Podcast Episode Transcript: Helping patients navigate their unique health journeys

With L. Gordon Moore, MD

Gordon Moore: Welcome to the Inside Angle podcast of 3M. This is Dr. Gordon Moore, your host, and today I’m talking with Dr. Daniel Knecht. He is a board-certified internist and currently serves as Vice President, Transformation Clinical Products at CVS Health. Welcome, Dr. Knecht.

Dan Knecht: Thank you, Gordon. Delighted to be here.

Gordon: I’m curious, what is the Vice President of Transformation Clinical Products doing at CVS Health?

Dan: Sure. So, I have the privilege of leading a team of passionate, dedicated folks that are thinking and developing new products and services, leveraging many of the great assets we already have at CVS and Aetna, creating with them together in an innovative way to develop products that improve the health of our patients, members, customers, as well as reduce unnecessary medical spending.

Gordon: That’s a mouthful. It sounds like a pretty broad purview. You mentioned members, you mentioned customers, you mentioned patients. That’s folding a lot together. So, you’re both healthcare provider-insurer, as well as retail health clinic.

Dan: Yes, it is a pretty wide mandate. Essentially what happened was when Aetna and CVS came together a few years ago, there was an appetite and a vision to bring together all these new capabilities in ways that really are patient-centric, that are aimed at improving health. So, the way the team is structured is through a population health plans, right? We have a team looking at patients who are struggling with cancer and other serious illnesses, so they’re building products around oncology, caregiver support, care in the home. We have another team looking at chronic conditions, so that’s a group that is developing and has already deployed a program called “Transform Diabetes Care.”

Then, another group is thinking about people’s individual health journeys. So, folks that are healthy, just want to stay healthy, or perhaps considering having a child, or are during their maternity journey. So, that team is developing products to accompany folks on their unique health journeys.

Gordon: Within the bounds of what’s appropriate, give me an example of a kind of program that you’re either thinking about or doing for diabetes.

Dan: Yes, certainly. We have a program called, “Next Generation Transform Diabetes Care.” Essentially, we leverage analytics to identify members enrolled in this program that have diabetes and perhaps are not achieving their health goals. So, we’re looking for gaps in care, missed screenings, opportunities to embrace lifestyle change, or up-escalate medication. So, what this program does is, it sends nudges to those individuals, whether it be a text, an email, a phone call by a certified diabetes educator, to coach and support those folks in those gaps of care, and to get better support.

There’s an analytics component to it, but I think, really, where the magic occurs is all the local, community assets we can bring to bear and help those folks. As you know, we have about 10,000 pharmacies across the United States, more than 1,000 MinuteClinics, and we have several hundred HealthHUBs. So, our ability to invite those folks into our stores and help them better understand their medication, coach them on lifestyle changes, and provide clinical support for, for example, diabetic retinopathy screening, or up escalation of medication is really, I think, a very unique differentiated and impactful component of the program.

Gordon: Yes, I remember as a solo family doc in Rochester, New York, I was reading some of the literature around how pharmacists could bring a whole bunch of clinical support to bear, and you could expand a care team by thinking about how to link with somebody like that. It was out of my reach, as a solo, independent doc, but it sounds like you’ve got that completely folded in.

Dan: Yes, absolutely. We have a capability we call it “Pharmacist Panels,” and this is a really exciting and unique feature to the program and a number of other programs we have. So, what we do here is, we provide our pharmacists and stores that are enrolled in this capability data to provide recommendations for their patients. So, through IT, clinical nudges that are surface, that are specific to the patient they’re interacting with, whether it be additional coaching and support for medication adherence, screening for comorbidities, recommendations to go back to a primary care doctor and ask for a particular clinical issue, as pharmacists have those messages surfaced, I think that’s one important point.

But also, we’re working to provide additional training and support to the pharmacists so they can engage in a meaningful, patient-centered, empathetic exchange, and then, finally, we’re providing pharmacists a little bit of extra time, so you’re not as rushed in that interim so they can spend the time and attention with that patient, to build that relationship. So, that’s a really exciting component. And as you know, CVS has been around for about 50-plus years. We’re a pharmacy at our heart. And so, trying to unlock and reimagine the relationship between our pharmacists and their patients through this added capability is just really exciting.

Gordon: It’s one of the challenges in any practice, medical pharmacy is the pace of patient encounters. It sounds like you’re figuring out how to give that time so that the consultations can happen. Have you launched that already? Is that working?

Dan: We launched in over 1,000 stores. I think first and foremost, the pharmacists really enjoy this. This allows them to practice at the top of their license. You know, evolving that role from a dispenser to an influencer and a coach, I know our pharmacists really enjoy the program. Patients are really getting a lot out of it, too. As you know, there’s an increasing amount of requirements for physicians, so the time they have to spend for a patient is decreasing, so pharmacists are ready, willing, and able to step into that gap and provide additional coaching and support.

And so, we’ve been very happy with what we’re seeing in the field. We’re seeing incremental closures in clinical gaps of care. Those are patients getting appropriate treatment, screenings, and support around lifestyle changes. So, we continue to roll this program out and we’re hoping to have it go live in our entire fleet by the need of this coming year.

Gordon: I do a bunch of work with healthcare data, looking at claims. We work with a lot of healthcare provider systems that are using natural language processing to sift through electronic records. I can see those as huge data sources that are vastly interesting. Where are the data sources for you at CVS health?

Dan: As a health insurer, we sit on a vast repository of claims data, medical data, demographic data. We’re able to apply machine learning, as well as bring in external data sources. Like for example, during the COVID-19 pandemic, which is still going on, we were able to take data sources from the CDC and public health authorities to inform our outreach to notify and support people living in hotspots. Not only do we sit on a large internal data repository, we’re able to go externally and bring other data sources in to help people on their path to better heath.

Gordon: The other thing that occurs to me as I think about the advanced alternative models for healthcare, you’re bringing different stakeholders together that might be in different financing silos and figuring out, “How can we collaborate and work together as a clinically integrated network?” or something like that. How is it that for people who are under Aetna and CVS Health-Aetna insurance, I can see that, the big bucket captures everybody. Is that explicit in the way you work with clinicians who are out there in the community?

Dan: At Aetna, we have relationships and contracts with over a million healthcare providers across the country. Some of those are in value-based contracts with us. Others are the non-traditional fee-for-service environment, so we work with those providers regardless of how their contract is with us. I think what’s most important is to ensure data interoperability. What’s exciting about CVS is our use of Epic, which is America’s largest EMR, so when we have a patient that comes into the MinuteClinic, for example, and we change their care plan or update their care plan based on findings or a change in their health status.

That’s documented in Epic, and that is shared with the primary care provider. The same goes with the pharmacist. So, pharmacists have had those lines of communications with providers for decades, now. We’re able to share changes in care plans with prescribing a particular agent back and forth with a provider. So ultimately, our aspiration, we’re working towards this pretty aggressively, is to build collaborations with providers, and provide supplemental services and wraparound support for those patients.

I love to talk about nutrition. I think it’s a great example of what services we’re bringing to the market and really working to complement primary care docs’ efforts. We are poised to launch a program called “Transform Nutrition” in Arizona. We’re piloting it there, and the goal there is to find people, patients, and members, who are interested in a nutrition program, and we’re providing dietitians, meal plans, coaching, and then the idea here is to share that information with a primary care provider if so interested.

The idea is to help people on their path to better health, route through nutrition. As you know, nutrition and diet are, I would say, probably the biggest driver of chronic conditions in this country, so we feel that this is a space where we can play a really positive role. And moreover, as you probably remember from med school, we get very limited training around nutrition. This is definitely a gap in the training given to providers, and I think we can plug that gap and help physicians who are managing their patients influence and address that big unmet need around nutrition.

Gordon: Yes, that’s interesting. Are you focusing on a specific population with that? You mentioned the different segments you’re looking at, or is this broadly applicable, even down to healthy people?

Dan: I would say everyone, myself included. I could probably do better with nutrition. We are casting a wide net and really welcoming anybody who wants to embrace a more healthful diet. That being said, we’re really putting a lot of effort on people living with hypertension, diabetes, hyperlipidemia, because those folks probably need it the most. And another question I get is how we’re thinking about nutrition meal plans. We’re going about this just understanding that we need to meet people where they are.

Some people are highly motivated and want to embrace something like a ketogenic diet. Many other folks don’t have the resources or just really are not interested in such a restrictive diet. We’re really going out there with diet diagnostic and offering a number of different options that could be individualized. For example, plant-based diets, DASH diets, Mediterranean diets, I think ultimately what we want to do is provide members of this program choice, education, support, and let them essentially choose what makes the most sense for them, because ultimately, we want to catalyze a change in lifestyle, as opposed to a diet fad.

Gordon: How do you actually bring this to bear? If somebody’s coming into CVS, or is this a MinuteClinic, or this a virtual venue, or is it all the above?

Dan: It’s all the above. We are deploying this in a number of HealthHUBs in the Arizona market. We’re teaming up with providers to raise awareness about this. We’re also providing marketing in those regions to debut this new capability we’re rolling out. Within the HealthHUBs, we’ll have dietitians who are specially trained. We’ll have a digital component. And also, we’ll provide, in addition to coaching, access to a discounted meal plan.

Gordon: And just for folks who might not know, give me a thumbnail sketch of what’s a HealthHUB.

Dan: A HealthHUB is a CVS store that has expanded its footprint in health services. So, we have a larger suite of clinical services. We have additional support in the store. For example, in many stores, we have something called a “care concierge,” and this is a CVS representative that can help people navigate the services at CVS and make sure that their experience is individualized, it’s helping them to select the right health services, and engage them in a way that’s really remarkable.

Gordon: I want to ask you, to spin back to work you had done on opioid misuse and addiction, which sounds interesting. I want to hear about that, because partly, I’m also interested in what’s been the success of the kind of interventions that you’ve brought to bear?

Dan: In my prior role at CVS-Aetna, I supported our chief medical officer. As you know, unfortunately, this country is struggling with a substance use disorder, and it’s largely driven by opioid misuse and abuse. So, one program I’m particularly proud of is an initiative that’s still going on today; it’s called The Guardian Angel program. And what we did was, we leveraged the data analytics I mentioned earlier to identify Aetna members who have been victims of an opioid overdose resulting in an ER visit.

So, we were more able to identify people who’ve shown up in the emergency department across the country due to an opioid overdose, and then we have a few really dedicated, highly trained clinicians to provide assertive, telephonic outreach to these folks. So, the Guardian Angels, they get a list of Aetna members who had an overdose event, and they make outbound calls, they deploy motivational interviewing skills, trying to understand what happened, how we can help.

I think most importantly, too, is discussing the benefits of evidence-based care, which includes medication-assisted therapy, and what these angels will do is educate folks about the benefits of medication-assisted therapy, as well as psychotherapy. If the patient’s interested, which is often the case, we’ll work to find a provider in their community and provide MAT and additional resources.

It’s been really successful. When we went into this, this was the pilot, and we were not sure if we would actually even be able to engage with these folks. As you imagine, they’re struggling with a lot of challenges. Not only are they struggling with, likely, a substance use disorder, but it’s so severe that it resulted in an overdose. So, we went in there, cautiously optimistic and the engagement rates have been really impressively high, between 40 and 50 percent of outbound calls resulted in connecting with these folks. Earlier this year, the team notified me that we had helped over 1,000 overdose victims, and the work continues today.

Gordon: What I’m also curious about with the Guardian Angels program, if it’s been around long enough and you have large enough data to tell whether or not this has bent the curve in terms of opioid overdose.

Dan: That’s a great question. We have been tracking data and outcomes pretty closely since the inception of the program. We have been seeing the encouraging data. We’re seeing the folks that we engage with are receiving evidence-based care. As you know, substance use disorder, like many chronic conditions, are relapsing and remitting, so I think it’s too premature to say that these folks have been cured, but that being said, we do see encouraging data. I think also, anecdotally, we hear really encouraging stories of people who are able to get treatment and get their life back on track. That’s been really heartwarming as well.

But ultimately, these folks will be living with substance use disorder for a long time. With that insight, the team has changed their approach a bit. Now, the angels, if patients are interested, will provide follow-up calls and coaching and checking in on these folks, potentially months after their overdose. So, we feel like that also can help these folks on their path to better health.

Gordon: One of the things that I hear about a lot is the challenges to innovation, because of the rigid structure around financing healthcare and the different silos people are in. It sounds like you guys are really out there, in terms of just doing things that are right, and figuring out how to put that all together. That’s really heartwarming. When you think forward to the kind of challenges you want to be overcoming, are there big things you need to fix, or you’re hoping that the nation fixes so that you can continue to innovate?

Dan: Yes, to your point, CVS I think is just so uniquely positioned to make a positive impact on health. It’s a Fortune 5 company. We have a delivery arm with MinuteClinic and HealthHUBs, as well as Coram, which is a nursing service that’ll go to people’s homes and provide them infusions. We have the payer arm, with Aetna. We’re America’s largest pharmacy with more than 10,000 stores across the country. We have the pharmacy benefits manager arm.

We have all the pieces that we’ve brought together to really develop a patient-centered health experience. It’s fascinating. I look back at the history of CVS. It was founded back in 1963 as a health and beauty store, and it’s evolved so much in the past 50 years. I think the company’s gotten to a place that it’s so well-placed to bring high value, coordinated, accessible care to the country. It used to be called “Customer Value Store,” and so, I think it’s funny that the name depicts where we want to go as a company. We want to be customer centered; we want to bring value to healthcare.

I think we’re just so well-placed for this mission. As you know, the healthcare, it’s not just the system, but society in this country needs help as it relates to health. We’ve seen a reduction in the life expectancy, a resurgence of heart disease. These are important. It’s such an incredible opportunity for the company, and I know we’re working hard to bring that health delivery vision to life.

Gordon: Dr. Knecht, as we think about wrapping up, where are you going next? What’s your big dream?

Dan: We have a strategy, we’re calling it “Hub, Hand, and Home,” and so, the aspiration there is to develop products and services that meet people where they are. The term “omnichannel” is really frequently used. I like to say, “meeting people where they are.” We want to engage people on their path to better health through the hands of telephonic. That’s digital, that’s through apps. Through the HUB, that’s our HealthHUBs, but that’s also CVS Pharmacy and MinuteClinics. And at home, as you know COVID has accelerated the shift for services and products being delivered to people’s homes. That’s sending products, but also sending clinicians, and telehealth directly to people’s homes.

That’s our strategy. We’re driving hard to do that. We already have a lot of exciting programs. Like I mentioned, diabetes. That is bringing that strategy to life. We have this vision, and we’re moving pretty quickly to realizing it.

Gordon: Well, Dr. Knecht, I want to thank you so much for your time and the insights around CVS Health.

Dan: Thanks for having me.

View Session Spotlight (PDF)