[00:00] Bryan Hyde: Welcome to the Health Policy Podcast. I'm Brian Hyde, and today I'm joined by John E. Harrison. John is the founder and CEO of Gesundheit, a specialist e-consult platform serving community health clinics. And John, first of all, I've got to say, that is— that's a very catchy name. But welcome to the program. Tell us a little bit about your background and about what you do. [00:19] John Harrison: Hey, thanks, Brian. Appreciate you having me on the show. Well, Gesundheit, as you said, is an e-consult company, but nobody seems to know what that means. And, um, you know, to be perfectly frank and at the risk of, uh, showing that it's not that creative, we stole it from the VA. I mean, in 2012, they were running out of money and resources. They weren't going to go out and hire more doctors. They weren't going to go out and hire more specialists to cater to the primary care because they just didn't have the funds for it. So they did something incredibly unique. They, they took specialists and instead of having the patient go to them, they put them on the front lines of care, right up with primary care. And what's interesting about that is they had seen a substantial increase in their number of referrals. Every time increased from 10% per PCP visits to nearly 36%. So 1 out of every 3 times they were sending a patient From the primary care clinic to a specialist. And sometimes that's a 2-hour drive, 120 days, and 50% of the time the patient doesn't even go. So they go, well, we gotta— this is too costly and our disease progression is increasing, so we've gotta do something about that. And they go, we're gonna put specialists right on the front lines. And now instead of referring out, they confer with the specialists before any referrals go out. And the results are incredible. Uh, 40%, uh, cost savings. And I thought this was interesting. 60% of the, um, visits ended up— or, or the guidance that came from a specialist did not need to eventually see physically a specialist. So now you go, okay, America just needs to do this. And that's incredibly hard because the VA is a homogeneous system. They have top-down directives saying, hey, we're going to move our specialists here, we're going to do this, we're going to make a policy across the board. And well, you're probably aware that the US healthcare is nowhere near that controlled. It's very fragmented. People don't talk to one another. And so what Gozuntai did is we figured out a way to plug in specialists in a fragmented system so that we can achieve the same goals. And So far, we're doing really well. We're sort of matching what the VA has done. We have a very unique approach to it. [02:45] Bryan Hyde: John, I'm looking at an article that you originally had published in the Baltimore Sun. I saw this on the Maha Report about American healthcare's Moneyball moment. And for those who've seen the movie Moneyball, this is all going to make sense. I'm going to ask you to kind of tie this together for us, but everybody, I think, understands healthcare in America right now is Very expensive. It can be extremely complicated, like you were just outlining. Talk to me a little bit about— let's, first of all, let's visit the Moneyball premise, and then let's talk about how that could be applied to American healthcare to help solve some of these problems. [03:18] John Harrison: I live in D.C., and I was on the roof of a friend of mine who actually works for HHS, and we were talking about the World Health Transformation Program. And I don't know if you're familiar with that, but it's, it's, you know, if anything about Maha and, and the Kennedy administration is— or, or, uh, yeah, administration, um, is they're at least shaking things up. They're moving things around. And the, the key word of the RHGP is transformation. You know, we can't keep doing things the way we're doing them, so we're going to give you some money. And think about it as a venture capital fund. They're basically saying we're gonna, we're gonna shake it up a little bit and we're And those programs that succeed are gonna get, you know, further policy directives behind them. And so we're gonna ferret all that out. But while we were on the roof and it was sunset, we were having a few drinks and they were talking about it. And I overheard the conversation and I go, well, we think we're the Yankees, but we're actually the A's. And this one guy looked at me and he goes, Moneyball? And I go, yeah, absolutely, 100%. Then the conversation just went from there. If you know Moneyball, it's a great story of an under-resourced team playing against the most-resourced team and achieving the exact same number of wins, but just by really looking at the game differently, looking at where you can position players differently and use them in a different way to reach the economy of scale that you need. And that's essentially what we're doing in healthcare. We're actually saying, okay, let's just— if we just move one of our pieces, the specialist, to the front lines, there's tremendous downstream savings, and in both terms of financial and incredible health outcomes. [05:12] Bryan Hyde: So you say in the article, look, it's when you compare Moneyball to what healthcare needs, it's not about the movie, it's the method. Tell me a little bit about Billy Beane, who was the inspiration for the movie Moneyball, and How did he leverage that underfinanced team in such a way that it could keep up with one that was spending much, much more money? [05:34] John Harrison: He was a little bit like the VA. He was in a position where he had to try to keep up with the wins that they had had the prior season, but they had lost about 3 or 4 of their players. And he was surrounded by a bunch of scouts. that were trying to go the old traditional way. Get your hits, get your fielders, buy the team that is going to get you these wins. But they didn't have the money to do that. So there— I forgot the guy's name, but there was another guy who said, wait a second. He ran some numbers and basically said, look, getting on base is what's critical. Once you get on base, it's much cheaper to get a player who walks and gets on base than it is to buy a hitter. And so then you look at what Billy Beane did. Now, he didn't invent this. He just went and looked for the ability to extend his wins with the resources that he had. And that's actually, we're looking sort of in healthcare, we're looking for our Billy Beane. The guy's gonna have the courage to go out there and look for new methods. And we're finding it in, obviously Bobby Kennedy's out there shaking things up. And even at the state level, now there's, they have to spend $200 million a year on these type of initiatives. So hopefully we'll get a bunch of, of, of Billy Beans out there with the courage to try something new and then get the number of wins that we need. Does that make sense? [07:07] Bryan Hyde: Yeah. Is there a lot of inertia within the system due to the bureaucracy that you were referencing earlier? Does that kind of keep things moving slow in its current state? [07:16] John Harrison: Yeah, I think the culture is, is the biggest problem right now. You know, here's the way we do things. We just want to throw more money at it. We're going to hire more specialists. We want to relocate those specialists to these rural areas. We want to get new primary care doctors and, um, and provide the same healthcare we do. And first of all, we don't really need that. We just need to adjust what we have so we get better outcomes. And I gotta tell you, it— this is healthcare. It's, it's slow moving. It just— they just don't really like change. Um, we are finding some future-looking, uh, uh, people within these leadership positions that are kind of excited about what we're doing. And we've had some successful outcomes in Kentucky, particularly, that are helping move the needle, helping them look at what we're doing and then say, okay, wait a second, if they can do it in Kentucky, in these rural areas, Appalachian areas, that's no different than mine. In fact, you know what's interesting? I was watching CNN not too long ago and I saw a guy in Ukraine. He was in Kharkiv and he was basically 70-something years old, had a bit of a belly, looked like he probably had heart failure and diabetes. And I watched him and I go, I wonder what this guy's doing for care. He was basically saying, look, I don't care how many missiles, I don't care how many drones are coming towards me, and I'm staying home. And I was like, okay, he's probably got the same issues we have. I wonder who's taking care of him. I actually got on a plane and flew to Kyiv and met with all the leaders over there. And now we're within 2 months, we're planning a pilot to cater to those exact same people using our same service. So the sense of urgency there versus the sense of urgency here for the same problem— actually, you could say it's a little bit extreme over there— is what we need here, that sense of urgency. [09:14] Bryan Hyde: You mentioned in the article, you actually give an example of a patient in Kentucky, in rural Kentucky, with kidney disease and heart failure. Talk to me about that story. And let's, let's use this to kind of flesh out how, how this approach differs from the fragmented pieces trying to communicate with each other in vain. [09:36] John Harrison: Yeah, that story changed me. It took this from a business into now a mission. Yeah, a guy comes in, same profile as the Ukrainian. Um, he had heart failure, as you say, kidney disease, and normally he would have to drive 2 hours for each one of those appointments both ways. He would have to take 2, 3 days off of work. Um, the earliest appointment for a nephrologist was, I think, at that point, 4 or 5 months. We average about 120 days, but in this case it was actually much longer. A cardiologist was another 100 days plus. So 50% of the time, this guy wasn't even going to go to them. So that disease was just going to get worse and he was going to go to the emergency room. And that's a $10,000, $12,000, uh, venture that actually doesn't improve the patient's health. So we had just started with this one clinic in Somerset, Kentucky, and mostly staffed by nurse practitioners. And this one really— I— this is one of my favorite nurse practitioners. He's, he's just, uh, really embraces things. He's an early adopter and an aggressive user. And he goes, uh, he sends the case to our nephrologist. Our nephrologist looks at it, writes the, the treatment plan, and says in the treatment plan, hey, uh, we probably should bring in cardiology on this one. It looks like we need to do a care coordination on this. They bring in our cardiologist. They took— all 3 of them, you know, kind of go over the treatment plan, and within 8 hours that was sent back to them. So that means the patient didn't have to travel anywhere, didn't go to the emergency room, and the disease was addressed almost immediately. It's— it can happen anywhere now. I mean, now that we've seen that happen and we could do it in that extreme case, everybody needs this. I mean, put yourself in your shoes. If you— I don't want to ask you about your healthcare, but if you go to a primary care and they say, Brian, you know, we need to see— you need to see a cardiologist, even if it's the next day, you don't want to go. But most of the cases, it's 30, 60 days, even for urban settings. Wouldn't it be nice if he says, hey, wait a second, you mind if I just send your results to our cardiologist and I'll get back to you on a treatment plan? I mean, that's— you go home and then they call you up with the treatment plan. It's that easy. It's that much of a game changer. And it's really, as convenient as it is, it also saves a ton of money. [12:11] Bryan Hyde: I mean, 100+ days versus 8 hours. [12:16] John Harrison: Yeah, that's a no-brainer. That's a no-brainer. Yeah, I agree. It was fun. [12:21] Bryan Hyde: So how do we scale this up? I mean, I think you mentioned in the article it's been tried before, but, but they missed some of the essential pieces like the software, was scaled up, but, but putting it into practice, it didn't happen. [12:34] John Harrison: It's interesting. Um, one of the things we recognized that the VA was doing so well is they have named specialists, so the primary care gets to know the specialist. Uh, and the other— the, the people who have tried this, or the companies that have tried this, are— I mean, they're, they're great technologies, and, and they've, they've done well But they use a random pool of doctors, and so you never really get to know who it is. And then on top of that, they don't get their— they're not accountable for the care that they give. So we, we actually— you get to know our doctor, but we sign these notes and recommend recommendations and put them strictly directly into the EMR. So now they're saying— now you're telling the nurse practitioner or the doctor, the primary care doctor, Hey, we got your back. We are— what we say, we hold to. And the only caveat being is, hey, we didn't actually physically see the patient, so all the information we got is dependent on what you gave us. Yeah, it's scalability. Golly, we could be— we could get all 50 million Safety Net Clinic patients in the next 5 years. I mean, that wouldn't be a problem. The, the clinics that we go to actually increase their patient visits by about 25%. So they become financially self-sustaining. The, the doctors that join on our side actually make more than they do, uh, in their day-to-day practice, if for no other reason, they can get more in a day. in an hour and without compromising care because our technology goes out and scans all the standards of care against what we're being fed and recommends an approach that they either modify and say, no, I don't agree with that, I agree with that, and then goes in. So their time to treatment goes down, the quality of our information or our suggestions goes up. And patient care improves. [14:44] Bryan Hyde: Now, with the Rural Health Transformation Program, there is money that's been appropriated, you know, to help transform rural healthcare and fix some of these problems. Are they inclined to look at new ways like you're describing? Are they inclined to look at putting people in the right position? Or is there still that tendency to, well, we've always done it this way, so let's just keep keep adding to the old system. [15:09] John Harrison: Yeah, it's— they don't know that this even exists. And it's funny, I— when I talk to— I've talked to some really forward-thinking secretaries of health of states, particularly I would say Arvind Singh of West Virginia is one of the more forward-thinking. Um, who really, uh, sort of looks at this as an exciting way to go. Um, but you're really talking about a new, new way of doing things that people really don't know about. And when we go in, we don't really need RHTP money directly. So we're not asking for any money from an RHTP. We're saying, hey, we go in there, we actually make these clinics self-sustaining. What I would love to see is if we can get more diagnostics, some of that RHTV money to go to diagnostics at primary care so that we become even more powerful in supporting them. But that's really our only mission, is just get us more clinics and we'll show you what we can do. [16:14] Bryan Hyde: So where do those decisions begin? In other words, who has to make the first move to get this ball rolling? [16:21] John Harrison: Boy, if I knew that. If I knew that. It is a sort of obscure world. path for sure. So really all we do is go clinic to clinic and clinic to clinic to clinic, and hopefully we'll build some, some mass there. And then as we get more, leadership will start to view it and see it and execute on it. [16:44] Bryan Hyde: So I guess if I'm hearing you correctly, it's— this is not something that Congress, by sheer, well, we'll just pass another bill or we'll pass a resolution— it's, it's not, it's not so much that it has to happen at the upper levels of government as much as it needs to be adopted by the people who comprise the system itself. [17:05] John Harrison: I mean, if the Congress could pass something like this, I would be all for it. If they could sit there and say, hey, the VA's done this, the VA works for us, the nation should do this. We've got a great successful program here. Why are we not doing it across the board? I just don't see that happening anytime soon. But really, look, they've— each one of these states has 500 to 800 federally qualified and rural health centers and Indian health systems that serve 50 million people. To give incentives in whatever method they could use would be great. Just get us, get us a little bit of a knock on the door, at least get the information out there so it makes our job easier to go in. [17:57] Bryan Hyde: So let's connect our listeners with, with more information on this subject. Would it be best for them to go to your Gesundheit website? [18:05] John Harrison: It would be hugely informative, I believe, and we're adding to it as we go. I can give you my website if you like. [18:14] Bryan Hyde: Please do. [18:14] John Harrison: Gesundheit is a unique name, and I understand most people, you know, sort of shudder at the thought of spelling it. So here we go. It's www. And we'll get you all the information you need. And, you know, certainly reach out to me if you need any more. [18:37] Bryan Hyde: Yeah, no, you don't need to be fluent in German. You can— this one is spelled phonetically. It's, it's actually very easy to find. And again, we are talking with John E. Harrison. He's the founder and CEO of Gesundheit, a specialist e-consult platform serving community health clinics. And John, thanks again for joining us. On the Health Policy Podcast. [18:56] John Harrison: Thanks, Brian. This was fun.