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Richard Helppie
Hello, welcome to The Common Bridge. I’m your host, Rich Helppie, and today we’ve got a great guest with us in studio, Dr David Miller. Dr Miller is a physician. He is the chief executive officer of Michigan Medicine here in Ann Arbor, Michigan. He is also the Executive Vice President for healthcare at the University of Michigan. Today we’re going to be talking about healthcare as we continue to investigate, inform and probe what’s going on in the healthcare delivery system. Now, if you think about healthcare, it is the largest economic sector in the largest economy in the history of the world. We spend a lot of time talking about the business model and how the money flows, and who’s making money and who’s distressed, but bear in mind that at the heart of healthcare is helping people stay well, applying diagnoses and treatment for those that are sick and injured. And as former Senator Frist - who is also a physician, a heart surgeon - said, all families have issues, but if a person is sick, then the family has one issue. So today, we’re privileged to talk to Dr David Miller from Michigan Medicine. Dr Miller, welcome to The Common Bridge. It’s really a pleasure to have you today.
Dr David Miller
Thank you, Rich. I’m really grateful for the opportunity to be here with you today, looking forward to our conversation, and deeply grateful for the opportunity to talk about our extraordinary teams at Michigan Medicine.
Richard Helppie
Well, you do life saving work there every day as well as research. I know our listeners, readers and viewers are going to be fascinated to hear that, but first tell me a little bit about yourself. Where were your early days? What did you do? What led you to your career as a physician and now in executive leadership?
Dr David Miller
Thanks, Rich, very much. Well, I’d start by saying I’m a lifelong Wolverine. I often say that when I was very young I shared a bedroom with my brother in Midland, Michigan where we grew up, and we believed we were the first and second biggest Rick Leach fans in the state of Michigan when he was the quarterback at University of Michigan. So I’ve been connected to the university, really, for my whole life, and have a deep, deep love and appreciation for the university, for the state of Michigan more broadly. As you mentioned, I’m a urologist. My clinical background is in caring for patients with urologic cancers, and currently my practice focuses on taking care of patients with prostate cancer. That continued presence in clinical care delivery is really important. I love taking care of patients. It’s fundamentally what we do, and it keeps me deeply connected to the work of our organization. In terms of my journey to this particular position, it’s probably some combination of serendipity and planning. I started my career trying to build a practice taking care of patients, doing research - almost as a clinician scientist - at the University, writing grants to the NIH, building a research program, publishing papers a lot, thinking about quality of care for patients with urologic cancers. That led to some opportunities to begin to work on quality and safety across our growing statewide system, including our partnership with My Michigan Health in Midland, where I grew up, and where my dad was a physician for many years. Ultimately into some operational leadership roles coincident with the pandemic, that gave me a much broader view on the opportunities and challenges in healthcare delivery here at Michigan Medicine and more broadly. Now, the great fortune to be in the CEO role and EVPMA role, and really having the opportunity to say - across all of our missions of clinical care, research and education - an academic health system should draw strength at those points of intersection between research, education, innovation and clinical care and how can we really be an asset for the state of Michigan and beyond. After all, our mission is to advance health, to serve Michigan and the world. I often say that concept of advancing health is a commitment to continuous improvement in the work we do every day, access in the healthcare delivery space, safety and quality, and then to serve Michigan and the world. I believe we have a statewide opportunity and responsibility to help bring our expertise and services to as many communities as possible, and then to innovate, to advance the field more broadly. And the last thing I’ll say is, I often reference my having grown up in Midland. Alden Dow was an architect in Midland who talked a lot about the built environment and the concepts of honesty, humility and enthusiasm. I would say those are the leadership attributes that I’ve tried to apply along the way. Honesty, foundational for any effort at leadership; humility, because you face difficult circumstances and decisions, and if you have humility, your team will stay with you during those ups and downs. Then enthusiasm, because despite the challenges in healthcare delivery, as you said, and - as I think you referenced Dr Frist - in that moment when patients and families are facing a healthcare issue, it is the single most important thing on their agenda. And despite the complexities of the business side of healthcare, the technology that now infuses every aspect of healthcare, it remains fundamentally and essentially human. It’s people taking care of people.
Richard Helppie
It’s a miracle of modern medicine and the expectation that anything can be cured. In your area of specialty that was a debilitating or deadly disease, and we’ve all known many people - you, many more - that have survived it. Nate Kaufman and I talk often on The Common Bridge and on the Healthcare Bridge about the need for clinically oriented people, doctors that are influencing healthcare policy. In Washington, in Lansing and often at the heads of healthcare delivery systems and health insurers, you can’t find a physician around. It just makes sense that if you’re running a car company, you want engineers, if you’re running a technology company, you want data scientists. And it stands to reason that we should have more physicians that have followed your path. Now I know Michigan Medicine is a big place, anchored by the world famous University of Michigan Hospital. What are all the components of Michigan Medicine today?
Dr David Miller
Thanks. I’ll just mention that yesterday we celebrated the soon to be opening of our new inpatient tower, the D. Dan and Betty Kahn healthcare Pavilion, and we’re very excited about that. And so if we then zoom out and say Michigan Medicine as a whole, it really represents what I call our full academic health system. It’s inclusive of the University of Michigan Medical School, this year celebrating its 175th anniversary of extraordinary education, innovation and leadership, and then our clinical delivery system, which we reference as University of Michigan Health. So Michigan Medicine includes University of Michigan Medical School and University of Michigan Health. University of Michigan Health then comprises all the elements of our academic medical center here in Ann Arbor; our adult hospitals, Children and Women’s Hospital, the Cardiovascular Center, the new D. Dan and Betty Kahn healthcare Pavilion, and all of our ambulatory facilities that you see in the community: West Ann Arbor, East Ann Arbor, Northville, Brighton, the newly announced facilities in Troy. It also includes our regional health system; our member systems in Lansing and in West Michigan: University of Michigan Health Sparrow, which is six hospitals and many ambulatory sites in Mid- Michigan, and University of Michigan Health West, our hospital in Grand Rapids and its ambulatory sites, that in totality... Michigan Medicine is the medical school, plus all the elements of our clinical delivery system across the state. I think it’s, in total, 12 hospitals, hundreds of ambulatory sites, and 30,000 incredible employees working to advance our mission across the state.
Richard Helppie
Then also affiliations like Traverse City, Midland, Chelsea and elsewhere, spreading the outstanding work that you do to more places out state.
Dr David Miller
Thanks, Richard. What I referenced are the fully integrated members of our system, but you’re absolutely right. Our goal is partnership as another way of enhancing impact. Strong partnerships with My Michigan Health in mid and northeastern Michigan, our partnerships with Trinity here in southeast Michigan, including our partnership at Chelsea Hospital, where we’re very proud of our presence in the community. And in West Michigan, we have partnerships in cancer and cardiovascular networks with Trinity. Then we have clinical partnerships with many other systems in the state, including - as you mentioned - growing partnerships in clinical programs with Munson Healthcare. So we are trying to support community-based access to services at the level that Michigan Medicine can provide across the state, really consistent with our mission.
Richard Helppie
Also, Michigan is known as a world class research center, and I would imagine that oftentimes somebody has a unique disease that’s being researched at Michigan. They might look at Memorial Sloan Kettering or MD Anderson or Cedar Sinai or Mayo Clinic, and then say, gosh, the best care is at Michigan. They could be coming from any place in the world.
Dr David
We have a tripartite mission; research and education are in our DNA and as you think about where healthcare is going - some new and emerging curative therapies, whether in gene therapy or cellular based therapies for cancer, autoimmune diseases - the availability of the science and innovation side of that - access to clinical trials, the ability to administer new and emerging, complex therapies - we really think that’s one of the key differentiators of Michigan Medicine in the state and nationally. As you mentioned a number of our peer academic medical center organizations, I’ll give you an example where we’re really starting to try to capitalize on that capability. We know, for instance, for patients with advanced cancer, that up to 70% of those patients have - if you could do what we call a next generation sequencing to understand the actual types of mutations in the tumor - what we call an actionable change, something that would benefit from a specific medication. But a much smaller proportion are actually getting that testing. We’re now working to set up an infrastructure that would greatly increase access to that testing, which would not only help identify better treatments, but pair that with understanding accessibility to clinical trials. That’s where we see a real opportunity to harmonize one aspect of the research we do along with our clinical care. I’ll give you one final example. Last week, I visited the research symposium for our postdoctoral fellows in molecular and cellular pathology. It was remarkable, the work that’s being done now at the foundational understanding of genetic and molecular changes and how those not only help us identify the next generation of treatments, but understand who will respond and benefit from those. Where the fields are going now was really represented in that seminar. And I think Michigan medicine will be at the heart of that moving forward.
Richard Helppie
That is fascinating. As a non-clinical person, when someone explains to me about gene editing, that somebody has a particular condition and the gene is identified, we know the variant in the gene, and that there’s a method for removing that gene, fixing it, putting it back in so when cells are generated, it is not carrying the disease anymore - it’s an amazing thing. That research is lengthy, it’s time consuming, it’s very expensive. Research funding in the current administration, we’ve heard some of that research funding is at risk or suspended. Where does the source of research funding come from? Has there been any impact on it with the current presidential administration?
Dr David Miller
It’s a such an important question. I’ll start with the observation... what you referenced, these new, emerging, gene-based therapies, it’s incredible, because the concept of having curative opportunities - many of these are conditions that present in childhood - really have transformative potential. So how do we continue to support discovery, which is at the heart of what we do at Michigan Medicine and at the university more broadly? Just in the medical school alone, we have close to, in total, $800 million of annual funding from the NIH every year for an incredible group of faculty, investigators and trainees that we need to sustain, support, and continue to help build their careers and impact. The current environment has been challenging. I will be the first to say we have had a long and positive and impactful partnership with the federal government to support research, and we seek to continue that. We know that whether the changes have been in the timing of the release of the budget and appropriations to the NIH, whether it relates to so called indirect costs and how those are allocated to support research infrastructure, those are points of uncertainty that exist in the research environment. We continue to advocate for the importance of research like that. The efforts done at University of Michigan, when you look at most FDA approved medications, at some point they’ve been evaluated through NIH funded research. We have to tell the story of that impact and then we have to advocate for it. Now we know that if you look, for instance, at funding, actual dollars allocated from fiscal year 24 to fiscal year 25, the decrease in that total dollar amount has been modest for Michigan Medicine, and we’re grateful for that. What has changed is that the total number of grants has decreased a little bit. So we’re looking at that. How do we continue to support our investigators - who are submitting excellent science - during this moment of uncertainty, to keep their work going even as we have important conversations about budget allocations, indirect costs. So we are going to continue that work and really find ways to continue to support our investigators, and we’re doing that both at Michigan Medicine, with the campus more broadly, and as part of advocacy for biomedical research in higher ed. I’ll give you one story that tells why this is so important. Just in the last couple of years, there’s a technology called histotripsy that emerged from a partnership between the College of Engineering and the Medical School — a new mechanical, non-invasive ultrasound approach for treating tumors. It’s now FDA-approved for liver tumors and is being disseminated nationally and internationally, culminating in a major exit for the company Histosonics, which grew out of research at the University of Michigan. And that level of connectivity between the innovation, the research and development, the clinical assessment and then the dissemination to scale, not only in Ann Arbor, but in Grand Rapids, and now moving across the country, and the world, that model is something that we have to be committed to replicating. We need the continued support and partnership with the federal government.
Richard Helppie
And this alternative treatment? We’re talking chemotherapy, surgery, liver transplants versus non-invasive ultrasound treating of liver tumors?
Dr David Miller
The data around the long term impact continues to emerge. But when you think of it from a patient perspective, a very difficult, complicated situation of cancer that has either originated or spread to the liver, the treatment options that exist have been much more invasive with higher risk. This is really a non-invasive, very low side effect profile treatment that is showing very early promise. And so that type of approach - an innovation based in the best available science connected to a clinical delivery system made available to patients broadly in a way that lowers the potential risks of treatment - is a model we want to pursue over and over again.
Richard Helppie
It’s the epitome of the three part mission that you have at Michigan Medicine. Dr Miller, when I hear these kinds of things, it’s very exciting. I’m sure all of our listeners, readers and viewers are going to be excited about these breakthroughs in medicine. I’m a simple guy, all right, we have people that want wellness, they want diagnostics, they want treatment, and we have this amazing delivery system to provide that wellness and diagnostics and treatment. From your role as a leader of a health delivery system, what are the pressures facing you, and what are the differences between a community-based system or a faith-based system or an academic medical center?
Dr David Miller
Thanks, Rich, I think it’s a really important question. I think if you look at healthcare delivery more broadly, I always say in that mission of advancing health to serve Michigan and the world, the concept of advancing health means we, as an academic medical center, academic health system, have to acknowledge that we’re imperfect in some ways, and we have to continue to improve concepts like access. How long does it take for patients to schedule an appointment? How long does it take us to answer the phone when you call? How do we ensure that we’re balancing access to primary care with the specialty care? So I think for us, ensuring better access, a broader and more welcoming front door, even as we grow and expand, that we’re ensuring safety and quality measured by external factors and by the excellence of our clinicians, continues to be preserved and doing that in a way that also ensures an excellent experience for our patients and our team members. Those are complex dynamics as we grow, as we face the demands we have with constraints and capacity in other areas, finding that balance between ensuring improved access, ensuring safety and quality, managing experience, are our operational challenges. We have a set of strategic priorities we call building our BASE: Belonging, Access, Safety and quality, Experience. How we enhance both our measured performance and our stories in the organization in all those areas, but then we do that in the context of a complex regulatory and financial environment. Healthcare systems run on relatively small operating margins in a highly regulated, highly complex organization. And if you ask most CFOs, or leaders of healthcare systems, they tell you that in the last five years, the revenue and expense curves are crossing, if not converging. So how do we continue to have a financial operating model that allows us to invest in our programs and in our teams, in our facilities? One distinction between an academic medical center and a community-based health system is that investment in education and biomedical research. The clinical enterprise for Michigan Medicine and University of Michigan Health is an important engine in those investments in the medical school and biomedical research, which means we have competing constraints for other capital investments; they might be strategic capital or routine or replacement. At the same time, the relationship between community-based health systems and academic medical centers can be very positive. I think an example of that is here in Washtenaw County, where, with Trinity, we have an excellent community-based health system that’s providing great primary, secondary and tertiary care, but allowing for - we hope - continuous, easy interactions and movement for patients in scenarios where the higher complexity services at the academic medical center are available. Then, using the example of Chelsea Hospital, that one of the great community-based assets can be a site of partnership, where services for patients who might be referred to Michigan Medicine from across the state can get care in the right environment. (Richard Helppie: They get their inpatient rehab there.) Exactly, lower complexity care in an environment that’s very used to efficiencies and make it easy to receive that care in a high quality, safe setting. And then they have particular programs like inpatient rehabilitation, where you can really build a center of excellence. So there are differences, there are points of connectivity, and finding the ways to collaborate has been one of our commitments.
Richard Helppie
You mentioned education and the medical school. Training physicians is different. Several years ago, we were looking at the numbers, and the same number of physicians were retiring as were entering practice, but those retiring were 75 hour /week physicians, and those entering, 45 hour/week physicians. And then, beginning in the 1990s the supply of physicians was restricted with the graduate medical education budgets being severely cut. So when you look at that mission of training doctors and other caregivers, what are some of your challenges today, and what’s Michigan Medicine doing about making sure we have enough doctors?
Dr David Miller
It’s a great question, I’ll start by... I won’t remember the exact numbers, but Dr Louito Edje, who’s one of our deans leading all of our educational programs at the medical school, often references the pace with which medical information is doubling. Back at around 1950 it was estimated that it was somewhere around 50 years. By 2020 that had decreased to about 70 some days. And now it is even less than that. The pace with which medical knowledge is proliferating is extraordinary. It’s almost breathtaking. So how do you prepare the next generation of students to practice in that environment? I think one of the things that Dr Edje - and we’re extremely grateful that we’ve recruited an incredible new dean for our medical school, Dr Tommy Wang - is thinking about at the medical school, is how do we better prepare students to learn and to practice in that environment, particularly in the setting of new technology, generative AI and other areas. I think there’s this concept of building AI or technology fluent students through curriculum revisions that support that. In the clinic, how do we think about using technology to support the ability to continue to see patients and ensure access? Then, even training programs, there are some primary care programs that are developing fellowships called digitalist fellowships, where it’s a group of physicians who are really committed to understanding how to implement technology in their clinic. So one is curriculum reform and revision that reflects the growing role of technology, because, in fact, our students are going to demand that. I mean, I watch my kids on any given day and how they use technology, it’s fundamentally different from how I do it. It’s certainly different from how my parents do so. One is building that technology fluency within the curriculum, and then how do you actually implement that in practice. It may be that there’s a particular group of interprofessional clinicians who have technology enabled practices that are able to be accessed from a whole community, or that those elements get diffused in individual practices, and we’re looking at that. So curriculum reform and then implementing reforms and practices that create a digital first environment. How can we use elements of remote patient monitoring to identify early escalation of conditions? How can we take advantage, for instance, of radiology imaging? If you apply generative AI, you can identify unexpected risk factors for cardiovascular disease that can then help us move upstream in the prevention space.
Richard Helppie
My understanding is that the AI reading of images is actually more accurate than a human being looking at something because it remembers every image it’s ever seen and every anomaly there. In that education process, again, as a lay person, so many conditions present the same way. They can be fairly easy to deal with, or they can be very, very complicated. I think we’ve all had family members or perhaps personal experience with thinking it was one thing and it was actually something else. Will this push to digitization and AI help winnow through some of those conditions?
Dr David Miller
I think it’s a great question. I think there are probably three broad approaches to generative AI and healthcare delivery. The first is how can we use it to support operations in a way that allow our team members to work at the top of their particular area? Some of the processes that we have in areas like revenue cycle or pre-authorization, can we thoughtfully automate those to allow our team members to work on even more patient focused activities? Second is coming back to your point of how do we support our clinicians in this incredibly changing time, which is, how can generative AI reduce administrative burden in some ways for our physicians, our advanced practice teams, our nurses, all of our team members. Great examples there include the ability to work within the electronic medical record to generate responses to pharmacy refill requests. It’ll help the patients because it may get done more quickly. It reduces some activities that allow our teams to focus on patient care. Really impactful has been ambient AI technologies that have been introduced so that you and I can sit in clinic together, I can listen to your history, do a physical exam, and a note is generated through that interaction that reduces the time of documentation. We’ve seen excellent data, particularly at University of Michigan Health West and now here in Ann Arbor, that it’s reducing the time spent charting for our physicians. Finding ways to do that in a patient centered fashion, but that reduces that administrative burden is going to support our workforce moving forward. And then the last frontier is, what you said, can we use generative AI to support more precise diagnosis, better treatments? I think that there’s a lot in that, understanding the data around reliability and consistency, how you keep a so-called human in the loop in some of those interactions. But I think particularly exciting is on the research frontier. Now there is starting to be AI used to identify what we call previously undruggable targets in cancer. You can imagine a cloud where you have all the available therapeutics, all the available genetic changes in patients with cancer and identifying new ways to match those. I think that’s where generative AI is really going to push the frontier of innovation in healthcare delivery to an even greater degree.
Richard Helppie
That is just, again, one of those very exciting things as we move to the future of humankind. Does that change the kind of person that is applying to medical school, or does it change the selection criteria? How does the recruitment or the selection of medical students go? What might be different about the journey of a medical student today versus perhaps during early training?
Dr David Miller
I think so much has changed. A lot has changed in medical education; to how course materials are presented, to the timing of your pre-clinical work, to your clinical rotations. I think the fundamental issue is that embracing and applying technology is part of day to day life for the next generation of medical students, and so building curriculums to match that is going to be fundamentally important. In fact, I think it will be demanded of healthcare education across all of the medical and allied health professionals, that technology be part of that. I think that the commitment still to patient care, to understanding the information involved will endure, but I think an embracing of technology and a willingness to apply it will be a foundational element of individuals who pursue a career in medicine. Now I want to temper that by saying what I said earlier; fundamentally, healthcare is still essentially human interaction. And so that commitment to humanism, to empathy, to the idea that when I walk out in my clinic and I see my patients, almost all of whom have cancer, what they would like is to be able to get back to being concerned about what’s for dinner. But I will say this though, I think it is true and I say this often publicly. My parents, for instance, may never embrace a healthcare system that’s technology first, virtual first. I don’t think my kids will ever embrace one that isn’t. So how we evolve that from both education to clinical care delivery to patient expectations to how we balance the art and science of medicine, is the great opportunity in front of us.
Richard Helppie
Look, I’m in strong agreement with you. By way of example, the ability to get a virtual appointment - in the old school, it was the appointment is at 10am so you have to drive to the clinic, you have to park, you have to go to the waiting room, you get seen, and then you get your follow up – now you get a text that says the physician will be ready for you, make sure you’re in front of your computer in five minutes. You get your exam, and, okay, we think you’ve got shingles, you actually did get diagnosed with shingles, and we’ve got your pharmacy on record, you can go pick up the antiviral there, and I’m done in 15 minutes. Like, how much better is that? But in between the demand side of this, human beings seeking wellness, seeking diagnostic, seeking treatment, and this amazing digitization and all of this research, we’ve got a payment method. I won’t call it a payment system because it’s not a system. Let’s break that down a little bit. We’ve heard a lot about Medicaid changes, and I’ve had people on The Common Bridge talk about how we’re going to have more under-insured and more uninsured. As you sit down to deal with your budget, which is substantial, what impact do you see on Michigan Medicine, or perhaps academic medicine in general, given the dialog around Medicaid?
Dr David Miller
This is an incredibly important question, and I will say first, there’s a lot of discussion about affordability and healthcare, I think that’s an important conversation. You mentioned the size and scale of healthcare for the economy as a whole in your introductory comments. I think as healthcare providers, we absolutely have to be engaged in that conversation and accountable to thinking about affordability. In many ways that becomes, do we practice medicine according to the best available evidence in a patient centered fashion, and what decisions do we make around when to utilize care in a particular setting or to order a high cost imaging test? I spent a lot of my early career thinking about that in the context of prostate cancer; how do we determine those patients who need aggressive treatments like surgery or radiation therapy, and how do we identify those patients who could be safely monitored over time? The number of factors that converge around those decisions is multiple and complex, but that’s part of the responsibility. When we think about affordability, we have to be focused in on appropriate selection of diagnostic tests and treatments, delivering those in a high quality fashion that avoids downstream complications and more costs. Then, selecting cost conscious options when those are appropriate, that requires careful conversation with patients. We need to be involved in those conversations. At the same time, I don’t think that healthcare delivery systems are the only element that contributes to those affordability conversations. Coming back to Medicaid, certainly elements of the reconciliation bill will affect our patients. First, we know that it is likely that there will be a decline in Medicaid eligible individuals in the state of Michigan, for instance. How does that affect us? At Michigan Medicine, 40-50% of our patients in Children’s and Women’s Hospital have Medicaid. Around University of Michigan Health Sparrow and the surrounding communities, anywhere from 25-35% of patients are Medicaid eligible. If there is a decline in eligibility, empirical data suggests more use of the emergency department, missing opportunities with preventive care, and so downstream, more expensive scenarios.
Richard Helppie
Let’s zoom out and look at the insanity that we have right now. We have amazing life saving care. We have people that need it. And just as you said, your clinical workup says this is a patient that needs more aggressive treatment, or maybe not so aggressive treatment, whatever it might be. But the reality is that person sitting in front of you, well, this is a Medicaid patient, and Medicaid won’t allow us to do this, or they’re a commercial insurance... and by the way, the insurance companies have always been ahead with technology, and no doubt their AI engines are going to be geared to saying you can’t have it, because that’s what they do. How do we get the payment system to reflect the great care delivery, diagnostics and treatment, with the demand, without the administrative burden that you and all healthcare providers have?
Dr David Miller
That’s a fundamental question, and I think one that, first and foremost, essential clinical interaction between a physician, advanced practice team member, or one of our nurses and the patient, has to be grounded in the best available evidence in selecting treatment options. That fundamental contract, if you will, between the physician and my circumstance... [cross talk.]
Richard Helppie
But there’s a third person in the room. You say you need this, right? But I’ve got to go talk to somebody in Minneapolis.
Dr David Miller
Then I think there has to be dialog and collaboration around a set of guardrails that allow that clinical judgment to be expressed more easily into the payment. AI has created - you’re right - this ability to say yes or no in different ways. We work hard with our payer partners to understand what are the right indications for certain imaging tests and to smooth that pathway for patients. I don’t know that there’s a simple set of criteria, but one, it requires demonstration of a commitment to evidence-based care. Two is open collaboration around guardrails within which pre-authorizations can be more easily implemented, with that accountability and feedback. I do think it is reasonable on the clinician side to say if you get data showing you’re outside of some of those boundaries, how are you going to work within your clinical teams? There are some good examples of that in the state of Michigan, where partnerships with Blue Cross Blue Shield of Michigan have looked at issues like appropriateness of imaging and other areas. I think we need to keep building on those.
Richard Helppie
Indeed, it’s complicated, but having that second guessing going on is the thing that is a dilemma that we need to unwrap. Maybe I’m putting you on the spot. If you could design an ideal payment system for the United States of America, what would it look like?
Dr David Miller
That is a complex question. I think there have been some efforts to consider payment reforms that focus on creating lower friction decisions to pay for services in those areas that demonstrate the greatest value to patients. For instance, there’s an initiative out of the University Michigan called value-based insurance design that I think has some elements that would want to be incorporated in that. In other words, making it easier and lowering the financial and administrative burden to get the most effective therapies to the biggest number of patients in a way that improves health, which is really the desired outcome. So some elements of that are likely to be important. Second is the fundamental concept that healthcare should be accessible to patients who need it wherever they are and whatever their circumstances are. That’s a commitment we have at Michigan Medicine. A focus on ensuring the greatest levels of access, lowering the friction to ensure that the most effective diagnostics and therapies are available, and then keeping that patient/physician/provider interaction at the heart, those are the design principles. How we get to the more granular layers, I think we’d probably need another full session on that.
Richard Helppie
When you think about it, the least friction is in the ER. You come in, you present, you get triage. You’re not a cardiac event and you wait based on your condition. You might be turned away from the ER because you’re not sick enough, you’re not injured enough. We need to get there. When you think about something as based as primary care, it’s not, oh, my appointment book is full, we’ll see you in three weeks - no other retail business works that way. It needs to be, I would like to see you. We’ve got to turn that model around to say, I want to get more patients through using these technologies.
Dr David Miller
If I could just make one comment on that, which I think some of my initial responses were related to. The transactional elements of payments for classic bricks and mortar healthcare delivery, what you’re referencing, I think, is a really important part of designing a payment system. Which is making sure that these innovative care delivery models are reimbursed in a way that there are transparent economics within the relationship between expense and cost. Because if we don’t have reimbursement that supports virtual visits, that supports care at home in some circumstances, that supports the ability to access remote remote monitoring, then all those different channels of connectivity are limited. It is through those different channels of connectivity that takes the “I’m calling and seeing if I can be seen in four weeks” to “here is my circumstance right now.” What are the tools available to me to better understand it so I can interrupt the progression or get answers to my question? I think your comment there really reflects the expansion, and many of those are in the midst of the policy debates in Washington right now; extension of telehealth coverage from what we saw in the pandemic, some extension of different home-based care models. Those are really important questions, because they broaden the lens of what healthcare delivery looks like and how it’s reimbursed.
Richard Helppie
Indeed, and money is wasted with eligibility requirements, on dueling computer systems between the provider saying this is necessary care and the payer saying it’s not necessary care, people getting gaps in their coverage. In my humble opinion, the most insane part of this is having someone’s healthcare coverage come from their employer. Maybe in my grandfather’s time, who was 40 something years at Chrysler Corporation, it made sense. But in today’s gig economy, why would that make the least bit of sense? So I think there’s a lot to be said about healthcare payment reform, and hopefully we’ll get a chance to talk about that. But as you look back on your career, at which you’ve still got a long way to go, what’s changed? I can tell you are very excited about the future, but what’s changed since you got in? What should our listeners, readers and viewers be thinking about in terms of healthcare, and particularly as it comes to policy decisions?
Dr David Miller
In many ways when I look back over the last... I joined the faculty at University of Michigan in 2008, so over the last 17 years, it’s hard to underestimate the impact of the pandemic. And it may be routine to say that in some ways, but the impact of the pandemic on healthcare delivery was profound in several ways. First, its impact on the healthcare workforce, which still continues to be in recovery today: staffing, recruitment into all the different fields of healthcare, supporting our staff and our team members and recognizing their great work. Trust in the healthcare system and the relationship between patients and clinicians, that has ebbed and flowed in the time since the pandemic, and we continue to want to to build that fundamental trust, that we’re doing the right thing for our patients. Those have been very important. I think what has been particularly profound, though, has been the way that the delivery of care has changed as a consequence of some of the technological issues that were adopted so rapidly out of necessity during the pandemic. And that really sits in the relationship between, for instance, the electronic medical record and care delivery. One has been the expansion of virtual care options, we talked about those earlier. In some areas, like next week, I have a clinic with many of my patients who live across the state, where all we need is a ten minute video-based conversation, and they had a blood draw locally. There’s no reason for them to drive 200 miles, we know we’ve saved thousands and thousands of miles of an expense for our patients. But that hasn’t been the case in every single specialty. So where that virtual first option makes sense, where it doesn’t, how you prepare clinicians for those different care delivery models and students for those different care delivery models is important. Another fundamental element has been what we call asynchronous care, which is all the ways that information arrives through portal messages, through requests. There are estimates that for every hour of actually seeing a patient, there’s been exponential growth [of these messages] and that has had a real impact on our workforce. That is what our primary care physicians will say; well, yes, I’m still seeing all the patients I see in clinic, and then I finish my clinic and I have really complex portal messages. So the implications of how technology has changed, what that means for how we educate and deliver care, that has been a profound change over the arc of my career and my time and has really affected clinical care delivery. It also affects research, because that electronic medical record is a new source of discovery, and it affects how we train the next generation, as we mentioned. How are we ready to prepare for that asynchronous care? How do we use technology to support it, and then how do we connect across a bigger system? Because when I started, the University of Michigan was an academic medical center in Ann Arbor, one of the best in the world. We’re now an academic health system across the state, I believe one of the best in the world. How do we create consistency in areas like quality and safety, access and patient experience that reflect the block M, wherever it is, while at the same time recognizing that the circumstances in Grand Rapids or Lansing or Ann Arbor are going to be different. Those are some of the changes I’ve seen and some of the opportunities we have in front of us.
Richard Helppie
Well, I hope that we get to a payment system that will let people access the wonderful world of Michigan Medicine. And look, the fact of the matter is had payment methods not been modified during the pandemic, most health systems in America would have gone bankrupt. And if there’s ever proof positive that what we’re trying to do makes no sense, that’s it. But look, you operate in a very complicated world, and I appreciate you sharing the nuance beyond the sound bites in the headlines. You’re also dealing with a social world; Michigan’s been in the news around DEI, Michigan’s been in the news around transgender medicine, Michigan’s been in the news about making sure that the workforce is diverse. People want to go to a sound bite, but I don’t imagine in your office or in your clinic, these are sound bite issues.
Dr David Miller
In many ways, academic medicine sits at a particularly significant interface between higher ed and healthcare delivery, both of which are experiencing the impact of external changes, research funding, funding for healthcare delivery, elements of diversity, equity, and inclusion in many of these conversations. Our focus has been, how do we continue to be an organization that lives its values every day, our core values of caring, integrity, inclusion, innovation and teamwork. To have a set of strategic priorities that include the concepts of belonging, access, safety and quality and experience in a way that ensures each of our employees feel like they have the opportunity to thrive and reach their full potential. We are committed to resilient mechanisms to ensure that endures over time, because we believe that’s what drives our mission forward. Each of the items you mentioned is complex and has multiple levels. Our focus has been to continue on transparency in our organization, support for our team members and our patients, telling the story of the good work we do. I think, Rich, I’ve seen data that if you go out and you do it... there was a survey done in the state of Michigan through the university, and it asked what are some of the biggest impacts of the university for you and your community? Michigan Medicine is often at or near the top of that list, and I think we want to continue to be that source for the entire state, the most consequential academic health system in the country, moving our mission forward, and bringing our expertise to as many communities as possible. I think if we do all those things, we’ll be able to weather some of the some of the changes that are happening around us. Again, continuing to be an excellent partner with communities, with the state government, with the federal government, and most importantly, on behalf of our patients and our team members. It’s not an easy equation. I don’t sit here and say that we’ve solved every element of that, but we’re committed to the internal dialog and to the support for our team members that are necessary in this moment in time and moving forward.
Richard Helppie
The world renowned reputation as a research facility, a research organization... if you have a particular case, you might be anywhere in the world, the best place to come is Ann Arbor, Michigan. Dr Miller, you’ve been really generous with your time. This is really informative. Is there anything that we didn’t cover, or any closing comments that you’ve got for the listeners, readers and viewers of The Common Bridge?
Dr David Miller
Well, thanks, Rich. I’m really grateful. I want to start by just expressing my incredible gratitude and admiration for all of our team members at Michigan Medicine. I always say when you think of the clinical delivery system, we are a 24/7, 365 day, forever organization. There’s never a moment when we’re not available and ready to step in and help our patients in our community, and our research and educational endeavors drive the next level of innovation and are a source of incredible pride and impact. I want to acknowledge that as we look forward, we see that the moment is challenging, but I believe our teams are built for this, and I’m so grateful to lead and work alongside of our teams. We talk about our strong BASE priorities, and we talk about looking forward to more innovation impact, like the story of histotripsy I told you, and really committing to the idea that if we can work at that interface between discovery and education and our clinical delivery, we’re going to find new solutions to challenges that affect our patients, that allow them to continue living their lives well. I think we are such an extraordinary asset in this community, in the state, nationally and internationally. I’m proud to be part of it. I want us to be held accountable to continuously improving, but I also want us to feel confident that this is a moment where we’re going to move forward and drive impact in healthcare and education and research for the public good.
Richard Helppie
We’ve been talking today with Dr David Miller of Michigan Medicine. I hope this has been encouraging to the audience of The Common Bridge, because The Common Bridge is about saying that there are solutions to today’s problems if only we have the will to work on them. I certainly am uplifted by hearing about some of the miracles that are going on right here in the city of Ann Arbor, across the state, nationally and internationally. We have good people like Dr Miller leading great teams of people to make positive change in our world today. And so with our guest today, Dr David Miller from Michigan Medicine, this is your host, Rich Helppie, signing off on The Common Bridge.
Dr David Miller
Rich, if I can say - I always have to close with this - Go Blue!
Richard Helppie
Yes, especially in this month, yes, indeed. All right, Go Blue!
