Transforming Healthcare Through Interoperability and Innovation

[00:00:08] HIT Like a Girl and I'm Demi Radheva. And I'm Kristen Valdez, founder and CEO of BeWell. All right, Kristen, let's talk about, let's start with a quick intro. Can you share a bit about your background and your role in healthcare? Yeah, I've had the good fortune of being a healthcare executive for almost three decades now. I started my career in healthcare as a contractor to the Centers for Medicare and Medicaid Services. And my first job was to go into every large payer across the country, consume all of their data,

[00:00:35] and build an aggregated national set of data for the trust fund, which had not been compiled previously. And then do the same thing to match it to state Medicaid, information for the purpose of things like fraud, waste and abuse analytics, and then more advanced quality and cost analytics that have now become the underpinnings of what is value-based care. And then I had the unique opportunity from there to go work for one of the country's first private Medicare Advantage plans.

[00:01:00] We were a CSNIP, so we only enrolled seniors suffering from diabetes, heart failure, COPD, and stage renal, and got to build a health plan from the ground up. So we grew that profitably in a 12-year period. And then naturally, we were acquired by UnitedHealthcare. So I stayed on there as an executive for many years before launching BeWell just about a decade ago. Amazing. We're here at Vive discussing what's coming with the new administration. From your perspective, what are the biggest policy shifts or industry changes on the horizon?

[00:01:28] I think we're going to actually see acceleration or more of the same when it comes to the agenda of HHS, CMS, and ONC. And the reason that I say that is that when you think about transparency and innovation, and I think a lot of times federal mandates and rules are passed and people think, oh gosh, another compliance box I have to check, when in fact they're not stepping back to say, why are these federal mandates coming down?

[00:01:53] And it is unequivocally aimed at creation of an innovation ecosystem, because we as a country have a runaway freight train of a pricing problem. And the only way economically to really bring prices down is to create more competition. Well, it's hard to create competition if you don't have transparency and data liquidity that can move throughout the country. And so I think while a lot of people refer to things like the information blocking and interoperability rules,

[00:02:20] there are price transparency rules, there are prior author forms, there's provider directory rules, and they're all aimed at solving a problem. It wouldn't surprise me if we saw new rules in this administration around time to get care, because it's a pain point for consumers. So if you look at all of the implementation guides that were created with open standards, data technologies that become mandated, they're all specifically trying to solve a consumer problem. And so I do think that we're going to see more acceleration, just like we did in the last Trump administration.

[00:02:50] That's great to hear. So BOL is tackling one of healthcare's biggest challenges. You mentioned it already, interoperability. What's the biggest barrier still preventing true data sharing across the industry? I'll first start with a positive, which is we are so, so much further than I ever thought we would be. When I say tears come to the eyes of people who've been working on this for decades, when we can actually leverage NIAL2 credential, we can run a record location services across Tefka,

[00:03:18] even though it's not widely adopted, and we can see where consumers' data is, since most consumers don't know where all of their healthcare data is. But we also have so few remaining information blockers, by definition of the term, who are not sharing open APIs using a higher standard direct to third-party applications on behalf of consumers. So I think that the hurdle around adoption of technology and implementation guides

[00:03:44] and getting people to say it's the right thing to give consumers access to their data, I think that where the ball is finally rolling downhill and we're not on roller skates, holding a boulder above our head going uphill, I think we're finally on the right trajectory. And I think where we need to head from here is more refinement of the data that's available and the completeness and quality of that data and timeliness of things like tokens and how hard it is for users to remember their portal names and passwords,

[00:04:13] which is why we're so excited about IAL2 technologies, which is really just, if you can use your retina to board an airplane, why can't you use it to get your record? And we're proving and have acceptance in the community to people who are willing to say, if somebody's gone through that really advanced identity solutioning, that we can, in fact, safely with today's patient match rates and wrong record scenarios, we can actually give people access to their data more simply. So I'm incredibly excited about where we are from an interoperability perspective.

[00:04:42] I think that the next war to be won that we need to move on to now is access to care. How do we create the same type of open implementation guides that get widely adopted so that regardless of where a consumer is, they can see if a care plan, you know, walking out of the doctor, they can, in the same transaction, in the same application, be able to fill their medication, decide if they want to pay cash or benefit, have it delivered to them versus pick it up at the pharmacy or book the follow-up, you know, therapy

[00:05:10] and see what the availability is in network to their insurance. I don't think that we should continue to build portal after portal after portal that a user has to go navigate because it is estimated that consumers' information is now in more than 70 different disparate locations and that has to stop. Which leads exactly to my next question. Consumers expect a seamless digital experience in every other industry and that's what we're kind of running up against.

[00:05:35] So why has healthcare lagged behind and I guess how is BeWell working to change that? So there's a couple reasons why healthcare is lagged behind. One is that we have over-indexed on the HIPAA privacy rule. We have made it so that families can't consume healthcare as a unit, but we know that 86% of healthcare decisions in our country are made by women. Our whole system is governed and run by monolithic infrastructure. There are so many on-prem instances of monolithic systems

[00:06:03] that tie data up in proprietary data models that we still can't access today. They're still trying to get to, we're in our cloud-based moment, right? So healthcare largely completely missed not just the digital era, but the internet era, right? And so we're trying very hard to catch up with that, but it did require federal mandates and federal dollars to make that happen. So why is another like big blocker, why people haven't created these seamless digital consumer experiences? Simply because they're not getting paid to do so.

[00:06:33] We have a system that's working exactly as we designed it. And if we don't change the way that we design it or change the mandate that force people into that, they're not going to change willingly. And so digital transformation has been on a 10-year journey where every time you've got somebody trying to move in the right direction, you've got 10 more people pulling back in the opposite direction, trying to keep things the way that they are. So it is a transformation. It is hard. But until we create more incentives or until we get enough proof points out there,

[00:07:02] which is where I think B-Well plays a role, that says by doing the right thing that people want, you actually get extended loyalty. You get higher ROIs. You reduce your administrative costs, that your profitability and your, and quite frankly, technology can be a revenue generator for healthcare companies. But we have to be willing to adopt it. And so I think the more data that comes out that proves that, alongside these transparency mandates and the infrastructure in cloud-based and FHIR-type technologies, I think you're going to see more adoption. It's just taking longer than it should.

[00:07:32] So the new administration may bring policy shifts affecting data access and interoperability. What key policy changes do you think will have the biggest impact? You know, I don't think that the first thing on the agenda is going to be interoperability policies. I just don't. I think that there is going to be a reckoning when it comes to price transparency. So I think if you think about all of the federal mandates, price transparency is going to be really key to this administration.

[00:07:58] We do know that the administration is very favorable to risk-based contracts, right? I mean, the goal is still by 2030 to have everyone in Medicare in a value-based plan, whether it is with Medicare Advantage or it's with ACO Reach. Doesn't matter if it's on the provider or the payer side, but everyone's going to be trying to continue to shift away from fee-for-service and onto value. And that is a very slow change. But we have to see companies disrupt their current models in order to get into that change. But I don't think that there's going to be a slowdown.

[00:08:27] And I don't think you're going to see the new administration come in and saying, hey, Medicare for all. In fact, I think they're going to say more Medicare Advantage for all. And do they make it more of a de facto go-to-Medicare Advantage before coming into the federal infrastructure? And quite frankly, there's better benefits to Medicare Advantage plans because they can underwrite to the populations that they serve. And they can offer more rich benefits than even what fee-for-service Medicare can. But we don't do a lot of education for people around that.

[00:08:54] So I think that's probably going to be where the emphasis sits right up front. But we're still going to be pushing and writing transition memos and asking for the new national coordinator to focus on access because what we've learned is that convenience is king. And when you make something easy for someone to do, they're a lot more compliant. And without being able to write an appointment to the point of care and have some bi-directional real-time data exchange away from just being able to pull data, I don't think we're going to get where they want to go fast enough.

[00:09:23] You mentioned education. If we make it seamless, is education really even necessary? Right. It's interesting because, and there's some other folks that I would encourage you to talk to from a podcast perspective who have learned that sometimes it's easier just to help people understand what they need to do and make it easy for them to do it versus educating them on the why. And that's true, by the way, on provider behavior in the same way that it is on consumer behavior.

[00:09:51] So if you have, you know, health plans have been, you know, banging providers over the head for years, basically saying, hey, you're not performing well in this value-based contract. And the payer's like, or the provider's like, I don't even know who's enrolled in this program. Do you think that when somebody walks in my door, I know what insurance company they have, which contract they're covered under, what is the gap in care that I'm most incentivized for? So if you create a provider enablement tool that says, hey, Kristen is due for the following three things. We want you to do it in this order. By the way, she's missing this HCC code, which just means that, hey,

[00:10:21] you don't have a diagnosis code on her record for a lower extremity complication to her diabetes. We know she has it. She didn't suddenly regrow a limb. Could you just code it, right? So that we get the appropriate premium to cover Kristen's costs because she needs additional lower extremity care. So if you just tell the provider, these are the things I need you to do in an overlay to the system that they already have, it's much easier than going and trying to educate on HCC coding to every provider in America, right? Because that's not why they took the Hippocratic oath.

[00:10:49] So let's just be honest, like we're mix matching things. Consumers are the same thing. Your doctor wants you to have this lab panel drawn. We don't need to educate them on necessarily what that lab panel means, but if their doctor wants them to do it, the easiest next step should be, here's the availability. It aligns to your digital calendar. Can I book it for you? So until we string these things together to make them no brainers, I don't think we have a prayer at education. Now that's different than lifestyle and nutrition

[00:11:19] and the behavioral change that needs to happen for people with metabolic disease and other things. But we're intermixing task-based things with education. And I don't think that you can do both. So you might as well make the easier part of, can I just at least get people to the care that they need more seamless? This brings the question of partnerships. And I'm even curious from B-Well's perspectives, are there any innovations or partnerships around innovation that you're exploring this year? Oh, absolutely.

[00:11:48] You know, one of my, and we've talked about this before, it's been, you know, kind of pushed in the public, but one of the most innovative things that we're excited about is the fact that because of all of the interoperability mandates, because of the transparency, new players are able to come into healthcare outside of the traditional players, right? We've always had the health plan, the provider, the patient, the pharmacy, the lab, and these are like- Everybody in their silo. Everybody in their silo, right?

[00:12:15] So how can big tech companies come in and support healthcare in a way that connects everything, right? And so we have this amazing partnership with Samsung Health. They are masters of the sensors and the wearables and the aging in place and the connected home. And they have better technology around sensors that just honestly is mind-blowing. And I'll give you a quick example outside of health to help you understand how advanced these technologies are that we're not leveraging in health, but we should.

[00:12:42] They have a sensor that I watched a video on where they can detect in motion when a female is brushing her hair and they can deploy the robot vacuum to clean up the floor. I need one of those. So talk about hit like a girl, right? Like they really are understanding the sensors and the needs. So if you think about the fact that if we can do that, we should be able to help people in their healthcare at work, at home, and everywhere that they are.

[00:13:09] So Samsung's partnership to give their 64 million US users natively on their phone the ability to connect and aggregate their longitudinal health record where they can get more personalized insights that integrate not just in the traditional evidence-based medicine guidelines that we all run and try to get people to do. But they could open up an entire ecosystem on a device that people already have in their hand most of the day anyway. And if you think about their smart things, you know, I laugh because my husband and I moved

[00:13:38] about a year ago. And I was like, I really want to understand the smart things since we're going to be partnering with Samsung. And so I have the Samsung refrigerator and the washer and the dryer and the TV. And it's, you know, I put a cup of water in the microwave to get warm. And if I happen to have the TV on, the TV will tell me that my water is hot. Oh my gosh. It syncs to the phone and the calendar reminding me of doctor's appointments. So where are people mostly? In their kitchens, right? And so if you think about the ability to connect all of those things alongside the average 1.4 times a year someone goes to the doctor,

[00:14:08] which is what generates the medical record in the claims, you can get to health in real time. So I would say what I'm most excited about is advancing more partnerships like that where we can bring the disparate silos together. And they even announced that because another, you know, big partner of ours is Walgreens. We announced on stage at Health that we were going to allow for people on their Samsung phones to be able to book their vaccine appointment at a Walgreens or transfer their script if it could save them money.

[00:14:36] So by opening up cloud-based technologies and APIs, people can stop thinking about what is my experience with a consumer and they could actually live their promise of the cliche statement of we meet people where they are, which is on their televisions, on their phones, you know, on their watches and their wearables in their everyday life. Grocery stores. Exactly. If you had to make one old prediction about the future of digital health, what would it be? Well, I'm sad to say that I think most digital health innovations, especially those that are desperately needed,

[00:15:05] are going to die on the vine because, before that they can really be realized because we have not created payment and reimbursement mechanisms to be able to deploy digital health technologies. But digital health technologies hold the promise of the 98% of the time that people are not in a doctor's office. So, I think we're going to have to, if we really want to see people age in place and we want to be able to get into the home and if we really want to mitigate risk, it can't be 1.4 times a year. We have to be able to create

[00:15:35] payment and reimbursement models and get digital health right because it's not a technology problem. It's not an education or content problem. It's not a privacy and security problem. And what I get frustrated with is it's also not, every startup company in digital health isn't some kid out of college who's never worked in healthcare. Some of them are caregivers and patient advocates and people who've been in healthcare that think they know a better way to solve a problem that's not being solved today. And we have to be able to unlock the point of care and get information to the doctors.

[00:16:04] And I don't mean flooding them with data, but I mean giving them the right information and insights at the right time to make it easier and more helpful. So, I think we're going to have to do a little bit of a reboot in digital health and I think it's going to, as more and more of these ROIs come out about data and health in real time, we're going to have to find the reimbursement models in order to make it work this time. And you mentioned having worked at one of the largest payers. I'm very curious, are you seeing things that they're working on where they are as payers

[00:16:33] trying to drive innovation and partner with these solutions and open doors for them to make the technologies more accessible to their members? So, I will say, I think they went through a phase of doing that and I think that they're pulling back a little bit, especially on the payer side and for a good reason. And it's because they need to get their data strategy right. At the end of the day, healthcare payers are technology companies and data is their product. They just didn't treat it that way.

[00:17:01] So, now with AI and LLMs, what they're realizing is I can't just utilize these newer technologies because my data is locked up in, you know, one, two, or 70 different silos where when you think about companies like a B-Well, we normalize and standardize everything to FHIR. So, we're training against one of the most documented data models in the world. It's so much faster for us to bring LLMs live for health systems and for payers and for pharmacies because we're not having to deal with those data challenges. So, I think right now

[00:17:31] payers are going through the one, no, we can't build everything ourselves. Two, we have to get to the cloud and with a strategy that allows us to make this easier because we can't go partner with 100 digital health companies right now, they're doing 100 contracts, 100 integrations and implementations and the data to even share with those organizations is too hard to get to and it's too stale by the time it does. So, even if they deploy it, it's not going to have its digital moment that the consumer expects. So, I think most of them are actually working on their data strategies and I think that's the right thing

[00:18:01] for them to do so that they can speed up down the road. So, I think I've seen some slowdown for them to speed up but I think they're focused on the right things now. Completely agree. In my experience, I was in a very much a corb dev role within a very large peer and one of our vendors had seven different touch points with the organization and they were asking for different types of data, etc. So, I completely agree with you. If you could just send one message to, again, bringing it back to policy, to policymakers about the future of healthcare,

[00:18:31] what would it be? It would be that we have to take what we started with transparency and data and we have to apply the same pattern to transparency and access because access is the war to be won. It's way, I mean, 90% of humans, especially in the U.S., when they need a doctor, they just ask a friend. Do you have a dermatologist that you like? But we're not looking at quality. We're not looking at covered benefits. We're not looking at out-of-pocket costs. We're not looking, and when I say quality, I mean, what are the outcomes

[00:19:02] for people like me? And we are barreling in science towards precision healthcare because the science of medicine has so far surpassed the administration of it. And we're fighting over whether or not we should expose APIs to tell somebody if it's more convenient or fast to get their flu shot at a CVS versus a Walgreens. But every payer in the country can say, hey, if you can give me a provider directory every 30 days, you can expose an endpoint of where every provider in your network is a condition of being in your network, how they can access

[00:19:31] scheduling and they can start to advance the ability to have doctors open up their schedules in order to facilitate care access faster. And I think if we can do that and marry that with the price transparency and we can marry that with the quality, you have actual competition where people are going to have to raise the bar if they want to fill their panels and that will help accelerate the move to value-based care as well. So I just think that we need to pass more legislation on oversight for accessing care,

[00:20:01] not just the data around it. Amazing. Where can our audience find and follow your work? They can find us at www.icantheletterbewell.com. Amazing. Thanks for being here with us. Thanks so much for having me. I appreciate it. Thanks for listening. You can learn more about us or this guest by going to our website or visiting us on any of the socials with the handle HitLikeAGirlPod. Thanks again. See you soon. Again, thank you so much for listening to the

[00:20:31] Hit Like a Girl podcast. I am truly grateful for you and I'm wondering if you could do me a quick favor. Would you be willing to follow or subscribe to this podcast or maybe leave us a rating or review? Or if you're feeling extra generous, would you share this episode on your Instagram stories or with a friend? All those things help us podcasters out so much. I'm the show's host, Joy Rios, and I'll see you next time.