Socrates tells us, “The unexamined life is not worth living.” We can’t improve and move forward without an understanding as to where we are. From where to how healthcare will be delivered, deep thought has been given to our future. While anyone can speculate as to the future of medicine and healthcare, few, if any, are more qualified than Stephen Klasko, MD, and Ken Terry. Your time is about to be well spent. Prepare for a great ROI with this episode of SoundPractice.
This transcript of their discussion has been edited for clarity and length.
Mike Sacopulos: My guests today are Stephen Klasko and Ken Terry. Stephen Klasko is a physician, author, and educator. He has also been a university president and dean of two medical schools. Ken Terry is a national expert on healthcare policy and practice. He was senior editor at Medical Economics, and he’s the author of multiple books related to the healthcare field. Stephen and Ken, welcome to SoundPractice.
Stephen Klasko, MD: Great to be on SoundPractice. I actually love the name, so it’s great to be part of SoundPractice.
Sacopulos: Well, speaking of names, I’ve got to say your new book, which is Feelin’ Alright: How the Message in Music Can Make Healthcare Healthier, is a fabulous title. Stephen, can you tell me why you wrote the book?
Klasko: Well, I started my career as a DJ and got fired as a DJ, and my major was broadcast journalism, my minor was chemistry. When I went back to Lehigh University after I had been fired, I thought, “What am I going to do?” And I said, “You’re obviously not going to be a DJ, but in a weird way, you’ve taken enough chemistry courses, you could apply to be a doctor and take the MCAT.” I said, “Well, why would I want to do that?” “Cause again, you’re going to need a job, and you’re not going to be a DJ.” So that’s how I started. That’s how I got into medical school. I got into medical school in just 15 seconds because the interviewer was an OB-GYN, which I am now, and we do a lot of verse between midnight and 5:00. I was a midnight to 5:00 DJ. I was Little Stevie Kent in Philadelphia, and when he saw my one-pager, he wasn’t impressed by my MCATs or my science GPAs, but he saw Little Stevie Kent of WYSP.
He goes, “Oh, my God, you’re Little Stevie? I’ve almost missed some deliveries listening to your stories. It’d be so cool if you came to our medical school.” So when I realized that, I became a doctor and eventually a dean and a CEO and a president, partly because of my DJ world, I thought it’d be really cool to find the right person to write a book with, which was Ken, around bringing those two worlds together. The one interesting fact was we originally wanted to call it Staying Alive, had the message in the music. But as lawyers will do, one of the lawyers thought that the Bee Gees would sue us. I reminded him that two of the Bee Gees had passed away and the other one is a little out of it, but that didn’t help. “Feelin’ Alright” also happens to be the name of a song, but we were lucky that the lawyer had never heard of that song by Joe Cocker, so they allowed it to come through.
Sacopulos: Why did you use song titles at the beginning of each chapter, and how do you think Message in the Music can improve healthcare?
Klasko: Yeah, thanks for that question. I think this is what I found: that music brings people together, and I think when Ken and I started researching the book, we recognized this. When COVID hit, I ran an 18 hospital system. We had the largest COVID load of any place in the Northeast. We had a trifecta of a financial tsunami, COVID, and the George Floyd protests, and I communicated with my 35,000 employees through songs. Every Friday I would do a playlist—I’ll give you an example. We had angry people during the George Floyd protests. I remember putting out a song called, and we talked about this in the book, “Choice of Colors,” by Curtis Mayfield. “If you had your choice of colors, which one would you choose my brothers, if there was no day or night, which would you prefer to be right?” I got these emails back, probably 200. “Well, I noticed you didn’t include The Revolution Will Not Be the Televised, et cetera. That’s how we’re feeling today.” What was fascinating about it is I realized that people were talking to me as a DJ.
As a DJ they had every right, whether you’re an environmental service worker or a faculty member or a nurse to say, “Hey, I have a better song than you.” If I had done this as a CEO writing an email, they would’ve just rolled their eyes and said, “Look, I’m not going to get involved.” So I think it started to hit me that that can bring people together and we can use songs to send a message that isn’t as threatening. So if you think about the first chapter, “Courage to Change,” by Sia, do you have the courage to change? That’s the question for every health system CEO today when they’re losing $250 million or $150 million a year, and they’re sitting there saying, “Instead of taking any risks, let’s keep our slow road to obsolescence.” So I think the way that Ken and I were able to write this, we were able to use the songs as very strong messages, but it’s a lot less threatening when you’re saying Simon & Garfunkel, “Keep the Customer Satisfied,” versus just making a statement that hospitals are the least consumer-centric part of the sectors of anything.
Sacopulos: Absolutely, you’re right, music does bring people together and start a conversation in ways that other things do not, so very interesting. Can you tell me why you believe that most care now provided in hospitals will move to outpatient sites, including the home? I thought this was a very interesting point of your book.
Klasko: I worked at Apple in the early 2000s, and one of the geniuses of Steve Jobs was his willingness. Apple stock was $15. That was about 8700 splits ago, and I didn’t keep any of my options, so I’m not that smart. But he talked about the old math and the new math; the old math being computers and operating systems, the new math being this digital lifestyle. Now, you’ve got to think in 2003 people were going, “Hey, dude, you’re either crazy or on drugs, ‘cause that’s our entire revenue,” and he actually was on drugs. He wasn’t crazy. When I got to Jefferson and I took over a large health system at a university, and I said, “The old math is inpatient revenue, outpatient revenue, in-person tuition and NIH funding; the new math is going to be literally strategic partnerships with digital health companies, et cetera,” I got the same thing: “You’re either crazy or on drugs.” Opposite of Steve, I wasn’t on drugs, but I might’ve been crazy.
The fact is, all you have to do is look at One Medical getting sold to Amazon for $3.5 billion. One Medical is not this amazing company. It’s basically saying, “Every single health system has failed at primary care. I need an appointment. Gosh, I’d like to see somebody.” “Yeah, how about two Wednesdays from now?” One Medical, literally, you sign up for $99. Through AI, they pick a doctor for you. If you need to see him today, tomorrow, it’s done. We could have done that. So the answer is, it’s going to happen. It’s in our book, there’s a Harris poll, 62% of people think we specifically make healthcare complicated to not get care.
So we have a broken, fragmented, expensive, and inequitable system. There’s not like, “But I wonder how that could be?” It’s a case of everybody benefits, but from us having a broken, fragmented, expensive and inequitable system. During COVID, think about this, people died at home because they didn’t have broadband. Insurers quadrupled their net operating income because people died at home because they had actuarialized that people would get care. Hospital systems got killed because people died at home and didn’t get care. There’s no way on the planet that you would have the payer, the provider, the employer, and the government be four separate things that just don’t talk to each other.
So the simple answer to the question is, the United States, Haiti, and Bangladesh are the only three countries in the world where maternal morbidity and mortality have gone up over the last 10 years. We spent four times more per obstetric patients than any other country, and why? Because we’ve done this to benefit Pharma and health systems and insurers. Hey, by the way, if you don’t have broadband, in Philadelphia, there were five zip codes where 60% of people were denied broadband, and we’re the home of Comcast. So the issue is we haven’t really, really, really wanted to solve health problems. We’ve wanted to say we’re the best healthcare for people like you or me or Ken, which we are, in the world, but we’re not the best health system. We’re not even close to the best health system.
Sacopulos: Yeah. That’s some pretty shameful statistics there, right?
Klasko: Yeah. By the way, the whole issue of it’s not healthcare at home or outpatient, it’s healthcare at any address. It’s pretty simple. It’s wherever you are, you should be able to access healthcare. We have one of these things, that’s how it should be. By the way, telehealth would still be an anomaly if it wasn’t for COVID. Again, I know I sound like an angry guy, but we’re already seeing callbacks on telehealth because some of the insurers are deciding it’s bringing up the cost of care. Why? Because if you can access more care, you’re going to use more care, and that’s not always good for everybody. What’s happened is we created mistrust. How many people believe today when President Biden said, “Good news, Moderna and Pfizer are making some new vaccines, everybody should get one?”
We have an unprecedented percentage of people saying, “Yeah, I don’t believe that. Moderna and Pfizer’s stock has gone down and they’re making something up.” Now, we never used to think that, and I’m not saying at all that’s happening, so let me make that really clear. But the fact that there’s even people that think that’s the case—and one of the things we talk about in our book is how the trust factor has gone down. So one of the things we have to recognize as we start to talk about generative AI and large language models—and I’m doing a lot of work with that in my new role at General Catalyst and others—is trust is so much more important than technology.
If we knew from the beginning that Facebook wasn’t just so I could see my unbelievably cute grandkids in Providence, that it was going to affect elections and spew hate, we might’ve put some guardrails in. If you don’t think LLMs [large language models] and generative AI can either be the most amazing thing that’s happened to health, including for the underserved, or be this devilish thing that will be misused by people—both of those are possible. The issue isn’t stopping it; the issue is putting the ethical guardrails in at the beginning.
Sacopulos: Ken, do you want to weigh in on this, how we address the general level of cynicism that we have in the country toward certain areas of healthcare?
Ken Terry: Well, that’s a very large question that we could probably spend the rest of the session on, but I really wanted to comment a little bit more about the healthcare moving to the home. First of all, since CMS began allowing hospitals to move some of this care to home with the help of telehealth and, of course, actual clinicians visiting the patients, a number of health systems around the country have begun doing this. It has become a real movement. So clearly, there was a need for it, but because Medicare didn’t cover it, hospitals didn’t tend to take it seriously.
The other thing is that I think we should remember that population health management is becoming more important. As that happens, health systems, physician groups, and other people who are taking financial risks for care are going to want to know what is happening with patients after they leave the hospital on a more continuous basis, and, also, people who have various serious chronic diseases in between doctor visits. We’re not seeing the widespread use of remote monitoring yet, but we expect that that will happen as you get more AI-based applications that can parse the data and automatically bring actionable insights to clinicians at the point of care.
Sacopulos: It seems to me that in general, the hope of technology is overestimated in the near term and underestimated in the long run. Do you think that that’s true, and if so, how does that play out with medicine?
Terry: Well, it certainly is true and something that Steve often talks about. I think that a great example of that really is the current debate over AI. Certainly, a lot of AI applications have been around for years, although it’s gotten more notoriety with the advent of ChatGPT and generative AI. Everyone is saying, “Well, we’ve all got to move to the AI,” and yet they really don’t know how to do it, and there hasn’t been enough research yet to show what kinds of things may be safe. In general, we’ve seen that AI applications can identify a diagnosis correctly probably as often as a medical student or a resident can do, but we need to really investigate this in depth at a granular level before using this for clinical decision support. On the other hand, there are things like AI use in radiology scans—analyzing radiology scans and deciding where the anomalies are—that have been shown to be pretty reliable, as reliable as a radiologist’s report. I’m sure you have more to say about that, Steve.
Klasko: Yeah. Well, look, I was on the advisory board of IBM Watson in 2016, and we said, “AI is going to take over the world. You might as well not have a job,” and that got sold for parts. I think large language models are different, and here’s where they’re different. In the company that I’m working with in LLMs, they’ve brought in millions of recorded conversations in 50 different languages. So for 18 cents an hour, we will now have a nurse that will be able to do a pre-op check in with you, which is exactly the kind of things that nurses don’t like to do. They want to do nursing stuff. When you look at the crisis in the workforce and staffing levels, a lot of it is because of the things that nurses are doing that they really don’t want to have to do.
So I think the ability to start to use the robots and the large language models to do that, imagine a nurse at 18 cents an hour that knows everything about you that can call you up and say, “You’re having surgery tomorrow. I have to ask you some questions and tell you what you need to do.” If you’re having a colonoscopy in two days, “Here’s what you need to do,” and will literally without any prompting check on you at 6:00 and say, “Did you start your preparation, et cetera. Is there anything that you need?” Among seniors, we have an unprecedented amount of people going on to Medicare. Again, 18 cents an hour, our large language model will be able to talk to a senior for an hour, and as this gets better and better will be more and more empathetic. So much of senior care is around loneliness and having the ability to talk to someone.
The second thing that I think is going to be amazing is wearables—not five Apple watches and three Oura rings, but the T-shirt that I’m wearing will basically send continuous seamless data. We talked about this in the book, but my car gets better care than I do. My car literally sends continuous signals. I was on a nine-city tour last week, and I got back to Miami. I turned on my car and it was, “Hey, Steve, while you were away, my right front passenger tire got a little low. Could you fill it up?” Meanwhile, in two weeks, I’m going to have a physical, somebody’s going to take my calcium score or my blood pressure, four or five other things and tell me what I should do for the next 18 months. Now that’s asinine.
I’m 69 years old, nobody has any idea what’s going to happen to me six months from now. So the combination of the large language models, the ability to start to create wearables that will continuously not just send my pulse and my temperature, you can imagine in a pandemic situation, literally the moment that my temperature went up a little bit, having the large language model say, “Look, Steve, we’re sending you a home COVID test and Paxlovid because your temperature just went up 0.7 degrees, and that’s an early sign of the pandemic.” That’s what’s happening.
Then the whole issue, the third huge disruption is around 3D printing. I’m helping to lead a company to conglomeration of 3D Systems, which is the largest 3D printing company in the world, and United Therapeutics, and we are now bioprinting organs for transplantation. So we have a bioprinted breast that’s going through human clinical trials, post-breast cancer. We have a 40 trillion Voxel bioprinted lung that a pig will be living on in October, based on its stem cells and lung cells, and that will be ready for clinical trials hopefully in five years. So 15 years from now, your grandkids will be saying, “Is it true back in 2023 if you needed a kidney, somebody needs to take out that kidney? That’s seems really barbaric.” So those are just three examples, getting back to your short term and long term, that are happening now that are going to more than incrementally transform healthcare.
Sacopulos: That’s amazing to think that that’s our future. It seems to me that healthcare systems could benefit by working with and helping tech companies test new products. You talk a little bit about this in the book, maybe you could go into more depth.
Klasko: Ken, do you want to start on that?
Terry: I think this is really more down your alley.
Klasko: Okay. Well, yeah. So look, the book I co-wrote prior to the one I wrote with Ken was with Hemant Taneja, who’s the CEO of General Catalyst, now the largest venture capital firm. We have about $35 billion in companies. The concept of that book, called UnHealthcare: A Manifesto for Health Assurance, was basically exactly what you’re asking. What if a CEO of a 197-year-old academic medical center, which is what I was, and a Silicon Valley entrepreneur, which is what Hemant is, basically had a baby, what would that look like? What we were able to do at Jefferson is really, if you think about HIMSS [Healthcare Information and Management Systems Society] or any of those conferences, you have 900 28-year-old founders saying, “Buy my company, and it’ll transform healthcare,” most of which isn’t true, so I decided I didn’t want to be a vendee anymore.
In fact, I had written an article called” I’m Never Getting Fleeced Again.” Concept was back in the mid-2000s, I worked with a telehealth company. We were the first partner. I helped advise them. It was when I was a CEO at University of South Florida. After about two years, as the founder called me and said, “Steve, I want to take you out to dinner. We couldn’t have done it without you. We couldn’t have done it without USF. Literally, you were the reason that this happened.” I said, “Why do you want to take me out to dinner?” “Well, we just got valued at $2 billion.” I said, “Well, that better be a hell of a dinner,” and they said, “Well, no, I’m also going to send you and your team four fleeces,” so the concept of “never getting fleeced again.”
So the concept of if you’re a health system and most health systems are losing money because the old math doesn’t work, if you’re a health system and you are going to across your enterprise put in a digital health solution or population health solution or a large language solution, you ought to be able to co-invest and co-develop that. If you think about a company like Livongo, which was a GC company that got sold for $18.4 billion, and you think of all the early health systems that worked with Livongo to make that happen, the traditional way of doing that would be, “Oh, that’s nice. I’m glad you got sold for $18.4 billion, and I’m glad we could help.” By the way, that was okay when every health system was making 3%, 4%, and 5% margins. Now that the average health system is losing 1%, if there’s going to be $30 or $35 billion every year spent on digital health, and especially now with AI, I think it’s important that health systems get into that game.
Sacopulos: Your book has a novel proposal about how to reform healthcare financing and delivery without adopting the Medicare for all concept. Ken, can you give me an overview of how you propose that?
Terry: Sure. Our basic insight is that no fundamental healthcare reform is possible unless it keeps the major players mostly whole and harnesses the power of consumer choice. Our proposal concerns healthcare financing, but it would also change how healthcare is delivered. That is because hospitals and physician groups would have to take financial risk as part of the transition to value-based care. When they do that, the whole game changes, because their facilities and services become cost centers rather than profit centers. So our model would blend the public and private sectors into a single system while leaving space for private insurers to thrive.
Ambulatory care would be provided by competing primary care–driven groups that would charge subscription fees subsidized by the government and employers. So in effect, each group would have a budget covering all the services they provided, ordered, or contracted for. Hospital care would be covered by insurance under a setup similar to the global budgets that hospitals had in Maryland for many years, except it would also include post-acute care. The government would subsidize premiums for Medicare and Medicaid and other public programs along with people who didn’t get this catastrophic insurance through their employers. That’s basically how it would work.
Sacopulos: Very interesting. Steve, you think physicians should have some skin in the game and financial risk in providing care?
Klasko: Yeah. I think first of all, let me make one blanket statement. We have lied to docs, and I’m one of them that’s both a doc and that have lied to docs for 35 years, that technology will make their life easier, starting with the epidemic “We’re going to spend $3 million with an EMR, it’s going to make your life easier.” Well, it didn’t make their life easier. In fact, they had to hire scribes just to get back to the doctor–patient relationship they had before, and now they’re literally, for no compensation, getting 120 messages a day from patients to answer questions. Again, and with all due respect to the legal profession, there aren’t too many lawyers that I know that have taken that same tack. So I think the concept of doctors starting to look and say, “How do we become part of a different kind of system where we are thriving along with the other parts of the ecosystem?” is a good one.
The hospitals started to acquire them, so everybody’s looked out for themselves. Nobody’s crying for doctors. There’s a lot of things around the compensation of doctors that are really mismatched. Why should a dermatologist make eight times what a family medicine person would make? Why should an orthopedic surgeon make 15 times what a family medicine person would take in? In fact, as we start to talk about accountable care organizations, I remember going to my chair of family medicine saying, “Good news. You’re going to get to be the quarterback of our ACO.” I remember she said to me, “Steve, you pay me like the kicker. You pay your orthopedic surgeons and your neurosurgeon and dermatologist like the quarterback, let them be the quarterback. If you want me to be the quarterback...”
We started a health system for about 160,000 seniors in mid-Florida called The Villages. It’s, in essence, think about this, a patient-owned primary care–driven health system without a hospital. We hired 50 amazing primary care docs, paid them like specialists to actually provide primary care as a quarterback, and it’s done incredibly well. So getting back to Ken’s thing— is our health system geared for the hospitals, the specialists, the insurers and the pharma, oh, yes, and the patients, but that’s after those four. I think what’s happened is that doctors have said, “Hey, where are we in that whole continuum?”
Sacopulos: Our time together is wrapping up, and there are so many fascinating points of your book. I want to end on one question related to social determinants of health. Why are social determinants of health so important, and how can programs to address them reduce healthcare inequalities?
Terry: I can take this one, to start anyway. Social determinants of health, such as food, transportation, housing, and social support affect somewhere between 20% and 50% of health. That’s twice as much as healthcare does. So any organization that seeks to improve individual and population health has to pay attention to what’s happening to their patients outside of the doctor’s office and the hospital. They must also develop intervention strategies such as hiring social workers and referring patients to social services. So now you ask, how does that affect health equity? Well, health inequities have many causes, including racial prejudice, but they are usually rooted in adverse socioeconomic and environmental factors that have a disproportionate impact on certain groups. So to the extent that the government insurers and healthcare providers can ameliorate those conditions, especially for high risk patients, they will reduce health inequities.
Klasko: Yeah, and I think what I would add is just that we have to get population health, social determinants, health equity from philosophy to the mainstream of clinical care and payment models. Nobody has paid for those things, and until that really starts to happen, nothing’s going to change. There’s a great Upton Sinclair quote, “It’s hard to get somebody do something when their salary depends upon them not doing it.” We get paid for providing sick care, and I’ll give you another example. We had done a survey at one point where we looked at health systems’ websites and what their boards were saying, and then we looked at how the CEOs got paid. I remember it was, what is our health system about? Diversity, inclusion, community engagement, quality access, social determinants? I interviewed the CEO. “Oh, wow. That’s great, and I just saw the website. You must get paid based on diversity, inclusion, community engagement, access, quality.”
“Oh, no. I get paid based on EBITDA [earnings before interest, taxes, depreciation, and amortization], hospital census through the doctors I play golf with, like me, and U.S. News & World Report.” So, the concept of the paper was if you want to look at what hospitals are going to look like 10 years from now, look at how the CEO gets paid and ignore what’s on the website or what the boards say. So the fact is, just the example I’d give you—at Jefferson, we changed our mission from being the premier academic medical center in Philadelphia, which really nobody cared about other than me and my mother, to we improve lives. I made 25% of my incentive based on reducing five health inequities in Philadelphia, and that changed things for us because that was clearly putting some of our money and mission where our mouth was.
Sacopulos: Excellent. The book is Feelin’ Alright: How the Message in the Music Can Make Healthcare Healthier. I think from this discussion, you should have lots of new readers. It is a fabulous book. Thank you both for being on SoundPractice.
Terry: Thank you.
Klasko: Great talking to you. Thanks so much.