Ep 16: Technology, Leadership, and Quality: Healthcare’s Anthem

with Shantanu Agrawal, M.D.

July 1, 2021

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Shantanu Agrawal, M.D.
Chief Health Officer, Anthem, Inc.

Dr. Shantanu Agrawal is Chief Health Officer for Anthem, Inc. Dr. Agrawal oversees Anthem’s enterprise health strategy, including medical policy and clinical quality, as well as the company’s industry-leading work to address the social drivers of health. He will also lead Anthem’s community health strategy and the Anthem Foundation.

Dr. Agrawal most recently served as President and Chief Executive Officer of the National Quality Forum (NQF), a non-profit organization dedicated to working with members of the healthcare community to drive measurable health improvements. He is also the former Deputy Administrator for the Centers for Medicare & Medicaid Services (CMS), where he led an effort to improve the physician experience with Medicare and was also one of the main architects of CMS’s strategy to address the national opioid epidemic. Dr. Agrawal also served as Director of the Center for Program Integrity (CPI), where he was instrumental in launching new initiatives in data transparency and analytics, utilization management and payment models.

Dr. Agrawal serves on the board of the Grameen Foundation and the Presidential Advisory Council of Brown University’s School of Public Health. He is also an Adjunct Senior Fellow at the Leonard Davis Institute of Health Economics at the University of Pennsylvania and Associate Clinical Professor of Emergency Medicine at the George Washington University School of Medicine.

Throughout this pandemic, we've learned we need to put disparities and equity of various populations front and center in measurement.

Transcript

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Gary Bisbee  0:06  

Healthcare leadership is hard work, but what if you could learn from the most brilliant and influential minds in healthcare and beyond? What would you ask them? Would you ask about politics, policy, or maybe leadership? On The Gary Bisbee Show, I’ll do just that. You’ll hear from healthcare’s most successful leaders and those experts who they listen to, as together we’ll explore how the healthcare economy is transforming.

 

Have you wondered what is the role of the Chief Health Officer at Anthem, one of the largest health insurers in the country? We’ll find out today during our discussion with Dr. Shantanu Agrawal. Shantanu’s interests lie in medicine, policy, and politics. He was a senior official at CMS, where he was active in building data sharing arrangements through public/private partnerships, which have become increasingly important during COVID. He also led us through the introduction at CMS of predictive modeling and claims payment. Shantanu left CMS to become the CEO of NQF. We used his experience at NQF as an opportunity to dig into the provider burden of collecting and reporting multiple quality measures. He provided a nuanced framework for better understanding the challenges and resolution. Shantanu discussed his responsibilities as Anthem’s chief health officer, starting with ensuring that Anthem operates under a single community health strategy and leading the clinical quality team, the medical policy team, and the Anthem Foundation. We explored Dr. Agrawal’s experiences as a leader and his conclusion that the two top characteristics of a great leader are continuous communication and willingness to listen.

 

Good morning, Shantanu, and welcome.

 

Shantanu Agrawal  2:09  

Thanks, Gary. I really appreciate the chance to be here.

 

Gary Bisbee  2:12  

Great to be with you, and thanks so much. We love having you at the microphone. We like to dig into our guests a little bit early in their careers to figure out what their motivations are and decisions that they make later on. What was life like growing up for you?

 

Shantanu Agrawal  2:30  

I grew up in a small town in Northwest, Ohio. Most of my childhood in Findlay, Ohio. We actually emigrated from India when I was very young, first to the Detroit area and then my dad got a residency in anesthesiology in Toledo, Ohio. Growing up, it was a small town. I had friends who lived on farms. My dad worked most of his career at the community hospital. Because of our last name and everything, people knew us by name, they knew my dad. Anywhere I went in town, they could guess who my parents were.

 

Gary Bisbee  3:16  

Normally we ask our physician guests when they became interested in medicine. You were probably interested from a relatively early age, but did you always think you wanted to practice medicine?

 

Shantanu Agrawal  3:29  

I didn’t. I was exposed really early. This was way before work hour reforms and things like that, so my dad was on call a lot. I remember going into the hospital and seeing him there. Once in a while on call, he’d actually let me stay with him, so I’d be in the call room. I’d be sleeping and he’d go in and out, which probably wasn’t great for either one of us in terms of sleep, but that’s how I could spend time with him. I’ve had a lifelong exposure to medicine and healthcare, but actually started college thinking I’d be a PhD chemist and not necessarily go into medicine myself until I had some other experiences personally and academically and then decided to do that.

 

Gary Bisbee  4:20  

You’re a chemistry major at Brown, and then you went off to Cambridge for your M.Phil in public affairs or public policy. Were you interested in politics at an early age?

 

Shantanu Agrawal  4:32  

I credit Brown for this. I got exposed to different disciplines and areas in college. I went to a small high school in Ohio, so we had the core subjects, but not a lot beyond that. College was a time when I started getting exposed. I was pursuing my chemistry degree, so a lot of science courses and math courses, but then I started taking philosophy and political science and public policy. Ultimately, as I was thinking more about healthcare and medicine, those courses started influencing my thinking a lot more and I became much more interested in the broader social sets of decisions around healthcare and how we think about healthcare financing and who gets help in health care. That’s when I realized I actually wanted to get a deeper understanding of that, and that’s what took me to Cambridge for the master’s degree. Frankly, in part, I went to Cambridge because the UK sort of sits in this middle ground between the US approach and the European approach on a lot of different areas. I really liked how their take on healthcare was tied in to the broader social safety net. It stood in much more continuity than how we often think about it in the US. Then obviously, with the NHS, they have a system that is much more publicly driven and more integrated than we have here. It was very interesting to reflect on our health care system and the social and public policy generally sitting in a UK context.

 

Gary Bisbee  6:12  

We’ll wrap back around to that when we talk about your new posting at Anthem, I suspect as well. Growing up in Findlay, Ohio and then spending four years at Weill Cornell in Manhattan, that must have been an interesting juxtaposition.

 

Shantanu Agrawal  6:32  

They could not be more opposite of each other. I enjoyed both. It’s funny, I look back at my childhood and there was a simplicity to it in some ways, being in a small town in Ohio. I didn’t think a lot about some of the things I would if I’d grown up in New York City or some big city. Even my kids growing up in DC, they think about certain areas. There are pros and cons, but they think about certain things I was never exposed to. I actually love New York and, aside from the pandemic, look forward to going back there as a tourist and a visitor. What is incredible to me is the diversity. At the end of the day, we were an immigrant family in a much more homogeneous town and that affected my upbringing and the way I view the world. Then to be for med school in the middle of this incredibly diverse city where I could go and speak in Hindi at a restaurant or at a grocery store was such a novel thing for me.

 

Gary Bisbee  7:41  

It’s interesting. It’s a great town from that standpoint, for sure, and we all hope it snaps back from the pandemic. I’m sure it will. Let’s fast forward, you spent some time at Accenture, but let’s go to your CMS experience. You started out as CMO, ended up as Deputy Administrator of CMS. What was involved in that position? What were your main responsibilities there?

 

Shantanu Agrawal  8:06  

I first was exposed to CMS as a consultant. My organization was brought in shortly after the passage of the Affordable Care Act to do some strategic consulting work, and that was my first real exposure to the government and CMS in particular. I was really impressed. There was this moment when healthcare transformation and the energy around it captivated me. A lot of the people I was interacting with at CMS were incredibly very socially-minded people, very intelligent, driven individuals. When the opportunity came up to join the Center for Program Integrity as its chief medical officer, I almost jumped at it. What was really amazing about that work and overall the six years I spent at CMS is there were a lot of new authorities and statutory requirements that we were responding to so, even within a very large organization with a huge mandate, it felt like we were a startup. I was one of the earlier employees of the Center for Program Integrity and we were having to do a lot of build over the next several years to get into whole new areas, implement new authorities. We implemented things like predictive analytics for the first time for CMS, so it felt very new and there was a lot of energy around that and there’s a lot of energy around the mission. It was an exciting time to be there.

 

Gary Bisbee  9:34  

When you move to a position like Deputy Administrator of CMS, how do you formulate your priorities? It seems like it’s so huge. How do you zero in on what you think you can influence?

 

Shantanu Agrawal  9:48  

In some respects, it’s like starting at any other job. You start by listening to your peers, to others. In this case, the administrator, the Secretary of the White House. There are plenty of stakeholders to listen to in the government, so you go on a little bit of a listening tour. You need to be open to the input. What’s the track record been? Where can you make improvements and changes? With the government and often with healthcare in general, you have statutory and regulatory requirements you need to respond to. Then there’s The Hill and The Hill becomes an extremely important stakeholder to make sure they’re brought into your approach and what you’ll be working on. Getting in front of that as a stakeholder group early is really important as well. The second broad category is where you want to make your impact. In all of these really big jobs, big positions, there’s always this question of what am I going to bring to this role? Why is it me in this job? How is that going to be unique compared to anyone else that could be in this role? Over the years and over my career, I’ve gotten much more comfortable asking what are my priorities? How will I drive the impact that I want to see both in this position and in the world generally? That becomes another lens to view a job through. I feel really fortunate that I’ve been able to apply that lens at CMS and outside and try to address areas I thought were incredibly important.

A few things. I mentioned predictive modeling. I’ve always been data-focused and, no matter what organization I’m in, want to make sure we’re always using the best possible data to meet our mission and make sure we’re responding to it. Predictive analytics was a huge, new tool we were implementing at the time. Given the claims volume that CMS got at that time (something like 4.5 million claims per day), without an advanced algorithm-driven approach, it wasn’t possible to see patterns in the claims and in the utilization, so that was huge. We got to do some critical data transparency work around The Sunshine Act, around creating public/private partnerships to encourage more data sharing between payers and providers. I was running program integrity, which oftentimes had some really hard tools we could utilize in order to meet our mission. Early on, of course, it was really important to implement those tools and get them in use because CMS didn’t have them but, as we got more sophisticated and involved in our approach, some of the questions became, “How do we utilize a softer set of tools to still drive the goals?” So we started doing a whole series of work around behavioral approaches to altering utilization and billing outcomes. That’s felt really interesting to me. It’s a great area to work and study and apply data and apply different approaches, but it also showed that, even in a government context, you could bring this kind of innovation and apply it at scale, so that was really fascinating and something I continue to try to work on these days.

 

Gary Bisbee  13:01  

As you know, we like to focus on lessons for leaders on this show. Thinking back to the CMS experience, what lessons from a leadership standpoint did you take away that you could apply to NQF and now Anthem?

 

Shantanu Agrawal  13:17 

So many, and some by doing things right and making mistakes along the way. Getting stakeholder input is really critical. Communication is always critical. I have been told that 1,000 times in the course of my career, and I don’t think you can hear it enough. Communicating, over-communicating to your team, communicating up to your own leadership. Sure, there are a lot of stakeholders in the government, but there are a lot of stakeholders throughout. Even in a private enterprise, you need to be able to communicate to external stakeholders, get their buy-in, communicate a vision. Communication becomes critical in almost any job. Sometimes when I speak to medical students or physicians who are relatively earlier in their career, I have a kind of career guide algorithm I provide to them about how to think about a non-clinical career with their clinical training, career, and background. That’s probably a whole conversation in itself, but for physicians, we have to think about how important being a physician and working clinically is to us and how that should figure into a broader career. It’s also important to get management experience, as a physician especially. Oftentimes, we can get placed into roles that don’t have management requirements. For some, that’s great, but oftentimes moving ahead in organizations, moving ahead in businesses requires knowing how to lead teams, being a dynamic leader, getting people to organize and coalesce around a vision and strategy. Those are often skills you can only learn by doing and observing others. Thinking about how leadership figures into their career as well as the expertise they have as clinicians are critical for physician leadership.

 

Gary Bisbee  15:10  

Yeah, that’s a key issue. I’d love to follow up with you on that. That is a whole nother conversation. Onto NQF, when that opportunity arose, what was your decision process to move to that role?

 

Shantanu Agrawal  15:23  

I was amazed by even being given the opportunity to lead that organization. It’s one that I knew really well as an outsider. I followed the history of it. I’ve shared this with Ken Kaiser, the founding CEO of NQF, that I remember seeing an article when I was in medical school that he’d written about the founding of NQF and the goals and the aspirations for that organization. In many ways, it was a return to work I’d done before. For most of my consulting career, I’d been focused on quality improvement for health systems (I was actually using NQF measures in that work), so it was an opportunity to contribute again to quality. At CMS, because it was program integrity, I spent a lot of time on the cost side of healthcare and trying to think through how we address costs, what kind of interventions a payer like CMS can put into place. NQF (obviously focused on quality) became an opportunity to bring these two aspects together in a meaningful way, so that figured into my decision as well. One thing I experienced in my time at NQF is there’s an incredible amount of goodwill in the ecosystem toward that organization. Lots of people, leaders, experts step forward to support the work, to volunteer for the organization. NQF became a great place to meet these thought leaders, to get to work alongside them. It was a valuable experience for me. I felt honored that I was given the chance.

 

Gary Bisbee  16:57  

Looking forward to the rest of this decade or maybe the next three to five years, where do you see quality going in the country? Are we going to spend more resources on that? Will it become more a part of our delivery and financing of health care? What’s your thinking about that?

 

Shantanu Agrawal  17:18  

There should be nothing more primary to healthcare than assessing our quality, making sure that the quality is ever-improving. In the last few years, there’s been a good and rightful focus on the burden of measurement, but I want to be really thoughtful that as an ecosystem we don’t let that overwhelm the mission and focus on quality itself. Our measures are just beginning. Even a couple of decades into the modern enterprise, we’ve learned a lot about measurement, what works, what doesn’t. We’ve become very sophisticated in the analytics behind measurement, but we have to continue to evolve it. Our measures have to get better, they have to get more real-time. We learned in 2020 that the enterprise was not situated for success when the system needed it the most. That says a lot about how we have to be less focused on the mechanics of collecting data to support measurement and we can only do that by being more automated, taking advantage of new technologies, being much more digital. We have to be far more inclusive of the patient voice in measurement. Going back to everything we learned throughout this pandemic, we have to put disparities and equity and various populations that have been chronically underprivileged in our system and have experienced disparate outcomes as a result, we have to put them front and center in measurement. We have to ask ourselves—if we’re not measuring and prioritizing their outcomes—then the system is not meeting its goals. Those are all places measurement absolutely needs to go. We cannot stop focusing on measurement. That’s something I have said at NQF and will continue to say. I don’t want the need to be efficient to overwhelm the need to put measurement and quality outcomes at the center of our system.

 

Gary Bisbee  19:14 

I agree with you on all of that. There’s a discussion point around the number of measures and employers are somewhat confused, the providers perhaps as well. What’s your thought about that? Is it possible to somehow consolidate the good work that’s been done here into a more manageable set of measures?

 

Shantanu Agrawal  19:37  

We can consolidate and align around a manageable set of measures, and more work needs to be done there at places like NQF and other venues. The focus on the sheer number of measures is in and of itself symptomatic of other problems in healthcare. If we as an industry operated like other industries where data flows much more seamlessly, where things were more automated, where we had data interoperability instead of the barriers we have today, the number of measures would become largely irrelevant. Measures could be far more algorithmically driven, they could be far more self-calculating. Now working at a private payer, I see from another lens how much work goes into just collecting data, oftentimes in paper or essentially paper-like formats and then needing to extract that data, how much effort goes into that, and I know the same level of effort is being put into on the provider/clinician side. That is all wasted effort. We really should be utilizing that and actually improving on quality. Before we start cutting down the number of measures and getting to a place where we’re no longer assessing what we need to assess. Before that happens, we have to solve for these other issues. Quality suffers. The issues we face in quality are really symptoms of broader dynamics we have to address first. I often got into these conversations at NQF. Yes, let’s decrease the number of measures. On the one hand, that would be part of the discussion. On the other hand, people would say, “But we need more measures in maternal care. Look at the yawning gap that’s happening in maternal care. We need more measures around social drivers of health. We need more measures on how patient safety or diagnostic safety.” There’s a multitude of areas that are still under measure today, despite the concern that our measurement enterprise might be growing too far. We have to acknowledge there are still these critical gaps and not lose the focus on those gaps just because we want to get down to a certain magical number of measures.

 

Gary Bisbee  21:55  

You make a good point. What did we spend? $35 billion in this country on the HITECH act to digitize medicine. That was just last decade so this decade, if we can focus more on the practical uses of digitized matters, then this is one of the areas that could benefit.

 

Shantanu Agrawal  22:14  

Yeah. Like most clinicians, I’ve yet to meet an EMR system that I love. I’ve yet to meet one that helps me in that moment of practice. We have talked for a while about clinical decision support and concepts like that, but I’ve yet to meet that system that can point out something that is vital towards patient care, help guide me, and really be that partner to me. I definitely hope that happens in the next decade. It’s critical.

 

Gary Bisbee  22:40  

You talked about predictive analytics during your time at CMS. How useful is that or could that be in application of the quality measures?

 

Shantanu Agrawal  22:52  

Oh, sure, yeah. It was very useful in the CMS context. It brought out patterns in an otherwise morass of data in claims. It became part of our standard workflow day-to-day to utilize this kind of analytical engine and the outputs. If we can get to a place where the data going into the EHR is much higher quality— We all acknowledge that data, often being input manually by physicians and others, is not high quality. There are mistakes. There are issues of copy and paste, etc. If that could be high quality data, if the claims that get generated can be high fidelity, those should absolutely be inputs for quality measurement. I would love to see not only a set of those measures— however many there are and should be that are publicly reported, that are made transparent, that consumers, employers, and others can rely on, that providers can use for quality improvement. All of that should be happening, but underneath that should be a much larger layer of measures that are used for internal purposes at every delivery system to drive quality and value improvement. That relies on data being abstracted from EHR. EHR is from clinical registries, other data sources, even from patient level inputs for PROs. As long as it’s accurate, high quality data, all of that has to become used in real time to inform quality measures and inform improvement work. That would be what I would love to see happen in the next several years.

 

Gary Bisbee  24:35 

For sure. Thanks for that terrific review of the quality landscape. On to Anthem, what was the decision process you went through to leave what looked like an ideal position at NQF, given your background and interest, to become the Chief Health Officer at Anthem?

 

Shantanu Agrawal  24:56 

The opportunity here was too big and too great to pass up. I was amazed by our leader who is a longtime health insurance executive who understands the business but is also extremely focused on driving improvement in community health, in population health approaches, in addressing social drivers of health and of care. That level of strategic focus was not something I saw throughout the ecosystem. It felt very specific to Anthem at this time. It’s a strategic focus for our CEO, for our board and was imbued in this Chief Health Officer role he created. The opportunity to come into this environment with that kind of push and impetus behind this role and be able to utilize the scale and scope of a place like Anthem, which has been in the community (like so many blues plans) for quite a long time, has had that focus, but then able to say, “Look, this is going to be important to every single thing we do, every line of business. We’re going to put resources and real thinking and strategy behind it.” That was an incredible opportunity.

 

Gary Bisbee  26:11  

You’ve indirectly answered the question without my asking it. Let me ask it specifically: What are your responsibilities as Chief Health Officer?

 

Shantanu Agrawal  26:23 

The largest piece of this is coming in to the organization, making sure we are operating under a single community health strategy. That’s tied very, very closely to our mission statement around improving the health of humanity. When I take a step back and say the word “improving the health of humanity,” which literally comes out of my mouth at least daily in conversations and meetings, that’s a huge mandate and we take it seriously. Gail, our CEO, takes it seriously. We have this focus around not just improving the health of our members, improving the health of our associates, our employees and team members but really thinking about our role in the ecosystem at large and making sure we are bringing to bear our expertise, our resources to help communities that we are not in the same way directly tied to. We want to do that because we are a member of these communities as an employer or just our families living out in these communities, so that’s a huge mandate. On the one hand, I feel amazed that there is this mandate that I get to operate under, think about, and create a strategy around that we can drive. Of course, it’s also really daunting to think about improving the health of humanity, but I think it’s incredible. In addition to leading our community health work, I lead our clinical quality team, our medical policy team, and the Anthem Foundation, which of course, becomes a really important arm and leverage point for the community health strategy.

 

Gary Bisbee  27:52 

Digging into social determinants of health, how much focus will that be in terms of your responsibilities and your priorities?

 

Shantanu Agrawal  28:00  

A tremendous focus. I view community health through a couple of lenses. First, it’s really important in our community health work to be addressing both social drivers of health as well as the clinical drivers of health that are more traditional for an organization like ours to do. That lens means working with our providers, our clinicians, making sure we’re implementing and incentivizing the right care models that will be safe, that will lead to appropriate health care decisions and utilization and optimize care. At the same time, working with community level resources. That might be community based organizations, other players. There are new startups and emerging actors in this area in particular that I think we can work with to make sure that we are accounting for the context of our members and our associates lives, that we are inclusive of that thinking and trying to integrate as best as possible those social risk interventions with our clinical risk interventions. A second lens for our community health work goes towards that larger community role. Even with individuals or populations that we don’t directly interact with because they’re our member, because they’re our employee, we can still play a role as a major employer in the United States. We have 80,000 employees at Anthem, all of them with families that live, work, go to school out in the communities that have experienced this pandemic in their communities. All of those people can be ambassadors for our community health strategy if we give them the right resources, if we help educate and train them in how to think about community health. Then of course, we have all of our philanthropic work as well, so making sure we’re specific, we are driven by a set of priorities, that we are assessing our outcomes across all of our different levels of community health engagement. That becomes really important and it gives us the ability to affect certain priority areas really deeply, not just for our directly connected individuals and lives, but to have a wider societal impact that is critical to us as well.

 

Gary Bisbee  30:13  

Improving the health of humanity is obviously a broad goal and it suggests that you can’t do it yourself. What’s your thinking about working with the provider systems on something like social determinants of health? Obviously, there’s been friction in the past between the providers and the health insurers. There’s also been plenty of examples of them working together. How do you see that playing out over the next several years?

 

Shantanu Agrawal  30:47  

To your point, we can’t improve the health of humanity on our own, even with our scale and footprint. It really does come down to collaborations and partnerships. A wide variety of providers, health systems, clinicians will always be really important, critical stakeholders for us to be working with. We can do that by aligning on the right payment models, so making sure we’re incentivizing the right uses of healthcare and social care. We can do more to provide resources and capabilities to our clinician partners, whether that means bringing in a social care model, helping to lay out social risk screening tools, creating referral patterns so patients, members can get access to community level resources to say to address food and security or other social risk areas. That relationship with clinicians will always be important. Over 1,000s of years, we have invested in a very high touch, clinical model. We literally have millions of our members interacting with clinicians every single day. There’s a lot of richness in that interaction, there’s an opportunity to learn so much about what’s going on in a person’s life and to get those things addressed. We need to bring the same richness to social risk intervention. How do we bring a high touch model that Anthem can help to promote and promulgate so that we are seeing our members, our associates in their lives, seeing them in their home environment, understanding what social risks they face, and then as best as possible working to meet those risks. That will mean a different operating model. Right now, we as an ecosystem, as an industry, don’t do the kind of holistic social risk assessment that clinicians do to assess health risk on our behalf. We have to change that. We have to collect social risk data. We have to share it, we have to act on it and make sure we’re partnering with CEOs and other organizations to intervene on the social risks that we’re identifying.

 

Gary Bisbee  32:58  

The explosion of telehealth over the last year has changed life for providers and I’m sure for health insurers. I’ve spoken to more than one physician who loves the whole tele visit idea because they get to see what’s going on behind discussing with that patient on video. It’s almost like a home visit in the old days. How do you think about that?

 

Shantanu Agrawal  33:25  

I became a tele provider during the pandemic. I’m ER trained so I ended up working on a telehealth platform just to get some experience with it and, yes, it is incredible. On more than one occasion, being able to see the person in their home context gave me a level of understanding I wouldn’t have had if they came into my ER and we had them put on the funny gown and all that stuff. The traditional clinical environment wipes away the context, which is not ideal. I am really optimistic about that. I’m really optimistic that digital health platforms, telehealth will be a permanent feature of our system. It can be great for longitudinal care, especially when there’s an established relationship. You can more easily check in on the patient. You can do some quick diagnostics or a quick evaluation because you already have that foundation of a relationship. There still needs to be some improvement. We need some improvements with the technology. A lot of people are using telehealth on small cellphones with poor bandwidth and you can get a very grainy picture. We need to solve some technology problems. We need to think about some sort of regulatory approaches to making sure we have a common understanding of what needs to happen in a tele encounter or in a digital encounter. What does the standard of care look like? How do we protect things like privacy? Yes, being able to see a person in their home is really helpful, but I don’t know who else is in the home perhaps listening to that encounter. If we’re going to solve for issues like domestic violence or other sensitive topics (substance use disorder, behavioral and mental health issues) we need to know what’s happening from a privacy standpoint. We have to be able to tackle privacy as well so we are doing the right thing for the patient just as we would in a more traditional clinical setting. I’m really optimistic about it. We need some sort of standards and protocols to make sure that telehealth fits into our broader framework of how healthcare should be conducted.

 

Gary Bisbee  35:35

That begs the question a bit, thinking about your background at NQF, what are the quality measures? How do you even assess quality in that tella-visit environment?

 

Shantanu Agrawal  35:47  

We did some work on that at NQF, so I’ll quickly plug NQF recommend some great reports people can get access to. From a quality standpoint, there are at least two opportunities. One is quality measures can generally be more inclusive of the tele encounter. Because of the experience of 2020, we have seen telehealth use skyrocketed. I believe it’s here to stay. Even with the numbers coming down a bit and leveling out, I think there’ll be a permanence to that. When we have other measures (whether they’re measures of primary care, care, coordination, etc), telehealth can be much more a part of that. When I think back to NQF, a lot of our care coordination measures still mentioned fax machines. We have to stop doing that. We are the only industry that has codified the use of fax machines and continues to codify it. I’d love to see telehealth replace that, as an example of how to coordinate care whether it’s telehealth and digital apps or whatever. As another exemplar of care coordination, that’s someplace we could make a change in the near term. The second broad area of change for measures is telehealth specific measures. We need to see more of those being created so we are assessing quality in the tele encounter in a way that’s specific to that, makes sense for the tele health visit, and patients can understand the quality of care they’re getting. There is a whole report on that. One important caveat that emerged from that work is, on the one hand, yes, we do want telehealth specific measures or digital specific measures. On the other hand, we don’t want to hold those encounters to a different standard. It should feel very much like you are still going to an office, still going to a clinical care setting. In terms of your expectations as a patient, maybe even a little bit higher expectation. The accessibility should be higher, the privacy. The quality of the encounter should at least be the same, if not better. Yes, we want to measure it in a specific way, but not hold it to a different or lower standard than the rest of healthcare.

 

Gary Bisbee  37:53 

I agree with that. That’s well said. If you look at Anthem or other insurers, how has COVID changed the way they may be thinking about their processes, different strategies, or objectives going forward?

 

Shantanu Agrawal  38:16  

It changed the way pairs insurance companies work dramatically. And I think a lot of those changes will be permanent. So I’ve learned and just recognizing I’ve been here for a short time. But what anthem did in the course of 2020, to respond to the pandemic I think was nothing short of heroic. So there was sort of an immediate call to action to change processes that perhaps can be characterized as bureaucratic, right to be much more focus to be faster to speed up support of the community of providers, remove some of the barriers that have existed in the payer world, even at anthem prior to the pandemic. So, telehealth is a great example of that to move quickly, and say we should scale this up, we should support it, we should support it on par with the in person encounter, that whole series of decisions was really important both on the public sector side and what private payers did. That’s number one, right? Like it was there was just a call to action that I think an organization like this needed to respond to. And I think the decreasing of bureaucracy needs to stick with us. Being able to be a good and efficient and fast style partner that can pivot on a dime needs to stick with us. A second thing in terms of member support. So I’ve learned looking back at the experience, this organization like so many others, and I do want to credit the ecosystem for doing this really stepped up to try to understand what patients members needed in the moment. Right, so this organization literally made hundreds of 1000s of phone calls to our members in order to find out if they needed food, if they were safe at home, if they needed medical attention to get them that medical attention, because there was so much concern about going into a hospital or office, and then turned around not only to assess those risks, but actually to meet them to meet our members where they needed to be met, right did literally 10s of 1000s of food deliveries in the home, set up the telehealth encounters, that level of engagement with our members, I think felt probably very different. It felt really right. I know for the teams that worked on it here. And I don’t that is an ethos and a spirit that I don’t want to lose going forward. I mean, we need to be as connected to our members lives post pandemic as we as we did out of a sense of kind of urgency and just doing the right thing in the moment of the pandemic. So I absolutely i think i think the payer landscape is gonna change in fundamental ways and state change. And I imagine the same is gonna hold true on the provider side.

 

Gary Bisbee  40:48  

I think that’s absolutely right. Shantanu, this has been an absolutely terrific interview. Let’s wrap up with two questions. The first is along this lines of lessons for leaders. And that is the art of listening. As I talk to leaders such as yourself, they have pretty specific views about the importance of listening. Can you share whatever thoughts you have about that?

 

Shantanu Agrawal  41:14 

Yeah, well, so I got to do a lot of talking here. So I didn’t exemplify listening. But but it is absolutely critical coming into a new job, I think acknowledging people have been engaged in whether it’s meeting my quality team or meeting the foundation team, they’ve been engaged in that work for years and years. And sitting down with them. I think, especially at the beginning and saying, alright, relay the story, to me the history, your priorities, how you have conducted this work, and just being in a listening mode is really important. I think there’s a great emphasis, especially when you come into a leadership role or an executive role, you want to lay out your 30, 60, 90 day plans and show that you are having impact. But I think a lot of what you can do initially is be less focused on the impact, you can try and be more focused on just understanding where the organization is both its assets, its opportunities, and then using that to kind of craft the vision of what you might do moving forward, what to change, and, frankly, what to preserve, because the foundation is strong. Listening, I think is an absolutely important element of that you can’t get any of that without just taking a step back and hearing what the team has to say.

 

Gary Bisbee  42:19  

Final question is a bit of a longer term question. And that is what issue do you think is going to stand out as the issue of this? You’ve kind of actually intimated how you think about that. But let me ask that question directly.

 

Shantanu Agrawal  42:34  

I think it needs to be disparities, health equity, and addressing disparities has been a stated priority for decades. And yet, we have not made very much progress on that, I would argue very much at all, you can see disparities in basically every single quality measure that is reported, we can see disparities in the way care is accessed, we can see disparities in the way we even talk about the kinds of insurance that people have, I think we have to move entirely away from that, we’ve got to get to a place where we are specifically looking at our most vulnerable populations and making sure that they are getting the appropriate care with the right outcomes. Anyone that’s been in quality that’s been in the ecosystem knows this to be true. And yet now, I think the average American knows that to be true with the experiences that we’ve had in the in the last now over a year, even the way we think about COVID vaccination, the way we think about the distribution of COVID itself. I mean, it’s become readily apparent, we have a highly unequal system. And we there own up to making changes, or we acknowledge that this is the system that we want. And I think that would be a terrible outcome if we made that kind of acknowledgement. So that has to be the story of the next decade. I hope it doesn’t take that long. But that’s got to be the focus.

 

Gary Bisbee  43:54  

It’s obviously a long term issue, but you’re right, we need to bear down on it now. Terrific interview, Shantanu. We really appreciate your time. I’d love to follow up on your suggestion of a conversation around physician leaders and a framework for thinking about that later. Maybe we can do that in person.

 

Shantanu Agrawal  44:13 

That would be great. I’d really enjoyed that.

 

Gary Bisbee  44:15  

Thanks so much.

 

Shantanu Agrawal  44:17  

Thank you.

 

Gary Bisbee  44:19  

New episodes will debut every Thursday. Join me in conversations to gain advice and wisdom from CEOs, presidents, and healthcare experts. Health care leadership is hard work, but it becomes more manageable as we learn from the remarkable lives and careers of our guests. I’ll see you there.

 

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