time, both as a patient and when you go into hospitals, just the discourse that you hear, there’s more focus on being more efficient in whatever it is that they’re doing, because now the incentives are pushing you to be.

Will: Well, it’s good to hear that that change is happening rather than just getting paid to do more and more test.

B.B.: Yeah. Can I tell you, Will, I use this example with my mom the other day, about fee for service versus value based care. She seemed to track. So, I just want to share it. I told her it was like going into a restaurant, looking at the menu and just seeing the meals with no prices whatsoever. And then the other catch was that the amount that you paid would be different than the amount of the person sitting by you paid. Because it depended on what the chef who made your food decided to do versus what the chef who made the other guy’s food.

For every step they could decide to charge and the amount that they charge could change without explanation. And definitely wasn’t transparent to you. It just was mind boggling to have that that system had existed for so long. I am sure that there are reasons why this is the way we were paying, and actually indeed are still paying for a lot of our health care service based on the activities that are done, instead of the outcomes. But it’s something that I personally I’m so excited to see is changing because it just seems to make sense.

Will: I love it. Love the analogy. They could serve me and charge me for two or three bowls of soup.

B.B.: They could drop one on you and it doesn’t matter to you.

Will: Not whether I like it or not, that’s cool. Now, being in that healthcare space and doing it for eight years, tell me a little bit about the range of work. I understand that you work with providers on adopting healthcare IT. Can you give us an example of a project that you’ve done? You’ve sanitized the details if necessary.

B.B.: Can I expand just what I do, also, just to make sure I don’t forget to talk on it. I also work with the health IT vendors. It’s not just with the providers. With the providers, it’s mainly about helping them evaluate what their options, helping them pick from hopefully what a good set of options is. One project would be looking at an opportunity to use telehealth and saying which use case would make the most sense. Primarily, the option was using it in urgent care, which you could make a big splash about or in a more quiet and less flashy frankly use case of doing pre and post OP visit follow ups.

Over there was helping them think through what, one was the strategic impact of using that as the first use case for telehealth would be for the organization is and what the economics were. What I found is that when it comes to adopting new technology in the early stages, there’s going to be a lot of forgiveness if there’s no ROI. But very soon, and invariably at some point, some CFO or even the director is going to have to justify why the expense is being made. If you are not using it for a particular segment of the population, which could ever hope to return any ROI, it becomes a question at that point why you started. So, helping them pick the use case for which they’re using the solution.

Will: What about implementation and actually getting adoption and so forth?

B.B.: On the implementation side, it’s mainly about helping them just design the workflows. It is a very, actually, sadly common, but also, big indicator of telehealth program about to fail when the thought is that you will just put the technology in and keep using the same process, or basically you’re going to make the process that was in place electronic. You have to be thoughtful about the operational changes that you need. In some cases, the changes in the people infrastructure, you may need a role that wasn’t in place before so that you are not wasting the time of the physician to who is now online with somebody checking their insurance eligibility. Whereas in the past it may have been fine to send the patients straight in because you had the information on file.

If you’re doing things in a virtual visit, you would need to have an interim step. That may not have been there in the full touched patient being present on site situation. Some cases they don’t think about things like that, and put the technology in. And then find that there’s a big push back and backlash from the physicians, nurse practitioners who are finding themselves doing work that nobody thought would arise out of using the technology.

Will: Tell me a little bit about your work with healthcare IT vendors.

B.B.: Oh, it’s also around evaluating new opportunities. But it is more directly related to the go to market strategy. So, helping them think about the product that they’re working on. Is it a worthy problem that they’re trying to solve? Is the solution that they’re putting out there promising? Will someone pay for the solution?

The thing with health IT today is that the hype is just laid on thick. If you throw in AI, big data, and what’s the third one there? Analytics, you get people looking up. Much of that in practice is not what is needed to actually move the lever on the problem that’s being solved. So, helping them separate out what sounds like is going to get you good early investment angels and seeds to something that is actually going to have a believable path to be in a sustainable business. Because health systems and payers who are usually the paying entities for these sort of solutions, they require quite a high bar of proof and a high bar that it’s worth it taking their money. And not just the money but even the time it takes to implement. Because you are asking providers who are already inundated and very busy to do something different, change their practice.

So just helping the IT vendors put themselves in the shoes of the people that they’re going to serve and make sure that the solutions are actually practically what are needed?

Will: What are some of the healthcare technologies that you’re most excited about that are on the early part of the adoption curve?

B.B.: I think that very very early is voice, voice enabled solutions in healthcare. My mind through in that word, telehealth because it really is telehealth when you’re using a voice enabled solution. I worked with a company that is thinking through how it can use AI like Alexa or Google Home to help with managing chronic conditions. Both when the patient is at home and on the provider’s side.

That was really exciting because when you think about the population that is driving the highest use in healthcare and the population that suffers most really from a high burden of managing their conditions, they’re often 65 and above, multiple chronic conditions. May have some impairment or disability. I have found voice so freeing in my own experience and use, and I’m excited about the possibility that we can bring solutions like that to healthcare.

Instead of asking patients record your blood pressure every day, record your weight every day, you can give them a solution where even if they take the blood pressure with a non-Bluetooth enabled cuff, they can speak out the answer instead of having to find a pen and paper and write it down and keep track on it. You can even go a step further by just giving them the Bluetooth enabled cuff. They just do it, it’s recorded. They in turn speak with Alexa or Google and ask, what trend am I on? What changes do I need to do today? Yeah, that’s something that I find exciting.

Will: Or imagine your home device, Alexa can say, “Hey, Will, it’s time to take your blood pressure. Put the put the arm thing on.”

B.B.: Yeah. Or, “Will, get up and take a walk. How about that?”

Will: Take your pills. I’m really going to enjoy that. “Will, stop eating that. You said that you were going stop.” Can you find some vegetables.” Oh my God. Alexa is going to be remind me to take the pills or to get some exercise. Or just, hey, time take your blood pressure. I can easily imagine that because even being sort fit and relatively healthy it’s sometimes hard if you have some prescription or something for a cold or something. It’s like take this four times a day, three times a day. Totally forget at lunchtime, and, for someone who’s older who has the whole kind pills throughout the day, it’s like a major job?

B.B.: Yeah. People are taking 16 different regimens. Some of them have to be tailored depending on the weather, depending on what they’ve eaten. It’s just really exciting to be able to have that support. It’s almost like you have the physician or the caregiver in the home with them because you can program the solution to take into consideration what has been happening and spit out the best answer for the client. It’s an improvement on asking people to remember. I’m really excited about that.

Will: That’s very cool. I’m curious about your own personal productivity routines. You are accomplishing an amazing amount. What are some habits or practices or daily routines that you found really helpful?

B.B.: I should call out as many people identify with this. I got into independent consulting because I wanted to be productive and yet have a life that I was happy with in terms of balance. In productivity, I’d say I mix a good dose of living activities with work activities and consider them almost part and parcel of what I need to achieve each day.

I play the piano. I start my day each day by playing the piano for at least 30 minutes. I have recently taken up painting. I try to fit some painting in maybe two times a week. I’m laughing because I wasn’t able to do that this week during my lunchtime if I am not on site. But otherwise I am pretty much in a very office like setting where I set up an office and come to my office and in the office I set where I’m doing calls and meetings and problem solving from a set number of hours each day. Sometimes late in the evening after I put my little girls to bed.

Will: I love that you’re playing the piano every day. I’ve asked a lot of people about their productivity routines or their daily routines and I have not heard a lot of people say that. So, I think it’s awesome that you still playing music. May I ask what kind of music you’re typically playing? You’re doing classical jazz?

B.B.: It’s classical. The piece I’m working on right now is it’s a Bach piece right now. It’s from the well-tempered clavier, Prelude nine. It’s going to take me a while because 30 minutes is not much time to practice. But it’s something that I love doing. Something that I was not able to do when I was a consultant in another setting or even working in an office. I’m really glad that I’m able to do that.

Will: What’s it mean to you? How is your day different on days when you have that piano practice, and the days when you don’t?

B.B.: I am nicer. Can I say that? It is the time where I am able to because I’m focusing so much on learning the piece or practicing the piece that I am not actively trying and sometimes succeed thinking of anything else. So I feel like I have had a great big sloppy burger with all the fries and the Ketchup, and I have had my treat. Then I can come down and say like, “Okay, you got the treat first. Now let’s do this.”

A lot of the work that I do, I consider a treat also. But I love just being able to even psychologically say that you have taken this time out and I’ve done me, and now I’m coming to give part of me to someone else.

Will: What about the painting? Tell me a little bit of that yet. Is there any place online where we can see some of your work? Tell me a little bit about your painting.

B.B.: I started the painting by looking at YouTube videos. Actually, that’s still what I’m able to do. I send pictures of the paintings to my friend and they’re like, “Oh my God, this is so amazing. We didn’t know you were so talented.” I’m like, “I am not. I can follow instructions.” I follow instructional videos on YouTube. I do mainly landscapes because I just love the openness and the feeling of being outside. If I can’t do that, I’m going to paint about it. It’s very similar to the piano playing where I’m so intent on doing that thing that everything else is stewing on the back burner for a little bit and then I come out and able to focus more.

Will: B.B, where can folks who want to learn more about what you’re doing and perhaps get in contact with you, what’s the best place for them to go?

B.B.: My website would be the best place. I formed an LLC when I went independent. It’s called soundhealthadvisory.com. That’s a website. It’s a play on the sound advice I hope to give, the sound health I hope to have. It’s a place where you can find contact information of me. Of course, there’s also LinkedIn Afua Branoah Banful is the name to search.

Will: Great, we’ll include links to those in the show notes. Any books that have really shaped you?

B.B.: The books that I’ve read most recently and top of my mind has been David Field’s book, the one about the irresistible consultant for obvious reasons. A book that’s shaped me so much when I first was thinking about what I’d do in engineering itself was Stephen Hawkins, A Brief History of Time. I think that was the title. I read it when I was 13 also. Whenever I think about any book that has actually had the biggest impact and that’s the one. I and the only time in my life skipped class because I was holed up in the library reading that book as a 13 year old and I came out with my mind blown. Yeah, that’s it.

Will: That is awesome. Perhaps the first and only ever person who skipped class for reading Stephen Hawkins, but it was a page turner. I remember reading it in high school. That’s a great story. B.B, thank you so much for joining. I’ve really enjoyed your discussion. It was cool learning about telehealth and all the stuff that you have working on. So, thank you so much.

B.B.: Likewise. It was my pleasure to be here.