Empowered Health


How the MAVEN project solves access to care issue in America with Dr. Lisa Bard Levine

America has a critical need for more doctors, especially in underserved communities. The American Medical Association estimates a shortage of about 35,000 primary care physicians and 60,000 specialists by 2025. Rural areas will be hit hardest by this, along with inner-city communities, both of which already face additional socio-economic barriers to adequate healthcare. The MAVEN Project is working to connect experienced volunteer physicians to vulnerable health centers to combat these shortages.

This idea that most of the people who are dying from COVID-19 are people who have underlying chronic illness and that something like The Maven Project will hopefully be able to help people with chronic illness in a way that allows them to change factors that get them healthier.

Emily Kumler

Emily Kumler: I’m Emily Kumler and this is Empowered Health. I love nothing more than when somebody has an idea for something that takes an over plentiful supply and somehow finds a way to meet a demand. And that’s what this week is going to be all about. The Maven Project is basically a telemedicine platform that links up doctors, many of whom are retired, so they have a lot of skills, but they’re not using them for anything anymore. And they probably miss being at work and they match them up with practices, mostly in rural areas or in places where people don’t have access to specialty care and specialty care is everything from like an ob-gyn to like an endocrinologist. And since we know that like a third of the United States, according to the CDC is pre-diabetic, we know a lot of people need specialty care, right? And I think right now, while we’re all living through this pandemic, it’s become really clear that having access to care shouldn’t be limited just by your physical ability to get to a doctor. That we have technology now that will allow us to talk to doctors and even allow doctors to see us and evaluate us in many ways. And while that’s not exactly what The Maven Project does, I think we’ve all been touched by this in a way recently where we’ve been able to get care or we’ve been able to feel like we could get to our doctors if we needed to, despite the fact that we aren’t leaving our homes. The Maven Project more specifically does something different. It sort of match makes doctors who have, you know, sort of like a pro bono lawyer who have the skills and are fully sort of credentialed. And The Maven Project actually gives them sort of a liability policy and then matches them up with healthcare centers where doctors either want to mentor or training, or they really want like a case review of somebody who’s come into their clinic and they don’t know what to do with them. And they don’t have access to anybody in the area who can come and see them. And I think more and more we’re realizing that our medical environment is pretty divided and that there’s a lot of places in the United States where people don’t have access to care. And this, The Maven Project really solves for that. We’re going to talk this week about The Maven Project, what it does, why it’s so significant and yet sort of just coming about right now and how it was formed by like a group of alums from Harvard Medical School, who realized that they had all these skills and resources and that there were a lot of parts of this country that needed those skills and resources. And that with the use of technology, those dots could be connected.

Dr. Levine: I’m Dr. Lisa Levine, I’m the CEO of The Maven Project. We’re a nonprofit healthcare organization that works with doctors across the country who volunteer their time and expertise. And we connect them via telehealth technology to primary care providers working in safety-net clinics across the country that serve the un- and under-insured.

Emily Kumler: We are so excited to talk to you for this on telemedicine. And I feel like a good place to start would be just to explain a little bit about how the Maven project is doctor to doctor rather than doctor to patient, which is what a lot of the other applications that we’re seeing popping up around are and where the idea came from.

Dr. Levine: So the Maven Project started with a proof of concept with what we call direct to patient, which was a patient showing up in his or her primary care provider’s office and together with the primary care provider had a joint appointment with our volunteer to access specialty care that was needed. Well, the model works and worked very well. What we found was that the operational lift in the clinics of aligning kind of all the stars, a patient showing up on time, a provider, a primary care provider being available, the exam room being available, potentially interpreter services being piped in together, all made the list for a clinic very heavy. And yet we still wanted to connect the knowledge expertise of our volunteers with the community at large. So we took those learnings and refine them and then went to early growth with a provider-to-provider model, which really enables the volunteer to connect with a primary care provider at the time that’s convenient for him or her with the mechanism of connection that they want. So phone, email, video connection, and it really enables care to be delivered where it’s needed when it’s needed, how it’s needed and information to be transmitted to the frontline primary care providers to really apply to the patients that they’re caring for.

Emily Kumler: And so right now we have this sort of crisis of rural care. And I feel like I know this most acutely from the reporting I’ve done on the maternal mortality crisis. And the fact that like 50% of rural communities are lacking in ob-gyn. So is that the kind of environment or a situation where somebody could call up a Maven volunteer and get a consult with them as a primary care doctor, who’s going to be charged with treating a pregnant woman or like, maybe give me an application for it.

Dr. Levine: Sure. Well, let’s take a clinic, a free clinic that we’re working with in Miami. And this clinic serves a population of uninsured patients for which many of them were deemed to need a urologist visit in an ideal world for a insured, better insured population. The wait time for urologists might be, you know, several weeks to, something like that. And certainly from a patient’s perspective, there’s a lot of concern about fear about the disease itself, fear about taking time off of work for the appointment, transportation, childcare and the like, and for this community, the access to urologist the wait time was a year. So if you can imagine being a patient waiting over a year with the fear of having cancer and also being concerned that you have an appointment a year away, that’s a problem. So the primary care provider in this clinic had the resources to connect with the Maven Project connected with the urologist and the urologist shared clinical pearls with that primary care provider. Those clinical pearls enabled that primary care provider to realize that three-quarters of the patients on that list that he was sending out to a urologist, truly did not need to be seen by a urologist, did not have a risk of cancer, and instead could be taken off the list. The weight goes away and the concern and fear and the stress of having potentially cancer goes away. And then for that small population that truly does need to see a urologist, we’ve now cleared the way for hopefully, you know, sooner access for that patient. So we work with clinics in both rural and urban settings, the patients lack timely access to specialty care, some lack, complete access to specialty care. And by enabling their primary care provider to connect with our volunteer, we’re both answering the question at hand for the primary care provider that’s caring for that patient, but also really educating them so that the next time they see another patient similar to that, they have some additional tools in the toolbox and additional pearls that they can then apply to the subsequent patients to help manage care locally in the community.

Emily Kumler: And so then how do you guys follow up to make sure that that advice is correct like that those patients really didn’t have any risk for cancer?

Dr. Levine: The way our model is structured, the primary care provider is always accountable for the care of the patient and they serve as the nucleus. We want the local provider, who’s culturally competent, who’s sensitive to the needs of the patient in the community, to own an anchor, that relationship and that continuity of care. What we’ve given them is a virtual multispecialty group practice or a virtual network of really seasoned experts that they can tap into to help them really optimize the care of the community they’re caring for. And the clinics we work with are really primarily federally qualified healthcare centers and free clinics around the country, which are under-resourced and likely to face in the early aftermath of this acute epidemic of COVID-19 significant, further strains.

Emily Kumler: And so how are the people within the Maven network vetted?

Dr. Levine: So the Maven project has a full credentialing process, similar to the credentialing process that a doctor would go through if they were to work at an academic medical center. And so they’re carefully vetted. They have an application, there’s a whole process. And then we bring them on board should they meet all the criteria. And we cover them from malpractice insurance, and then we train them to be part of our volunteer corps.

Emily Kumler: And so they’re not paid they’re volunteers that are sort of donating their time to help with this.

Dr. Levine: They are completely volunteers. They range from physicians who are recently retired, some that are working part-time that might be thinking about tapering their practice. Some are working full time and some might be working in industry with an active license. The Maven Project concept really started through our founder, who at the time was the president of the Harvard Medical School Alumni Association. And she was running a meeting one day with its diversity of really experienced physicians and recognize that there was a really an enormous untapped workforce sitting in the room in front of her. And so through Harvard Medical School Alumni Association, and several other medical school,alumni associations, you know the proof of concept from the Maven Project came forth. So can, the questions got answered around, can we recruit a volunteer workforce? Can we use telehealth technology to connect them to resources and communities that don’t have access to them? Can we find funding that can support this and are there clinics that really will tap into this expertise? And so the answer to each one of those was yes. And so that brought us forth to our sort of early growth phase after proof of concept.

Emily Kumler: And so the clinics don’t pay either, right? The money is from like government funding or private sources, or what is the main funding source?

Dr. Levine: We’re a 501(c)(3) nonprofit. The majority of our funding comes from philanthropy and grants for some clinics who are able, we ask them to contribute to the operating cost of the services, but it’s a contribution that offsets the cost of delivering the services but we’re heavily dependent on philanthropy and grants.

Emily Kumler: In terms of, you know, just like thinking about the application of this, how many clinics are you guys partnered with right now?

Dr. Levine: That’s a good question. We’re partnering with about a hundred clinic sites around the country between nine and ten states. We’re just about to open up another state. You know, our goal is to grow thoughtfully so that our resources are in places that need it and that will use it and that will access it. But at the end of the day, big picture, our job isn’t done until every community has our resources that needs it. So our physicians provide education that really increases the knowledge capacity among all the frontline primary care providers. So we’re doing a series on COVID-19 for example, which is given by an infectious disease physician that’s also an epidemiologist plus we have a panel of other specialists that are on including pulmonology and gynecology and psychiatry. We provide mentoring resources to the clinic. So we actually pair our physician volunteers up on a one-on-one basis with the frontline primary care providers to give them the tools they need to both feel and perform successfully. We also provide what we call leadership mentoring. So we have physician executives who are volunteers. We pair up with the leadership of the clinics to give them the tools they need to really manage their clinics effectively. And then we provide consultative advice, which is through our telehealth platform as well, which again is through video, through email messaging and through phone.

Emily Kumler: And the last one, the consultation service directly about a patient, whereas the others are more topical. Is that correct?

Dr. Levine: Generally, although some of the questions that do come through through the consultations are more generic. You know, I have questions about patients with high blood pressure on X medication, but often it’s, I have a, I have a case that I’m struggling with, you know, thinking about next steps or thinking about adjusting medications or thinking about labs or thinking about testing, you know, what are next steps that you think about or here are the different diagnoses that I’m thinking about. So I’m ordering these tests to rule these things out. Is there anything else you’d add? Is there anything else you think of.

Emily Kumler: Is that sent out to a host of other doctor volunteers or is that sent to one specific specialist?

Dr. Levine: Yeah, so the way our platform works currently is that each primary care provider gets a log in the telehealth platform. And if they need a question answered by a cardiologist, they push a button that says cardiology, and then they can see all the photos and bios of all of our amazing volunteers. And then they select a volunteer that they want to ask the question to either because the background seems to match up with the question that they have. It could be because they have an existing relationship with one of our volunteers. So that volunteer, you know, has answered other questions for them before, or they can also just schedule some time with the first available cardiologist, if they want to discuss a question at hand. And what we’ve found is that, you know, A. No question is too small to ask. Many of our end users are within the first five years of their training or of their first role. Many of them are nurse practitioners, physician assistants, early-career physicians. And they haven’t seen a hundred or a thousand of X, Y, or Z. So some of their questions are just really, I haven’t seen a lot of these, you know, what else should I be thinking about? Or let me double-check this with you. And then we also find that the community health centers are really treating and managing complex chronic diseases. So the beauty of having this preserved time, if they want it on the phone, audio or video, is that they can discuss the science and the art of medicine. So there’s a lot around the science of medicine. You can look up in literature and it’s dense to get through. So our volunteers really create, you know, actionable summary of the data for the primary care providers, but there’s also the art, which you can’t get from the literature, which is, you know, I’ve seen thousands of these patients. The one you’re describing to me falls at one of the tail ends of the bell shape curve. This is one I keep an extra eye on, or this is one that, you know, I wouldn’t worry about. So really melding the art and medicine of science I think is really important. And one of the values that our volunteers with decades of experience can provide to these frontline primary care providers, really managing a whole host of diseases in the local community, with the understanding that the communities that they’re serving don’t have access to all the timely specialty access that some other people in the country may have.

Emily Kumler: Well, and I think the idea of sort of like charging up or enlisting the retired physicians is brilliant in the sense that like, they probably miss medicine, right? And so like, you’re, they’re happy to volunteer their time, but their expertise is priceless, especially for somebody starting out.

Dr. Levine: Yeah. And what we’re seeing around the country more and more is that, you know, when you become a physician that it becomes part of your DNA and how you define yourself, and it often becomes hard to hang up your hat. Some institutions around the country are developing, um, sort of emeritus physician groups or retired physician workforce or groups in order to create an environment for people to have a soft landing. When they’re thinking about tapering, their clinical practice, or thinking about retiring, because retiring is a scary thing. When you built your whole career and developed all your muscles in treating patients with X, Y, or Z disease. So what we find is that this is a really meaningful way for doctors to flex the muscles that they’ve developed their whole career while giving back at the same time. And actually, when we think about the beneficiaries of The Maven Project resources, actually, we can’t think of many other solutions where every party wins. So the primary care provider, that’s connecting with our volunteer gains knowledge and resources, to be able to take action on questions they have for their patients. The patients that now are cared for with timely information, that’s helping them manage their conditions, keep them out of the hospital, keep them out of the emergency room. Actually keep them many times from even needing to see a specialist, almost 70% of the time. We’re able to avoid that specialty referral for a patient in the first place, which could have been six or 12 months to begin with. And then our volunteers find such value in sharing their wisdom, sharing their expertise and connecting in a meaningful way with those that are looking for help, that actually all parties win.

Emily Kumler: And so how are you guys measuring success?

Dr. Levine: That’s a great question. We have a set of metrics that we measure on a regular basis based on experience and outcomes based on the consults, for example. So number one, we always ask about the experience with our volunteers. Our volunteers are absolutely incredible. And the ratings from one to five are generally in the high 4.8 and our volunteers are simply amazing. Other metrics include things like were referrals avoided. So almost 70% of the time through our services, referrals are actually avoided for the patient, which is a huge burden lifted for the patient. Often it’s managing a condition sooner earlier, before it progresses. Other things we capture our information on, you know, is this information that you can apply to subsequent patients. And the answer is yes, across the board, generally speaking, but we actually had a pro bono relationship with McKinsey to help us with some strategic planning and they quantified, we call it the multiplier effects. So when information is obtained with one consult, how many patients beyond that specific case actually benefit from the information that’s obtained. And so they’ve quantified it, amazingly with one consultation with a patient six to seven similar patients that primary care provider will see within a year will benefit directly from the learnings. And this is, these are conservative numbers and 11 patients with a related condition seen by that primary care provider within the year will indirectly help. So, you know, up to 19 patients can benefit from one quick consult. We’ve had some just case examples of a, you know, a 15-minute consult with an endocrinologist, really information is gained that can apply to their entire panel of patients. So 20% of all of their patients benefit from 15 minutes of like clinical pearls and wisdom shared. So we really feel like it’s a really efficient model in a way of really sharing knowledge in a way that can reach communities at large.

Emily Kumler: And is there any followup or study happening of the work you guys are doing with the patient outcomes directly like meaning… like, I think it’s fascinating that like, you know, and it, in some ways it’s very logical, a doctor learns something about one specific patient that then he or she applies to every other patient that they see, right, that comes in. And that’s part of the art of it as well as the science of it. But, you know, I do think there is this other side that I feel like almost like this old curmudgeon when I think about telehealth stuff. And one of the other people that we’re going to feature on this sort of series was very specifically focused on psychiatric telemedicine and that’s sort of like pluses and minuses of that. And I feel like as somebody who’s, you know, gone to therapy and like, there’s something about being in front of somebody that’s such a different experience than being in my house on a computer, talking to somebody. And I see this even like with my kids zooming all their school stuff, right? Like it’s just a totally different experience than sitting at a desk with your teacher, looking at you. And I wonder like what, from the patient perspective, it’s like, okay, the doctor basically said like, I don’t need to see this specialist, but this thing is still bothering me. And like, does that have any longterm positive or negative consequence that you guys are studying or looking at to have a better idea of like patient outcomes?

Dr. Levine: So that’s one thing we do want to study for your example, what I would argue is that that question, if the pain’s still coming up, that pain should go back to the primary care provider and the primary care provider should then consult again and say you know, plan a didn’t work. And we see this plan a didn’t work. Can we talk about plan B and plan C? And plan A for the, for the communities that we’re serving. So currently the community health centers around this country, service many of the 100 million that are on an under-insured around the country (editor’s note: some studies put this closer to approximately 80 million) and that data was pre-COVID-19. Certainly, we have significant concerns about the number, the increasing number of unemployed that will contribute to an increasing number of un- and under-insured as this pandemic sort of unfolds. But at the end of the day, part of the solution between our volunteer and a primary care provider is thinking of what’s plan A and plan B and plan C and in the context of what resources are available for that patient. So you can look up in a textbook, you know, plan A for this disease requires an infusion in a hospital setting. And if that resource isn’t available or isn’t within reach or physical distance to that patient plan A isn’t planning for that patient plan A is a different plan A. And so part of the solution and part of the really nice marriage of our volunteers and the clinic primary care providers is there’s a conversation they can have about what does the patient need, what resources are available and what are the possible ways we can help, you know, you can help manage that, but, you know, healthcare, medicine is an iterative process anyway. So the patient’s saying they’re still pain would be a trigger to say, okay, let’s ask for some more advice because that plan isn’t working.

Emily Kumler: You guys have a really interesting kind of like finger on your pulse of these communities. And like, I immediately think of like diabetes being higher in those populations, but are there other medical kinds of trends that you guys see that you’ve realized either by surprise or that you perfectly predicted that you’re spending the majority of your time consulting on?

Dr. Levine: That’s a good question. I would say common things are common in that some of the specialties that are the most frequently consulted for us should not be a surprise. Endocrinology is number one, for example, number one, diabetes is so prevalent. Diabetes is disproportionate in certain populations and the supply and demand mismatch between those leads to, you know, struggles with access to care within certain communities, there are some that say we actually have access to this specialty, but not those ones. So there are some variations, but in general, I don’t think anything’s truly surprised me other than the questions that were asked around how to manage chronic conditions in the community health, you know, health setting. And if these conditions can be managed well and soon and earlier, we can avoid this equality that happened. If diabetes is unmanaged, we can avoid the emergency room visits.

Dr. Levine: The hospitalizations one case we had was a child who was in and out of the hospital in and out of the emergency room, on the hospital for exacerbations of his asthma missing school all the time. And, you know, parents in and out of work. And his pediatrician consulted with one of our pulmonologists and they discussed some adjustments of his medications and they adjusted his medications. And he hadn’t been back in the, he hadn’t been back to the emergency room or the hospital, parents back at work. It’s those tweaks that, and that with that expertise that can make a lifetime of difference for a family and a community at large. So now that child’s back at school, he’s learning, he’s not in the hospital, he’s not sick. The ability to transfer expertise in an efficient and effective way can really make a difference for both the communities, but also for the primary care providers. So this is a workforce that is burning out. I mean, there’s a significant amount of literature on physician and provider burnout. And it really, I think it’s magnified as you get into more under-resourced communities. And so the more we can provide resources that are at the fingertips of these providers that give them places to go, to get answers, to help them help them feel confident in their work. The more we can stabilize that workforce as well. And certainly the concern with COVID-19 right now is that we’re taking a burned out workforce and we’re bringing them out at an exponential rate. We’re not protecting them safely at times, we’re exposing them to illness. Some of them are getting sick and some of them, the added stress is just furthermore tipping them to the burnout phase. So we are also worried about the provider and some community-based providers are being pulled into the inpatient land to help with patients that are actively, you know, hospitalized with COVID-19. But we also worry about the early aftermath of the provider workforce in the communities for example.

Emily Kumler: I think that there is something just about connecting people in general, right? That probably is helpful. And if you’re out in some environment where you don’t feel like you have enough resources or mentorship or education access, this seems like an incredibly powerful tool. Another aspect of this that seems potentially very powerful is that as we learn more and more about the influence of like sugar on rates of diabetes or lack of exercise, or like these kinds of things, I mean, like I’m always struck, we’re doing a series on peer review and just sort of medical journals in general. And we’re talking to all of these like world experts and the editor-in-chief of Nature, we interviewed last week and I kind of keep about this idea of how much money we spend and how much attention we pay to treatment versus preventative care. And that, you know, things like NIH, I mean, like from a very naive layperson’s perspective, it’s striking to me that like most of the money goes to funding drug targets, right? Or like finding drug targets that will then become drugs rather than finding ways to prevent the illness in the first place. And I feel that way about COVID right now. Right? I mean, I feel like we’re so heavy-focused on, you know, locking everybody away and the social distancing and, while also at the same time, like all the money is going into turning every factory into the respirator factory and developing a vaccine. From the research, it looks like there’s a big question about whether these respirators are, you know, 98% (Editor’s Note: referenced study found 88%) of people who get put on a respirator who have COVID die. So we’re spending all this money on developing treatments for COVID rather than testing to find out how many people actually have it, how many people have the antibodies and how many people are probably just fine, right. Or asymptomatic and have already had it. Like we don’t, I feel like we don’t have any handle on the denominator with us. And it feels symptomatic of this larger thing where it’s like, we’re all about treatment rather than really understanding both the root cause of something and the prevalence of it and the impact of it. And like some of the mechanisms of action before we start just, you know, doling out more medications.

Dr. Levine: Yeah. So there are a bunch of things I can respond to. The first thing I was going to comment on was you alluded to an isolation factor for providers that you were talking about and you’re spot on, which is The Maven Project really seeks to form relationships in this relationship. between our [?] primary care providers in the field, actually every party in many ways has a potential to feel isolated. So primary care providers today, even if they work in a group practice, often feel like they’re working alone together. They feel very isolated. They’re in their own exam room, seeing their own patients. And when they need to ask their colleague a question, their colleagues likely busy with his or her own patients. So there’s a lot of isolation that even people in group setting experience. So part of our role is to create, break down that barrier and say that you’ve got, you’ve got friends here, you’ve got relationships here that can help you. And then for our volunteers, going back to retirement can be hard and it can be hard to hang up your hat. And there can be some isolation in that as well. This brings volunteers together. We do social events for our volunteers, as well as deploy them to actually the services [?] helping. We’ve converted some of ours to like, you know, virtual get-togethers, which are really nice, but, you know, to create community amongst our volunteers as well. So all of them really try to like mitigate isolation and then certainly, you know, trying to manage disease as early as possible and prevent whether it’s the onset or the escalation of the condition is ideal. You know, with COVID, we’re struggling to do two things in order to reopen the country, you know, to develop a vaccine and to be able to test people, to know if they’ve been exposed to see if they’re immune and without either of those pieces of information, it’s really difficult to open up the country.

Emily Kumler: Yeah. And so, I mean, I feel like just to tag team off of that a little bit, I think my question is more of like, if we know that like looking at, let’s just take the COVID-19 since it’s on all of our minds. So it’s like the rates of mortality are like 99.1% of all COVID-19 deaths reported from China, Italy. I think United States is now consistent with this, are people who have chronic illness. Right. And diabetes is actually the highest rate. And so you sort of think like maybe there’s an opportunity to educate people that like the more, I mean, this is so obvious, but it’s so missed, right. That like the more you take care of your health in the day-to-day life, the more preventative it is for you in the long run, right? Like the more robust your health is, the more you can handle something like a pandemic and not be terrified. And I think we are missing some of this in a way where everything is so quick when you go to the doctor. Right. I mean, I can’t remember what the number is, but it’s like the average woman spends like five minutes with her doctor a year. It’s incredibly short. Right. And so like, you kind of think like that’s not to blame the doctors, they’ve got five minutes to like sess you up. Right. And like then they’re going to look at your labs and do all this other stuff. But the time with the patient is super limited. And so like, when we talk about, which is, you know, the theme of the podcast is really this idea of like, you have to advocate for yourself and you have to be kind of aware and ask the right questions and, you know, be your own guide through the sort of medical landscape. And I think when I’m looking at something like what you guys are able to do, it seems like there’s a huge opportunity to also sort of help educate people. Not, you know, I know you guys are focused on educating the doctors, but educating the doctors on things like, you know, like the VirtaHealth trial that basically like put all these diabetics on a low-carb diet and they reversed diabetes and 90% of participants, I mean, it’s unprecedented, right. I think in these communities where people don’t have access to care, they don’t have insurance and they probably have huge medical bills. That’s the kind of information that seems maybe the most valuable to share with them. Do you guys work on stuff like that or is it mostly just sort of a triage? Like this is an acute situation and this person needs advice and they’re rushed too.

Dr. Levine: It’s a loaded question, but time is a factor for all of the clinics that we work with. And really in general, you know, providers around the country. So frontline providers are struggling with a busy day full of patients that need more time than they’re given access, you know, made available. So when you’re with the patient, you’ve got to pick and choose what conversations you’re going to have and what you’re going to focus on. But really, I think some of the key to all of this, going back to your, like, how do you empower the patient and how do you get them to make meaningful change that will improve their health is really, I think based on having someone that they trust, that’s their advocate, but someone that they trust and that’s [?] their care. So getting that primary care provider is really key to anchoring any discussion you’re going to have with a patient about health or illness alike. And so our goal is to give the trusted nuclear person, the primary care provider, some tools so that they can have those actionable conversations with the patients, but also some extra kind of ammunition. So an example, and so patient hears that they, you know, we’re worried about colon cancer and we think you need a colonoscopy. They might say to their primary care provider, you know, no thanks. But if the primary care provider in a culturally competent way where they think their patients going to understand it, because, you know, they’re familiar with the cultural customs, et cetera. The patient also says, you know, I’ve run this by a gastroenterologist and we’re both concerned, and this is a case for which we together think you need this. I also think that some additional.

Emily Kumler: Back up.

Dr. Levine: Kind of backup to say, like wow the expert also think, you know, it’s something concerning. It’s not just my own primary care provider and they cared enough to check and to ask about me. And now boy, maybe I should be concerned. Maybe I should get that, you know, that test. But I do think that it’s, you know, our system really has to focus on the patient primary care provider relationships. So the more we destabilize these clinics or under-resource them, or send more patients than they can manage to the clinic, the less time these providers are going to have to really gain that trust of the patient. And instead they’re going to have those five minute interactions or just the reactive, like, you know, I have a sore throat, I need a swab. I might have strep. You know, in-and-out, like acute needs. So, I do think it’s a combination of factors. I would just emphasize that with COVID-19, the healthcare landscape overnight ripped a lot of the bandaids off that traditionally had been on around virtual care, around how we communicate with patients, how we access care. And at this moment in time during the, you know, here in Massachusetts, and it’s going to be the kind of apex couple of weeks, you know, care is primarily being delivered in two settings, the inpatient world and virtually. And we just, we hope that as we early, as we recover from this pandemic, that we are able to incorporate virtual care more and more in practice, because we think it’s an important way for people to connect and communicate that’s efficient and effective. Some of it does not replace hands-on in-person care, but I suspect that the way we’ll be delivering care in the future will look different than the way it did a couple months ago.

Emily Kumler: Are there any regulations that usually would prohibit sort of telemedicine that have been lifted because of this pandemic?

Dr. Levine: Yes. So, some of the regulations around going direct to a patient for telehealth have been lifted. So things like, many of the interstate licensure laws that would say, you’re a doctor in Massachusetts, you can’t help a patient in California. That’s been lifted off. The HIPAA requirements, which would say you need to connect and communicate in a HIPAA-protected technology solution have been ripped off. They said, you know, just connect, use FaceTime, use Skype. Even if it’s not HIPAA-protected. Use your phone, whatever it is just connect and communicate. And many of the payers are reimbursing for this. Some of the looming questions are now that some of those bandaids have been ripped off that I would say like have artificially kept some of those meaningful connections from happening what’s life gonna look like in three, six, 12 months. Are some of those going to be regulations put back on, are we going to keep that off? Who’s going to reimburse for what in environments where there is reimbursement. And so, you know, a lot of the reimbursement will actually impact whether or not people maintain using things like telehealth, but those are some of the examples for telehealth that of those regulations that have been lifted up and the reimbursement has followed.

Emily Kumler: Right. No, I mean, that makes so much sense, right? Like the adoption rate of something is always going to be higher after people have been forced to come sort of try it out, right. People don’t like necessarily changing the ways that they, you know, sort of like business as usual, but when they’re forced to, they may find that there are all kinds of benefits to this, that they would have missed because they were, you know, for lack of a better word, just not interested in trying something new.

Dr. Levine: Yeah. And we found that, you know, with our services, it’s implementing something new and it’s implementing something that uses technology. So in healthcare, we’re generally pretty slow at doing that in general from a, you know, new process, technological adoption kind of standpoint, and overnight by necessity, we’ve had to, we’ve had to do that. So, you know, most ambulatory care practices, if they’re still open right now are using telehealth and they might have some in person visits for specific needs, but otherwise the providers are working from home, our physician volunteers that are still working their practices currently, at least a group that I spoke to yesterday, all converted to telehealth overnight.

Emily Kumler: Yeah. I mean, I know my kids’ pediatricians have sent out an email basically saying like, we’re available for telemed appointments whenever you want. And then they also have like, I don’t know, a van or something that’s like traveling around to people. I think they’re like really trying to pull out all the stops so that people don’t go to the office.

Dr. Levine: Yeah.

Emily Kumler: And I think maybe the office is still open for well visits. I’m not a hundred percent sure on that, but it’s like, they have really limited who is coming in and out.

Dr. Levine: Yeah. I mean, the challenge with COVID-19 is that we have asymptomatic carriers and we have people that are not feeling well. So the combination of having someone that’s an asymptomatic carrier come in is that they look well, feel well and they’re transmitting disease. And then for those that aren’t feeling well, they might not be well. And the same concern. So protecting both patients, families, and the medical staff themselves is all paramount right now. The goal is right now, how do we maximize patient care and protect patients and staff alike? And some of the concern is that some of the care that needs to be delivered, whether it’s in-person or not, you know, is, is not able to be fully done. So there’s some procedures that are being delayed and postponed. And what does that going to mean and look like for patients we don’t know, but there are going to be some conditions for which we wish we could have intervened earlier, but we couldn’t, and that’s hard.

Emily Kumler: I keep sort of, not in a doomsday way, but like sort of trying to figure out what are the unintended consequences of this that we’re not talking about. And I do think this idea that like, you know, my ob-gyn canceled like routine appointments. That’s okay. I mean, if you don’t like, if it’s just really a routine thing, but how often does she pick up something in a routine appointment that’s now missed.

Dr. Levine: Exactly. Or people that have known conditions for which they have to wait. So hospitals have closed operating rooms. If you need a procedure for a, you know, something that’s concerning for cancer or, you know, it is cancer and you have to wait, what does that mean? And to your point, even if you’re missing screening, you know, you could have acted earlier, had you had the information.

Emily Kumler: I think that’s going to be massive.

Dr. Levine: So there’s a lot of care that we’re worried about also as being delayed. We’re doing the best we can, but there are limitations to what we can do.

Emily Kumler: Yeah, no, I think, and I think this is a massive problem because I don’t know how we’re, I mean, I guess I sort of feel like we’re making these big decisions without really the right kind of accurate information. And yet the unintended consequences of this are going to be a lot of people who don’t have insurance. Right. And I’m sure deaths result from people not having insurance. You know? I mean, I think there’s so much of this, right? Like the death rate is down right now from what it usually is because probably because people aren’t driving right. Or like other things that impact the overall population death rate. But I just, and we’re off topic, but I just feel like it’s sort of interesting to think about how, you know, we’re sort of advising people on all of this stuff and probably missing a lot of care that that may save lives. Right.

Dr. Levine: Well, there’s a lot, for example, there’s concern about domestic abuse and those rates rates of report are at least my understanding lower than you would expect. And the concern is, you know, with people being sheltered in place, what’s happening that’s not being reported.

Emily Kumler: Right. Well, and also like, I mean, a lot of law enforcement, DEA agents and local police officers are being told not to arrest people because the courts aren’t open to deal with them. So like, there’s a ton of that.

Dr. Levine: Oh, well we’re also releasing people from jails and prisons.

Emily Kumler: Right, right.

Dr. Levine: In order to diminish the, you know, how in densely populated these places are because it does spread like wildfire in environments like that. Homeless shelters too, you know, we worry about the spread there. And you know, there’ve been some wonderful hotels and colleges that have opened up their facilities just to let people give them some separation so that we can try to diminish the spread of this.

Emily Kumler: Well, thank you so much. I feel like we covered a lot.

Dr. Levine: I can talk to you forever about all sorts of stuff.

Emily Kumler: This idea that most of the people who are dying from COVID-19 are people who have underlying chronic illness and that something like The Maven Project will hopefully be able to help people with chronic illness in a way that allows them to change factors that get them healthier. And if we, as a population were healthier than something like COVID-19 would not be such a threat to us. The fact that we have so many people who are suffering from chronic illness, diabetes being a primary one, which puts you at the highest risk for getting COVID-19 and for suffering a severe outcome or death from COVID-19, that’s something that I think is a chronic illness that we need to all be talking about more so it wasn’t at all surprised to hear Dr. Bard-Levine explained to us that they consult on diabetes more regularly than anything else. And I think it should be a warning to all of us or a message of like, you know, diet and exercise are certainly a huge part of type two diabetes. And that you can do something about that and that getting the right kind of care for yourself. And that means probably like finding a good doctor and having the right information. And I would obviously turn everybody over to our VirtaHealth episode that we did, which is a phenomenal study where they’re reversing type two diabetes in patients. But I think, you know, hopefully these sort of telemedicine platforms will ultimately make people healthier by giving them access to good quality care. I’m Emily Kumler, and that was Empowered Health. Thanks for joining us. Don’t forget to check out our website at empoweredhealthshow.com for all the show notes, links to everything that was mentioned in the episode, as well as a chance to sign up for our newsletter and get some extra fun tidbits. See you next week.


Dr. Lisa Bard Levine

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