June 21, 2023 • 37 mins
How are we seeing health care in the home and virtual care grow, and what are the propellers for that growth?
Join Zayna Khayat, Health Futurist – Health Care and Life Sciences (Canada) at Deloitte, and host Ann Somers Hogg as they discuss the future state of care anywhere, integrated approaches to disease management, and the benefits for consumers.
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Ann (00:01):
A lot of leaders and innovators talk about disrupting health care,
but what does that really mean and how does one
actually do it on life centered health care? We dive
into these questions and more talking to innovators who are
leveraging Clay Christensen's theories to transform our health care ecosystem.
I'm Ann Summers Hogg, senior research fellow of health care
at the Clayton Christensen Institute. And I hope these stories
(00:23):
help inspire you along your journey to transform health and care.
I'm thrilled for today's conversation because I could not imagine
a better guest with whom to discuss the future of
health care. Zanna Hyatt, Health futurist at Deloitte Life Sciences
and Health Care in Canada. Adjunct faculty at the University
of Toronto's Rotman School of Management and former vice president
(00:46):
at Teladoc Health Canada, is here with us today. And
before these roles, Zaina served as the future strategist with eHealth.
She served as the innovation Sherpa in chief to strengthen
the Dutch health innovation ecosystem. She led the Health System
Innovation platform at Mars Discovery District, a major innovation hub
(01:07):
in Toronto and much, much more. She completed her PhD
in biochemistry and also had a career in strategy consulting
as a principal in BC's health practice. Welcome, Zena. Thank
you so much for being here.
Zayna (01:19):
Great to be here. An excited about this podcast.
Ann (01:22):
Thank you. Thank you. And I gave a brief overview
of your background, but before we dive in, I'd love
to give you the opportunity to tell our listeners a
little bit more about you. So I like to start
with why could you tell us a little bit why
about after four years as the first ever and perhaps
the only futurist in a large national home care agency,
(01:45):
you made the move to a commercial leadership role in
the Canadian arm of Teladoc Health. What drove you to
join Teladoc? What attracted you to this organization in their approach?
Zayna (01:55):
So my why is I think my personal mission is
to improve the health of Canadians with the platform. I have.
My lever to do that is by modernizing the Canadian
health and care system. And so when the opportunity to
bring the Teladoc platform into Canada as part of an
acquisition they did a few years ago, you know, it
gave permission to enter the market. This is the platform
(02:16):
to bring modern solutions at population scale that already have
proven to work elsewhere. And so I kind of had
to jump on board because I think that's at least
in our market, has been the lock. And the key
is lots of point solutions and pretty good neat ideas,
but nothing really done at scale. And that's that's the
next unfinished business.
Ann (02:36):
Awesome. I love that. Modern solutions at population scale. I
think that's what so many startups in the health care
ecosystem are striving for right now. Many are promising, few
will deliver. So exciting to see Teladoc make progress in
that area now. More recently, you also became the in-house
futurist with Deloitte Healthcare in Canada. Tell our listeners what
(02:57):
that is all about.
Zayna (02:58):
As a changemaker in health care, I've got two levers.
One is rolling up my sleeves and doing the work,
and that's what I've done in every job you just
listed earlier. And what I'm doing now with Teladoc and
it's hard and it's punishing. You got to be in
it near the clinicians and near the patients and with
the tech people and the contracting people, etcetera. The other
(03:18):
lever is to actually build capacity for others to do that.
And that's what I do through my teaching at the university,
also with the Dutch Health Innovation School, which I continue
to teach in. And then now is this role with Deloitte,
where I can bring thinking about the future into the
work they do, our own staff and our clients, so
that at least some big choices in bets people are
(03:41):
going to make today are consistent with an ever evolving future.
And I don't think we do that enough when we
make big bets today. So that's my vector for scale
there in capacity building.
Ann (03:51):
I like how you broke it into the two different
levers to pull. So you're either the change maker on
the ground doing the hard punishing work on the front
lines or you're building the capacity for others to do it,
and you're really teaching and leading. But what I love
about your roles is that you're doing both, which will
make you a better capacity builder because you can talk
(04:13):
about how it's truly done on the ground and speak
about it with first hand experience.
Zayna (04:16):
Exactly. One informs the other and vice versa. And I'll
tell you, and I never knew this until I reflected.
So I teach in our global MBA program, and, you know,
we've got these doctors and CEOs that come through. And
six months after one of my lectures, one of our,
you know, graduating students will come to me and say, Xena,
because of you, because of this one class, I took
(04:37):
this trajectory and now this is happening. I think I've
had more impact on my mission, which is impacting the
health of Canadians through that than any of my on
the ground work, if I have to be honest. So
I hold both very dear to my heart and they
do feed off each other.
Ann (04:52):
That's great to see the the return on investment and
in the capacity building so quickly we could talk about your.
Background in your experience for the entirety of the podcast?
And I find your roles so interesting and I know
our listeners will too. But I do want to dive
into our topic at hand here and talk about how
(05:12):
we're seeing health care in the home and virtual care
really grow and what are the levers or propellers to
that growth. So pre-pandemic telehealth and virtual care were already
taking off. And in our world we just saw this accelerate.
It was fuel on the fire and really gave it
the momentum in the push that it needed to grow
(05:35):
hospital at home models, remote patient monitoring solutions and home
based care all grew rapidly. So from your point of view,
what are some of the most innovative business models in
the space today?
Zayna (05:46):
So maybe before I share the models and I agree
there was fertile ground for some experiments to scale, you know,
I would just be clear. In my view, the word
home is really care anywhere. You know, if you're a
truck driver and there's millions of them, your home is
your truck. If you're an adolescent in high school, your
home is your school. It's just this idea of untethered
(06:09):
being one place called the facility from care as being
the only channel and then really decentralizing, which was, you know,
a big thesis, as you know, of Christensen's original book
about this massive decentralization that's coming. It's just the home
is one of those places that doesn't have traditionally a
lot of infrastructure for much more higher acuity care, like
(06:30):
the examples you gave. And I know and you even
talk about I'll just call out three and then we
can get into them. You know, I really love what
dispatch is doing, you know, started in Colorado and now
they're in multiple states of the idea of an air
to home, you know, whereas most health systems have diverted
people from coming to the air or getting them out
(06:51):
as fast as possible, they're literally bringing the air level
care into the home using humans and machines. And I
just think to me, what that business model is about
is a fundamentally inflexible infrastructure, like building EDS, you know,
for a the most dynamic thing in the world called care.
(07:11):
So making it flexible and, you know, asset light, I'm
quite a fan of that model and I haven't seen
that scaled in too many well, really anywhere outside the US,
I'm waiting for them to open a Canadian branch. The
second is, you know, maybe a lighter version of that,
which I think has grown because of Covid was always
there but is really getting creative, which is what I
(07:33):
call tele hospitalists. So, you know, these highly trained, high
acuity resources that you need, particularly like things like stroke
and critical care and ICU, where like every minute is
brain or a life and limb thing. And these places
like in North America, with these big floppy geographies where
(07:54):
there's just no way you're going to have the cadre
of these experts in every place where bad things happen
that are unexpected, like a stroke or a car accident or,
you know, a gunshot wound, really being able to get
that hospitalist or intensivist level expertise at the point of
care without that person being in the room and laying
(08:15):
eyes on them. And again, we're doing this and, you know,
this is a big part of one of the platforms
Teladoc enables that I was excited to bring to Canada,
you know, in very, very remote and rural areas of
the world where our clinicians who are sitting behind the
screen and, you know, manipulating these devices to see the
patient who could be 6000km away, I don't know what
(08:36):
that is in miles. I don't even remember that I'm
behind a video. They don't like to them, they're in
it and the outcomes are huge. So that's another one,
I think, of just spreading capacity for hospitals, specialists, intensivist,
and that includes for specialty referrals. We're doing this in
the NHS in England for over 34 million patients. That's
about the whole size of Canada. And then the final
(08:57):
is like the new era of you mentioned the word
remote monitoring and just really much less clumsy and clunky,
you know, really continuous and proactive monitoring enabled by payment
models and care models that create value. So I'll just
give a couple examples. You know, remote monitoring companies have
(09:18):
been around for post-acute type monitoring because the incentives are
very clear. You don't want to readmit. And there's a
lot of risk in the first few days after surgery
or discharge. But with Teladoc, for example, with the Chronic
condition platform from the Livongo acquisition, that platform has been
working really well to decentralize care of chronic conditions, diabetes, hypertension, etcetera.
(09:42):
But then recently we added last mile we added do
your A1C test at home. And so that just integrates
another layer into this which makes the value proposition higher.
And that's what I'm seeing these stacks and stacks of
these home monitoring programs that are well beyond some devices
measuring vitals.
Ann (09:59):
Three really good examples. And I can say as someone
who lives in a market where dispatch health operates, they
are great. And if they do ever come to Canada,
I would suggest using them for listeners who may not
be as familiar with them. Dispatch Health is urgent Care
that comes to your house. When they first launched, their
tagline was urgent care in the back of a Prius.
So they've eliminated the bricks and mortar of urgent care,
(10:21):
and they send a nurse practitioner and a technician to
your house and can basically provide all the services that
you would need, that you might need or could get
in an urgent care. Even if you need an x ray,
they will send portable x ray to your home, which
is awesome. So very asset light model. Definitely an innovator
worth watching. And I find it interesting in how they
(10:45):
have actually pivoted their business model from originally just being
direct to consumer to actually partnering with health systems. Here
in the US, they've partnered with Health Systems, which helps
dispatch health make their market larger and also helps the
health system. Should this individual need care that Dispatch health
can't provide. I'd love to dive into one thing you
(11:08):
said about the new era of remote monitoring and how
the work Teladoc is doing with Last Mile. You said
you can now do your A-1 test at home. So
we're really seeing not just these point solutions of remote
monitoring or home based care, but truly an integrated approach
to disease management. Could you talk a little bit more
(11:30):
about what that partnership with Last Mile looks like and
perhaps from the consumer perspective, the benefit they get out
of it?
Zayna (11:38):
So I mean, this was announced maybe last year and again,
we don't have this yet in Canada. That's a big
part of why I came to Teladoc is to bring
the platform. There's nothing like it in our country. And
I thought, wow, I get to be part of bringing that.
So I've had my eye on this for a while. And,
you know, my PhD is in diabetes, and I left
academia because I was like, the papers I'm publishing are
(11:59):
never going to impact anybody with diabetes in this country.
And I thought, wow, if I could bring Livongo. And
then when I saw this one announcement, you know, because
I know that's a big gap in care is just
getting the test. So I think this was our partnership
with Let's Get Checked, which is a company already doing that.
And just like you said, just like dispatch, it's much
easier to attach to an existing platform that has a
(12:20):
population it serves versus going after it alone for a
point solution. So that's just an example of that. If
you think about it, you know, if you even look
at Teladoc's Roots or any other virtual care, we were
already doing this for 20 years with home delivery of medications, right?
So you do a virtual care appointment, you know, some
percent of the time the result is a medication as
(12:41):
part of the treatment plan. And then just with an algorithm,
you pick the pharmacy and it's a home delivery service
and they deliver the drugs to your house, like that's
the last mile. It's just we don't think about that
because it's been part of our infrastructure. And of course
Amazon will put that on steroids with with the Pillpack acquisition.
So this is just, you know, another version of that
(13:02):
where diagnostic testing, again, thanks to Covid, is now coming
to the home, whether that's cassette type point of care
testing where, you know, you put the specimen on some
device and you get your result immediately or even phlebotomy
at home, urine sampling at home, where at least you're
not going to the collection center. It's coming to you
(13:24):
in a logistics and cost effective way that makes the
economics work. So so that's the idea. And I think
what I like about bolting on the home, a one
to the chronic condition model of Teladoc, which has already
6 or 7 innovations in one, right. I think I
had my students once analyze it through the Doblin innovation
lens and it kicks off like seven of the ten.
(13:46):
There's devices getting biological data. We're mailing the test strips
to your house. So you don't have to add that
as a barrier to your thing. We have an AI
as your partner, looking at your data and giving just
in the moment nudges. There's a human coach that's got
your back all the time, like there's so many pieces.
And then but one gap in care is a onesie testing.
(14:07):
And now we've taken that barrier away, right? And the
meds already were there. And the link to primary care
is already built into the program through the merger, obviously,
with Teladoc. So. So that's all it just takes. The
next one. And I'll tell you, we'll be next is
the two other big gaps in care with people with
diabetes is getting their eyes checked and checking their feet.
And if we can close those gaps in care, then
(14:29):
we're going to really have an even more holistic solution.
So we'll see what comes next with that.
Ann (14:34):
Very exciting. And I say that as not an incumbent
health care operator. So what do you think makes any
of these models that you mentioned innovators worth watching, what
makes them potentially disruptive to the incumbents out there?
Zayna (14:50):
So I'd say a few things I'd observe, and this
is more my lens of I was on the the
partnering side, so I was that org that had to
partner with these tech companies. Because we didn't have the
capabilities even though in my former org as Saint Elizabeth
health care, you know we were delivering care in people's
homes 10,000 times a day for like 118 years. I mean,
(15:10):
this was our our core business and we didn't have
the capabilities to have a platform that can adjust and
pivot everything the tech stack, the data stack, the payment models.
So I think that's to me, what makes these innovators
worth watching. One is just really thinking ahead and not
being locked in on anything so that you can keep
(15:32):
evolving both in real time and for the future. And
I think the second thing is being able to partner really,
really well. It's an art and a little bit of science,
and not many on both sides. The innovators or like
the health system partners are very good at this and
finding out the gives and the takes and the scalable models.
(15:52):
So I think that's what I see that works really well.
And then finally, because you're going into people's homes, it's
the Wild West. I mean, health care has been in
such an institutional and clinic based model where we can
control all the conditions, the light, the temperature, the hours
of operation, who's there, where they go? We have a
security guard that will kick you out if you don't behave.
(16:15):
The home is like the dog is going to be
humping your leg. You're going to slip on the ice.
When you're getting to the door, the person won't answer
the door, even though they said they'd be there. Like
so many things are going on. So you really, really
need people who know how to be in the home.
And that's why formal health systems have to partner. And
these new startups who don't get this will not make.
Ann (16:37):
It great insights. And I'm going to tie them all
together through the business model lens. So the first one,
effectively these startups have nimble business models. They're not locked
in to the incumbent approach to businesses. They are fast,
flexible and responsive because they're focused on what's needed for
the future, not what's led to their success in the past.
You also pointed to some key processes and key resources.
(17:02):
So from the partnership lens people need or these organizations
have processes and associated resources required to partner with the
health systems that they want to work with or other
entities that they need to work with. And then the
importance of having flexible resources who are okay, not being
in control in order to go into the home and succeed.
(17:25):
I had never thought about the juxtaposition between the environment
in health care. You're right, because in the health care facility,
from a supply side, everything is controlled. So the provider
has control over every detail you mentioned. And in the
home it's the exact opposite. You are walking into a
situation in which you have no control at all.
Zayna (17:44):
No control, and it'll change day to day. And just
to add to that, there's a whole other area of
talk and thinking and rethinking medical education. So med school,
nursing school, physiotherapy school, because if you look at the
applied hours, like the practicum hours that say a nursing
student goes through like 99% of that is at a hospital,
(18:06):
but 99% of health is created, made and destroyed everywhere
but a hospital. So these clinical resources are not trained
in the native environment where they're patients, where all the
action is and where it's going, everything we just talked about.
So there's a whole movement there where I think home
based training is having a renaissance. So it's going to
(18:27):
start to disrupt, I think. Med Ed, just one other point.
Looking at, you went through the business model lens. So
profit model, one of the the key elements, you know,
and I don't know the answer, but maybe an you
can think about it if you think about what happens
when you move traditionally facility based care models into a
home setting, you know, you've now you've changed the economics
(18:47):
because you've downloaded the cost of the physical place to
the patient. It's their electricity, it's their water, you know,
it's their real estate. So so that should allow you to, whatever,
stop building hospitals or, you know, streamline your clinics or whatever,
just like remote work. However, that cost can be a
big cost if you're going to start to do dialysis
(19:08):
at home at the rate that it can be done,
which is about 40% of all dialysis theoretically can be
done at home. There's a big cost to be borne
of that of supplies being stored and blah, blah, blah.
On the other hand, you're adding a cost that used
to be on the patient, which is trouble. They came
to you, they parked. Now you've got to pay for
(19:29):
getting these people to these places. And in a big
floppy geography, that's a very big cost. I mean, I
personally have a relative who works in home care. When
gas prices got really bad recently, she was net negative
income from a day of work just from filling up
her car twice in a day. So that aspect of
the fleet, if you will, becomes a very big part
(19:52):
of your cost model, not just the labor going into
the home in their hours of work. And I don't
think these companies that are in last mile understand those.
Not mix very well, particularly given the kind of geographies
we're talking about.
Ann (20:03):
That's an excellent point. When you think about the scaling perspective,
it might work really well in a small pilot where
your geography is really tight and you're the number of
people that you're serving is really small. But as you
seek to scale it, how does the profit model continue
to work or not? I think the biggest thing I
thought of when you mentioned profit model was the reimbursement side.
(20:25):
So in the US a big reason why home based
care did not catch on before the pandemic in the
way that it did during the pandemic is it wasn't reimbursed.
It wasn't paid for. Now, during the pandemic, there were
waivers that changed that, which made the business model economics work.
But you're right, the profit model component is going to
(20:47):
be key for many of these potential disruptors and new
entrants who are seeking to capture share in the market
to figure out because if they can't do that sustainably,
they won't be around long.
Zayna (20:58):
Yeah, I think there's lots of pools though, of financing.
Just like you said, it's in the interest of big
payers like a Medicare to pay for more things to
be in the in the envelope, if you will. And
that certainly happened and that's driving a market. I think
the other two drivers, though, of a market is everyday
people will pay out of pocket for this. It might
be not be the 85 year old person, but it'll
(21:20):
be their son or daughter, you know, because there's a
cost to them if their loved one isn't aging well
at home. So that market is exploding because a baby
boomer was born every 10s and it's still on its
way up. So there's a whole world of that economy.
And then the third is there's budgets of, let's say,
a hospital itself that has incentives to not have readmissions
(21:42):
or whatever, where you can use their OpEx that would
have financed, you know, an air room or an operating
room or a lab or whatever, like the OpEx can
pay for the home care. So it's part of the
extended budget, if you will, of an incumbent versus asking
some insurer to reimburse a task. It's just it's part
(22:03):
of the episode of Care. So that's how these models,
at least in Canada, have really taken off actually that
last that last bucket.
Ann (22:10):
And to that point, the US certainly has some unique
payment structures compared to other countries. And because of that,
a number of these virtual and at home care models
have not taken off the way they perhaps have in
other countries. So what do you think the US can
learn from other countries approaches to home based care? Are
(22:32):
there other home based models you've seen succeed elsewhere that
you think we should really look to?
Zayna (22:38):
It's one thing is interesting. This is definition. So there's
home care. And I think in the US the words
are home health is different from home care. If I
remember from a definition, one involves nurses, one involves, you know,
home health aides or something like that. Whereas in in
most places in the world, home care is any combination of,
you know, a licensed professional like a nurse and or
(23:02):
an RPN physiotherapist or somebody that's helping with activities of
daily living, like the equivalent of what you'd call a
home health aide. It's any combination of those rehab occupational
therapy is home health care. So that is a difference,
I'd say, because you're not siloing the kind of human
help you need and then it makes it a little
bit easier because now you can mix and match. I
(23:23):
would separate that, though, from home based care models like
we've been talking about like E.R. at home and hospital
to home, because those often don't even use the traditional
home health care agency people. It's all these other new entrants. Right.
So so they're just there's two things at play. Just
a couple examples that I've been tracking around the world.
(23:43):
So one big movement is this idea of client directed care.
So instead of some third party agency or assessor or
insurance adjudicator saying, okay, you qualify for this many days
of a nurse coming over or a home health aide
or whatever. And here's the price and here's the minutes
and to the shift to, you know, based on your
(24:06):
level of need and support you have at home, here's
your budget and you go and buy whatever you need.
And if if what you need is a person to
cut your lawn, it's in scope. You know, Medicare did
that a little bit, but this is really client directed
care or it's called patient budgets. So a couple jurisdictions
in Canada have now done this that probably the most
(24:27):
advanced is Nova Scotia. Australia was really one of the
first and Germany years ago to have these kind of
patient budgets. And they get the money, they get the envelope,
they go find what they need. Now you have no
intermediaries and you have a big incentive for, you know,
the people who deliver the services to actually do well.
Ann (24:45):
So what are their results? What becomes of this or
health outcomes better or costs lower?
Zayna (24:51):
It's a great question. So I don't know that there's
been great analysis, but I'd say the biggest benefit has
been two things I'd say. One is. Better client experience
or patient experience because they're directing, they're in charge. The
worst thing when you're getting home health care is to
be stuck with whoever, and they don't match you like
it's not a fit, whatever language you're I don't know what.
(25:13):
And then you're kind of stuck with them because you'd
rather have that than no care. So when you can
decide and direct who, when and what it just wants
better patient choice. So I think that's indisputable. And then
of course, formal health systems like it because they're now
absolved from all the bureaucracy and organization of managing and
(25:34):
micromanaging these resources, which is very, very it's another layer
of management that adds cost. And they're so far away
from the patient, they're making decisions about these people's lives.
They never see them, you know. So I think it's
consistent with that. I don't know that the results have
yet been quantified, but the fact that they keep going
probably is a good sign. A couple other examples. So
(25:55):
this idea of a nursing home at home in the US,
it got a lot of momentum of the skilled nursing
facilities or sniffs at home. And so this idea that
if you're a nursing home like you can't build it,
you can't grow like if you're full, that's it. It's
going to take you ten years for CapEx to build
another building. So how do you scale and grow? So
(26:17):
so either the the nursing home themselves building the model
or others doing it and then competing, if you will,
with the nursing home. But the data shows 20 to 25%
of people in a nursing home could manage at home
with appropriate supports. That's a pretty huge market. And at
least in Canada, 16% of people using a hospital bed
right now do not belong in a hospital. But there's
(26:39):
nowhere for them to go because we don't have a
care model that fits. And so there's just these new
models of what I call nursing home at home. And
in my former job, you know, we were rolling these
out and literally bringing people home from hospital who didn't
need to be at hospital with a new model. And
we were we call reactivating them, which is getting them
kind of back to their pre-hospital baseline in like 35 days.
(27:02):
These are extremely high. These people would have been sitting
in the hospital for six months or whatever until they died.
So high, high ROI business models that again don't have
a scalar rater yet their point solutions, but they work
A couple of other ones I'll just call out just
to throw the whole buffet out. I don't know if
(27:23):
you've heard of NORC, Newark's naturally occurring retirement centers. So
this is an idea in like urban environments. You've got,
you know, large multi resident apartment buildings that just skew elderly.
So as soon as you tip, 35% of the residents
are over 65, you're a naturally occurring retirement center, like
just by volume. There's just people who have a lot
(27:46):
of need who will self aggregate and do their own programming,
like a retirement center or an assisted living facility. So
so in an oxymoron, instead of them being naturally occurring,
there's now support from health systems to actually let them
become like a retirement center. And the cost is like
$10 a day. And that's contrasted with, I don't know,
a retirement home can be $300 a day or $500
(28:10):
a day. So so that's a big thing actually, out
of Canada that the world has come to study. And
there's a lot of infrastructure now to scale the Nordic model,
which is kind of cool. And then maybe just a
couple more and then you ask me questions, family, caregivers. So,
you know, the son or the daughter or the spouse
who's taken care of the loved one who needs home
(28:31):
supports becoming like part of the patient unit of care
and having a whole set of program services, infrastructure policies,
payment models to support them, because as soon as they
go down, everything goes down. And so why don't you
intervene then? There's a huge movement and, you know, places
like Sweden paying an allowance for a family caregiver, a
(28:55):
lot more employers are now creating a benefit for family caregivers.
ET cetera. ET cetera. So that's a whole market that's
exploding and solutions are coming up. So anyway, those are
just some examples.
Ann (29:05):
Thank you for sharing those. And just when I thought
I'd heard all of the health care acronyms, now I
have a new one. So just one quick follow up
question on that one. In these retirement centers, are health
systems placing nurses and providers with in the centers? How
where's the health care tie in?
Zayna (29:24):
Yeah, So what they've done and that's been studied and
evaluated as what's the best model to make a naturally
occurring retirement center, not naturally occurring. It's actually place a
coordinator in the building that is the liaison both of
internally volunteer based programming and activities. There's always a room
or a space for these so that you could have
(29:45):
like a, you know, a meds clinic, a diabetes clinic,
a cardiac, whatever. So there's space, there's a coordinator and
then there the liaison out. So if it turns out
that in this building, you know, 35 people need some
nursing care in the home. Or they need some phlebotomy
to get, you know, lab work. Then they can coordinate,
have one provider come in and do the whole building
(30:07):
versus the old way, which is literally a revolving door.
Like sometimes we looked at some of these buildings, 35
different providers coming in and out of the building every day.
So really streamlines and then you get a longitudinal relationship,
of course, as well, between those providers and the residents
of the building.
Ann (30:23):
So that's a huge cost savings for Canada because they're
sending one provider instead of 35. Yeah.
Zayna (30:29):
And you have continuity of care because the turnover of
these providers is very high. So I'm saying I think
they quantified about ten bucks a day for this program.
And a typical like if you were just getting traditional
home care that got assessed by some remote person and
nobody really follows the data, it could be anywhere from
30 to $150 a day. And then a hospital stays
(30:50):
like 1500 to 3000 a day. So you could see
the economics multiply pretty quickly.
Ann (30:55):
Yes, very quickly indeed. So Zena, is very clear from
this conversation. You're a visionary. So let's look to the future.
Pretend we're having a similar conversation again. But it's three
years from now, so it's 2026, Which innovative business models
will be thriving and which ones will be struggling.
Zayna (31:13):
So let me just unpack that and some of the
different vectors of at home that are happening. So I
think any of the more traditional medical care at home,
emergent care, as we talked about, primary care at home, physio, rehab, palliative,
you know, post-acute care, I think those will just be
business as usual. Business models, I think lengths of stay
(31:33):
in acute facilities will be almost nothing. There'll be a
few hours and this will just be how it's done
and I think it'll be that good that it'll be
on an outcomes based model. So some kind of a,
you know, if you think of Christiansen, you know, VAP
value add process type model just because we'll have the numbers,
I think the coordination and the communication to enable at
(31:56):
home models so omni channel everyone on the same page
sharing the data. I don't have as much confidence that's
going to be where it needs to be because of
all the fragmentation. And I certainly don't know how next
modalities like right now we can barely deal with app phone,
text and video, but voice and VR and you know,
(32:17):
telehealth portation, like these things are coming on and I
don't think we'll be there. So I still think it's
going to be a fragmented experience and it's going to
be patchwork of interoperability. That's my guess from what I'm
seeing today. I think diagnostics at home is going to explode.
So all this last mile is going to be so
much better than what it even is today. You know,
we basically take blood and urine from people. I think
(32:39):
those are going to be very old ways to get
information about one's biology. But what I am not sure
about is will it still be a bunch of discrete
tests like sleep apnea, AIS, you know, fertility, all these,
you know, each with a different company, Well, that's not
going to work. So I don't know what will be
combined and not. But I think a lot of that
(33:01):
will happen at home, I think is going to be
a big change of life for all your labs providers
and central kind of diagnostics. I don't think imaging at
home will take off. As much as I'd love to
see it. I think, you know, in theory you could
do MRI at home, but that's, you know, colonoscopy at home.
But I don't think the business models are ready or
the incumbents are going to hang on way too tight.
There's too much fixed infrastructure. So I wish I saw that,
(33:25):
but I don't think so. And then finally, procedures at
home like chemotherapy, dialysis, IV infusions. I think those will
just kind of follow along with labs and imaging and diagnostics.
I just think we really don't need to be bringing
people to buildings for this stuff anymore. And I think
those business models will fall out. Last thing is, you know,
(33:48):
the headlines for years where the end of hospitals, the
hospitalization of health care, you know, home spittle is like
another word, right? I don't know. I mean, from everywhere
I see other than one country, maybe two Denmark and Netherlands,
maybe the UK a little bit. The number one policy
(34:09):
agenda is build more hospitals. So that's what I'm struggling with,
is how can this whole movement be happening Yet, you know,
these long term capital bets are still all about building
more so. So I'm not sure if hospitals will be
shut down in most markets, although a few countries that
is the policy agenda.
Ann (34:26):
I love the the vision of what's to come especially
around at home diagnostics exploding and your comment that it
can't continue to be a bunch of discrete tests. There
will have to be combination and just the resulting business
model change that that will mean for lab services. We'll
see more procedures at home and we likely will not
(34:47):
see the end of hospitals. Awesome. Zena, thank you so much.
My last question for you is, do you have any
parting thoughts that you'd like to leave with the audience
about the future of home based and virtual care?
Zayna (34:58):
So maybe. We used a couple of things. Anderson Horowitz
thesis for this year is health care is leaving the building.
I thought that was interesting. You know, your VCs and
your PE funds are saying, you know, it's a land
grab for the home. So there is a lot of
center of gravity moving here. And so I'll just leave
with two points. One is, again, to me it's about
care anywhere. It's not necessarily the home. You know, home
(35:21):
is a feeling, you know, feeling comfortable, feeling safe, and
you don't feel that usually in facilities. So it's that's
what I would be thinking about is care anywhere. And
then finally, as I mentioned, you know, all these new
entrants that are coming in, whether they're, you know, a
big grocer or an Instacart or a new startup, you know,
if they get logistics, that's what's going to make or
(35:43):
break it at scale and they can either disrupt. But
as you've mentioned, they can also partner because the incumbents really,
really need these capabilities and they do not have them
in house. So double opportunity.
Ann (35:55):
Fabulous. I love your concept of the care anywhere. It's
not just the home, but it's really care anywhere. And
that gets back to really meeting people where they are
in the flow of their lives because the hospital is,
I would venture to say never in the flow of
anyone's life. So I'm excited for this future that you've
painted for us, Dana, And thank you so much for
(36:17):
coming to speak with me today and for sharing all
of your insights with our listeners. My pleasure.
Zayna (36:22):
I think you're going to be very busy and in
team evaluating these business models when they start to pop.
Thank you.
Ann (36:29):
You are certainly right about that. Well, thank you so much, Dina,
and thank you, listeners, for tuning in to hear Zena
share her insights of the future of health care. Until
next time, thank you for listening to life centered Health Care.
If you like what you heard, please leave a review
on Apple, Spotify or wherever you're listening. And for more
(36:51):
of the latest in health care, check out our website,
Christensen Institute. Org. You can sign up for our newsletter
and read our latest industry insights. Until next time, have
a wonderful day, everyone.
A lot of leaders and innovators talk about disrupting health care,
but what does that really mean and how does one
actually do it on life centered health care? We dive
into these questions and more talking to innovators who are
leveraging Clay Christensen's theories to transform our health care ecosystem.
I'm Ann Summers Hogg, senior research fellow of health care
at the Clayton Christensen Institute. And I hope these stories
(00:23):
help inspire you along your journey to transform health and care.
I'm thrilled for today's conversation because I could not imagine
a better guest with whom to discuss the future of
health care. Zanna Hyatt, Health futurist at Deloitte Life Sciences
and Health Care in Canada. Adjunct faculty at the University
of Toronto's Rotman School of Management and former vice president
(00:46):
at Teladoc Health Canada, is here with us today. And
before these roles, Zaina served as the future strategist with eHealth.
She served as the innovation Sherpa in chief to strengthen
the Dutch health innovation ecosystem. She led the Health System
Innovation platform at Mars Discovery District, a major innovation hub
(01:07):
in Toronto and much, much more. She completed her PhD
in biochemistry and also had a career in strategy consulting
as a principal in BC's health practice. Welcome, Zena. Thank
you so much for being here.
Zayna (01:19):
Great to be here. An excited about this podcast.
Ann (01:22):
Thank you. Thank you. And I gave a brief overview
of your background, but before we dive in, I'd love
to give you the opportunity to tell our listeners a
little bit more about you. So I like to start
with why could you tell us a little bit why
about after four years as the first ever and perhaps
the only futurist in a large national home care agency,
(01:45):
you made the move to a commercial leadership role in
the Canadian arm of Teladoc Health. What drove you to
join Teladoc? What attracted you to this organization in their approach?
Zayna (01:55):
So my why is I think my personal mission is
to improve the health of Canadians with the platform. I have.
My lever to do that is by modernizing the Canadian
health and care system. And so when the opportunity to
bring the Teladoc platform into Canada as part of an
acquisition they did a few years ago, you know, it
gave permission to enter the market. This is the platform
(02:16):
to bring modern solutions at population scale that already have
proven to work elsewhere. And so I kind of had
to jump on board because I think that's at least
in our market, has been the lock. And the key
is lots of point solutions and pretty good neat ideas,
but nothing really done at scale. And that's that's the
next unfinished business.
Ann (02:36):
Awesome. I love that. Modern solutions at population scale. I
think that's what so many startups in the health care
ecosystem are striving for right now. Many are promising, few
will deliver. So exciting to see Teladoc make progress in
that area now. More recently, you also became the in-house
futurist with Deloitte Healthcare in Canada. Tell our listeners what
(02:57):
that is all about.
Zayna (02:58):
As a changemaker in health care, I've got two levers.
One is rolling up my sleeves and doing the work,
and that's what I've done in every job you just
listed earlier. And what I'm doing now with Teladoc and
it's hard and it's punishing. You got to be in
it near the clinicians and near the patients and with
the tech people and the contracting people, etcetera. The other
(03:18):
lever is to actually build capacity for others to do that.
And that's what I do through my teaching at the university,
also with the Dutch Health Innovation School, which I continue
to teach in. And then now is this role with Deloitte,
where I can bring thinking about the future into the
work they do, our own staff and our clients, so
that at least some big choices in bets people are
(03:41):
going to make today are consistent with an ever evolving future.
And I don't think we do that enough when we
make big bets today. So that's my vector for scale
there in capacity building.
Ann (03:51):
I like how you broke it into the two different
levers to pull. So you're either the change maker on
the ground doing the hard punishing work on the front
lines or you're building the capacity for others to do it,
and you're really teaching and leading. But what I love
about your roles is that you're doing both, which will
make you a better capacity builder because you can talk
(04:13):
about how it's truly done on the ground and speak
about it with first hand experience.
Zayna (04:16):
Exactly. One informs the other and vice versa. And I'll
tell you, and I never knew this until I reflected.
So I teach in our global MBA program, and, you know,
we've got these doctors and CEOs that come through. And
six months after one of my lectures, one of our,
you know, graduating students will come to me and say, Xena,
because of you, because of this one class, I took
(04:37):
this trajectory and now this is happening. I think I've
had more impact on my mission, which is impacting the
health of Canadians through that than any of my on
the ground work, if I have to be honest. So
I hold both very dear to my heart and they
do feed off each other.
Ann (04:52):
That's great to see the the return on investment and
in the capacity building so quickly we could talk about your.
Background in your experience for the entirety of the podcast?
And I find your roles so interesting and I know
our listeners will too. But I do want to dive
into our topic at hand here and talk about how
(05:12):
we're seeing health care in the home and virtual care
really grow and what are the levers or propellers to
that growth. So pre-pandemic telehealth and virtual care were already
taking off. And in our world we just saw this accelerate.
It was fuel on the fire and really gave it
the momentum in the push that it needed to grow
(05:35):
hospital at home models, remote patient monitoring solutions and home
based care all grew rapidly. So from your point of view,
what are some of the most innovative business models in
the space today?
Zayna (05:46):
So maybe before I share the models and I agree
there was fertile ground for some experiments to scale, you know,
I would just be clear. In my view, the word
home is really care anywhere. You know, if you're a
truck driver and there's millions of them, your home is
your truck. If you're an adolescent in high school, your
home is your school. It's just this idea of untethered
(06:09):
being one place called the facility from care as being
the only channel and then really decentralizing, which was, you know,
a big thesis, as you know, of Christensen's original book
about this massive decentralization that's coming. It's just the home
is one of those places that doesn't have traditionally a
lot of infrastructure for much more higher acuity care, like
(06:30):
the examples you gave. And I know and you even
talk about I'll just call out three and then we
can get into them. You know, I really love what
dispatch is doing, you know, started in Colorado and now
they're in multiple states of the idea of an air
to home, you know, whereas most health systems have diverted
people from coming to the air or getting them out
(06:51):
as fast as possible, they're literally bringing the air level
care into the home using humans and machines. And I
just think to me, what that business model is about
is a fundamentally inflexible infrastructure, like building EDS, you know,
for a the most dynamic thing in the world called care.
(07:11):
So making it flexible and, you know, asset light, I'm
quite a fan of that model and I haven't seen
that scaled in too many well, really anywhere outside the US,
I'm waiting for them to open a Canadian branch. The
second is, you know, maybe a lighter version of that,
which I think has grown because of Covid was always
there but is really getting creative, which is what I
(07:33):
call tele hospitalists. So, you know, these highly trained, high
acuity resources that you need, particularly like things like stroke
and critical care and ICU, where like every minute is
brain or a life and limb thing. And these places
like in North America, with these big floppy geographies where
(07:54):
there's just no way you're going to have the cadre
of these experts in every place where bad things happen
that are unexpected, like a stroke or a car accident or,
you know, a gunshot wound, really being able to get
that hospitalist or intensivist level expertise at the point of
care without that person being in the room and laying
(08:15):
eyes on them. And again, we're doing this and, you know,
this is a big part of one of the platforms
Teladoc enables that I was excited to bring to Canada,
you know, in very, very remote and rural areas of
the world where our clinicians who are sitting behind the
screen and, you know, manipulating these devices to see the
patient who could be 6000km away, I don't know what
(08:36):
that is in miles. I don't even remember that I'm
behind a video. They don't like to them, they're in
it and the outcomes are huge. So that's another one,
I think, of just spreading capacity for hospitals, specialists, intensivist,
and that includes for specialty referrals. We're doing this in
the NHS in England for over 34 million patients. That's
about the whole size of Canada. And then the final
(08:57):
is like the new era of you mentioned the word
remote monitoring and just really much less clumsy and clunky,
you know, really continuous and proactive monitoring enabled by payment
models and care models that create value. So I'll just
give a couple examples. You know, remote monitoring companies have
(09:18):
been around for post-acute type monitoring because the incentives are
very clear. You don't want to readmit. And there's a
lot of risk in the first few days after surgery
or discharge. But with Teladoc, for example, with the Chronic
condition platform from the Livongo acquisition, that platform has been
working really well to decentralize care of chronic conditions, diabetes, hypertension, etcetera.
(09:42):
But then recently we added last mile we added do
your A1C test at home. And so that just integrates
another layer into this which makes the value proposition higher.
And that's what I'm seeing these stacks and stacks of
these home monitoring programs that are well beyond some devices
measuring vitals.
Ann (09:59):
Three really good examples. And I can say as someone
who lives in a market where dispatch health operates, they
are great. And if they do ever come to Canada,
I would suggest using them for listeners who may not
be as familiar with them. Dispatch Health is urgent Care
that comes to your house. When they first launched, their
tagline was urgent care in the back of a Prius.
So they've eliminated the bricks and mortar of urgent care,
(10:21):
and they send a nurse practitioner and a technician to
your house and can basically provide all the services that
you would need, that you might need or could get
in an urgent care. Even if you need an x ray,
they will send portable x ray to your home, which
is awesome. So very asset light model. Definitely an innovator
worth watching. And I find it interesting in how they
(10:45):
have actually pivoted their business model from originally just being
direct to consumer to actually partnering with health systems. Here
in the US, they've partnered with Health Systems, which helps
dispatch health make their market larger and also helps the
health system. Should this individual need care that Dispatch health
can't provide. I'd love to dive into one thing you
(11:08):
said about the new era of remote monitoring and how
the work Teladoc is doing with Last Mile. You said
you can now do your A-1 test at home. So
we're really seeing not just these point solutions of remote
monitoring or home based care, but truly an integrated approach
to disease management. Could you talk a little bit more
(11:30):
about what that partnership with Last Mile looks like and
perhaps from the consumer perspective, the benefit they get out
of it?
Zayna (11:38):
So I mean, this was announced maybe last year and again,
we don't have this yet in Canada. That's a big
part of why I came to Teladoc is to bring
the platform. There's nothing like it in our country. And
I thought, wow, I get to be part of bringing that.
So I've had my eye on this for a while. And,
you know, my PhD is in diabetes, and I left
academia because I was like, the papers I'm publishing are
(11:59):
never going to impact anybody with diabetes in this country.
And I thought, wow, if I could bring Livongo. And
then when I saw this one announcement, you know, because
I know that's a big gap in care is just
getting the test. So I think this was our partnership
with Let's Get Checked, which is a company already doing that.
And just like you said, just like dispatch, it's much
easier to attach to an existing platform that has a
(12:20):
population it serves versus going after it alone for a
point solution. So that's just an example of that. If
you think about it, you know, if you even look
at Teladoc's Roots or any other virtual care, we were
already doing this for 20 years with home delivery of medications, right?
So you do a virtual care appointment, you know, some
percent of the time the result is a medication as
(12:41):
part of the treatment plan. And then just with an algorithm,
you pick the pharmacy and it's a home delivery service
and they deliver the drugs to your house, like that's
the last mile. It's just we don't think about that
because it's been part of our infrastructure. And of course
Amazon will put that on steroids with with the Pillpack acquisition.
So this is just, you know, another version of that
(13:02):
where diagnostic testing, again, thanks to Covid, is now coming
to the home, whether that's cassette type point of care
testing where, you know, you put the specimen on some
device and you get your result immediately or even phlebotomy
at home, urine sampling at home, where at least you're
not going to the collection center. It's coming to you
(13:24):
in a logistics and cost effective way that makes the
economics work. So so that's the idea. And I think
what I like about bolting on the home, a one
to the chronic condition model of Teladoc, which has already
6 or 7 innovations in one, right. I think I
had my students once analyze it through the Doblin innovation
lens and it kicks off like seven of the ten.
(13:46):
There's devices getting biological data. We're mailing the test strips
to your house. So you don't have to add that
as a barrier to your thing. We have an AI
as your partner, looking at your data and giving just
in the moment nudges. There's a human coach that's got
your back all the time, like there's so many pieces.
And then but one gap in care is a onesie testing.
(14:07):
And now we've taken that barrier away, right? And the
meds already were there. And the link to primary care
is already built into the program through the merger, obviously,
with Teladoc. So. So that's all it just takes. The
next one. And I'll tell you, we'll be next is
the two other big gaps in care with people with
diabetes is getting their eyes checked and checking their feet.
And if we can close those gaps in care, then
(14:29):
we're going to really have an even more holistic solution.
So we'll see what comes next with that.
Ann (14:34):
Very exciting. And I say that as not an incumbent
health care operator. So what do you think makes any
of these models that you mentioned innovators worth watching, what
makes them potentially disruptive to the incumbents out there?
Zayna (14:50):
So I'd say a few things I'd observe, and this
is more my lens of I was on the the
partnering side, so I was that org that had to
partner with these tech companies. Because we didn't have the
capabilities even though in my former org as Saint Elizabeth
health care, you know we were delivering care in people's
homes 10,000 times a day for like 118 years. I mean,
(15:10):
this was our our core business and we didn't have
the capabilities to have a platform that can adjust and
pivot everything the tech stack, the data stack, the payment models.
So I think that's to me, what makes these innovators
worth watching. One is just really thinking ahead and not
being locked in on anything so that you can keep
(15:32):
evolving both in real time and for the future. And
I think the second thing is being able to partner really,
really well. It's an art and a little bit of science,
and not many on both sides. The innovators or like
the health system partners are very good at this and
finding out the gives and the takes and the scalable models.
(15:52):
So I think that's what I see that works really well.
And then finally, because you're going into people's homes, it's
the Wild West. I mean, health care has been in
such an institutional and clinic based model where we can
control all the conditions, the light, the temperature, the hours
of operation, who's there, where they go? We have a
security guard that will kick you out if you don't behave.
(16:15):
The home is like the dog is going to be
humping your leg. You're going to slip on the ice.
When you're getting to the door, the person won't answer
the door, even though they said they'd be there. Like
so many things are going on. So you really, really
need people who know how to be in the home.
And that's why formal health systems have to partner. And
these new startups who don't get this will not make.
Ann (16:37):
It great insights. And I'm going to tie them all
together through the business model lens. So the first one,
effectively these startups have nimble business models. They're not locked
in to the incumbent approach to businesses. They are fast,
flexible and responsive because they're focused on what's needed for
the future, not what's led to their success in the past.
You also pointed to some key processes and key resources.
(17:02):
So from the partnership lens people need or these organizations
have processes and associated resources required to partner with the
health systems that they want to work with or other
entities that they need to work with. And then the
importance of having flexible resources who are okay, not being
in control in order to go into the home and succeed.
(17:25):
I had never thought about the juxtaposition between the environment
in health care. You're right, because in the health care facility,
from a supply side, everything is controlled. So the provider
has control over every detail you mentioned. And in the
home it's the exact opposite. You are walking into a
situation in which you have no control at all.
Zayna (17:44):
No control, and it'll change day to day. And just
to add to that, there's a whole other area of
talk and thinking and rethinking medical education. So med school,
nursing school, physiotherapy school, because if you look at the
applied hours, like the practicum hours that say a nursing
student goes through like 99% of that is at a hospital,
(18:06):
but 99% of health is created, made and destroyed everywhere
but a hospital. So these clinical resources are not trained
in the native environment where they're patients, where all the
action is and where it's going, everything we just talked about.
So there's a whole movement there where I think home
based training is having a renaissance. So it's going to
(18:27):
start to disrupt, I think. Med Ed, just one other point.
Looking at, you went through the business model lens. So
profit model, one of the the key elements, you know,
and I don't know the answer, but maybe an you
can think about it if you think about what happens
when you move traditionally facility based care models into a
home setting, you know, you've now you've changed the economics
(18:47):
because you've downloaded the cost of the physical place to
the patient. It's their electricity, it's their water, you know,
it's their real estate. So so that should allow you to, whatever,
stop building hospitals or, you know, streamline your clinics or whatever,
just like remote work. However, that cost can be a
big cost if you're going to start to do dialysis
(19:08):
at home at the rate that it can be done,
which is about 40% of all dialysis theoretically can be
done at home. There's a big cost to be borne
of that of supplies being stored and blah, blah, blah.
On the other hand, you're adding a cost that used
to be on the patient, which is trouble. They came
to you, they parked. Now you've got to pay for
(19:29):
getting these people to these places. And in a big
floppy geography, that's a very big cost. I mean, I
personally have a relative who works in home care. When
gas prices got really bad recently, she was net negative
income from a day of work just from filling up
her car twice in a day. So that aspect of
the fleet, if you will, becomes a very big part
(19:52):
of your cost model, not just the labor going into
the home in their hours of work. And I don't
think these companies that are in last mile understand those.
Not mix very well, particularly given the kind of geographies
we're talking about.
Ann (20:03):
That's an excellent point. When you think about the scaling perspective,
it might work really well in a small pilot where
your geography is really tight and you're the number of
people that you're serving is really small. But as you
seek to scale it, how does the profit model continue
to work or not? I think the biggest thing I
thought of when you mentioned profit model was the reimbursement side.
(20:25):
So in the US a big reason why home based
care did not catch on before the pandemic in the
way that it did during the pandemic is it wasn't reimbursed.
It wasn't paid for. Now, during the pandemic, there were
waivers that changed that, which made the business model economics work.
But you're right, the profit model component is going to
(20:47):
be key for many of these potential disruptors and new
entrants who are seeking to capture share in the market
to figure out because if they can't do that sustainably,
they won't be around long.
Zayna (20:58):
Yeah, I think there's lots of pools though, of financing.
Just like you said, it's in the interest of big
payers like a Medicare to pay for more things to
be in the in the envelope, if you will. And
that certainly happened and that's driving a market. I think
the other two drivers, though, of a market is everyday
people will pay out of pocket for this. It might
be not be the 85 year old person, but it'll
(21:20):
be their son or daughter, you know, because there's a
cost to them if their loved one isn't aging well
at home. So that market is exploding because a baby
boomer was born every 10s and it's still on its
way up. So there's a whole world of that economy.
And then the third is there's budgets of, let's say,
a hospital itself that has incentives to not have readmissions
(21:42):
or whatever, where you can use their OpEx that would
have financed, you know, an air room or an operating
room or a lab or whatever, like the OpEx can
pay for the home care. So it's part of the
extended budget, if you will, of an incumbent versus asking
some insurer to reimburse a task. It's just it's part
(22:03):
of the episode of Care. So that's how these models,
at least in Canada, have really taken off actually that
last that last bucket.
Ann (22:10):
And to that point, the US certainly has some unique
payment structures compared to other countries. And because of that,
a number of these virtual and at home care models
have not taken off the way they perhaps have in
other countries. So what do you think the US can
learn from other countries approaches to home based care? Are
(22:32):
there other home based models you've seen succeed elsewhere that
you think we should really look to?
Zayna (22:38):
It's one thing is interesting. This is definition. So there's
home care. And I think in the US the words
are home health is different from home care. If I
remember from a definition, one involves nurses, one involves, you know,
home health aides or something like that. Whereas in in
most places in the world, home care is any combination of,
you know, a licensed professional like a nurse and or
(23:02):
an RPN physiotherapist or somebody that's helping with activities of
daily living, like the equivalent of what you'd call a
home health aide. It's any combination of those rehab occupational
therapy is home health care. So that is a difference,
I'd say, because you're not siloing the kind of human
help you need and then it makes it a little
bit easier because now you can mix and match. I
(23:23):
would separate that, though, from home based care models like
we've been talking about like E.R. at home and hospital
to home, because those often don't even use the traditional
home health care agency people. It's all these other new entrants. Right.
So so they're just there's two things at play. Just
a couple examples that I've been tracking around the world.
(23:43):
So one big movement is this idea of client directed care.
So instead of some third party agency or assessor or
insurance adjudicator saying, okay, you qualify for this many days
of a nurse coming over or a home health aide
or whatever. And here's the price and here's the minutes
and to the shift to, you know, based on your
(24:06):
level of need and support you have at home, here's
your budget and you go and buy whatever you need.
And if if what you need is a person to
cut your lawn, it's in scope. You know, Medicare did
that a little bit, but this is really client directed
care or it's called patient budgets. So a couple jurisdictions
in Canada have now done this that probably the most
(24:27):
advanced is Nova Scotia. Australia was really one of the
first and Germany years ago to have these kind of
patient budgets. And they get the money, they get the envelope,
they go find what they need. Now you have no
intermediaries and you have a big incentive for, you know,
the people who deliver the services to actually do well.
Ann (24:45):
So what are their results? What becomes of this or
health outcomes better or costs lower?
Zayna (24:51):
It's a great question. So I don't know that there's
been great analysis, but I'd say the biggest benefit has
been two things I'd say. One is. Better client experience
or patient experience because they're directing, they're in charge. The
worst thing when you're getting home health care is to
be stuck with whoever, and they don't match you like
it's not a fit, whatever language you're I don't know what.
(25:13):
And then you're kind of stuck with them because you'd
rather have that than no care. So when you can
decide and direct who, when and what it just wants
better patient choice. So I think that's indisputable. And then
of course, formal health systems like it because they're now
absolved from all the bureaucracy and organization of managing and
(25:34):
micromanaging these resources, which is very, very it's another layer
of management that adds cost. And they're so far away
from the patient, they're making decisions about these people's lives.
They never see them, you know. So I think it's
consistent with that. I don't know that the results have
yet been quantified, but the fact that they keep going
probably is a good sign. A couple other examples. So
(25:55):
this idea of a nursing home at home in the US,
it got a lot of momentum of the skilled nursing
facilities or sniffs at home. And so this idea that
if you're a nursing home like you can't build it,
you can't grow like if you're full, that's it. It's
going to take you ten years for CapEx to build
another building. So how do you scale and grow? So
(26:17):
so either the the nursing home themselves building the model
or others doing it and then competing, if you will,
with the nursing home. But the data shows 20 to 25%
of people in a nursing home could manage at home
with appropriate supports. That's a pretty huge market. And at
least in Canada, 16% of people using a hospital bed
right now do not belong in a hospital. But there's
(26:39):
nowhere for them to go because we don't have a
care model that fits. And so there's just these new
models of what I call nursing home at home. And
in my former job, you know, we were rolling these
out and literally bringing people home from hospital who didn't
need to be at hospital with a new model. And
we were we call reactivating them, which is getting them
kind of back to their pre-hospital baseline in like 35 days.
(27:02):
These are extremely high. These people would have been sitting
in the hospital for six months or whatever until they died.
So high, high ROI business models that again don't have
a scalar rater yet their point solutions, but they work
A couple of other ones I'll just call out just
to throw the whole buffet out. I don't know if
(27:23):
you've heard of NORC, Newark's naturally occurring retirement centers. So
this is an idea in like urban environments. You've got,
you know, large multi resident apartment buildings that just skew elderly.
So as soon as you tip, 35% of the residents
are over 65, you're a naturally occurring retirement center, like
just by volume. There's just people who have a lot
(27:46):
of need who will self aggregate and do their own programming,
like a retirement center or an assisted living facility. So
so in an oxymoron, instead of them being naturally occurring,
there's now support from health systems to actually let them
become like a retirement center. And the cost is like
$10 a day. And that's contrasted with, I don't know,
a retirement home can be $300 a day or $500
(28:10):
a day. So so that's a big thing actually, out
of Canada that the world has come to study. And
there's a lot of infrastructure now to scale the Nordic model,
which is kind of cool. And then maybe just a
couple more and then you ask me questions, family, caregivers. So,
you know, the son or the daughter or the spouse
who's taken care of the loved one who needs home
(28:31):
supports becoming like part of the patient unit of care
and having a whole set of program services, infrastructure policies,
payment models to support them, because as soon as they
go down, everything goes down. And so why don't you
intervene then? There's a huge movement and, you know, places
like Sweden paying an allowance for a family caregiver, a
(28:55):
lot more employers are now creating a benefit for family caregivers.
ET cetera. ET cetera. So that's a whole market that's
exploding and solutions are coming up. So anyway, those are
just some examples.
Ann (29:05):
Thank you for sharing those. And just when I thought
I'd heard all of the health care acronyms, now I
have a new one. So just one quick follow up
question on that one. In these retirement centers, are health
systems placing nurses and providers with in the centers? How
where's the health care tie in?
Zayna (29:24):
Yeah, So what they've done and that's been studied and
evaluated as what's the best model to make a naturally
occurring retirement center, not naturally occurring. It's actually place a
coordinator in the building that is the liaison both of
internally volunteer based programming and activities. There's always a room
or a space for these so that you could have
(29:45):
like a, you know, a meds clinic, a diabetes clinic,
a cardiac, whatever. So there's space, there's a coordinator and
then there the liaison out. So if it turns out
that in this building, you know, 35 people need some
nursing care in the home. Or they need some phlebotomy
to get, you know, lab work. Then they can coordinate,
have one provider come in and do the whole building
(30:07):
versus the old way, which is literally a revolving door.
Like sometimes we looked at some of these buildings, 35
different providers coming in and out of the building every day.
So really streamlines and then you get a longitudinal relationship,
of course, as well, between those providers and the residents
of the building.
Ann (30:23):
So that's a huge cost savings for Canada because they're
sending one provider instead of 35. Yeah.
Zayna (30:29):
And you have continuity of care because the turnover of
these providers is very high. So I'm saying I think
they quantified about ten bucks a day for this program.
And a typical like if you were just getting traditional
home care that got assessed by some remote person and
nobody really follows the data, it could be anywhere from
30 to $150 a day. And then a hospital stays
(30:50):
like 1500 to 3000 a day. So you could see
the economics multiply pretty quickly.
Ann (30:55):
Yes, very quickly indeed. So Zena, is very clear from
this conversation. You're a visionary. So let's look to the future.
Pretend we're having a similar conversation again. But it's three
years from now, so it's 2026, Which innovative business models
will be thriving and which ones will be struggling.
Zayna (31:13):
So let me just unpack that and some of the
different vectors of at home that are happening. So I
think any of the more traditional medical care at home,
emergent care, as we talked about, primary care at home, physio, rehab, palliative,
you know, post-acute care, I think those will just be
business as usual. Business models, I think lengths of stay
(31:33):
in acute facilities will be almost nothing. There'll be a
few hours and this will just be how it's done
and I think it'll be that good that it'll be
on an outcomes based model. So some kind of a,
you know, if you think of Christiansen, you know, VAP
value add process type model just because we'll have the numbers,
I think the coordination and the communication to enable at
(31:56):
home models so omni channel everyone on the same page
sharing the data. I don't have as much confidence that's
going to be where it needs to be because of
all the fragmentation. And I certainly don't know how next
modalities like right now we can barely deal with app phone,
text and video, but voice and VR and you know,
(32:17):
telehealth portation, like these things are coming on and I
don't think we'll be there. So I still think it's
going to be a fragmented experience and it's going to
be patchwork of interoperability. That's my guess from what I'm
seeing today. I think diagnostics at home is going to explode.
So all this last mile is going to be so
much better than what it even is today. You know,
we basically take blood and urine from people. I think
(32:39):
those are going to be very old ways to get
information about one's biology. But what I am not sure
about is will it still be a bunch of discrete
tests like sleep apnea, AIS, you know, fertility, all these,
you know, each with a different company, Well, that's not
going to work. So I don't know what will be
combined and not. But I think a lot of that
(33:01):
will happen at home, I think is going to be
a big change of life for all your labs providers
and central kind of diagnostics. I don't think imaging at
home will take off. As much as I'd love to
see it. I think, you know, in theory you could
do MRI at home, but that's, you know, colonoscopy at home.
But I don't think the business models are ready or
the incumbents are going to hang on way too tight.
There's too much fixed infrastructure. So I wish I saw that,
(33:25):
but I don't think so. And then finally, procedures at
home like chemotherapy, dialysis, IV infusions. I think those will
just kind of follow along with labs and imaging and diagnostics.
I just think we really don't need to be bringing
people to buildings for this stuff anymore. And I think
those business models will fall out. Last thing is, you know,
(33:48):
the headlines for years where the end of hospitals, the
hospitalization of health care, you know, home spittle is like
another word, right? I don't know. I mean, from everywhere
I see other than one country, maybe two Denmark and Netherlands,
maybe the UK a little bit. The number one policy
(34:09):
agenda is build more hospitals. So that's what I'm struggling with,
is how can this whole movement be happening Yet, you know,
these long term capital bets are still all about building
more so. So I'm not sure if hospitals will be
shut down in most markets, although a few countries that
is the policy agenda.
Ann (34:26):
I love the the vision of what's to come especially
around at home diagnostics exploding and your comment that it
can't continue to be a bunch of discrete tests. There
will have to be combination and just the resulting business
model change that that will mean for lab services. We'll
see more procedures at home and we likely will not
(34:47):
see the end of hospitals. Awesome. Zena, thank you so much.
My last question for you is, do you have any
parting thoughts that you'd like to leave with the audience
about the future of home based and virtual care?
Zayna (34:58):
So maybe. We used a couple of things. Anderson Horowitz
thesis for this year is health care is leaving the building.
I thought that was interesting. You know, your VCs and
your PE funds are saying, you know, it's a land
grab for the home. So there is a lot of
center of gravity moving here. And so I'll just leave
with two points. One is, again, to me it's about
care anywhere. It's not necessarily the home. You know, home
(35:21):
is a feeling, you know, feeling comfortable, feeling safe, and
you don't feel that usually in facilities. So it's that's
what I would be thinking about is care anywhere. And
then finally, as I mentioned, you know, all these new
entrants that are coming in, whether they're, you know, a
big grocer or an Instacart or a new startup, you know,
if they get logistics, that's what's going to make or
(35:43):
break it at scale and they can either disrupt. But
as you've mentioned, they can also partner because the incumbents really,
really need these capabilities and they do not have them
in house. So double opportunity.
Ann (35:55):
Fabulous. I love your concept of the care anywhere. It's
not just the home, but it's really care anywhere. And
that gets back to really meeting people where they are
in the flow of their lives because the hospital is,
I would venture to say never in the flow of
anyone's life. So I'm excited for this future that you've
painted for us, Dana, And thank you so much for
(36:17):
coming to speak with me today and for sharing all
of your insights with our listeners. My pleasure.
Zayna (36:22):
I think you're going to be very busy and in
team evaluating these business models when they start to pop.
Thank you.
Ann (36:29):
You are certainly right about that. Well, thank you so much, Dina,
and thank you, listeners, for tuning in to hear Zena
share her insights of the future of health care. Until
next time, thank you for listening to life centered Health Care.
If you like what you heard, please leave a review
on Apple, Spotify or wherever you're listening. And for more
(36:51):
of the latest in health care, check out our website,
Christensen Institute. Org. You can sign up for our newsletter
and read our latest industry insights. Until next time, have
a wonderful day, everyone.
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