Ep 60: Dr. Rebekah Gee Is Reinventing In-Home Care With Nest Health

0:00We're not solving the easy problems when they're easily solvable, but we're willing to spend a ton of money. At the last minute, I wanted to save it. Yeah. Right. So Nest is really getting at the root cause of so many of these things. We come to the home, take care of the entire family. We do primary care, vaccines, blood draws. Everything that's in a PCP's office is in a bag we bring with us.

0:29Rebecca Gee is one of the most interesting thinkers in healthcare in our country. She ran the Louisiana Department of Health. She's done all sorts of policy that's helped all sorts of people. She's run a big health system herself. Now she's running Nest, a really exciting startup that's approaching how to help moms and babies with value-based care. She's recreating the home visit, turns out. This traditional home visit is a great way to treat families. You can get 15 things done at once versus everyone having to go in individually. The only chance we have to provide health care to everyone well, we have to raise productivity, help more people for less.

1:00Rebecca has some great ideas about this. Let's hear from her. Rebecca, you ran a health system most recently, LSU Health, before starting Nest Health. But before that, you were also the former secretary of Louisiana's Department of Health, right? That's right. You've been in the government. You've been running a health system. Now you're doing a startup. Tell us a little bit about your background. Sure. So I'm an OBGYN, still practicing a little bit. I have a background in health policy. I've done health policy at the federal level, doing reforms around drug pricing, maternal mortality, babies and moms outcomes.

1:28I've done that in the public sector. And then at the state level have run under a Republican governor an initiative to improve quality. Then for Governor Edwards, a Democrat, ran the state health department and led the expansion of Medicaid. I have a background in quality improvement. So how do you make things better in health care? Will we measure them and make sure that we're actually improving things if we make a change? I'm also the daughter of a university president, someone you know well, Gordon Gee. I grew up under his wing as an only child and seeing what it meant to be in a public role and the impact you could have.

2:03So I always wanted to be both practicing and also having a meta impact on health care. And so I've really enjoyed my career. Of course, most recently, a nest, which you helped me found. Your father, actually, when you're running university, sometimes you end up having to run health systems as well. So I guess he was in this role a little bit, too. Oh, yeah. He's been at seven universities. He's a 42-year tenure. He has more names on diplomas than any president in American history of universities. So, again, I had an amazing childhood. I grew up having Twyla Tharp and Baryshnikov in my home, traveling the world with him, have lived in other countries.

2:41and, you know, of course now live in New Orleans, which is a city that brings together the French and Spanish heritage and the gumbo of Africa and all of those fun things. And so I've found kind of a home in a city that's small but worldly. But, yeah, I've grown up all over the country, which has been fun too because I've seen Colorado, West Virginia, Ohio, Tennessee. So it's been a fun travel across the U.S. as I followed my dad. And tell us about some of your big health care initiatives. You've done some big things with drug pricing, right? Innovative work around Sovaldi. That was hepatitis C drug.

3:14That's right, Joe. Yeah, so I've tended to like to find problems have come to me. And instead of saying, hey, look, this is insurmountable, I have tended to and enjoy the times in my career I've had the most fun of saying, OK, look, this is an awful problem. How do I solve this problem? And when you and I first met, we talked about, well, here are 20 problems, right, that ought to be solved. And so that was my approach as I did my government work or academia. is first i looked at the problem of reproductive health access how do we get access to plan b emergency contraception did work on that sued walmart won a national lawsuit what do you have to sue them for yeah because i had a patient who went to the pharmacy to get her prescription filled for a prescription i wrote her for a plan b a mom that had a bunch of kids didn't want another one wanted protection couldn't get it and so under in the state of massachusetts required that all commonly needed prescriptions be available in pharmacies.

4:09So we want it. And then Walmart changed its national policy. So that was when I was a resident at the Brigham in Boston. And so I got a taste for a while, even as a young person in my twenties, I can, uh, be an advocate and make change. And so, uh, in state government really led the work to address quality outcomes for moms and kids, starting with dashboarding out what those outcomes were, then focusing on really key areas we could improve. And then as secretary of health looked at a bunch of things, how do we run disability services better? We had a 25 year long wait list that was average weight of 13 years for kids, 25 years.

4:47And it had been there for 25 years where kids, we got rid of it by saying, look, we're going to tailor what people need when they need it, rather than bucking them into these super expensive, uh, you know, waiver programs. When the hepatitis C problem came to my attention, it was because of a letter from an advocate saying, Dr. Gee, you're just a crummy person or, you know, you're not covering these drugs. I'm dying of this disease. And I thought to myself, actually, they're kind of right. You know, this isn't right that we can't in the wealthiest country on earth. I can't, as a health secretary, solve an infectious disease problem that is actually costing me money.

5:23That was a tough one because it was just so expensive. It costs a Bentley, right? So if you have, we had 90 ,000 people, we thought, on this drug. And I mean, that would need this drug if we were to eliminate the disease. A billion and$0.8 or something. It would be more. It was going to be more than we spent on all of K through 12 and corrections combined. In the state. In the state. So you had to go negotiate, obviously. It took three years. It was not only a negotiation, but it was a media and communication strategy. You had to threaten them. Yeah, it was politics because money and politics, right?

5:56As you know. But we enjoyed it. And now what's exciting is Senator Cassidy, who's a hepatologist, who's really one of the Republican thought leaders, as well as the Biden administration. The president Biden put an initiative into his budget this year that was mirrored off of what we did in Louisiana. And now I've been working with Francis Collins, who ran the NIH for a long time on democratizing this innovation across states in the U.S. to be able to have a polio type approach. So how do we take an infectious disease and virtually eliminate it so that our future children won't have to deal with it?

6:29That's awesome. So you're working on a lot of really cool areas of health policy right now. I want to get your thoughts in general about health care. Health care costs are going up every year. Productivity in this space is declining. It's one of the only places where productivity tends to go down over time, which is crazy. Outcomes seem to be relatively flat. What's going on? Yeah, we have a crummy health care system in the U.S., right? We spend way too much money on it and we don't get good outcomes for our money. and that spend is crowding out spending on i mean as secretary of health i knew it was a zero-sum game right the u.s can print money and borrow from china well you can't when you rent a state you have a zero-sum game so when one thing goes up another goes down so when health care spending goes up education spending goes down and arguably health is more related to education than health care um and you actually don't have to argue very much to make that point so you know it was frustrating to me, but the problem is the political machine, uh, is very interested in keeping the status quo, right?

7:25So you have all of these companies making a ton of money. So the health systems, you have the doctors groups, you have the pharma groups, you have all sorts of others, I'm sure too. Right. And then it becomes a political battle. So I work for a Republican governor and the, the, I mean, for a democratic governor and the Republicans would always say, Oh, you know, you're spending so much money. You guys are wasteful. So I would say i had my list i had my list of 15 programs and i would bring it to the legislature and say look these are the things i have to pay for to have a medicaid program if we don't pay for these things we'll lose 10 billion dollars here's all the stuff that we can choose to pay for tell me what you want on this list they don't want to choose either they'll be in trouble yeah yeah they would say they would throw up their hands and say we want to pay for all of it and i would say well then if that's the case don't you're spending so much you're being wasteful yeah yeah don't tell them Don't tell me it's the Democrats fault.

8:12I think both sides do this, where as soon as someone actually gives a concrete answer, it's so easy to attack, but no one wants to put forward a plan that actually works. Yeah, because you make an enemy and nobody wants it. Well, to me, some of the answer is that you need more competition, you need less cronyism, you need to make it easier to compete with every sort of level of this complex. But what are the answers for you? Well, part of the problem, Joe, is there's not transparency. I thought about this a lot. I was thinking about my husband and my kids and their health care recently. You know, you get information.

8:39Great example is a surgeon, right? So I, I was trained as a surgeon. The only people who know how good the surgeon is truly are, well, either you have a national data set showing outcomes, which we don't, except for a few small surgeons probably don't want that. Maybe a couple of them might. So, but you, but the people who operate with that guy or gal know how good they are, but that isn't democratized information. So there's, there's a, the, the problem is you want in a competitive environment, you want parity of information, ability to access it. And it's truly not there in healthcare. And so you've got, and you've also got this human, my view, human rights issue where you don't want to be in a country that can afford to pay for the basics, you know, babies dying of starvation.

9:20You have to pay for the basics, right? So then, but then you get to, well, what do I need? And so this is my view on what should happen is not everyone should have everything they want and need exactly when they need it. So we need to, you know, there've been a lot of policy proposals. I think the best ones look like you have some kind of national system. that provides a floor. I mean, Medicaid is sort of that. It's expanded. And states like Texas, unfortunately, you don't have that. You still want competition to provide the floor, though, right? So maybe you're paying for the floor for everyone, but then you want to make it efficient.

9:52Yeah, private companies, just like we do now, providing that. But right now, productivity is not going up. It's going down. Right. And the way that we budget and contracts for states is, so, for example, well, Medicare is a problem because Medicare can go, the spend can go up and up. And, you know, there's not a lot of controls. Medicare drug prices are the best example of this, where there's been tremendous political will to change drug pricing to negotiate them. And yet we are still have made very little progress. There's someone in the background who seems to kill it every time they get really close to fixing it.

10:22There must be some really good lobbyists. Pretty much. Yeah. In Louisiana, when I my first year as secretary, when I started to take on this issue, there were three lobbyists hired for every legislator in my state. Yes. And these are health system lobbyists. They're, they're AMA doctors groups. They're pharma. They're everyone. Pharma. Just for pharma. Just for pharma. There was three. Pharma. Pharma lobby. Just for pharma. There are three per legislator. Three per. Yes. Yes. That's amazing. Yes. So the doctors. So it's, it's complicated, but we've now got this convoluted system where you've had the whack-a-mole.

10:54I mean, the problem is the whack-a-mole concept. You know, you get rid of fraud and be somewhere and it pops up somewhere else. So I think, um, the way to deal with this is either, um, you know, Senator Cassie and I disagree a little bit on the contours, but some kind of a black grant program that's realistic where you cap spending and truly... You need scarcity somehow. Yeah, you need some scarcity, right. And then you should reward value. And what we're finding at Ness, Joe, is that the value proposition, especially for Medicaid, it's so nascent, is these companies don't really know how to do value.

11:24They understand how to do value. Let's tell them to Ness. So you're passionate about moms and babies who are an OBGYN. Ness is going to try to do value-based care in this area. What is that? Tell us about that. I'm a parent of five and including two sets of twins and have run initiatives at the state and national level for maternal and child health. So at the state, I led the efforts to reduce maternal mortality at the state. I led the quality initiatives around how do we take safe care of sick kids and NICUs. But I couldn't change the delivery system. And so I was frustrated by the fact that we continue to have bad, you know, poor access to primary care.

12:00you had very high unintended pregnancy, very high, um, chronic disease that was untreated in women prior to pregnancy. And then that causes a lot of the issues, a lot of the issues. And after you've got so many children who for lack of medical care are not being, you know, their developmental delays are not being picked up. We're not solving the easy problems when they're easily solvable, but we're willing to spend a ton of money at the last minute when it just saving. Yeah. Right. So Nest is really getting at the root cause of so many of these things. We come to the home, take care of the entire family.

12:33We do primary care, vaccines, blood draws, everything that's in a PCP's office is in a bag we bring with us. This is really interesting. I was just reading Peter Atiyah's book and he talks about medicine 3.0 versus 2.0 and his framework is medicine 2.0 waits till the last minute and then treats the thing and medicine 3.0, you're thinking about it even years ahead of time. Would you say that kind of goes a little bit along with a value-based framework in that way too. That's right. We're creating what we hope to be generational change. We've already seen it and I can share a couple of stories of families we've seen, but we're going to create generational change.

13:04What's the story? What's the way you, what's the way you make a change? Yeah. So family last week, mom had five kids. She calls us because she has a two-year-old with an earache. We get in the home. It turns out she's eight days after having a baby. Neither she or her baby had been examined. There was no plan to get to the hospital. Well, she had the baby in the home, which is there. No, she had the baby in the hospital, but then came home. No followup for her. No transportation, no husband, no partner. So it's too hard for her to get there. Yeah. Other kids at home. The other kids were behind on their vaccines.

13:36They were at risk of losing their ability to go to school. If they hadn't gotten their vaccines, they wouldn't have been able to attend school next year. Wow. And the family had used the ER seven times. Which is their only option when it's that. Yeah. That's horrible. So in one visit, Joe, we took care of everything, right? So think about a parent with five. So when you vaccinated them, you checked out the baby. Everyone screened the mom for depression, looked at the home. There were roaches in the home. She couldn't afford, we got, yeah, we got, you know, how do you do bug abatement? We got that involved.

14:05There's actually like certain just types of things you can help with. The roaches I wouldn't have thought of as something you would maybe help with, but you have to do whatever. It's going to create the right environment for the kids, I guess. Yeah. You have a kid. We had a kid with asthma in the home. So if you don't deal with the roaches. So the bottom line is that some of the situations, and that's one family, we've had a bunch of families, some with autism with one child, but we've seen unimaginable challenges in homes where we can go into a home where that parent, that family could have never have gotten care.

14:34How does that intersect with healthcare? Should we be coaching people in certain bad situations how to get out of it into a better place? Well, I think one of the things is, A, it's people need to be, you know, if you're depressed, and that's why Nest is such an important model, right? the wellbeing of parents and children are intimately connected. If mom is not, it's depressed. If mom has issues with substance use disorder, if dad is depressed, has issues with substance use disorder, or if, you know, kids have untreated disease, that whole family is not well and you get into a vicious cycle, right?

15:03So part of it is breaking that part of it is Joe is having an example of, okay, all of our, one of the things we're proud of is all of our family advocates have been on Medicaid and have come from the community we serve. They understand what they're dealing with. They respect people. Yeah, but also to say, look, here I am. I am a Ness family advocate. I'm here to help you. And people can say, oh, man, that's a career path that I could take. So part of it also is we're doing enrollment assistance with families. So let's say you're not eligible for Medicaid anymore because you get a job, but you want health care through the exchange.

15:36We can help you do that and continue to provide care for you. So we're really excited. I think part of it is simply that when you have in this country, we do not have a system that provides adequate child care support. I mean, we know this. It's really hard to find daycare. For single moms, especially, it's just going to be really tough for them to even do any of the health care stuff because they're so busy without daycare if they can't afford it. That's right. And in Louisiana, most low-income moms are single moms for obvious reasons, right? One income leads to lower income for that family. And so then it's a cycle.

16:12And, you know, when you don't have transportation to go to your visit, to get birth control, to prevent the next pregnancy, then you have additional pregnancies. So overall, you're obviously you're you're saving kids and you're cutting costs, which is really positive. It sounds like there's like beyond this, there's like larger cultural issues and life coach issues, which I guess are not the not the purview of Ness. But is that do you think about those at all when you look at that? Because there must be all these other things like you kind of want to teach people how to how to do certain things.

16:36Well, I don't see it as much as life coaching as that there's the Maslow's hierarchy of needs. Once you help them with the basics, they can figure it out themselves. Right. So like I can I can think meta because I am not hungry. I don't. And by the way, we have even people who work for us who've said, I don't have a meal for my kids today. And that's on when even at twenty dollars an hour in this country, if you're trying to pay rent, you're trying to pay your bills, you have three kids. That's not enough necessarily to get all your basic needs met. So you're dealing with people who are having tremendous challenges.

17:11So I think we got to have kind of the basics covered, especially inarguably. Look, there's you can have tons of policy debates on should we be doing this for everyone? But I think we could all agree as a country that for for babies and those children in the early years, it's a great investment for us to think about. Yeah. I mean, A, we should be taking care of babies and children morally. but B, you're actually bringing down the costs, right? Because they're not going to use the emergency room as much, you're not only helping them, but you're going to make the whole system be more efficient. Absolutely.

17:38And think about, Joe, if we find, and we're doing hearing and vision screening for kids that aren't getting it, we pick up just that one thing. And, you know, in New Orleans alone, 59 % of children do not get their well care. 59 % of kids did not go to the visits. So think about just the downstream impacts of that one vision screen, okay? So a five-year-old doesn't get vision screen. Five-year-old can't read. Think about the life course of that individual not being able to work. No, we figured out our three-year-old daughter needing glasses, which is really important. That'd be crazy if you just didn't figure that out forever.

18:11To step back a bit on this, I'm curious, are there lots of maternal deaths and baby deaths you're preventing, or it's much more just about the health overall? What are the key things you're fixing there? Sure. So we're focused on, just first and foremost, vaccines, mental health, well visits, making sure baby's growing, making sure baby's feeding. We've already, as I said, we've been to a family with a baby that hadn't been seen. You know, part of the NEST model is how's baby sleeping? You actually led an effort as Secretary of Health in Louisiana to improve birth outcomes. Like what were the key things to improve the outcomes?

18:42It was how they're sleeping. Is that kind of stuff? That's important. But I mean, certainly as secretary, I focus on hospitals because that was in my purview. You know, are we treating hemorrhage when it's happening? Are we treating hypertension when it's happening? Are we safely delivering babies at the right time? Are we doing C-sections only when needed? So that was kind of before and now, and now really focused around, and then also birth spacing. Are we, are we able to, and Louisiana made huge strides in availability of birth control. You know, our planned pregnancy is happening at a greater rate.

19:13Now we're focused on, okay, you've gotten, we've seen this at home. You've got a mom who went home with high blood pressure of, so half of maternal mortality happens after moms go home. So, and a lot of it's cardiovascular. So she had an enlarged heart, right? She had high blood pressure, but no one's checking. We know that moms will, even though, and I gave you the data on kids, 59 % don't get all their well visits. Even fewer moms get their care. They're focusing on their kids first. So if they're not getting their hypertension treated, they can have a stroke. They can have chronic morbidity.

19:48You know, if they have gestational diabetes, 50 % of them will have diabetes. That doesn't get treated. You know, then you get, you know, diabetic foot ulcers, all, you know, put this down the line. So it's about, and then with kids, it's avoid, you know, when we looked, we were talking to parents also about how do you, you know, we're treating depression. We're helping with parenting skills. So all of these things lead to, okay. Or let's say one example I like is we helped a dad who was smoking, right? Dad's smoking. We have two and seven-year-olds with asthma. So we're now, we help dad quit smoking.

20:22That not only helps him and reduces his costs of getting cancer and whatnot, but now we've dealt with the asthma problem. That makes a lot of sense. And it's interesting because house calls were generally the thing, it was the norm. It was what people did before. And then that kind of went away. It's interesting because you're saying with Nest Health, part of the value-based care thing is the house call, it's just so much more efficient to help families. Why do they go away? What do we have to do to bring it back? Well, I think there were policy initiatives that did a lot of, you know, there's a saying in public health called Romer's Law, a bed built is a bed filled.

20:53Right. So there were these huge investments post-World War II to build a bunch of infrastructure. And then the medical establishment was like, oh, I'm going to set up in these buildings. You got to monetize it once you built it. Yeah. So it's not. And then, you know, then the health systems have an interest. Well, I want to bill because I can bill higher if it's a clinic. They get paid a lot more if you're coming into the health system than if they're going taking care of 14 things at once in the house. Bingo. So that's why this only works, in our view, in a value-based care initiative. We want to get paid to do better, do less with bigger savings, do the right thing.

21:31This is the key point. Rather than getting paid for everything you're doing, you want to get paid to have a certain family you're keeping healthy or a certain set of mom and kids you're keeping healthy. Exactly. So the principle is give us, you know, you would already be paying for primary care. You would already be paying something for care coordination. Give that to us. And then let's true up at the end of the year. How much should we save you? We'll get some of the savings. You keep some of the savings. So it's a, you know, it's a really, we are the first mover company in this space to take care of the entire family.

22:02And Joe, we talked about why the whole family we think is a bigger opportunity for savings. Because if you're just picking off each individual separately, treating the conditions separately with different provider teams, you're not actually addressing. You can do it much more efficiently if you're taking care of everyone. So we think that we're in a really exciting place, but also we're driving this for kids. There is no other company right now that's taking care of that moderate risk child in the startup land. So we're the first there and really excited to be. Of course, you've got a ton of demonstrations and a ton of successful companies like Oak Street that have done this in Medicare.